The "All-better-now" fairy? Image: Tim Parkinson/Flickr
I began working for an NHS Trust in 1996.
I was totally unaware of the politics of the NHS.
My Trust covered a large area and many types of care. We did not compete and had a large pot of money with which to cross-subsidise between different departments, so the money went where it was needed most.
I first realised something was afoot when my boss told us that we had to make a 20% saving. We were to stop providing our service to people at home and in care homes and we had to inform a set percentage of our patients that they were no longer 'entitled' to treatment.
Overnight, someone who needed us miraculously no longer needed us.
The structure of the NHS was changing. The money pot had become several smaller pots as we morphed into new trusts. We started talking about the other trusts on our doortep as if they no longer worked for the same organisation. When once it did not matter who did a certain type of patient review for example, we now cried "I'm not doing that, the _ _ _ department/surgery get paid to do that".
The language of care changed too. To smooth the cuts, give them some sense, we were encouraged to differentiate between social care and medical care. There had been much unoffiical overlap until then. Both were provided directly from the public sector so it had not occurred to my colleagues and I that we were so different.
Many of us could not get to grips with the new separation – medical care and social care are entwined. How could we do our basic functions of caring for people if social care was to become such a separate entity?
But change was afoot and social care was being increasingly out-sourced - and charged for. Soon it seemed those in social care had different drivers, that their work was now about cutting corners in order to drive up profits.
I now realise the social care staff were having a very rough time watching their vulnerable patients (rebranded ‘clients’ or ‘customers’) get less and less of a service and become more and more isolated in their homes.
In the NHS we clung to the principle of care for the sake of care, of protecting the vulnerable.
But we began to say that patients did not need us if their problems were of a 'social' nature, not medical. Patients that had relied on us for many years were simply cut off from the service.
All around us the rebranding of ‘healthcare’ as ‘social care’ affected the most vulnerable in society.
As needs went unmet, health and social care workers were increasingly maligned in the media.
And so were our elderly patients, who became the fodder for an economic war.
Patients now come to me apologising profusely, "I'm sorry for being old and pushing the NHS to its limits," they say.
I too began to talk of 'bed-blockers'. I didn’t think about how emotive this term was. If elderly people were in a community hospital following a stay in an acute hospital, they were 'blocking' the system up, weren’t they?
Wasn’t it all the fault of the lack of beds in nursing and residential homes? "Those homes are awful, how dare they block up our precious hospitals?”
I did not think about the fact that hospital care was paid out of taxation whereas elderly and ‘social’ care was largely privately provided, and often means-tested or requiring large payments to be made by the ‘clients’. I didn't know the UK already had fewer actual hospital beds than in most developed countries.
Care in the community
‘Care in the community’ is where it's at now, whether for general health, mental health or social care. Specialist and mobile health professionals like myself, working in ‘NHS Community Services’, are leading the way.
Apparently, patients want to be at home when they are ill and diseased. Full service hospitals are so yesterday.
We are told hospitals can manage with less because we are all working on getting care more community-based. But - oops - they forgot to put the money in to the community!
And even if they did, there is no proof this is beneficial. I have been caring for someone who should have been treated with in-patient, hospital care. She needed to be non-weight-bearing and have 24 hour care. All who treated her agreed she needed a combination of 'community' and 'acute' care, first in a hospital, then at home. What she got was community care (at and close to home), with periodic reviews with hospital staff. Neither have been enough and as a result she continues to be our patient, in pain and increasingly immobile, two years on.
Why? Because the hospitals no longer tend the treatment she needs. They only want the in-and-out stuff, the stuff that is quantifiable, easy to cost. The person develops a malfunction, they go to hospital, get fixed, get sent home, never bothered with again. That is the way to make money.
Managers are working on ways to get consultants more community-based. "Surely all they do is sit in an office and consult", one manger reasoned with me. But a consultant's room is conveniently situated near imaging, pathology, and pharmacy. It’s conveniently near the wards, too, for admitting and visiting those awkward bed-ridden 'clients' who just refuse to get with the trend of suddenly no longer needing acute care.
Short term miracles
Appointments have changed, along with record keeping. Every patient contact - every treatment or contact or even phone-call - now has to be coded and computerised. Every patient interaction, broken down in to its constituent parts ripe for selling or buying or invoicing. So many more trusts and companies and steps along the way to and from care – so many more accountants and managers.
We now help people, not for the sake of helping people, but in order to meet targets. We have to write lengthy plans for patient care packages, with 'diagnosis', 'objectives', 'treatment plan', 'review timescale' and 'episode of care timescale'.
Plans are important - they help care-givers work together for the benefit of patients.
But these plans have to have short-term ends. Our patients had to ‘get better’ even when their problems were life-long, because you cannot bill a buyer for unending treatment.
So we now 'discharge' our patients. They have not suddenly become younger or un-disabled. We know they will be back again soon with a new 'episode of care'. And yet more paperwork, again only asking me about the short term.
In the short term, my job increases comfort and quality of life.
But the long term is what matters more. In the long term, my job prevents deformity, and huge economic, social and medical consequences. A reduction in time off work, an increase in family involvement as parents or grandparents, lesser chance of surgical intervention, hugely reduced chance of expensive, chronic skin ulcerations, reduced liklihood of orthopaedic appliances.....
Reducing patient care to short episodes that can be bought and sold takes all this away. It denies the long-term exists. It is all about making money now and sod the future.
So there you have it. I have told patients they no longer need me. I have blamed other trusts and other care agencies for failings in care. I have bestowed the imaginary all-better-now miracle fairy upon countless people who are still poorly. I have used language to make vulnerable patients feel bad about the current politics of the NHS. And I do mountains of paperwork to ensure the money moves around in circles within the NHS and government.
For all this, I am truly sorry.
I have broken the NHS in to little digestible bits ripe for being eaten up by private companies.