Systems under strain

An emergency ambulance
An emergency ambulance of SECAMS, a service under strain. Photo Dick Elbers; CC Attribution-Share Alike 4.0 International license.

On Sunday afternoon, there was a seven-hour wait for the South East ambulance service. The dementia patient needed transporting to hospital urgently. NHS111 advised that the best method was to phone 999 and call the police. They would then assess the safeguarding risk and take the patient to hospital.

A team of three police officers duly turned up. One tried to interact with the patient, another with the family member to get details, and the third to phone for the unavailable ambulance. The police said they have to do this work for the ambulance service almost every day. What is wrong with the system?

Emergency Department under strain

Altogether it took 90 minutes before the patient was taken to A&E. He was seen by a doctor six hours later. What is wrong with the system is that the A&E facility is now too small for the growing local population. There is building work to expand it but, meanwhile, hundreds sit around in the waiting area, and along the corridors patients are parked on trollies, usually with a tired looking relative sitting alongside, waiting for some care decision, mostly probably for a bed in a ward to become available. I myself remember waiting on one of those trollies in 2020 as a heart patient all night, waiting to be assigned a bed in a ward.

Connectivity problems

Once in hospital, some families may then find it difficult to visit the patient because of cuts to the bus services. Normally there are buses every 15 minutes between the town centre and the hospital. But this is not the case if the crisis occurs during a four-day jubilee holiday. Even after the holiday, the bus company, Stagecoach, is advising passengers to check if the service or their journey is actually running, with this notice on their website on 21 September 2021:

“We are continuing to run the majority of services in the South East, but in some areas there may be some day-to-day disruption to the advertised bus times as a result of a national shortage of qualified bus drivers.

“With record numbers of unfilled jobs in the economy and the emerging impact of Brexit, recruitment remains a big challenge for businesses and organisations in the transport sector. We’re seeing strong demand for bus driver jobs, but the lingering impact of the pandemic and the ongoing delays in processing new licences at the DVLA, is having an effect on our operations and the phasing of people joining us.

“We’re doing all we can to keep services running whilst we recruit more people. The majority of bus services are running normally, but where we do have to cancel a bus, we are providing live updates on our Twitter feed @StagecoachSE.”

So it is not just lack of drivers because of the pandemic, but also malfunctioning of the DVLA office that is causing disruption of bus services.

Where are the taxis?

So should we rely on taxis? My sister, who lives alone, almost died last year when she was too ill to drive or cycle, and there were no taxis available to take her to the hospital. Here we missed a train because there was no available taxi on a Sunday afternoon.

I recently asked a driver why it seems to be more difficult to book a taxi these days. He said some of it was because of the pandemic and people isolating. But also because the drivers are either retiring or getting other driving jobs.

Other systems under strain

If you want an NHS service in the south east, it is obvious the system is under strain. Our NHS dentist left last year, and the replacement only stayed a few months before going private. Our April appointments were cancelled, and new ones will only be bookable from June when a new dentist will, hopefully, be in place.

If you need the service of removing ear-wax (a common malady of older people), then you can no longer expect this to be done by the NHS nurse practitioner, as formerly. This service has been withdrawn from most GP surgeries in Kent. The result is that private providers, like Specsavers, are overwhelmed, with a long waiting list for appointments (that cost £55 each).

But their equipment is not good enough for some of the deepest wax, so back to the GP who can give a referral to some of the few surgeries that still do this service. As the waiting list for them is some six months, and their location not suitable for patients with mobility problems (it means a bus ride on some of those unreliably scheduled buses). So the GP refers to the Aural care clinic at the hospital, but their bookings have a three- month wait. If you try to phone them, there is a ten-person telephone queue.

Kent short of General Practitioners

Some GP surgeries are so overwhelmed that they cannot take new patients. There is a shortage of GPs in Kent. In fact, a map of the distribution of GPs showing the ratio of GPs to the population, shows Kent is one of the worst-hit regions. I asked someone involved in health planning and training why this is so, when more medical students have been recruited and there is even a new medical school in Canterbury.

He explained that one bottleneck is at the point of assigning qualified students to traineeships at the GP surgeries. Not every experienced doctor has the capacity or willingness to take on trainees. To mentor a novice is a big ask on top of an already very full job. In fact, as in all professions, mentors need to be trained as well as willing.

If one tries to find a common cause for all these systems being under strain, various suggestions may crop out: Brexit (and the loss of workers from the EU); population increase; Conservative government cuts. Underlying these is also the tug of war between leftist and rightist politics, between those who believe these socially needed enterprises should be publicly owned and planned centrally, and those that rely on the market to correct any shortages or imbalances. 

Calculating economic value

But I detect a fundamental modern misconception about how to calculate value and economic worth. There is a lack of systemic thinking, or realising fully how one thing connects to another, how a lack of DVLA office workers may affect the bus service in Kent or the delivery of fresh produce in the supermarkets.

When accountants draw up the profit and loss tables for financial entities, they apply this only to the enterprise they are contracted to scrutinise. Particularly for enterprises that have any connections to socially important activities, the accounts should be required to include ‘externalities’, which is to say they should state if cuts or losses affect or may affect other socially vital enterprises. This is so that we can all see, including taxpayers and shareholders, how economic decision-making affects whole interconnected systems.