Doctors say burden unsustainable as people in 40s lead surge in admissions, adding they risk cancer as result of drinking habits
More than half a million people have been hospitalised in the past three years because of drink or drugs, with those in their 40s behind a surge in cases that is putting a strain on the NHS, official figures reveal.
A total of 533,302 people in England have been admitted to hospital as an emergency since 2010 with serious health problems related to their consumption of alcohol or illicit substances. The vast majority were admissions for conditions specifically related to alcohol abuse, such as liver problems. Of those, 60,738 were aged 40 to 44 and another 60,083 were 45 to 49 – together, more than a fifth of the total. Some were admitted a number of times between 2010 and 2013.
The growing numbers have prompted warnings that a generation of the early middle-aged are risking cancer and other potentially fatal health problems as a result of their drinking habits.
According to hospital admissions data published by health performance experts Dr Foster in their latest annual Hospital Guide, problems related to alcohol and drugs now cost the NHS £607m a year. The cost of treating those kept in for at least one night owing to long-term alcohol misuse dwarfs the £22m a year the NHS spends on those admitted after binge drinking.
The stark differential prompted one senior NHS executive to describe as a myth the popular notion that binge drinking, epitomised by teenagers and hen and stag party revellers, is the main problem for the NHS.
Doctors called for a renewed focus on drinking among the middle-aged and for ministers and the NHS to take tough action to tackle a significant cause of illness and pressure on hospital beds.
Almost one in five fortysomethings admitted to hospital for any reason in 2012-13 were classed by the NHS as "emergency admissions due to a known drug/alcohol issue".
Matt Tee, chief operating officer of the NHS Confederation, which represents hospitals, said the less visible problem of middle-aged excessive drinking produced more harm than those who drink a lot at one time. "It's all too easy to dupe ourselves that binge-drinking teenagers or stag and hen parties in their 20s are the cause of alcohol-related pressures on the health service. Today's news puts this myth firmly back in its place and makes it even more important that as a society we seriously examine the impact our drinking habits have on our health – and on our health service."
The figures also show high rates of admission for drink or drugs among 30 to 34-year-olds (15% of admissions were drink or drug-related), those aged 35 to 39 (18%) and 50 to 54-year-olds, where the rate was 16%. Among the total admissions for drink and drug-related problems over the three-year period, 24,101 were 15 to 19-year-olds and another 3,013 were as young as 10 to 14.
The figures show problem drinking across socioeconomic groups. Of the admissions, 45,957 (8.6%) were from the wealthiest 20% of the population and another 61,672 (11.6%) were from the next most well-off 20%. However, the poorest were disproportionately represented, with 192,014 (36%) from the most deprived income group.
There is no comparative data, as this is the first time the figures have been compiled in this way.
Doctors' leaders and NHS bosses warned that alcohol's burden on the NHS was unsustainable. "It is vital that we take more action to tackle the impact of excessive alcohol consumption on the UK's population and the NHS," said a spokesman for the British Medical Association. "As the Dr Foster research highlights, this is a problem that affects large numbers of people across all age groups and as a result places serious strain on a number of already overstretched NHS services.
"We cannot afford to keep spending millions of pounds in today's economic climate on mopping up the after-effects of an alcohol problem that the government should tackle with a greater emphasis on preventive measures."
The BMA urged ministers to embrace "a comprehensive system of minimum unit pricing for alcohol, that has already been taken forward in Scotland, and improved labelling on alcohol products so that consumers understand the damage that might result from excessive consumption", as well as a crackdown on "irresponsible marketing practices".
Dr Martin McShane, NHS England's director for patients with long-term conditions, said the rate of admissions and high number of fortysomethings represented a "deeply worrying trend that we should all take heed of. Every day in the NHS we see the impact of excessive alcohol consumption. The figures clearly reflect what we see coming through the doors of our GP services and hospitals. It is so important people think about their alcohol intake – not just during the runup to Christmas but at all times of the year.
"We are the NHS. We are here to help anybody who comes through the door. But excessive consumption of alcohol does hit the public purse hard, there is no question about that."
As with many health problems, the figures show a sharp north-south divide in the proportion of patients admitted because drink or drugs. The areas with the lowest rates were Essex (10%), Thames Valley (11%) and Hertfordshire and the South Midlands (also 11%), while those with the highest rates were Merseyside (21%), Greater Manchester (18%) and Durham, Darlington and Tees (also 18%).
A Department of Health spokesman said: "We are helping the NHS target harmful drinkers with measures such as increasing the use of interventions by health professionals, and introducing alcohol liaison nurses in A&E. However, there must also be more focus on prevention, not just treatment, for those with existing problems. That is why alcohol is addressed by GPs as part of the NHS health check."
He added: "We are also working to both reduce harmful drug and alcohol use and to increase the numbers recovering from their dependence. Our focus is on combining health and social policies to help people affected access services, rebuild their lives and play a full part in society."Denis Campbell
Former home secretary attacks plans to shift funding away from industrialised northern areas to more prosperous southern districts with higher proportions of pensioners
Former home secretary David Blunkett has accused the government of "sleepwalking into the most gross act of injustice" over plans to switch a greater proportion of NHS funding from deprived to more prosperous areas.
Blunkett suggests the scheme being considered by NHS England, which would see more funds diverted to areas with higher numbers of elderly people, is a crude ploy to help Tory areas before the 2015 general election.
He says the move would exacerbate the north-south divide by taking money away from industrialised areas in which people have suffered "grievously" from the nature of their work and the resulting health hazards they have faced.
Ministers insist that the decisions on future funding formulas – how NHS money is distributed according to a range of criteria such as deprivation, age and gender – have been handed over to the non-departmental body NHS England and that it will make the final judgment on proposed changes.
Health minister Dan Poulter told the Commons recently that he would "find it strange" if issues of deprivation did not remain central to those decisions.
But Labour MPs, particularly in northern constituencies, are concerned that their areas are set to lose out while more prosperous and in many cases southern areas will gain. They are furious at suggestions that there will be no weighting for levels of deprivation, or places which have poor health outcomes.
If the changes go ahead, the amount of funding for Sunderland would fall by £146 per person while in south-east Hampshire, where life expectancy is 10 years longer, it would increase by £164 per person.
Blunkett, the Labour MP for Sheffield Brightside and Hillsborough, writes: "While South Yorkshire and Bassetlaw would need to reduce spend by £149m, Thames Valley would see a growth in allocation of £148m.
"We are, in short, sleepwalking into the most gross act of injustice and reinforcement of inequality in recent times." He says the coalition government is "about to take away tens of millions of pounds from areas currently struggling to make ends meet and to overcome historic disadvantage.
"This money will go into areas where, yes, there are more people who are retired but there are very many more people who are retired comfortably."
Blunkett adds that "it can only be presumed that those advising David Cameron and Jeremy Hunt [the health secretary] have calculated the political gain in key constituencies in May 2015 at the general election."
Read David Blunkett's piece at theguardian.comToby Helm
Basing NHS funding on numbers of old people, rather than their wealth, is the least debated active injustice
It will probably have come as a considerable surprise to some of those in retirement in my constituency to learn that national statistics show that while there has been a 6.5% drop in living standards for those in work, there's been an uplift for those who have put their working life behind them.
For a constituency such as mine, the income of those in retirement as well as those in work on low earnings is eye-wateringly different from areas in the south. This is precisely why we need a public debate before the government goes snap on their current proposal to switch NHS funding from some of the most deprived communities to some of the wealthiest areas purely on the basis that they have, in those areas, more people over the age of 65.
There is already a debate about whether the winter fuel allowance of up to £300 (£200 for most households) is fair. My belief is that it should be rolled into taxation, so that it is assumed that individuals over retirement age have received it and then placed against the main taxpayers' liability. But when it comes to health spending, there are some very big challenges.
It is certainly true that as we grow older our need for healthcare also grows. It is also true that those who have lived their lives in the most difficult circumstances and experienced the most exhausting and challenging work places need healthcare the most. Simple numbers of people of a particular age tell us nothing about the condition of their health, the environment in which they live and the support systems they can afford to pay for.
Those in our most heavily industrialised areas have suffered grievously not just from the nature of the job they undertook, but also of the health hazards that they faced. The longevity statistics bear this out starkly. For instance, you are, as a woman, likely to live to 87 in east Dorset but just to 79 in Manchester. For men, it's even worse – for that same coastal area of the south the male life expectancy is 83, but just 74 in Blackpool.
The question on this funding change is: why? A question that seems to be passing the politicians (and, sadly, officials in NHS England and the like) rapidly by!
Is it that they are under direct instructions from their Conservative masters (sadly with the collusion of Norman Lamb, the Lib Dem junior health minister) to redistribute money not on the basis of need but on the basis of numbers?
Take just a couple of examples of the funding switch, which has been put out to consultation. As Nick Brown MP pointed out in the House of Commons earlier in the autumn, the Department of Health is now consulting on taking £230m out of the budget for the north east and Cumbria. Draft figures suggest Yorkshire would lose £416m and the north of England as a whole would lose £722m.
There are stark variations. While South Yorkshire and Bassetlaw would need to reduce spend by £149m, Thames Valley would see a growth in allocation of £148m.
We are, in short, sleepwalking into the most gross act of injustice and reinforcement of inequality in recent times. It makes the suppression of the Black report on health inequalities by Margaret Thatcher's government in the early 1980s seem positively benign. For this coalition government is about to take away tens of millions of pounds from areas currently struggling to make ends meet and to overcome historic disadvantage. This money will go into areas where yes, there are more people who are retired, but there are very many more people who are retired comfortably. They have support systems, with the income to buy in the kind of help that keeps you active, interested and alive. The statistics prove it.
In our guts, we all know it, but it is the least debated and understated pending active injustice of all the injustices of the last few years.
This further dislocation to planned spending comes on the back of the most disruptive restructuring of the health service in recent times – £2.7bn spent on revamping the layers of health management and a whole range of quangos including the largest – NHS England – as well as Health Education England and the Health Research Authority.
All of this at a time when the NHS is under the most enormous pressures and when every penny counts. Taking away from Peter to pay Paul, especially when it transfers from the less well off to the better off, cannot be justified at the best of times – but should be unthinkable in the present period of austerity.
Given that this is also mirrored by the switch of resources away from the most deprived communities in eye-watering reductions in government grants to local authorities for essential public services, and the picture is extremely bleak.
Exacerbating the north-south divide is the exact opposite of One Nation politics, but it can only be presumed that those advising David Cameron and Jeremy Hunt have calculated the political gain in key constituencies in May 2015 at the general election.
David Blunkett is the Labour MP for Sheffield, Brightside and HillsboroughDavid Blunkett
Figures from 4,000 GP practices in England show only a minority of patients are fast-tracked for investigation by specialist
Thousands of people diagnosed with cancer may be being failed by GPs who are not referring them to specialists quickly enough, contravening official targets.
The figures from around 4,000 GP practices in England show that, in many cases, only a minority of patients are fast-tracked for investigation by a specialist.
Although NHS targets stipulate 95% of patients with suspected cancer referred by their GP must be seen by a specialist within two weeks, data from NHS England says many are not seen on this basis and are eventually diagnosed another way.
In some practices, only around one in 10 patients eventually diagnosed with the disease saw a specialist within two weeks.
Mike Bewick, deputy medical director at NHS England, said the level of variation between practices is too wide, adding: "When people go to their GP with red flag symptoms such as coughing up blood or changes in their bowel you would expect those patients to be picked up."
"But just imagine the scenario when you have an elderly patient with many symptoms and the one they are most worried about is not the red flag.
"It's often due to complexity rather than mistake."
While some GP practices show 100% of patients with cancer making it through the fast-track system, others fall far behind.
In about half of the practices in the sample, fewer than 50% of cancer patients were seen through the two-week system.
Not all patients with cancer visit their GP with symptoms.
Some are diagnosed in A&E, while others have cancer detected during routine tests, or are referred straight to A&E by their GPs because symptoms are so bad.
The health secretary, Jeremy Hunt, said: "Every single patient in the NHS has a right to the very best care – and to see a GP who can spot cancer symptoms early enough to make a difference.
"That's why we've introduced a rigorous new inspection regime for GP surgeries to tackle this unacceptable variation across the country.
"The new chief inspector will speak up for patients without fear or favour, rating each surgery so we can celebrate the best practices and take tough action where standards aren't up to scratch.
"GP surgeries are the bedrock of our NHS, providing vital long-term care for some of our most vulnerable and elderly citizens. I am determined that patients who rely on them get the excellent service they deserve every time."
Stuart Barber, head of communications and campaigns at Beating Bowel Cancer, said: "GPs have the tools. There are clear symptoms, there is a clear screening programme and if a patient visits their doctor with what are symptoms of bowel cancer they should have the confidence they are going to be referred quickly.
"It's intolerable that patients are having to wait. We know of cases where patients have gone multiple times backwards and forwards to their GP with what they think are bowel cancer symptoms. The symptoms get worse and worse and worse and it does turn out to be cancer.
"We know of patients who have seen their GP two or three times over a period of a year, year and a half.
"Some patients are being told it's IBS (irritable bowel syndrome) or another condition."
A report last year by the Welsh government found the NHS is failing to meet the target stating that at least 95%of patients should start cancer treatment within 62 days of being referred by their GPs.
It found that the 95% figure had not been met at an all-Wales level since 2008.Ben Quinn
Annual report finds NHS record on mortality has improved, with four fewer trusts reporting high death rates than last year
Do you have a question about the findings of Dr Foster's annual report on the NHS? Join our live discussion with health experts here
Sixteen hospital trusts in England have higher numbers of patients dying than they should have, according to an authoritative annual guide to NHS performance.
All 16 had a higher-than-expected mortality rate in 2012-13 according to the Hospital Standardised Mortality Ratio (HSMR), which records the number of patients who die while still in hospital, according to the report from Dr Foster Intelligence, which analyses the performance of the NHS.
But overall the picture is improving. The 16 trusts with high death rates are four fewer than last year, while 28 trusts had lower-than-expected mortality rates, up from 25 last year. And hospital mortality has fallen by 30% over the past decade.
"These findings reveal overall that while the number of people who are dying in hospital has risen slightly since last year, it is still a much more improved picture than in the 10 years previously," said Roger Taylor, Dr Foster's director of research.
Of the 16 trusts with high mortality, 13 also emerged from Dr Foster's analysis as having higher-than-usual mortality according to at least two of the healthcare information firm's seven ways of measuring death rates. Only five of the 13 were among the 14 trusts that inspection teams led by Prof Sir Bruce Keogh, NHS England's medical director, investigated earlier this year, 11 of which were later put into "special measures" by NHS regulators to improve their performance.
Those five are: Blackpool teaching hospitals NHS foundation trust; Medway NHS foundation trust; North Cumbria university hospitals NHS trust; Northern Lincolnshire and Goole hospitals NHS foundation trust; and United Lincolnshire hospitals NHS trust. All of them except for the Blackpool trust were placed into special measures.
The 13 emerged as having high death rates on at least two of four measurements, including HSMR, deaths in low-risk conditions, deaths after surgery and site-based HSMR. Three trusts were rated as high for deaths in low-risk conditions, five for deaths after surgery and 10 for site-based HSMR.
In all 237,100 patients died in hospital last year, 4,400 more than in 2011-12. However, the figure was 5,300 lower than in 2010-11 and the second lowest total recorded in the last decade.
The disclosures come after months of focus on and action to tackle hospital death rates, inadequate care and lapses in patient safety triggered by the publication in February of Robert Francis QC's report into the Mid Staffordshire hospital trust care scandal.
Keogh stressed that mortality among hospital patients had improved significantly in recent years. "We have fewer hospital mortality outliers than before. In fact hospital mortality in general has fallen by 30% over the last decade," he said.
"We have had a real focus on mortality over the past year and this report highlights some encouraging signs of improvement. But there is no room for complacency. The provision of safe care must be our number-one priority," added Keogh.Denis Campbell
Amanda Doyle works in Blackpool and is determined to help a community with some of the UK's worst health problems
Describe your role in one sentence: Half the week I am a GP in one of the most deprived parts of Blackpool; the rest of the time I am chief clinical officer for Blackpool clinical commissioning group (CCG), and I'm also co-chair of the NHS clinical commissioners leadership group.
Why did you want to work in healthcare? I always wanted to be a GP but what I find exciting now is being able to make a difference to the healthcare of a large population as well as to individual patients.
How do you want to see the sector change in the next five years? I would like to see clinical commissioning develop so that patients really see the benefits of frontline clinicians having a greater influence over the healthcare we deliver.
My proudest achievement at work was ... getting the full support of Blackpool GPs to lead the clinical commissioning group on their behalf.
The most difficult thing I've dealt with at work is ... continually balancing the demands of a busy GP practice with my role as a commissioner and, as I have four children, I face the usual problems working mothers have trying to get to their matches, school events and things.
The biggest challenge facing the NHS is ... restoring public confidence following the recent battering the health service has endured and reassuring patients that we can deliver high-quality care, albeit within resources available.
The people I work with are ... fantastic. There's a real commitment from GPs and managers in Blackpool to make a difference to a community that has some of the worst health problems in the country.
I do what I do because ... I hate the fact that people in Blackpool have shorter, less healthy lives than anywhere else in the country and I really want to be a part of changing that.
Sometimes people think that I ... must be mad.
Right now I want to ... stay positive. I want Blackpool to be a great place to live, as well as a great place to visit.
At work I am always learning that ... there are nowhere near enough hours in the day.
The one thing always on my mind at work is ... making sure the services I'm commissioning are the sort of services I'd want for me and my family.
If I could go back 10 years and meet my former self I'd tell them ... don't eat cake!
If I could meet my future self I'd expect them to be ... proud of all that has been achieved but still excited by the job.
What is the best part of your job? Being lucky enough to mix a senior commissioning role with still being able to see patients every week.
What is the worst part of your job? Not having enough time to do all the things I'd like to do.
What makes you smile? My four boys.
What keeps you awake at night? Nothing!
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As more staff have access to digital records, health boards must have measures in place to reassure patients
The shift from paper documents to electronic medical records means that more healthcare staff than ever before have simultaneous access to confidential and highly sensitive patient information.
The benefits of better data are clear and NHS Lothian will not place unnecessary restrictions on clinical staff who need to access critical information to save lives and to respond to the needs of the 800,000-strong patient population.
But the public are understandably growing concerned about how we share their information and control access to it. Health boards must have measures in place to reassure patients and to ensure access to their data is not misused.
Automated privacy monitoring: reducing suspected breaches
With this in mind NHS Lothian has become the first of 14 health boards in Scotland to bring in automated privacy monitoring. We can now stop suspected breaches in their tracks before they can escalate into serious incidents. And better internal intelligence has allowed us to address staff awareness and cultural issues head on.
The health board previously conducted retrospective and resource intensive investigations into suspected breaches. We used audit data to carry out random spot checks on information viewed by particular staff groups or departments. We would also respond to complaints when a patient was concerned that someone had gained access to information they should not have through our systems. But we had no way of easily running algorithms across different data sources to pull together a comprehensive picture of potential breaches.
Now through automated privacy monitoring we are able to use algorithms to proactively trace potential improper accesses. We can process very large amounts of data from multiple systems in just a few hours each month and very quickly flag up what needs to be investigated further.
Opportunities to misuse access to patient data and the temptation to peer into personal information have the potential to grow as electronic records are shared more widely within health boards. But NHS Lothian can now identify patterns that highlight when staff may be looking at the records of colleagues, family members, neighbours along with other inappropriate accesses.
In essence, NHS Lothian can now monitor whether access to records is potentially being abused. And we have already significantly reduced the number of suspected breaches.
The human element and senior management support
Technology alone is not the answer. Preventing inappropriate access to medical records is a human issue and key to achieving safety for patient information has been senior level buy-in.
We established a steering group with NHS Lothian's Caldicott Guardian, senior human resources staff, members of the information governance team and union representatives so that we could agree a consistent approach for dealing with suspected breaches and the people involved.
Without this broad senior support, there was a risk that potential disciplinary action taken against staff on the back of our intelligence could have been inconsistent. Now when we identify suspected breaches through our automated monitoring system we can be sure that line managers and HR teams will investigate correctly and consistently.
Effective intelligence has allowed us to issue warnings to staff who have breached policy. And a large-scale communications campaign has been targeted at all staff to remind them of their obligations. Every individual has been written to as part of this campaign, messages have been placed in payslips, data protection slides are included on clinical application training courses and annual roadshows are being delivered to larger sites.
Ignorance of the rules has been an excuse used by some people in the past. But now there is no excuse for committing a privacy breach.
Every health board in Scotland is now set to implement automated privacy monitoring. At NHS Lothian the biggest benefit has been for our patients. We can now reassure them that we are protecting their information by ensuring that only people who need to access their information are doing so correctly and appropriately. As data is shared more and more throughout NHS organisations this is something that every health board and trust should consider.
Alistair McLeod is clinical application and integration manager at NHS Lothian
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Knee and hip replacement operations and cataract removals fall to lowest level for five years as patients left longer in pain.
Do you have a question about the findings of Dr Foster's annual report on the NHS? Join our live discussion with health experts here
Patients are being denied knee replacements and cataract removals as the NHS struggles to meet its £20bn savings target, official data has revealed.
The number of those operations, as well as hip replacements, has fallen to its lowest level for five years, despite England's elderly population – which has most need for those procedures – having risen over the same period.
Surgeons, charities and Labour claimed declining access to three of the most common surgical procedures was leaving patients in pain and discomfort and was evidence of a widening "postcode lottery" in the availability of treatment.
NHS data contained in the healthcare information firm Dr Foster's annual Hospital Guide, published Friday, shows that 24% of England's population, more than 12 million people, live in an area where the number of these hip, knee and eye operations fell between 2009-10 and 2012-13.
While the number of those procedures overall rose 0.1% over that time, cataract removals fell from 327,210 in 2010-11 to 321,957 last year. Similarly, the number of people receiving a new knee, because of arthritis or a break, fell slightly, from 82,122 in 2011-12 to 81,572 last year. Hip replacements have been growing at only 2% a year since 2008, compared with 6% a year between 2002 and 2008, though have fallen in some places.
"It is scandalous that some commissioners continue to restrict access to cataract surgery through the use of arbitrary thresholds, and that they do so without a robust evidence base and without being able to demonstrate that they will not harm patients," said Steve Winyard, head of campaigns at the charity RNIB.
Denying people with sight problems corrective surgery leaves them at risk of depression, social isolation and breaking their hip, he added.
Colin Howie, vice-president of the British Orthopaedic Association, which represents orthopaedic surgeons, said NHS organisations which restricted access to hip and knee replacements were denying needy patients the chance to regain their mobility. "It's disappointing that the health service is failing to provide treatments of proven benefit to patients that make a substantial and real improvement in their lives," said Howie. Evidence shows such operations ultimately save the country money because they leave patients needing less pain relief, he added.
The charity Age UK said the Dr Foster figures showed that NHS organisations were guilty of "ageism" in deciding who deserved which treatments. "It is distressing that ageism remains deeply rooted in the way older people are treated by the NHS, despite being outlawed by legislation," said Caroline Abrahams, its charity director. "Too often decisions are made on age alone with informal 'cut-offs' imposed on whole services … with little regard for the impact on older people."
People denied procedures "will be condemned to live life with serious disabilities or illnesses, putting additional and unnecessary pressure on social care services and carers, that could be effectively managed or treated by access to the right care at the right time", Abrahams added.
The cuts come as the NHS has been trying to make £20bn of "efficiency savings" by 2015 at a time of rising demand for its services. The guide shows that the service has been achieving some of that target by clamping down on procedures of "limited clinical effectiveness", such as "knee washes". They have fallen by 8% since 2008, while there has also been 7% fewer operations where alternative treatments may be more effective.
Some places, such as Wigan, west London and east Leicestershire, have managed the NHS's financial squeeze well, maintaining hip, knee and eye operations while reducing operations of little value, Dr Foster said.
But it also found that the NHS is wasting money because it has failed to reduce the number of patients ending up being admitted avoidably to hospital. Despite many edicts from ministers and service bosses to do so they rose by 8% between 2009-10 and 2012-13, partly because patients were not managed properly by their GPs and community services.
NHS organisations in Croydon and West Cheshire have used their resources poorly by increasing spending on less effective treatments and avoidable emergency hospital admissions, the guide adds. Croydon clinical commissioning group (CCG) said the trends occurred under its predecessor, the local primary care trust, which it succeeded in April and it was pursuing a different approach.
Sir Bruce Keogh, NHS England's medical director, said the service was coping well with financial pressures and that in general CCGs were spending more money on operations of proven benefit and less on others backed by little evidence.
"While the data raises important questions, we should be wary of leaping to the answers. Cataracts, knees and hip replacements are generally 'good' but it is still the case that they can be overused. We do a very significant number of these operations all over the country and it should not be taken as a given that this figure should automatically increase. It may reflect readjustment in line with modern clinical practice," Keogh said.
Shadow health secretary Andy Burnham said: "It is simply wrong for thousands of older people to be denied the hip, knee and cataract operations they desperately need because of arbitrary, cost-based restrictions." "Ministers promised to stop cost-based rationing of care in the NHS. Their failure to keep this promise has left older people facing the agonising choice of struggling on or paying to go private", he said.
• This article was amended on 6 December 2013. An earlier version referred to NHS organisations in Croydon and East, rather than West, Cheshire.Denis Campbell
At Liverpool women's hospital the rising birthrate and understaffing are putting ever more pressure on NHS workers
"It gets a bit stretched," says Dr Joanne Topping. As a description of the growing pressures the consultant obstetrician and her colleagues in the maternity unit at Liverpool women's hospital are under, that turns out to be a notable understatement. A 25% leap in the number of babies born over the past decade, the highest birthrate in 40 years, the increasing challenge posed by medical problems in pregnant women such as obesity, and ongoing understaffing mean that NHS maternity units are struggling to deliver the ideal birth experience that all mothers-to-be are seeking at such a joyous, though also often stressful, time.
LWH, or "the Women's" as locals call it, delivers more babies than anywhere else in Europe; about 8,500 a year, which is almost one an hour, every day of the year. One of only two hospitals in England that specialise in looking after women and their babies, it has a great reputation on Merseyside and is popular and respected after delivering generations of Liverpudlians' offspring. Scores of thank-you cards adorn its lilac and blue-grey walls. "Thank you so much for delivering our beautiful baby girl. Sorry for shouting at you," reads one.
But, like every other maternity unit, it is increasingly hard-pushed to cope with the rising numbers of women needing care before, during and after giving birth. It gave the Guardian access during a typical Monday to see how it is doing. Tellingly, in the past 15 months the sheer demand for its services has forced it to temporarily close its doors on three occasions, for six to 12 hours at a time, for the first time in its history.
This forced women who were ready to give birth there to go elsewhere. "On some days, we just didn't have anywhere to put people – some of that was due to the complexity of the cases we already had and some of it was due to staffing," recalls Topping. "We had enough capacity for the women that were in, but if we had admitted more women at that stage we wouldn't have been able to care for them. It's the first time it's happened in this unit, but it's not unusual for us to receive phonecalls from nearby places such as Warrington, Whiston and Ormskirk saying they're closed due to capacity issues. They advise their women to come to us instead," she adds.
As with almost every NHS maternity unit, LWH does not always have enough staff on duty. Inevitably, there are consequences. When Care Quality Commission inspectors made an unannounced visit in July, the feedback from most mothers and their relatives was "very positive", they found. "People described the care and treatment they had received as 'excellent' [and] 'brilliant' and they described staff as 'amazing' and 'approachable'. People felt safe and confident in the ability and experience of the staff supporting them," their report said. Mothers had both good experiences and good outcomes, the CQC added.
But "people did also tell us they felt the staff were 'too busy' and 'very busy' and felt this prevented them from asking for too much support." This is typical of more and more of the CQC's reports on hospitals generally. Patients say most staff are very good most of the time, but see them often being close to run off their feet and do not blame them for care sometimes being less than ideal.
Understaffing, which is closely linked to the NHS's £20bn efficiency drive, is a problem across the service. At LWH, inspectors found there were too few doctors, midwives and healthcare assistants. Some women had to wait hours for pain relief, or did not have their call bell answered immediately or did not bother visibly busy staff to help them breastfeed. David Cameron's pledges to give the NHS 5,000 more midwives and protect the service's fabled frontline ring hollow at LWH.
"The doctor looking after me keeps getting taken away because there's an emergency or someone else needs her more," one woman told the CQC. Interestingly, staff shared the patients' concerns. "Emotional care and support" for women suffered, they said. "Staff reported a couple of shifts recently when one corridor of single rooms accommodating up to 17 women and babies had been staffed by only one healthcare assistant," the CQC said. Sometimes, mothers spending their first few hours with their newborn have to be moved elsewhere because the sheer number of births means their room is needed for a woman in labour. "They end up being looked after by a different midwife, which disrupts their continuity of care. That's not ideal for anyone and can lead to a poor patient experience, but is probably unavoidable," says Topping, who is also the hospital's overall clinical director for maternity care.
LWH has to save £4m this year, despite the baby boom increasing its workload. "A unit this size should have a consultant present 24/7. At the moment we usually have that for 14 or 15 hours a day. Our aim is 24/7, but that would need us to have four more consultants, which would cost £400,000. Given our £4m cost-saving target, realistically we aren't going to get those consultants," says Topping. The recruitment of 20 extra midwives since the CQC visit has helped, though.
During the Guardian's visit, staff delivered 26 babies during a typically busy day. In the privacy of their own room, Rachael and Andy Birley are a picture of contentment as they cuddle their new daughter, Lauren, who arrived at 10.47, weighing 3.7kg. She coos happily, like a purring cat. They have had a positive and euphoric experience, especially compared with the arrival 22 months ago of William, their first child. "My labour with Lauren was eight and a half hours, whereas it was three and a half days with William, and then I was in for three days after that as he wouldn't feed initially," explains Rachael.
"With William, it got complicated and multiple people just poured into the room, consultants and midwives, about 12 of them. A decision was taken to get him out and he ended up being a forceps delivery. But today it was just one midwife and a student doctor, which made it a lot less stressful," says Rachael. Both are full of praise for their midwife, Paula Cato. "She was with me all the way through and was great. She was calm and she kept me calm. I wasn't left alone for any length of time," adds the 34-year-old.
Her only disappointments were having to stop using an exercise ball because it was slowing down her contractions, and not getting the water birth she wanted in one of the unit's two pools. "I was told that would be dangerous because I had had diamorphine for pain relief and that could have made me sleepy in the water." Andy, a 36-year-old financial adviser, says: "I buzzed a few times because Rachael was getting distressed and they came straight in." The couple say are very happy with their care.
Childbirth is routine – about 800,000 women a year give birth in the UK – but is also unpredictable. While many births occur in hospital, at home or in a doctor-free midwife-led unit (MLU) for low-risk pregnancies – 2,500 of LWH's 8,500 annual births come in its MLU – more and more arrivals are proving complicated and potentially risky. Most women want a straightforward, natural birth. But almost one in three end up having their baby with the help of some form of medical intervention. Of the 26 babies born that day at LWH, 17 were girls and nine were boys. Three arrived overnight, the first at 01.15, and the last at 23.38. But just 13 of the 26 mothers had a normal vaginal birth. Of the other 13, three needed an emergency caesarean section and five had a planned C-section, while four babies were delivered using forceps and one using ventouse, a sort of suction cup.
Three involved serious complications. One woman suffered from placenta praevia, in which the placenta came down before the baby, completely covering the cervix. That can trigger what is known as "torrential haemorrhage", severe bleeding, in the woman during labour, which can put her life in danger. In this case, the woman had a spinal anaesthetic, then a planned C-section at 10.59 to get her baby out safely. Her condition, detected in pregnancy, made that unavoidable. She did suffer a haemorrhage, losing 1.25l of blood in the process; about two and a half pints, much more than the 300-500mls a woman usually loses while giving birth. Luckily for her, LWH is one of the few places with a cell-saver machine available 24/7, which collected and "washed" her lost blood so it could be given back to her, meaning she did not need any from a donor.
Mid-afternoon, another woman had an emergency C-section for "deep transverse arrest": she had reached the second stage of labour but her child came down the birth canal in the wrong position, with its head rotated about 45 degrees, making a normal delivery very difficult. The mother lost 800mls of blood. And at 20.45, staff performed a rotational forceps delivery to rotate a baby's head into the right position to allow it to be helped down the birth canal and born vaginally – the entire labour took 16 hours.
Cathy Atherton, the LWH's head of midwifery, cites many reasons beyond the baby boom and understaffing for the growing pressures they are under. They include the growing numbers of mothers who are obese, or have another underlying medical condition, or mental health problems, or are older – being over 35, especially over 40, involves extra risk – or who do not speak English. All these require more resources and more of the staff's time.
These days, LWH provides services that did not exist a few years ago, such as antenatal clinics with translators and female-only doctors for the growing number of women from China, eastern Europe and African countries such as Somalia, as well as a dedicated perinatal mental health service, where psychiatrists and community psychiatric nurses, as well as midwives and obstetricians, provide help, advice and treatment. There is also a pre-term labour clinic for women who have previously gone into labour prematurely and tests for those with severe hypertension in pregnancy, as they could develop into pre-eclampsia, which can lead to the woman suffering a fit and losing her baby, explains Atherton.
In LWH's neonatal unit, Candace Knight is adjusting to life with a very premature baby. Her son, Amadi, was born after just 25 weeks and three days of pregnancy, though tests have not identified why. He weighed just 845g, though has since grown to 995g. His first kilo is in sight. His birth illustrates a quiet scandal of maternity care: the national shortage of cots – incubators – for those born worryingly early.
Knight, a 23-year-old deputy manager for the bookmakers William Hill, lives in Birmingham. But when it became obvious at 24 weeks and three days that her baby's birth was imminent, Birmingham women's hospital did not have a cot available. LWH did, though, prompting a four-hour trip for Knight in an ambulance up the M6 in terrible traffic.
Home for Amadi now is an incubator at LWH, not a moses basket or his mother's arms. After an initial burst of breathing for himself, he is now on a ventilator. Knight has just moved into a flat provided by LWH and spends about 14 hours a day beside her son, as well as visiting him about 4am or 5am every day, touching him occasionally through doors that look like portholes.
Infection control at this stage is vital. "I still express milk every couple of hours, change his nappy, wipe his face and put talcum powder under his arms. "I can hold him, but only when he's well enough and there's a nurse around. He's getting tiny bits of my milk, he's on a fluid drip for nutrition and they say it'll be weeks rather than days before he's off the ventilator. Even now there's still a 40% chance he could die," explains Knight matter of factly. She is delighted with the care Amadi is receiving.
Women's greater expectations of how their birth should be have added to the pressures, as have the choice of place of birth that successive governments have promised mothers, such as the right to have a baby at home, in an MLU or in a consultant-led obstetric unit. The pressure on resources makes such choices impossible to realise for some women. Expectant mothers are also more savvy, and know they can have a range of types of pain relief if they ask.
On top of this, rising maternal obesity "is a major factor", says Topping. "If you have 20cm of fat on you rather than 5cm, that can make it harder to give you your 12- and 20-week scans and means you are at greater risk of developing gestational diabetes and also of having a stillbirth or C-section or being induced."
The number of women like that has "almost doubled" in Topping's 15 years as a consultant, she reckons. "These women need more tests, more clinicians' time, more monitoring, more medication and more intervention. Obesity is one of the things that make the job more challenging these days." But, as a recent National Audit Office report showed, the money going into maternity care – now £2.6bn a year in England – has not kept up with rising demand and growing complexity.
The trend towards older motherhood is less of a burden than reports have suggested, the obstetrician thinks. But women giving birth for the first time over the age of 35, and especially once they are 40 or above, or giving birth again after a long gap, perhaps because they have remarried, represent "a big societal shift and new dynamic that's not previously been there". Such women may be at greater risk of having a baby with a chromosomal disorder, such as Down's syndrome, or needing or wanting a C-section. People's desire to exercise choice means the government's target of reducing C-sections from 25% to 20% of all births is unattainable, Topping believes.
"Midwifery is as caring and compassionate as ever. But it's more difficult than it used to be. The birthrate means the demands are now very, very high, we get short-staffed and it's getting harder to give every woman the time they want or need when we are so busy," says Sarah McGrath, a midwife for 24 years. The round-the-clock nature of childbirth means the reception desk for the maternal assessment unit, where women who are anxious about their pregnancy can come, is now staffed 24 hours a day. LWH's telephone triage service, which pregnant women who are anxious because they have experienced some bleeding or have not felt their baby move for a few hours can ring, went 24/7 in March too.
So now, while women's need for help from the NHS with their birth and afterwards with their baby is only growing, the number of doctors, midwives, nurses and other NHS staff whose job is to make every woman's birth the special experience she hopes for – "her World Cup", as one midwife put it – are fewer than needed to achieve that ambition.
• This article was amended on 6 December 2013. An earlier version said that LWH was obliged to close on four occasions in the past 15 months. That should have been three occasions.Denis Campbell
Patients are being denied knee, hip and cataract operations as the NHS struggles to meet savings targets. Join health experts in a live discussion by posting your comment in the comment thread
Transparency won't be enough to make hospitals safe and on its own can make matters worse
A recent YouGov poll showed that 48% of people think the NHS has got worse over the last five years. Just 8% thought it had got better.
With the scandal of Mid-Staffordshire, the 11 trusts placed into 'special measures' and the fact that a quarter of hospitals are currently described as 'high risk', perhaps this isn't surprising. There is a growing sense that we're not doing enough to get the highest standards in our hospitals.
In a climate like that, the first instinct of many politicians is to increase transparency. Laudable though that it is – on its own, it won't do enough to make our hospitals safe.
At Circle, we publish every item of patient feedback we get – good and bad – verbatim on our website. We are committed to giving patients as much information as possible so they can choose where and how they want to be treated and vote with their feet if standards fall below their expectations.
But there are two problems. Firstly, transparency alone is not a cure. Indeed, on its own, it can make matters worse. The Freedom of Information Act has revolutionised transparency, but we know all too well that some people go to great lengths to subvert the Act and ensure discussions aren't written down. Transparency, if poorly managed, can lead to more cover-ups.
Secondly, patients rarely act like the empowered consumers we need them to be. Too often they feel trapped into being grateful for the services they are given and have little knowledge of the power they have.
We run two state-of-the-art independent hospitals in Bath and Reading. Despite glowing CQC reports, some excellent clinicians, and a Michelin-trained head chef, 80-90% of our NHS patients come to us exclusively because of a GP recommendation.
So the question then becomes: how can increasing patient power help if they don't always choose to use it, and how can we improve transparency without people gaming the system? The answer lies in transforming culture.
When we first took over the management of Hinchingbrooke hospital, a severely distressed NHS trust facing closure, we would typically get 1,200 items of patient feedback per year. We introduced a shortened questionnaire and pursued patient feedback constantly. We now get 24,000 a year, and every return is published on our website.
Doctors, nurses and managers on the frontline go through the feedback together every month and take action to improve services. Far from this cycle being resented, feared or hushed up, it is celebrated. This is the culture of transparency that can too often be missed. And it didn't happen by accident.
At Circle, empowering our staff to take responsibility and ownership for their work is key to our success. All of our partners value transparency because it allows them to hold themselves, and each other, to account.
One of the first things we did in Hinchingbrooke was introduce an initiative called Stop the Line. We told every member of staff they had not only the right, but the duty, to stop any procedure if they thought a patient might be in danger. All senior staff then attend the scene of the incident and a decision is taken before an operation can resume.
The culture change we saw was overwhelming. Staff across our hospital aren't looking to cover up failure – they're looking to root it out. And since we introduced the initiative, we've seen a 50% drop in serious incidents.
Transparency does have a role in improving care. But it is naive at best to imagine that this alone will miraculously improve standards. Without the accompanying culture of openness and accountability, efforts to increase information about patient care will fall on deaf ears. We need a cultural revolution in the NHS – and we need the leadership to make it stick.
Steve Melton is chief executive of Circle Partnership
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Under-treatment of retirees identified as factor in why UK is doing relatively badly compared with other European countries
Public health chiefs have promised extra efforts to raise awareness of cancer symptoms among older people to help close the long established gap in survival rates between parts of the UK and some other European countries.
The "under-treatment" of the post-retirement age group has been increasingly recognised as an important factor of why the UK is doing relatively badly in some cancer league tables.
In England there have been national advertising campaigns under the Be Clear on Cancer masthead for nearly three years to help older people, among others, recognise symptoms and visit their GPs as part of a drive to bring about earlier diagnosis and treatment.
It is understood there will soon be a drive to raise awareness in England of extensions to routine breast cancer screening programmes beyond 50- to 70-year-old women.
The latest discrepancies have been revealed in a study covering survival from a range of cancers in more than 10 million people across 29 countries who were diagnosed between 2000 and 2007 and followed-up as far as 2008. The statistics from EUROCARE-5 are published in Lancet Oncology and suggest, for instance, that in all four UK countries survival from breast cancer five years after diagnosis was broadly comparable with the European mean of 81.8%, though only Northern Ireland was it above that. Cancers of the prostate, rectum and non-Hodgkin Lymphoma were similarly within range.
But for cancers of the kidney, ovary and colon, the gap was more marked. Survival among older patients is generally worse across the whole of Europe but in England, the worst cancers in this respect were those of the lung, rectum, melanoma, breast , stomach, prostate and kidney. About a quarter of all those with colorectal cancers in England present as emergencies, usually at a late stage in the disease meaning poor prognosis. This proportion rises to 43% in patients 85 and over.
Across the UK, breast cancer screening by mammography is routinely offered every three years to women between 50 and 70 and in England moves to extend that to younger women between 47 and 49 and older ones from 71-73 are nearing completion. The NHS operates separate bowel screening programmes in England, Scotland, Wales and Northern Ireland, covering differing age ranges among older people, with that in Scotland starting earlier than elsewhere at 50. Most use do-it-yourself stool testing kits which people back. In England, a programme has recently started to look at the inside of the rectum and lower bowel involving a thin, bendy tube being inserted into those 55 and over. Cancer Research UK. which helped develop this Bowel Scope programme , said it was likely to prevent thousands of deaths a year once rolled out nationally. It had also campaigned successfully for more patients to get state-of the-art radiotherapy.
Sean Duffy, national clinical director for cancer at Public Health England, said "real inroads" were being made into improving cancer survival. "For example, the improvement in survival in lung cancer has been dramatic over the last 20 years with almost twice as many patients alive a year after diagnosis now as was the case in 1990 and we can see that for melanoma (skin cancer) that the (five-year) survival for England (85.3 per cent) is better than the European average (83.2 per cent)."
Duffy thought this reflected a combination of the better organisation of cancer services, the availability of better treatments and earlier diagnosis. "Our one-year survival figures show that for both of these cancers we are now approaching the outcomes of other countries where survival has historically been significantly better than in England. However, we want the best outcomes for all cancer patients and we know that we need to build on the improvements that have been made and do much more."
Dyfed Huws, director of the Welsh cancer intelligence and surveillance unit, said Breast Test Wales had the highest rate of screen-detected cancers of all the breast screening programmes in the UK, and Wales also had the highest 15-year survival rate for women diagnosed with invasive breast cancer.James Meikle