The Federation of Enfield Residents’ & Allied Associations
Enfield Residents’ & Allied Associations

Health policy issues in Enfield

 The local situation regarding health service provision can only be really understood against the national background and some comprehension of developments in medical practices. These notes summarise the important elements.

The National scene.

Expenditure on health service provision through the NHS has risen markedly over the last 15 years, and is projected to consume 20% of the entire government budget within 5 years. Demand continues to rise inexorably across the service, under the influence of an aging population, and an enhanced ability to deliver health benefits to patients where in earlier years matters were often allowed to take their natural course. Treatment of almost all conditions to a high standard is now considered a right, but projections of current cost trends will bankrupt the system if service delivery is not reorganised more efficiently.

The NHS is facing an enormous charge to maintain an estate that it cannot afford. It needs to operate from fewer hospitals. Attempts to get surplus county hospitals closed or restructured into polyclinics or service centres have been fiercely resisted by the public in the belief, it seems, that a nearby bed will offer the optimum prospect for health and survival. But the reality is that medical skills are less effective if spread over numerous units - better that patients go to the doctors than the opposite. Slowly, services will be moved into fewer larger units and patients will have to make the longer journey for a higher standard of treatment.

 Higher levels of medical care can be delivered more efficiently when patient traffic is concentrated in fewer regional centres where doctors can develop their skills and deliver enhanced outcomes. Advances in medical practice can only be delivered through specialisation; the benefits of this approach are proven beyond doubt.  Indeed there is a general concern amongst professionals that a consultant led service can only be offered this way, day and night every day, by concentrating resources.

The level of medical expertise available within small units is and will remain constrained. The NHS cannot afford to have consultancy lead services 24/7 in every unit. Consultants are the gate minders to medical practice; they control what is on offer. In practice, junior doctors who often man local units and who have restricted license to intervene, either call for a consultant’s permission before action, or ship the patient off to a larger consultant-lead unit. At weekends this arrangement is under particular strain when the availability of consultants is most restricted. So local beds may comfort the public but the service that accompanies the beds will be restricted - a feature that too many patients either do not understand, or wish to ignore.

The NHS has always been about rationing medical care to benefit the greatest number of patients: it has never been an intensive care system for all conditions under any circumstances. Rationing is not obvious - in past years, patients have either been scheduled for delayed treatment where the condition was not life-threatening or, the condition has been monitored but not actively treated. Expensive new drugs have been denied because the money could be applied to other patients with better effect. Treatments have expanded far beyond the original emergency health service but the way the NHS performs its function now is a sub-optimal response to voters’ expectations.

Today the professions recognise that medical conditions, the ones that threaten morbidity and foreshorten life, eg hypertension, obesity, diabetes etc are better treated early, before they become very costly loads on the service. Pre-emptive diagnosis and treatment was no feature of the early NHS; now it is given more weight and current planning requires this part of the service to be delivered in the community, outside of hospitals. This is one of the prime movers behind the current service reorganisation that is devolving services into the community, bringing GP’s more into the frame, so deterring cases from reaching hospital.

Protected from the current spending cuts, service adjustments have proceeded slowly. Hospitals have not closed; surplus capacity has not been eliminated and costs have not been reduced. But at some point, services will have to be more openly restricted – a default on the “free at the point of delivery” maxim, or taxes will have to rise, because health service demand is insatiable. Restricting the service is the more likely route, limiting services that are regarded as “inessential” eg fertility treatment, but a stance that has clear political implications.

As a result of these trends the NHS which inherited over 2000 hospitals across the country when set up in 1948 now finds itself over-invested in real estate. Medical practice has moved on in the last 50 years and dwell time in hospital has been cut for many acute conditions. Fewer beds and wards are needed despite over 9 million in-patient treatments being conducted each year, the so-called “consultant episodes.”  

Mental health is now looming as the next great absorber of medical and social spending. Patients retained in expensive acute hospitals dilute the service for more immediate cases, but care in the community is hard to delivery to any quality, and residential accommodation is expensive.

The NHS is now edging its way forward to accommodating the load posed by an aging population that lives longer, especially as acute conditions are better diagnosed and treated.

The NHS reorganisation

Current developments seek to address these issues and pressures.

In simplified terms, a great deal more pre-emptive diagnosis and early treatment will be conducted in the community, lead by GP’s – mostly in their own surgeries, taking blood samples, performing minor surgery etc. This will take quite a weight off the hospitals, but is only in its infancy at this time.

GP’s who have their fingers on the pulse of local health needs are grouping together to organise and contract for medical services as GP Consortia. From April 1st 2013 they take control of a huge budget - £80 billion nationally – to contract these services. They replace the 150 or so Primary Care Trusts who hitherto controlled a huge amount of NHS resources behind the scenes allocating health budgets; they were the gateway to services for us all – GP’s could recommend treatment but the PCT’s disposed. All that bureaucratic rationing, so important to all residents but invisible to them, has gone. GP’s will assess and process patients for the most suitable treatment, either as in or out-patients. This task requires managerial skills, and already a few GP consortia have overspent and need bailing out; they will adapt.

Major hospital units will intensify their specialisations and offer extended services: this is not yet fully implemented but the benefits to patients in terms of superior outcomes are without doubt. This is the bottom line for people who need treatment, surpassing all the other political arguments that the NHS gives rise to over state ownership and control, supervision, consultative processes, and all the rest of the state accountability apparatus.

Hospital services will cluster into fewer units offering more advanced medicine and superior outcomes; GP’s will lead the way in the community to deal with ill-health pre-emptively.

Which leaves accident and emergency, and maternity – patient flows generating many hundreds of thousands of cases a year. Much A & E work can be handled by nurses, junior doctors or GPs even in the community, but the serious cases will be beyond their skills and equipment. Deciding quickly when the patient first presents how serious is the condition, is central to achieving a good outcome. Taking all patients to a local hospital or clinic, waiting for triage (checking the seriousness of the condition) costs time, resources and possibly even the patient’s life. Paramedics are now trained to make the first assessment and direct the ambulance and patient to a suitable unit. In the case of difficult conditions such as stroke, the specialist unit may be some miles away, but it is in the patient’s best interests to be handled this way.

Maternity cases resolve into straightforward births, well within the capabilities of a midwife or junior doctor, and those where the mother or child is threatened by complications – which may appear only very late in the pregnancy. Transferring the mother / child to a specialist unit late in the delivery adds risk to a successful outcome. Many complications cannot be predicted but some classes of mother have a raised chance of difficulties and should accept advice to book into a unit with intensive care facilities. If the best chance of a successful outcome is the goal, mothers might reconsider a choice of unit based on medical facilities rather than local convenience or the insubstantial gains from a “natural” birth, however defined.

All these developments militate against many smaller hospital units from whom the case work is draining away. What is their future? They will either be closed or modified to provide other services, perhaps related to long term infirmity needs, ie to meet the requirements of an ageing population.

The Enfield Scene

The Borough is dependent on two large hospitals, Barnet and North Middlesex, both newly upgraded, that lie outside the borough. Chase Farm Hospital is reducing its acute load, whilst facilities and staffing in the two main hospitals are prepared to assume core services, maternity and complex A & E. From November 2013 Chase Farm is offering daytime emergency cover for non-critical cases, and no maternity.

Chase Farm is a unit that has been in decline for over 10 years and will never attract sufficient funds to make up for lost time. Several senior politicians have promised funds but those promises have always been whittled away by the huge bureaucracy that stands behind the NHS, checking, controlling, investigating – some of it useful, but much of it supporting “jobsworths.”

Chase Farm has some more recent surgical facilities and is capable of supporting serious elective (ie planned) surgery but not cutting edge procedures – such work is more safely carried out at other units, all outside the Borough.

Emergency cover at Chase Farm is adequate for more minor cases, but serious conditions require the staff only found at a larger hospital. So ambulance staff are now trained to determine at the point of pickup whether the patient needs taking directly to a major unit – it is life threatening for such cases to be taken first to Chase Farm, only to be waved on because the patient’s needs are too complex.

Likewise maternity services, lead by midwives and junior staff, can only deal with normal cases; a fair number of mothers or babies with complications have to be moved to a major unit quickly. This exposes staff and patients to risks that could be reduced if maternity was concentrated where more intensive and experienced skill sets were immediately available. It may feel cosy to deliver a child close to home where friends and family can walk to visit the patient, but if there are problems, the place to be is in a more capable unit where specialist surgery etc is available for mother or baby. The medical profession and political representatives have not gone all out to persuade the public of these truths, perhaps fearful of a backlash and, as a result, confusion and mistrust have abounded.

FERAA’s standpoint

FERAA has studied the various plans issued in recent years to meet the needs of a fast growing borough, and observed a litany of half truths, deceitful misrepresentations, and promises that could not be kept, all seemingly to put off the day when it becomes necessary to level with the public. Health is a very emotive subject and not all our elected representatives want to face a hall full of worried constituents and patiently take them through the realities.

Our contact with those responsible for aligning health resources for the Borough confirms that the trends visible throughout the health service are no less applicable here. Concentration of resources does hold out the promise of better treatment and outcomes; FERAA maintains a close scrutiny to ensure that the promise of the current round of changes does indeed deliver. FERAA cannot just guess what number of beds or ambulances are required to deliver the service, that must be left in the hands of the clinical management, but recovery rates, safe births, etc indicate how outcomes are inmproving.

Nor can FERAA champion a major investment into Chase Farm Hospital just to retain a unit within our boundaries. Such funds would be at the expense of a higher service delivery through the two allocated neighbouring hospitals, and definitely not be in the interests of Enfield residents; asserting to the contrary has no factual foundation.

But FERAA is acutely aware of the shortcomings in primary care across the Borough, especially the east, where health services and outcomes are notably weaker. FERAA urges resources to rectify this injustice, and knows that the GP Commissioning group has it at the top of its priorities list. We will watch closely for results.

Enfield is not immune to the demands raised by the rising number of older residents; in health terms it is the elephant in the room. FERAA has noted how the authorities are paying more attention to this sector and laying longer term plans to meet the need, especially for those with mental conditions.

Enfield set up Healthwatch in 2013, a supervisory organisation to pull together and oversee the provision of all aspects of health services across the Borough. It answers to a national Healthwatch body. Enfield Healthwatch also answers and consults with the Healthwatch Reference Group, a body of volunteer groupings representative of the community: FERAA occupies one of the seats and has an overview of how supply is being managed against demand. This is a first, and represents a level of oversight not afforded the public in earlier years where health provision was seen as far beyond the comprehension of the public!

FERAA will report back through its representative residents associations on what it discovers.