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Our health service is in crisis, but what’s causing it? With such a colossal organisation there is no single answer, just death by a thousand cuts

Words: Sid Ryan
Design: Adam Wilkinson

The NHS hasn’t really stopped undergoing massive, systemic changes since the late 90s, and now it seems to be at breaking point. Doctors and nurses are buckling under the pressures of dealing with more patients with fewer resources, and politicians changing the rules every few years.

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The most obvious and immediate problem is one of funding. Despite assurances to put more money into the NHS, the previous six years have cut funding in real terms, and on top of that NHS organisations are being asked to make sizable ‘efficiency savings’. After the longest sustained period of underfunding in its history the NHS is struggling to keep afloat, leading to a gigantic £49m budget deficit here at North Bristol Trust.

All these pressures start to add up, pushing NHS trusts to the brink of collapse.

What this inevitably leads to is a drop in the quality of care, which comes back around to make the financial situation worse. If you’re running a bare-bones service then a bad day for hospital admissions is a crisis. Agency staff have to be rapidly recruited, fines start to accrue from the local clinical commissioning group (CCG) because patients are left waiting in the corridors, and scheduled operations have to be cancelled, meaning a loss of income.

Nearly every doctor and nurse works longer and harder than they have to, but after so much stress and upheaval, and without much of a plan to solve it, patience is starting to wear thin. Not only are more people taking themselves off the payroll to take advantage of the higher rates they can command from being agency workers or locum doctors, but more people are leaving altogether. All this comes during a national recruitment crisis for doctors and nurses.

Someone might be able to fix it, if only the NHS was in a stable enough condition to do so. Even three years after their creation, clinical commissioning groups are still working out how they can effectively manage their local areas. Increasing marketisation and privatisation is also taking its toll, forcing the NHS to compete for contracts with private providers and requiring a small army of lawyers, contract managers and administrative staff to deal with them.

da-ambulance-drivingThe only ‘solutions’ offered by government are ‘Sustainability and Transformation Plans’ (STP). These clump the CCGs and trusts of 44 regional ‘footprints’ to develop strategic plans, which seek to ‘rationalise’ their component services, often by getting rid of some. Despite being in development for the last nine months, only a select few have any idea what’s in store for Bristol. The plans are so secret that not even the council’s cabinet member for health is allowed to know, let alone you and me.

So when the STP for Bristol, North Somerset and South Gloucestershire is released, this vastly condensed infographic should leave you better equipped to ask: Which problems does it solve? Which does it make worse? Because bad choices in the NHS ultimately mean two things: more people living in pain and more people dying early.

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nhs on it's knees Adam Wilkinson-Private finance initiative (PFI) Since the government stopped paying for new hospitals, trusts like North Bristol find themselves shackled into 30-year finance and maintenance contracts at huge cost. Healthcare lobbying and the revolving door The current chief of NHS England, which drives national NHS policy, used to work for United Health, one of the largest American health insurance firms. Although appointed under the coalition government, Simon Stevens was also an ally of New Labour, co-authoring the NHS Plan 2000 with Alan Milburn. Privatisation of the NHS A study of Department of Health accounts by the Centre for Health and the Public Interest showed £22bn spent on private sector healthcare contracts in 2013/14. There were approximately 53,000 contracts with private providers, administered by 25,000 staff at a cost of £1.5bn annually. Bed reductions The old hospital at Frenchay had 1320 beds; the new PFI hospital at Southmead, which replaced it, has 865 beds, a 35% reduction – and the community beds supposed to fill the gap are still in the planning phase. Long-term drain on budgets North Bristol will pay £50m for the new building at Southmead in 2016/17, with the cost rising each year to a peak of £92m in 2045. Marketisation of the NHS Within the NHS is an ‘internal market’ where healthcare is bought and sold by clinical commissioning groups (CCGs), the groups of GPs that commission healthcare services from providers, such as other GP practices, NHS trusts and private providers. Cuts to social care budgets More ‘bed-blocking’ Health and Social Care Act This Act means the Health Secretary is no longer responsible for the NHS, just a group of distant quangos. It also allowed NHS trusts to make up to half of their income from private patients. Hospital overcrowding The most recent data for bed occupancy shows North Bristol Trust averaging 97.3% full in August and the Bristol Royal Infirmary shows just under 96% in June. Safe levels are 85% so all patients can be given a bed during spikes in admissions. Systemic crisis In recent years the organisational landscape of the NHS has been ripped up, rebuilt and ripped up again, yet many of its long-term problems have gone unsolved. Fatigue across the system sets in after undergoing so much change while under so much pressure. Chronic underfunding The national NHS budget has increased by 0.9% each year but the cost of healthcare increases by approximately 3.5-4% per year, leaving a sustained funding gap. ‘Efficiency savings’ In the last two financial years North Bristol and University Hospitals Bristol Trusts have made £85m in efficiency savings, and there are plans for a further £34m this year. More agency staff Inability to perform ‘profitable’ procedures Trust mergers and service closures Fines and penalties Earlier this year North Bristol Trust was fined £7m by Bristol CCG for failing a series of patient treatment targets, including: £120 per person waiting in A&E longer than four hours and £300 for a referral to treatment of longer than 18 weeks. Service reorganisations First the ‘internal market’ for health, then strategic health authorities and primary care trusts were abolished to be partially resurrected as clinical commissioning groups; meanwhile NHS trusts have been converting to foundation trusts. By the time everyone has settled into one new governance system, another comes rolling along to disrupt the process again. Staffing crisis More staff are leaving the NHS and fewer people want to get into it. This leaves many NHS trusts struggling to cope with agency workers, recruitment from abroad or the blunt pressure of not having enough people to do the job. As the NHS sheds manpower and experience it struggles to keep up with its competitors. Rising drug costs More treatments available Funding crisis All these pressures start to add up, pushing NHS trusts to the brink of collapse. University Hospitals Bristol expects to make a £14m surplus only after a £13m grant from government. North Bristol’s finances are a disaster with an expected deficit of £48m. There is simply not enough money to provide the kind of healthcare we want and expect. Ageing population When the NHS was founded, only 52% of people lived to 65, but now 86% of people do. Job cuts and downbanding Less training for staff Greater need for healthcare More staff choosing to work as bank staff and locums More people leaving the NHS Yearly staff turnover at Bristol’s hospitals is 13-15%. Increased work pressure In North Bristol’s 2015 staff survey, half of employees reported suffering work related stress, a quarter said they’d experienced bullying or harassment from other staff, and 85% reported an error or near-miss in the last month. Recruitment problems for doctors and nurses University Hospitals Bristol Trust reports 439 vacancies, whereas North Bristol Trust simply records a ‘vacancy factor’ of 10.1%. Fewer people joining the NHS Cuts to student nurse bursaries

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