Since the health service was established, tensions have existed between patients, physicians and policymakers, partly centring on resource availability, deployment and demand.
Following a recent experience I've realised that carers, if better integrated into day-to-day NHS practice, could represent a means of reconciling these tensions.
A few weeks ago my mother fell down the stairs and attended A&E; an episode that caused me, as a doctor, policy advisor and most recently a carer, to experience these tensions first hand.
She was found to have fractures of the transverse processes in her lumbar vertebrae, being discharged with painkillers and recommended 4 weeks of rest. Only days later while I was staying with her, she experienced episodes of dizziness, palpitations and tachycardia. Following assessment by a paramedic, it was recommended she attend A&E, again, to exclude cardiac sequelae or an internal bleed.
My mother was seen in around three hours. Her examination, blood tests and ECG were normal. The Consultant suggested that while an internal bleed was unlikely, it could only be excluded via imaging. They advised she return home and if symptoms recurred, a CT scan would be conducted to enable a more detailed assessment. She was discharged.
As I reflected on this experience I felt conflicted.
Waiting in A&E was agonising; every hour that passed seemed too slow. Once my mother was assessed, part of me couldn't help wondering whether a CT scan should have been conducted to exclude anything more serious. As a patient's relative you always want the best, and possibly the most healthcare. After her discharge, I knew my mother wouldn't be able to cope alone. I commuted to work from her home, rotating on alternate shifts with my aunt to ensure someone was always with her. It's this home-care that supported her rehabilitation, more than the hospital-care she received.
In contrast, the doctor in me thought a thorough assessment had been conducted and red flags excluded. Management would be conservative, focusing on pain-control that could be delivered at home. Did she need a CT scan? Amidst hospital-demands for high-resolution imaging, this was a low priority case.
From a policy standpoint, quite simply, the 4-hour-wait had not been breached. This was on a background of 1.9 million attendees nationally to A&E in January alone; a 10% increase in demand compared to last year. Despite these pressures, my mother was treated within the expected boundaries of care we aim to provide in the NHS. There were no unnecessary admissions. She was seen promptly, on-demand, and in a manner exceeding international standards. An example of an effective, efficient NHS operating as it should; free at the point-of-access, universal and integrated.
The optics of these three lenses, however, don't seem to converge. Are patient expectations too high? Are resources too limited? Do we need better alignment between patients, professionals and policymakers?
Possibly.
Resource availability and demand do underpin some of these tensions.
What became clear to me was that the real NHS happens at home; and, it could be better coordinated.
Home-care is more comfortable, preferable and affordable. It's a patient's social fabric; their friends, families and carers, who are best positioned to support their management and rehabilitation. This is what hastens recovery, while preventing admission. Care must and is moving from hospital to home. Indeed, seeing my aunt care for my mother made me confident that it's carers who are the unsung heroes of our health system. From helping with day-to-day amenities, to assisting with medication and mobility - carers are uniquely positioned to transform a patient's healthcare experience.
Despite this, in A&E I received no guidance as to how best care for my mother.
From a national perspective, there are over 6.5 million carers in the UK, up by 10% over the past 10 years. 1.4 million are unpaid. Clearly this is a significant resource.
Yet, their efforts seem undercoordinated and detached from the NHS, at a moment when service pressures and the need to integrate resources couldn't be greater. This must change - the time that carers succeed because of, rather than despite the NHS is now overdue. As we look to make current services more efficient, we could also see how resources beyond primary and specialist services, such as home-carers, could be better integrated and coordinated, perhaps using technology, to resolve tensions across our health system.