Pressures on the health and social care system

If a better system is thine, impart it; if not, make use of mine’ Horace

This week the College of Emergency Medicine highlighted the challenges facing emergency departments across the country with unsustainable workloads and staffing shortages. Whilst the design, funding and running of the emergency care system needs urgent attention it is also a manifestation of a health and social care system under strain and unable to cope with current and future demands. This article highlights some of the strains on the system arguing that prevention is key to delivering a more sustainable model.

Many at the moment feel overwhelmed, with increasing numbers of older patients accessing GPs and attending hospital, often presenting with increasingly high  complexity and dependency. For example, from September to December 2012, 32,000 patients waited more than four hours in A&E, an increase in 38 per cent on the previous quarter, and the highest level since 2003 (DH: Feb 2013) – a sure sign that patients are not receiving care in the right place and at the right time. Other  pressures are mounting in the system with delayed transfers of care, increased waiting times for elective care and missed targets for savings.

Many believe that the system, as currently configured is unsustainable; the current health and social care delivery system is failing to keep pace with the needs of an ageing population, changing burden of disease and rising patient and public expectations. Across the country there are significant challenges, as highlighted by the King’s Fund ‘Transforming the delivery of health and social care.’ (Ham, Dixon and Brooke, 2012), such as:

• significant differences in health outcomes among social groups which is widening not closing (Marmot, 2010);
• UK has 2nd highest rate of mortality in health care among 16 high income nations (Note and McKee 2011);
• 10,000 lives would be saved each year if England achieved cancer survival rates at the level of the European best (DH: 2011);
• 1,500 children a year might not die if UK performed as well as Sweden in treating asthma and pneumonia (Wolfe 2011);
• 3/4s of people with depression and anxiety don’t receive treatment and the extra physical health care caused by mental illness costs NHS £10bn;
• 1 in 10 hospital admission result in some form of harm (HCHC 09);
• 85% of local authorities restrict publicly funded care to substantial/critical needs (Association of Directors of Adult Social Services 2012);
• And stock for specialist housing for older people will need to grow by 40 to 70% over next 20 years (Pannel et all 2012).

In March 2013, the Lancet published a seminal report by the Institute for Health Metrics and Evaluation (IHME) on UK Health. The report ranked UK 12 out of 19 countries of similar affluence for life expectancy at birth – 68.6 healthy years of life compared to 70.9 healthy years of life in Spain (ranked first) despite the increase in funding into the NHS over the last 10 years. The report re-emphasises that the leading causes of death in the UK are stroke, chronic obstructive pulmonary disease, lung cancer and lower respiratory infections. These are all affected by smoking. In addition, there has been a startling increase in the number of people dying from Alzheimer’s disease (10th leading cause of death), cirrhosis (9th leading cause of death) and drug-use disorders (21st leading cause of death). Their has also been a rise in early deaths among adults aged between 20-54 relating to drink and drug usage and as people live longer, disability (mental, behavioral and musculoskeletal) is becoming more common.

These challenges support the need for the health and social care system to focus more on prevention and early intervention rather than treatment. The newly established Public Health England (‘PHE’) starts work on 1 April 2013 to oversee, protect and improve public health and reduce inequalities. The £5.45bn public health budget is to be discharged to local authorities, who through health and wellbeing boards will tackle public health challenges such as smoking, obesity,  drugs/alcohol, sexual health and loneliness. A new approach is needed, as jobs, homes and families matter more than the diagnosis and treatment of illness in reducing early deaths. A new innovative public health approach, coupled with changes to support people to live in their own homes for longer, increase access to services in the community, use acute hospitals/care homes appropriately and integrate care around the needs of our population will go a long way to ensuring the current system functions more effectively.

Working in the NHS, it feels that the health and social care systems, as currently configured are based on 20^th century organisational structures, practices and payment methods. They are not set up to deal with the demands placed upon it in the 21st century. At the front line, good people across health and social care are struggling to provide integrated care despite the structural inadequacies. Is it sensible to keep supporting the current model or should a new model be adopted?  We look to answer this question next week in the last article of the series.