The must-read stories and debate in health policy and leadership.
- Today’s hub-date: Cancer hubs ‘here to stay’ after ‘massive jump’ in long waiters
- Today’s reluctant clinicians: NHSE/I urges ‘reluctant’ clinicians to share records with major mortality review
Health systems in the developing world have been trying to shift all kinds of things out of hospital for some time, and that includes death. Charities such as Marie Curie and Age UK have long suggested that there are many who would like to die at home but are not given the choice or support to make this possible, leaving them to endure their final days in hospital.
But in recent weeks, with the period of substantial mortality from covid now well passed (for now at least), there has been an enduring shift in where deaths are taking place, from hospital to people’s own homes. It is a big chunk: about a 10 percentage point increase in the share at home.
No one is entirely sure if it’s a good thing or a terrible thing. Perhaps some of those who are not dying in hospital are benefitting from enhanced out of hospital care in their final weeks which they would not have got before, with efforts across the health system redoubled to avoid admissions, and to discharge quickly after hospital episodes.
Sadly, the weight of opinion is that this is very much not the case. Age UK and leading geriatricians and palliative care doctors say the likelihood is most of the excess of people dying are home are missing out on crucial care, through not seeking it (many are still scared of hospitals) or not being able to access it (some services remain closed and with limited access). In some cases healthcare might have extended their life; or it may have meant they received better support and pain relief.
We are in a strange period, where many in health and care services are fighting to resume normal working despite the virus, but they have an uphill battle, and there is a desire to keep away some face-to-face activity, especially in A&E and GP surgeries. A worrying upshot appears to be that many vulnerable patients and service users are still not getting what they need out of the system, several months after the peak.
There are calls for enhanced proactive primary care to reach out to the vulnerable people likely to be at risk. That’s not currently on the NHS’s urgent “to do” list.
Fog of finance
It’s been months since we’ve had a meaningful update over the future of NHS finances. Some capital projects have faced delay; and the extension of current contracting arrangements implies some difficulties at the top; but smooth running locally under block payments has provided some much-needed breathing space.
However, with winter looming and a slow restart on electives, we’re still none the wiser about what extra funding the NHS may receive to respond to covid and other demands, or how those monies will be managed.
This week NHS board papers revealed the NHS, on paper, overspent by £2.6bn on covid through April and May — but says this was underwritten by the government, when the credo that the health service would get whatever it needed rang loud.
More recently, that noise has gotten quieter and updates have been piecemeal. And it’s virtual radio silence on how NHS finances will be run as services are slowly restored too.
Understandably, financial architecture, compared to the likes of the anticipated staggering waiting national waiting list, ranks lower down the to-do list.
And some are confident government will continue to cover what the NHS needs for further coronavirus response. But the silence on what it can expect to get for everything else, and how the kitty will be managed, is becoming uncomfortable. The longer we’re left to wonder, the greater the concern it may cause.