Public service professionals" hopes for the next government

In the run up to the general election on June 8, we asked professionals working across public services what they think are the biggest problems in their sector at the moment, and what they want to see from the UK’s major political parties.

Here’s what those working on the frontline in housing, local and central government, healthcare, social care, and the voluntary sector had to say.

‘I want to see compassion’

There is a lack of mental health services, a lack of supported housing projects and just a lack of resources generally. Homeless people who are lucky enough to find accommodation are hit on day one with letters about council tax, water rates, bin collections … It’s too much for someone who may have been rough sleeping for months and in temporary B&Bs for years before that.

I want to see compassion. I don’t believe people should “sponge” off the government but punishing people with sanctions is not the answer. Some people need a little more support then others and I believe if they get this they will have more chance of putting back into the coffers in the future. We need to care about each other, not penalise and punish those who struggle the most.

Anonymous, homeless charity worker

‘Address the reasons why doctors are leaving in droves’

A&E departments are increasingly stretched as patient demand outstrips what the NHS provide. Doctors are leaving in droves to work abroad or change career. We desperately need more nurses – but scrapping the bursaries for nursing students, a real terms pay cut and Brexit is disastrous for recruitment. GP numbers are falling, despite the government’s promise to appoint 5,000 new GPs.

Several things could be done. Guarantee the NHS budget for the next five years as a percentage of GDP (such as 8%), increase social care budgets so hospitals don’t have to keep patients longer than is medically necessary and reinstate the bursary for nursing students.

I certainly don’t want to see the introduction of the proposed conscription of doctors to four years in the NHS after medical school. Any government coming in needs to address the reasons why doctors are leaving (low morale, long hours, poor training, feeling undervalued, increasing workloads, increasing weekend work for less pay, demonisation by the media) rather than simply forcing them to stay.

Tom Palmer, 31, A&E doctor

‘I’d like to see national insurance breaks on health and future care provision insurance’

People are not planning for their future health, financially or
physically. The cost of a care home is astronomical and while taxpayers’
money is being thrown at it now, it’s going to get a lot worse
. I’d like to see national insurance breaks on health and future care provision insurance.

Fiona, 44, finance manager for a charity that provides care homes

‘We need rent caps and more social housing urgently’

The housing crisis is all-consuming and has a dramatic impact on virtually every other area of policy. The benefit cap, for example, punishes vulnerable people for not having access to social housing which successive governments have sold off. It is because families are forced to rent at high costs from the private sector that their benefits end up so high. That is the fault of landlords, not claimants. We need radical overhaul of the benefit system – I see things worsening on a daily basis.

I’d like to see a tenants’ union given the right to collectively bargain rent levels

There has been some focus on the insecurity of tenancies in the private sector. This is an important point, but what the increasing number of evictions boil down to is that landlords evict because they want to charge higher rents or because tenants cannot afford the rents they are already charging. We need rent caps. Other western European countries do this. I’d also like to see a tenants’ union given the right to collectively bargain rent levels at national and regional levels. The bottom line is we need to build more accommodation – especially social housing – very urgently.

Greg, housing adviser

‘I want a recognition that poverty contributes to social problems’

Social work is is overstretched and increasingly technocratic. The trend towards family therapy ignores socio-economic problems and seeks to reconcile parents to their current condition. I want to see a recognition that poverty is a contributing factor to social problems.

Many of our clients experience overcrowded housing conditions. There are fewer and fewer opportunities to remain in the area they grew up in, where their children go to school and where their family and friends can offer a support network. Many are unemployed and resigned to poverty. Very few are politically engaged.

After that we need investment in community solutions to social problems, such as increased funds from local authorities to youth arts and sports projects, as well as a firm commitment to social housing projects.

Arthur, 25, child protection social worker

‘Cuts have dramatically and irreversibly damaged local government’

Significant efficiencies have been achieved in local government since 2009, and it is certainly arguable that this – rather than increasing council tax – should have been done anyway prior to the recession. But eight years later there is no fat left to trim. Cuts have dramatically and irreversibly damaged local government.

If the new government does not reinstate a fixed central government grant (as opposed to fixing spending according to the level of council tax and business rates collected, which discriminates against poorer parts of the country) then very soon the Local Government Association’s warning that councils will need to make deep cuts to essential services will come true.

Finally, wages were frozen for three years, followed by five years of 1% rises. Give staff a pay rise, even if only at the level of CPI inflation. Five more years of pay freezes will force many talented members of staff to permanently leave the sector.

Anonymous, local government lawyer

‘Most police problems can be solved with more money for NHS and social services’

The police suffer from a chronic shortage of detectives, while overworked response officers get hardly any time off, or even time to adequately investigate at a crime scene. Most police problems can be solved with more staff and more money for the NHS and social services.

We need funding to recruit more detectives, and increase salaries for those detectives as an incentive to take on more stress and responsibilities. Then we need vastly more money for the NHS and social care; there is an overwhelming dependence on the police to deal with mental health crises, having cut social care to the bone and beyond. I would support a separate NHS tax.

We should h​​elp people to change their lives rather than imprison them

Vastly improving rehab programmes would prevent re-offending. Our current system costs millions and achieves nothing. This would involve legalising drugs and treating addiction as a medical problem not a crime. We should help people to change their lives rather than imprison them and make a life of crime more likely. Legalising and taxing drugs will save us a fortune in the long run.

Anonymous, police officer

‘We may need the return of housing inspectors’

Government policy does not reflect the realities of the housing market. Firstly, we need to increase supply. Quadruple council tax for all properties left empty for more than six months, rising to ten times if left empty for three or more years. This will prevent private landlords “going on strike”. A land tax designed to make land-banking extremely unprofitable should be followed by commitment to building council-owned homes for rent that are genuinely affordable. Councils are accountable to the public and elected representatives of their communities in a way that other providers are not. Right to buy should be extended to housing association tenants, but the properties must be sold at market value, no more discounts, and all proceeds used to build new homes to rent and for low-cost home ownership.

Then we need to raise standards, by putting in place mandatory registration and licensing of all privately rented accommodation. Housing association regulations should include housing management and value for money – we may well need the return of housing inspectors! Repeal the 2016 Housing and Planning Act and regulate rents – the amount of money being sucked out of the wider economy by ever-rising rents is damaging to the overall state of our country.

Andy, 52, retired head of housing in the West Midlands

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Public service professionals" hopes for the next government

Public service workers: tell us what you want in party manifestos

In the run-up to June’s general election, almost every aspect of our public services and social policy feels at breaking point: we’re in the midst of an NHS crisis, a social care crisis, a housing crisis, a local government funding crisis and a civil service staffing crisis, not to mention a collapse in public trust for charities.

The election will be dominated by Brexit, but domestic policies are equally vital – and must not be swept under the rug. It will be up to all those professionals working for and with the public to make that case. So we’d like to know what you want to see in the party manifestoes as top election priorities.

This is not just a matter of grand statements or pledging more money. What do the main political parties need to say that shows they really understand the issues?

Share your thoughts

Whether you work in healthcare, social care, housing, local government, central government, or any other part of public service – including the private sector or the voluntary sector – we want to hear from you. Tell us what you think are the biggest problems in your sector at the moment and what each of the political parties should be offering.

You can do so by filling in our encrypted form below – anonymously if you wish. We will do our best to ensure your responses are kept secure and confidential. A selection of contributions will be featured in our reporting.

Public service workers: tell us what you want in party manifestos

What we need is a national social care service | Anne Perkins

Neil Kinnock was on the radio at the weekend, talking about his hero Aneurin Bevan with the journalist Matthew Parris and one of Bevan’s biographers, John Campbell. Any conversation about Bevan’s life is mostly about the NHS and so it was this time, too. But it was a useful reminder of how, among all the battles fought over its creation, among the fiercest was the question of replacing a patchwork of local provision with a single centralised structure that tried to guarantee that everyone got the same level of care wherever they lived. At that the point the radical, big-government approach petered out. Social care was left where it always had been, with local councils.

Now the Institute for Fiscal Studies (IFS) has published a study looking at the difference in social care provision across England that raises the question of whether it too should be centrally funded. After all, whether it’s soaring demand for A&E or delayed discharge from hospital, the impact of inadequate or ill-designed social care services on the overall state of the health service has become the stuff of daily headlines.

Then there is the ageing population. Although we are all healthier in old age, the need for care doesn’t track changing demography exactly: men’s life expectancy is growing faster than women’s, so there are more old couples looking after each other rather than relying on formal care.

George Osborne’s response to the incipient social crisis was to set in motion plans to shift the entire cost of locally incurred spending to local taxes, with a system of equalisation that has yet to be explained. He introduced a social care precept allowing an increase of up to 2% in council tax to be spent on social care.

Since the amount councils can raise through council tax depends on their tax base, these changes are – as the IFS points out – hitting poorer councils much harder than well-off ones, even though in theory, the introduction of national criteria for eligibility for paid-for social care should mean a reasonably equitable approach. The IFS study found that cuts in social care were much steeper in metropolitan areas such as Greater Manchester, Tyneside and Greater Birmingham, which typically have significantly higher levels of need, than in the south of England (although that may be partly because there are more older people in the south).

But the distinction between what we pay for and what we expect wider society to support is more than just a matter of an arbitrary geographical divide. We are so familiar with it that we rarely ponder the palpable inequity between providing free care for, say, a cancer patient, regardless of their wealth, while charging someone with dementia who also has some modest assets.

Councils argue that keeping older people well is about much more than care homes and clearing hospital beds

Because social care is provided locally, the national focus is always on the NHS. So although last month’s budget made another £2bn available for social care, it is being delivered in a way that ties it in to supporting the kind of services that will ease pressure on the NHS. Councils rightly argue that keeping older people well is about much more than care homes and providing a bed clearance service for their local hospitals. It’s about wellbeing in the widest sense of the word, and the NHS’s provision of community services like stroke rehabilitation also have a significant role to play.

In some ways, NHS England chief executive Simon Stevens’ sustainability and transformation plans with their objective of integrating health and social care in ways that meet local priorities are an attempt to synthesise the national with the local. Yet there is such an inbuilt conflict between a free-at-the-point-of-use NHS and means-tested social care that it is hard to see how they can continue to coexist.

It comes at a high cost to patients. When hospitals are in effect incentivised to shovel the old lady who’s had a fall out of bed and off their books pronto (I exaggerate, a little), leaving her local authority to pick up the bill for getting her back on her feet, it seems the two arms of care that ought to be wrapped protectively around her are instead locked in a standoff. It is more arm-wrestling than hand-holding.

The government now promises (another) green paper on paying for social care in the autumn. But successive plans, each of which points to more central government funding, have crashed and burned on the runway. Oh, for a Bevan (and a Clement Attlee) with the courage and determination to sort it out.

Anne Perkins is a leader writer

What we need is a national social care service | Anne Perkins

NHS to fast-track nurses as record EU staff leave service after Brexit vote

NHS England is to launch a new nursing training programme to help plug the gap created by the record number of Europeans leaving the service in the wake of Britain’s vote to leave the European Union.

Simon Stevens, the chief executive of NHS England, acknowledged that the service relies on international staff, including more than 12,000 nurses who are EU nationals out of the 315,000 nurses on its payroll.

Speaking on the BBC Radio 4’s Today programme before the launch of a five-year plan for the NHS, he announced a training programme to “grow the workforce from within this country”.

The moves comes after new figures revealed that a record 17,197 EU nationals, including doctors and nurses, left the NHS last year.

Asked if he was worried about the impact of Brexit, Stevens said: “The NHS has always relied on international staff as well as staff from this country. It is about 4% of our nurses who come from the rest of the European Union. We are grateful for the work that they do.”

But he suggested newly trained British nurses could help fill the gap left by EU nationals once Britain leaves the bloc.

Stevens said: “We have got a curious situation where many more people in this country would like to train to be nurses than we have nurse training places. So we want to expand the number of nurse training places and the routes into nursing so that we can grow the work force from within this country as well.”

He said the new training programme would be modelled on an initiative to recruit more teachers.

“We are announcing a new programme called Nurse First, which is the equivalent of the Teach First programme, whereby new graduates can fast-track into nursing alongside other apprenticeship routes … so that we can expand the number of nurses we have.”

The programme will boost the number of newly qualified nurses by up to 2,200 more a year in 2019 when the UK is due to leave the EU.

In a wide-ranging interview, Stevens denied he was abandoning the 18-week waiting time target for non-urgent operations by relaxing the deadline for hospitals to meet the deadline.

He said: “Fifteen years ago you might be waiting 18 months for your hip or your knee operation, now for nine out of 10 people it’s 18 weeks. The average wait for an operation is 10 weeks. Over the next couple of years we want to have more funded operations on the NHS, but we recognise that the rate of growth is probably going to have to be a little bit slower than it has at points in the past, because we also want to make big improvements in cancer care, in GP services and in mental health services as well.”

The Royal College of Surgeons said the new guidelines amounted to “waving the white flag on the 18-week target”.

Asked if the target had been jettisoned, Stevens said: “It hasn’t. The reality is that there are pressures right across the health service. Under those circumstances we have to make a start on sorting out particularly those pressures in A&E departments which we have seen over the course of the last winter. But over the course of the next several years we want to continue to expand the amount of surgery that is being done, so that waiting times stay low.”

He also announced that all major A&E hospital departments will have to provide GP services to help emergency medics focus on the sickest patients. Steven said: “You can find about 60 hospitals right now that have got this arrangement. This is going to be rolled out to all major A&Es.”

Stevens confirmed that the NHS wanted to stamp out an estimated £4m spent on homeopathic medicine. He dismissed homeopathy as a “placebo at best” and said it was a “classic example of what we want to see less of”.

NHS to fast-track nurses as record EU staff leave service after Brexit vote

Half of £2bn boost for NHS "spent outside health service"

Health chiefs spent about half of the £2bn of extra cash allocated in George Osborne’s pre-2015 election autumn statement on buying care from private and other non-NHS providers, an analysis has shown.

The Health Foundation research for the Financial Times showed £901m was spent on buying services from outside the health service in 2015/16 for care provided free at the point of use for NHS patients. It compared with £800m spent on purchasing the same kind of care from NHS trusts.

In his 2014 autumn statement, the former chancellor described the money for NHS England as a “down-payment on the NHS’s own plan” and said it would go towards frontline services.

The report also found that £1 in every £8 of local commissioners’ budgets in England is now spent on care provided by non-NHS organisations. The Health Foundation said the figures showed NHS providers have not had the capacity to deal with rising demand.

Anita Charlesworth, director of research and economics at the Health Foundation, said: “Rising demand for emergency care meant that NHS providers haven’t had the capacity to deliver planned care and patients had to be diverted outside the NHS. NHS hospitals were left squeezed by sharply rising drug and staff costs with little additional funding. The result was big deficits that had to be covered by raids on investment budgets.

“The NHS urgently needs to look at how to ensure additional funds reach NHS providers. The health service needs to plan better for emergency demand, fund emergency care fairly and make sure it gets the best possible price for care provided outside the NHS.”

The Department of Health said the report showed the NHS was judging how best to deliver care and and spends less than 10% of its budget on independent providers. A spokesman said: “This report simply shows the NHS is making clinical judgments about delivering high-quality care for patients – the truth is that for many years the independent sector has made a contribution to helping the NHS meet demand, now amounting to less than eight pence in every pound the NHS spends.”

Half of £2bn boost for NHS "spent outside health service"

NHS to revamp 111 helpline after sustained criticism of service

The NHS is to revamp its heavily criticised 111 telephone helpline to ensure that many more people get to discuss their illness with a nurse, doctor or other health professional rather than a call handler.

GPs and mental health health nurses will also start to play key roles after the overhaul, which is intended to improve public confidence in 111 so that fewer patients visit A&E or a GP’s surgery.

The changes, which will be unveiled later this month, are part of a major effort by NHS England to better integrate 111 with its other urgent and emergency care services, including ambulances, out-of-hours GPs and walk-in centres. It envisages the improved 111 service being a central part of such care, which it wants to become “the front door of the NHS”.

NHS 111 has faced sustained criticism since it replaced NHS Direct as the health service’s telephone advice line in 2012 as part of then-health secretary Andrew Lansley’s controversial shake-up of the NHS in England.

Simon Stevens, NHS England’s chief executive, last month admitted that “substantial changes” to 111 were needed. A&E doctors claim it has not kept the pressure off emergency departments while NHS ambulance services believe call handlers order ambulances for too many patients who do not need one.

NHS 111 uses far fewer nurses each year to answer callers’ queries about their symptoms than NHS Direct did. Despite that, the number of people seeking help from 111 has risen from 5 million a year when NHS Direct existed to 14 million now.

But under the imminent overhaul, which is due to be phased in across England from next month, about 30% of callers will speak to a health professional through a newly created Clinical Assessment Service.

“It’s clear the current 111 system isn’t working as well as it could due to a lack of trained clinicians,” said Anna Crossley, the Royal College of Nursing’s professional lead for acute, emergency and critical care, who has helped devise the revamp.

“A script and a call handler can’t replace the knowledge of a skilled, experienced nurse, someone who can spot serious conditions and ensure people receive the treatment or advice they need.”

NHS England expects the changes not to make 111 any more expensive to run because health professionals will be seconded or loaned to it, mainly by hospitals. But costs may rise if more staff end up being paid overtime for shifts answering calls. Callers should also be able to speak to a paediatrician, dentist, cancer nurse or social worker, depending on the nature of their problem and the staff available.

Stevens is likely to cite the revamp as proof that he is making good on his pledge to transform patient care by 2020, when he launches his long-awaited “delivery plan” later this month.

The Royal College of Emergency Medicine, which represents A&E doctors, said the overhaul of 111 should ease the strain on overcrowded emergency departments.

“The improvements being made by NHS 111 are very welcome,” said Dr Taj Hassan, the college’s president. “We know that currently at least 8% of all calls to NHS 111 are referred to emergency departments – a figure the college suspects to be significantly higher – and we hope by introducing more clinicians to the service, this figure can be reduced.

“From an emergency medicine point of view one of the key problems with NHS 111 was that staff, often with a limited medical background, work with a computer system providing a virtual checklist to help diagnose the patient’s problem,” he added. “With access to further clinical support being limited, when the call handler was still unsure of the problem they would, understandably, refer the caller to A&E to be on the safe side.

“The new service will have expanded clinical back-up for call handlers to refer to for guidance, or to pass the caller on to an experienced clinician, meaning better quality of care for patients. These ‘clinical hubs’ will not just support patients and NHS 111 call handlers, but also provide support and advice to clinicians and ‘field staff’ such as paramedics.”

Dr Helen Thomas, NHS England’s national medical adviser on integrated urgent care, said: “During 2017 we will make it possible for up to 30% of NHS 111 callers to have a telephone consultation with a clinician who will have access to medical records and be able to book them into an appointment if required.”

NHS to revamp 111 helpline after sustained criticism of service

NHS poll finds public think service getting worse

Growing numbers of Britons think the NHS is getting worse and fear for its future, a survey has found.

Ipsos Mori polling last month found that 57% of people believe that the NHS’s ability to deliver the care and services it provides worsened over the last six months, up from 52% in January. One in four (24%) said it had got “much worse”, 33% “slightly worse”. Only 8% said “better”. The same proportion – 57% – were pessimistic about the NHS’s future. Asked how they expected it to fare in the next few years, 37% said “worse” and another 20% “much worse”; 21% said better.

The polling may reflect the NHS’s worst winter crisis in years. Record numbers of patients were forced to endure long waits – often on a trolley – and more than half of hospitals went on alert because they could not cope.

The over-75s were the only group in which more people thought the NHS would get better (41%) than worse (35%). Conservatives were less pessimistic (50%) than Labour voters (61%).

“This survey shows the public is realising that the NHS is buckling under the strain of meeting rising demand for services and maintaining standards of care,” said Chris Ham, chief executive of the King’s Fund health thinktank.

Chris Ham, chief executive of the King’s Fund health thinktank. Photograph: Frank Baron for the Guardian

A separate international study by Ipsos Mori found that Britons are more pessimistic about their healthcare system than people in 22 other countries. Almost half (47%) of Britons believe the quality of the healthcare they and their families can access will get worse in coming years.

However, Britons are also among the most positive internationally about the care they currently receive. Some 69% say that they and their family get good quality healthcare, well above the 47% seen across the 23 countries.

“Britain’s love for the NHS is one of our defining characteristics, and we remain among the most positive countries in the world about the quality of care we receive. But we’re also the most worried for the future of the service. This fear has been growing and is now at record levels”, said Kate Duxbury, Ipsos Mori’s head of healthcare research.

A spokesman for NHS England said: “It’s welcome news that a far higher proportion of people in Britain than in other countries rate the quality of their healthcare highly. And it’s noticeable that those people who use the NHS most and who therefore know most about it – the over-75s – are in fact the most optimistic about its future.”

He pointed to the very high scores recorded by 12 different types of NHS services in December under the “friends and family” ratings test. Dental care got the highest patient satisfaction rating, at 97%, while even the lowest scores – 86% for both A&E and mental health care – were still high.

Meanwhile, doctors and hospital bosses want some of the £700m-£1bn of extra government money expected to be given to social care in this week’s budget to be used to help cover the cost of “bed blocking”. They want to ensure that local councils do not use the cash to fill other holes in their budgets and ensure that any extra funding benefits both social care and the NHS.

The call has come from NHS Providers, which speaks for hospitals, and medical royal colleges representing A&E doctors, surgeons and hospital physicians. They want Philip Hammond, the chancellor, to make the money conditional on councils spending it on people who have had a spell in hospital, so that it reduces the 723,000 bed-days a year lost because patients who are medically fit to leave cannot be safely discharged for lack of social care support.

“If extra money is coming into social care it should either be spent on local authority packages of care or, if this doesn’t happen, on the alternative – the cost of keeping patients in hospital,” the four organisations said, in a joint statement to the Observer.

“Any solution to benefit NHS patients must be clear, simple and not capable of being manipulated. Local authorities would receive more funding if they support the NHS and less if they don’t.”

NHS poll finds public think service getting worse

"Risk-averse" NHS 111 sends more callers to A&E than previous service

The NHS 111 telephone advice service is sending growing numbers of people to A&E or calling an ambulance because its staff are too risk-averse when dealing with illness, a study has claimed.

Critics claim the trend is adding to the huge strain on hospitals and ambulances that have left them struggling to keep up with rising demand for care.

NHS 111 now either sends an ambulance or recommends someone goes to A&E in about one in five (20%-22%) cases of the 1.1 million people a month who ring seeking help, according to the Nuffield Trust.

That is up from an average of 18%-19% over the three years since the service was introduced, research by the health thinktank has found.

NHS 111 replaced NHS Direct across England in late 2013 as part of the coalition’s shake-up of the NHS.

Nuffield Trust’s analysis of the health service’s performance statistics shows that during the course of 2016 a total of 1.46 million of the 11.8 million people who rang 111 seeking help were sent a blue light ambulance. Another 1 million were advised to go to A&E. Taken together, that meant that almost 21% of calls overall were disposed of in one of those two ways.

“This report is further evidence that the NHS crisis this winter, and in particular the record A&E attendances, are the result of a catalogue of bad choices by the government,” said shadow health secretary Jonathan Ashworth.

“The decision to scrap NHS Direct and replace it with the NHS 111 was strongly criticised by health professionals, and today we have learned that NHS 111 is sending more callers, and a higher proportion, to A&E than in previous years, with great variations in performance across different regions.”

The thinktank has also uncovered “great variability between different areas in how likely NHS 111 is to send people to A&E or to the ambulance service”. The report says: “This might suggest that some areas are to likely, or not likely enough, to send people to emergency services.”

For example, while 12.4% of callers in east London and the City were sent to an emergency department, the 111 covering Cornwall did that with just 5.7%.

“These numbers are yet another sign of the unbearable pressure our health system is under,” said Norman Lamb, the Liberal Democrat health spokesman. “Whichever part of the system you look at it’s now at breaking point.

“But it also appears the overly cautious algorithm used by 111 call handlers is increasing pressure on already overstretched ambulance services and A&Es.”

The Nuffield Trust points out that “NHS 111 is more likely to despatch an ambulance than to simply send people to A&E, which is the reverse of the usual pattern of NHS use”, adding: “This lends credence to claims that the service is too risk-averse in some cases.”

That echoes concerns raised privately by many of the 10 NHS regional ambulance services that NHS 111 services too often practise “defensive medicine” and order an ambulance to take someone to hospital unnecessarily, which increases the pressure on them.

The 42 regional NHS 111 services are run by NHS ambulance trusts, groups of GPs and private firms such as Care UK, which has recently won more contracts. It uses far fewer nurses and many more call handlers than NHS did until then health secretary Andrew Lansley scrapped it.

However, the study also found that, paradoxically, NHS 111 is also reducing the pressure on A&E and ambulance services and successfully redirecting callers to GP surgeries and other services outside hospitals. While 45% of callers say they would have gone to A&E or dialled 999 if 111 had not been an option, call handlers send only around 20% of patients to them. Likewise, while a third of users said they would have gone to community-based services if 111 had not existed, the service itself sends about 60% to them.

NHS England said that NHS 111 is performing well amid rising demand for its advice. “The increased number of people referred to emergency care is proportionate to the higher number of calls being handled,” a spokesman said. “111 continues to do an important job helping patients to get the right care, at the right place and at the right time, and in protecting both A&E and ambulance services from unnecessary attendances and callouts.”

"Risk-averse" NHS 111 sends more callers to A&E than previous service

Will NHS transformation plans kill or cure the health service?

“Secret plans to change our NHS”: This is the allegation levelled at sustainability and transformation plans (STPs) – the government’s latest NHS reform initiative – by campaigning group 38 Degrees. Some politicians seem to agree, with former shadow health secretary Diane Abbott calling them “a dagger pointed at the heart of the NHS”.

Simon Stevens, the chief executive of NHS England, sees it differently: “Now is quite obviously the time to confront … the big local choices needed to improve health and care across England.” For him, STPs are a way of delivering the reforms he set out in the NHS Five Year Forward View (pdf) and the £22bn of efficiency savings he promised to the government, while maintaining or improving the quality of care.

As details of the STPs have been made public and the extent of the winter crisis in the NHS has become apparent, the debate about their role in the health service has become dangerously polarised. The question is whether these controversial plans will prove to be kill or cure. Based on a detailed analysis of all 44 plans, we at IPPR think the reality is probably more nuanced and complex than either side let on.

The IPPR’s STP finder tool gives a breakdown of the scale of the financial challenge facing each area, and outlines the changes each plan is expected to bring about.

On the one hand, it’s clear that some elements of the argument made by campaigning groups – for example, that the government is knowingly underfunding the health and care service – stack up. Our analysis shows that every STP area is forecast to be in deficit by 2020-21, and these deficits total more than £24bn. For Theresa May and (somewhat more reluctantly) Simon Stevens to suggest that this financial gap can be closed through reform alone is disingenuous to say the least.

On the other hand, campaigners are wrong to argue that the reform agenda is simply about delivering dangerous cuts. The NHS cannot stand still as the world transforms around it. Instead, it must respond to growing demographic pressures; new evidence about what works and what doesn’t; and cutting edge technologies that can transform health and care.

Hospital reconfigurations are a perfect example of the need for a more balanced discussion. Campaigning groups have raced to uncover “secret” plans to close local hospitals, arguing that these changes are evidence of the government’s deceit. And, they are right to highlight that these changes are afoot: our research finds that up to 44% of STPs include hospital closures or reconfigurations.

However, the potential benefits of these changes have gone largely unnoticed. There is strong evidence for some services, in particular A&E and specialist surgery (pdf), concentrating care in fewer locations. This can save lives by ensuring people have access to the most highly trained doctors and the best equipment. Likewise, there are many examples where treatment could be moved out of hospital all together, saving money but also improving outcomes: for example, only 7% of people say they would prefer to die in hospital with the vast majority opting for home.

This doesn’t mean that all the planned changes are justified, some are likely to be driven by the need to cut costs but many are not and should end up improving health outcomes over the coming years.

Likewise, the wider health and care reform agenda is yet to get a fair hearing, with a number of initiatives likely to result in better care, for example new “community care hubs”, which will bring together GPs, mental health services and social care at a local level; “a truly seven-day health service” with GPs opening on evenings and weekdays; and the adoption of new technology that allows people to receive support remotely.

STPs are an opportunity to deliver these reforms – which will help to transform the quality of care delivered up and down the country – ensuring that the NHS is fit for the 21st century. However, there is no doubt that the NHS will struggle to seize these opportunities without three key changes.

First, the government must recognise that the health and care system needs more funding both to manage the immediate pressures of the winter crisis but also to properly fund the reform agenda. A good start would be a rise in national insurance. This could raise up to a further £16bn over the next five years, dramatically closing the funding gap.

Second, the government – in particular Theresa May and Jeremy Hunt – must start supporting NHS leaders in making the case for reform, in particular controversial and little understood hospital reconfigurations. This will give local NHS leaders the political leadership they need to argue for their proposals locally.

Finally, once central government has helped local leaders win support for their reform plans, they must be given the tools to deliver these changes and allowed to get on with it. This may well mean giving NHS leaders real powers to intervene in their local area, as well as devolving functions currently undertaken by central government as has happened in Greater Manchester.

STPs are an opportunity rather than a risk for the NHS, but without these fundamental changes, it seems inevitable the NHS will remain a 20th century system in a 21st century world.

Harry Quilter-Pinner is a research fellow on public services at the IPPR thinktank. This is an edited version of an article on the IPPR blog and is part of a wider project on STPs.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Will NHS transformation plans kill or cure the health service?

Big Brother’s eye on the health service | Letters

Thirty years ago, when I learned that time and motion studies had been used to devise the work rota in the casualty department where I worked, it seemed logical and unthreatening. John Harris’s piece (They call it fun, but the digital giants are turning workers into robots, 21 January) reminded me that when computers in the out-of-hours service started to monitor general practitioners’ activity continuously in 2007 it felt very Big Brotherish. The times patients waited were colour-coded, spurring us on to stop them turning red, and our scores were fed back each month, with pats on the back or threats of sanctions. The monitoring coincided with a reduction in staffing levels.

At much the same time, GPs’ referrals to hospital started being scrutinised (and, indeed, triaged) by a Kafkaesque system of so-called healthcare professionals. An attendance certificate omitted from a lengthy online annual appraisal form could generate a warning. Small wonder that GP posts fail to attract applicants and that early retirement appeals to so many.
Dr Stuart Handysides
Retired GP, associate editor, ProMED-mail

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Big Brother’s eye on the health service | Letters

NHS crisis: the one act of self-sacrifice that could rescue our health service | Polly Toynbee

From every previous NHS crisis, the tipping point should have come last week. Prime ministers crumple when people die – as they have in the Royal Worcester’s corridors. When opinion polls send concern about the NHS soaring above everything else at 61%, above immigration at 41% and Brexit at 36%, sirens should wail inside No 10. But no, not yet.

When the Royal College of Surgeons protests at cancer operations cancelled, is that a tipping point? When nearly half of all hospitals declare major alerts for lack of beds, that’s an emergency. There’s no winter flu, no Arctic weather, just pressure from underfunding, like an aneurysm about to burst. But the prime minister is not for turning, not yet.

King’s College hospital is typical – as its clinical director of emergency medicine, Malcolm Tunnicliff, explains. He stands in the middle of a 10-cubicle emergency section where this week he had 17 trollies crammed in, jammed around the nursing station with barely enough room to squeeze past.

Other hospitals call a “divert” – to send away ambulances from their doors. “We never do that, on principle, because every hospital’s in the same boat. We are here for everyone, all the time,” says Tunnicliff. Like so many NHS staff you meet, his natural blend of enthusiasm and determination to cope leaves him perplexed by what’s happening. “The last four weeks are the worst I’ve experienced. We all worry all the time.”

Recently he’s had 6% more patients – with 10% more needing resuscitation – and he can’t fill all his vacancies, leaving him scouring the world for staff because of the government’s failure to train enough people: 19% fewer nurses are in training. “Day after day my staff here go the extra mile, like Duracell bunnies,” he says. But he fears many may leave as a result of the pressure.

The last straw may be the flame-thrower of blame from Westminster, attacking staff and patients and GP opening hours. No, Tunnicliff says, only 4% come here with things GPs should see. The blockage is a lack of beds for skyrocketing numbers of sicker and older patients. Nationally, 13,822 beds have been cut since 2010, losing 5m bed days. The 40% cuts in social care multiply the blocked bed crisis. NHS funding has never had a six-year squeeze like this, falling far behind similar countries in beds, staff and cash per head. Yesterday the axing of 538 staff from the Department of Health looked like panic, while public health is cut by cash-starved councils – storing up worse problems for the future.

Hospitals usually afraid to blow whistles now talk to anyone who’ll listen. I’ve never known normally cautious managers and senior staff show such unguarded urgency to reveal all. But one exception is the Royal Berkshire, where Theresa May’s Maidenhead constituents go in an emergency. They maintain omerta, allow no visit, put up no spokesperson, apparently paralysed with fright: the care quality commission brands it “needs improvement”, not “safe” or “responsive” nor “well-led”. Does May ever visit?

She should listen to Kings College hospital’s chair, Bob Kerslake – another NHS leader who has become extraordinarily outspoken. Here is a man of exceptional experience and wisdom, a former chief executive of Sheffield city council, elevated to permanent secretary of the communities and local government department and on up to head of the home civil service. He’s a maths graduate and chartered account, an exceptionally numerate civil servant. The government’s numbers are “kidology”, he says. As the Kings Fund showed, the NHS got £4.5bn, not £10bn, extra to 2020: and this was its frontloaded year, with far less to come after April, and zero – yes, zero increase – for 2018, the NHS’s 70th anniversary year.

Jeremy Hunt: up to 30% of people using A&E departments do not need emergency care

Here’s more kidology, Kerslake says. “Some 98% of trusts signed up to control totals that most know are impossible.” His own trust was told to make a surplus but has a £2m deficit, so they will be punished by losing their sustainability and transformation money, which will leave them with a £30m deficit instead. I asked him to repeat it twice, it was so incredible. Yet next year they are told to make a surplus, yes, a surplus of £26m – fantasy accounting that no one believes is remotely achievable. “And we have used every wheeze, holding off paying bills … using our capital budget so we have nothing for essentials, like replacing worn-out dialysis machines.”

But when he talks to the Treasury, “They give me the line. I don’t know if they believe it.” The line says what May says: “It’s only a winter blip, we gave the NHS more than they asked for, and GP opening hours are to blame.” Chancellor Philip Hammond is immovable: he says that to give more to the NHS’s “bottomless pit” would create a moral hazard. Kerslake says NHS England’s Simon Stevens forthrightness at the Commons public accounts committee last week has “opened the floodgates, letting others speaking out”.

Is May listening? Talk to the hand. No 10 hopes compassion fatigue will stop the flow of drearily identical stories from A&Es as the news moves on. Brexit has the merit of driving the NHS off front pages. Politically, why worry when there’s no opposition? Polls show that even the NHS is regarded as safer in the hands of May than Jeremy Corbyn. She has plenty of her own ignorant and partisan commentariat opining that “money isn’t the problem, it needs reform” – calling for top-ups and private insurance.

But May can’t defy the NHS laws of gravity that force every prime minister to U-turn on underfunding. Margaret Thatcher, John Major and Tony Blair all buckled. This crisis looks set to outdo all those, says Chris Ham, NHS historian and head of the King’s Fund. History shows – and this was proved in the Blair years – that when the NHS reaches roughly EU funding levels, its results soar. When funding falls too far, trolleys pile up in corridors.

What’s the tipping point? Disasters forced on to the Mail’s front page, the only media she cares about (yesterday it ran instead with a Nigerian health tourist mother giving birth to twins at taxpayers’ expense). What else would it take? Nightly news from the A&E war zone, more care homes going bust – and deaths. Until her final hubristic year, Thatcher knew when to swerve – but May’s obstinacy might do for her.

One thing would force her hand – a joint resignation by Simon Stevens and Jim Mackey of NHS Improvement, announcing they can no longer be held legally responsible for the safety of patients. They just might, as a final act of service to rescue the NHS.

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NHS crisis: the one act of self-sacrifice that could rescue our health service | Polly Toynbee

Binge drinking turning NHS into "national hangover service", says chief

The NHS is being transformed into the “national hangover service” as binge drinking diverts vital resources, the head of the health service in England said. Simon Stevens condemned “selfish” partygoers in a stark warning as the nation gears up for one of the most alcohol-steeped nights of the year.

The chief executive of NHS England added that the health service was already facing considerable strain from the annual spike in winter emergencies.

Millions of revellers are expected to pack bars, pubs and clubs across the UK to celebrate the arrival of 2017 on Saturday night. Figures from the health service show that admissions for alcohol-related incidents rocket on the first day of the new year.

Stevens told the Daily Telegraph: “At a time of year when hospitals are always under pressure, caring for a spike in winter emergencies, it’s really selfish to get so blotto that you end up in an ambulance or A&E. More than a third of A&E attendances at peak times are caused by drunkenness. Casualty nurses and doctors are understandably frustrated about the NHS being used as a national hangover service.

“In our towns and cities this Christmas and new year, the paramedic called to a drunk partygoer passed out on the pavement is an ambulance crew obviously not then available for a genuine medical emergency.”

Binge drinking turning NHS into "national hangover service", says chief

Guardian Public Service Awards 2016 health and wellbeing winner: Deventio Housing Trust

“Quite often people are in hospital and they’ve got nothing: no food, no clothes, no toiletries,” says Kate Gillespie, Derventio Housing Trust’s strategic lead for its Healthy Futures initiative. “We get all that sorted out, so people at least have a bit of dignity when they are discharged.”

That’s just the start of the scheme’s work with homeless people due to leave hospital. Many have multiple, complex needs, such as mental health problems and addictions, and are trapped in a vicious cycle of ongoing health issues and repeat admissions.

Over a 12-week period, staff work intensively to find housing for patients, settle them into their new homes and help them live independently – while making better use of primary care, rather than relying disproportionately on acute services.

“Sometimes it’s because they don’t manage their health, so they actually get ill enough to need to go in [to hospital] all of those times,” Gillespie says. “We’ve also got people who are going in because it’s their social contact. They’re so isolated that the only kind of love and nurture they get is a trip to A&E, where they get a sandwich and a cup of tea and a ‘there, there’ from the nurses. When someone has nothing else they’re going to keep coming back for it.

“It’s like they’ve got a dependency on acute care. We transfer that dependency to us, and then take the time to wean them off it. If we get someone who’s in A&E three times a week, the next step down from that is a walk-in centre. Then their GP, then the pharmacy.”

Healthy Futures, which also offers brief interventions to help with the timely discharge of inpatients with less complex housing and support needs, has worked with more than 330 patients since it began in October 2013. Some 170 patients have received ongoing community-based support.

In the six months before becoming Healthy Futures clients, those patients had been admitted to acute beds on 487 occasions, had gone to A&E 616 times, and had called 999 and been taken there by an ambulance 364 times.

The project has led to an 88% fall in avoidable admissions of clients, a 90% drop in clients’ visits to A&E, and 84% fewer 999 ambulance transfers. Hospital stays have also been cut by an average of 16 days. Two thirds of patients felt their physical health had improved, and the same proportion reported better mental health.

Healthy Futures’ achievements come despite working in a climate of cuts to adult social care, at a time when finding housing is harder than ever. Key to getting funding has been its use of robust data proving its impact and efficiency. Patients give consent for their health records to be accessed, so their use of acute care before working with the project can be tracked – and commissioners can clearly see the positive effect.

Great staff are also vital, Gillespie says. “They’re just amazingly capable and patient and resourceful. I’m immensely proud of them.”

Guardian Public Service Awards 2016 health and wellbeing winner: Deventio Housing Trust

Social care cuts take English service to tipping point, regulator warns

A&E units are struggling to cope because social care services that help elderly people have been cut so much that they are reaching a “tipping point”, England’s care regulator is to warn.

Hospitals are ending up dangerously full and have seen “bedblocking” hit record levels because of a widespread failure to give elderly people enough support to keep them healthy at home, says the Care Quality Commission.

A worsening lack of at-home care services and beds in care homes are forcing hospitals to admit more patients as emergencies, which deepens their already serious financial problems. “What’s happening, we think, is that where people aren’t getting access to [social] care, and we are not preventing people’s needs developing through adult social care, is that they are presenting at A&E,” said David Behan, the CQC’s chief executive.

Figures contained in the commission’s annual report show that the number of hospital bed days lost through patients being unable to leave because social care was not available to allow them to be discharged safely soared from 108,482 in April 2012 to 184,199 in July this year – a 70% rise.

The fact that growing numbers of mainly frail, elderly people are being left without the help they need with basic chores such as washing, dressing and cooking “creates problems in other parts of the health and care system, such as overstretched A&E departments or delays in people leaving hospital,” he added. GP surgeries are also having to treat patients who became unwell or suffered an injury because they did not receive help they needed.

Behan urged ministers to give social care a higher priority and urgently find extra money for it to prevent its ongoing deterioration causing even worse problems. “We are becoming concerned about the fragility of the adult social care market, with evidence suggesting that it might be approaching a tipping point,” he said.

The CQC’s assessment of health and social care, called State of Care, adds that: “The difficulties in adult social care are already affecting hospitals. Bed occupancy rates exceeded 91% in January to March 2016, the highest quarterly rate for at least six years, and in 2015-16 we saw an increase in the number of people having to wait to be discharged from hospital, in part due to a lack of suitable care options,” the CQC’s annual report says.

The number of people in England receiving local council-funded social care services fell by 26% from 1.1m in 2009 to about 850,000 in 2013-14, at a time of Whitehall-driven cuts to town hall budgets. The number of people with unmet needs has risen from 800,000 in 2010 to more than 1 million last year, according to Age UK.

Growing unavailability of social care was a key driver of the 3% rise in emergency admissions to hospital last year and 11% rise in bed days lost to bedblocking. That was mainly due to patients having to wait for a package of care to be put in place to let them return home or for a place in a nursing home to become available. “The effect of these delays on the NHS is significant, costing hospitals £820m a year,” the National Audit Office says.

NHS bodies, health thinktanks and charities urged government to use next month’s autumn statement to inject extra funding into social care.

Simon Stevens, the chief executive of NHS England, has already called for any extra funding for the health service to instead be used to prop up social care. Jeremy Hunt, the health secretary, is understood to privately agree. On Monday Stephen Dorrell, the ex-Conservative health secretary, said that the government’s policy of giving social care less and less money was “insane economics and bad social policy” and undermined its claim to be backing the NHS.

Cuts to social care and also mental health and public health mean “the NHS is being stretched to the limit,” said Stephen Dalton, chief executive of the NHS Confederation, which represents hospitals. “Relying on political rhetoric that promises to protect the NHS but fails to acknowledge that a cut in social care results in a cost to the NHS, is an economic deception.”

The CQC also disclosed that about 800,000 patients are registered with a GP practice that its inspectors have judged to be inadequate on safety grounds. It is concerned that some surgeries deliver “unacceptable standards of care”. Safety failings include poor management of medicines, inappropriately trained staff and premises that are unsuitable.

The Department of Health welcomed the CQC’s findings that “the majority of the NHS, 72% of adult social care services and 87% of GP practices inspected are good or better – and that improvement is taking place all over the country”.

A spokeswoman said: “The NHS is performing well at a time of increasing demand. The government is investing £10bn to fund its own plan for the future, and crucially is ensuring that the amount of money available to local authorities for social care is rising in future years of the parliament, reaching up to £3.5bn extra by 2020.”

Social care cuts take English service to tipping point, regulator warns

Mental health social workers aren"t giving up hope, nor are their service users

I entered the field of mental health social work just a few weeks ago, joining a psychosis team. I had been warned by friends, family, taxi drivers and the media that this area of work is in dire straits and suffering hugely from cuts and poor practice.

After a couple of days, I could confirm that the former is true: swingeing cuts have had a drastic effect. Therapeutic groups and the time practitioners are able to spend with service users are incredibly stretched, and diaries no longer set aside any time for breaks – or, it seems, any time to breathe. However, my observations of current practice contradict the tales of woe.

I spent one day with a mental health support worker, shadowing him on four home visits with service users, and I was touched by the remarkable work he is doing. In the car between visits, we spoke about the value of things like listening, getting fresh air, and working collaboratively with each service user.

I had come across words like “collaborative” and “active listening” time and again in literature and legislation on mental health practice, but had pessimistically assumed that, for the most part, this language served to tick boxes for inspectors.

The support worker valued the time spent with each service user as much as they did with him

Here, I witnessed these things being practised in the truest, most genuine sense. The support worker valued the time spent with each service user as much as they did with him, and I observed them continuously teaching and learning from one another.

This was not in an expensive psychiatric unit or over a £4 coffee, but simply during walks, exploring new areas and the changing seasons, discovering the best places to go. It occurred to me that so much essential work, even administrative obligations, could take place in these settings. Why not?

Understanding of what good practice means is changing, and mental health finally seems to be taking centre stage in public discourse.

Unfortunately, because these changes have taken place in the era of austerity, many ideas about the value of a social approach feel unfeasible in practice. As a result, a return to a medical model is tempting, and can seem like the most time-saving and cost-effective option. However, from what I have seen, expensive medication with often complex side effects, compares poorly with therapeutic support.

Medication is undeniably an important part of recovery for some service users, but the knowledge that they have been prescribed drugs to alter their thoughts automatically places them in a category of “in need”, or in some sense “less human”.

The social work I have observed is therapeutic input at its best. Despite the challenges ahead – inevitable in every job – I am so grateful that the negative attitudes towards the field of mental healthcare are being challenged and contradicted in daily practice. Workers, such as the people I’ve met, are not giving up hope, and as a result, service users are not giving up hope either. This, to me, is the greatest outcome we could wish for.

The Social Life Blog is written by people who work in or use social care services. If you’d like to write for the series, email socialcare@theguardian.com with your ideas.

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Mental health social workers aren"t giving up hope, nor are their service users

Lib Dems will turn NHS into National Health and Care Service, says Farron

Tim Farron will tell the Liberal Democrat conference that the party would rebrand the NHS to include a fully taxpayer-funded care service, warning that governments must be honest about raising taxes to ease the healthcare crisis.

In his leader’s speech in Brighton on Tuesday, Farron will say the party needs to be honest about the costs of making social care fully government-funded.

“If the only way to fund a health service that meets the needs of everyone is to raise taxes, Liberal Democrats will raise taxes,” he will say, promising to campaign to transform the NHS into the National Health and Care Service.

“For years, politicians have chosen to paper over the cracks rather than come clean about what it will really take – what it will really cost – not just to keep the NHS afloat but to give people the care and the treatment that they deserve.

“If the great Liberal William Beveridge [1879-1963] had written his blueprint today, when people are living to the ages they are now, there is no doubt he would have proposed a National Health and Care Service.”

The party insists it believes there is enough affection for the NHS for British people to feel positive about paying more taxes, not normally seen as an election-winning strategy.

The Lib Dem leader will talk about his own grandfather’s Alzheimer’s disease, saying the first home he was put in was “despicable”.

“I’ve seen enough terrible old people’s homes,” he will say. “It’s not civilised to let people slip through the net. It’s not civilised towards the people who love those people, who go out of their way to try and make their lives easier when everything else is making their lives harder. It’s not civilised and it’s not good enough.”

Earlier in the week Lib Dem health spokesman Norman Lamb told the conference the government should consider moulding national insurance into a ringfenced NHS and social care tax, to make it easier to increase the amount paid with public support.

An expert panel – which the party will call its Beveridge commission – will report back to the party in six months on the costs, but Lamb suggested the tax could mean an increase of a “an extra penny in the pound”.

Farron will say the Lib Dems “will not join the ranks of those politicians who are too scared of losing votes to face up to what really needs to be done”.

“We will go to the British people with the results of our Beveridge commission and we will offer a new deal for health and social care, honest about the cost, bold about the solution.”

Earlier on Monday, Lamb announced cross-party support for a commission into the NHS funding crisis, backed by Labour MP and former leadership contender Liz Kendall, and Tory MP Dan Poulter, a former gynaecologist.

Speaking to the Lib Dem conference in Brighton, Kendall said it would be politically difficult to dedicate a new tax to the NHS. “It’s very tough for anybody in any party to say any tax should go up,” she said.

“That’s the reality, however passionately we might think this is the right solution, but certainly when Labour was in government and we did the penny on NI [national insurance] for the NHS, it was a semi-hypothecation to say it’s going to go on this specifically. It’s an important option.”

Lib Dems will turn NHS into National Health and Care Service, says Farron

Local difficulties in the cash-strapped National Health Service | Letters

I pity the civil servants in the Department of Health who are forced to give platitudinous responses to the press (Leak reveals doubts over ‘seven-day NHS’, 23 August). In 2012 the then secretary of state for health, Andrew Lansley, fought tooth and nail (using taxpayers money) to hide the risk assessment done before the disastrous health and social care bill, despite intervention by the information commissioner. There, the “worst case scenario” has occurred after the passage of the Health and Social Care Act 2012. Civil servants are right to be worried that there is not enough money or sufficient trained staff available to carry out the policy, as there is insufficient money to run the NHS as it exists, providing a five-day elective (planned) and seven-day emergency service.

The lack of detailed planning of the proposed service is analogous to the way the Cameron government approached the EU referendum. What the NHS needs is more money to deal with rising demand, which could easily be found by scrapping the wasteful tendering processes which have resulted in almost £20bn of contracts going to the private sector since 2013, reviewing PFI debts costing over £2bn per year, reducing expenditure on the CQC, which has become unwieldy but arguably has failed to prevent hospital disasters, and reducing the six-figure salaries that too many top managers are now paid. Private contracts are expensive and have not yielded the promised innovation or improved services.
Wendy Savage
President, Keep Our NHS Public

• Most people will agree that the NHS is the jewel in the crown of British life and prized by almost everyone. David Nicholson wrote on his retirement as chief executive of the NHS, “It is built into what it is to be British” (Sunday Times, 2 March 2014).

Yet it is “threadbare, scrappy, perilously understaffed and barely held together by legions of nurses, doctors and allied health professionals” (These leaks show Hunt’s deception on the seven-day NHS, 23 August).

As a retired NHS physician and former independent MP, I talk to many people about the NHS and, without exception, they would willingly accept an increase in income tax, if it was hypothecated to the NHS, and if all measures for increasing efficiency and economy within the NHS had been adopted.

Would the Guardian consider carrying out a survey of its readers to assess the support for such a measure to rescue our beloved NHS?
Richard T Taylor
Kidderminster, Worcestershire

• You report that NHS England expects local doctors, hospitals and councils to work together in each of 44 “footprint” areas for the “first time on shared plans” (Revealed: plans to fight NHS deficit, 26 August). We recall how, in a 1968 green paper, health minister Kenneth Robinson proposed just such area health boards, to meet his paramount requirement that all the different kinds of care and treatment should be readily available to the individual citizen. We, who were involved in the preparation and promotion of those novel ideas in 1968, can but hope that our successors will get past the green stage.
Dora Pease and Tim Nodder
Ministry of Health long-term study group 1967-74

• Save Our Hospitals: Hammersmith and Charing Cross has been campaigning for more than four years against the downgrading of hospitals in north-west London, where we have already lost two A&Es, with dire effects on other A&Es in the area, and where two further major acute hospitals, Charing Cross and Ealing, are to be downgraded to as yet undefined local hospitals. As you note, these hospitals will be little more than glorified urgent care centres (Councils reject plans to ‘transform’ NHS, 26 August).

Already all hospitals in NW London are working at full capacity, failing to meet A&E targets, and with accelerated population growth in NW London, out-of-hospital care is even less likely to meet the health needs of our local population.

For four years we have been asking the local health authorities for the evidence that the proposed out-of-hospital provision can replace acute in-hospital care. For four years we have been promised this evidence. And for four years we have been presented with no evidence that suggests the changes can work.

It has become increasingly clear that financial considerations are driving the plans for this new top-down restructuring of the NHS. The outcome will be even greater privatisation of the NHS.

That two council leaders have been prepared to stand up to the NHS bullies and reject this attack on local health provision and local democracy is admirable. We know that the leaders of Hammersmith & Fulham and Ealing councils have the support of the local population as well as local campaign groups.
Merril Hammer
Chair, SOH: Hammersmith & Charing Cross

• Among your articles on the “sustainability and transformation plan” for the NHS, you mentioned the current efforts to remodel healthcare in North, West and East Cumbria. My local community hospital is threatened with removal of all inpatient beds. Alston Moor is a sparsely populated area of high moorland with four of the five roads leading over high passes; all are slow, frequently impassable in winter. The nearest hospitals are 20 miles from Alston, another five miles for some parts of Alston Moor; the nearest main hospital is over 30 miles away, in Carlisle. There is no meaningful public transport; even by car, it takes 40 minutes to the smaller hospitals, an hour to Carlisle.

If there are no inpatient beds, there will be no nurses. If there are no nurses, there will be no nurse-led minor injuries unit, and all will have to get to A&E in Carlisle. Without the hospital, our GP surgery is not viable (the relatively low returns of GP services for a mere 2,000 people are supplemented by the hospital work).

What family will want to live here with children if there are no medical services? Without children, our schools are doomed. What older person will want to live here knowing that their dying days will be spent in a hospital far from family and friends? What carer will cope with the burden of their task with no respite care?

How can it be OK to destroy a community? First they came for the small rural communities and I did not speak out because I did not live in a small rural community…
Alice Bondi
Alston, Cumbria

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Local difficulties in the cash-strapped National Health Service | Letters

I"m an NHS ambulance dispatcher and I know my service is failing you

If you were to call for an ambulance, most of you wouldn’t realise I exist. I’m an ambulance dispatcher, which is different to the call handlers you speak to over the phone.

Even though I rarely speak to callers directly, it is a stressful job. We are under incredible pressure to send the right resource to the right patient, hit government waiting-time targets, and deal with paramedics on the radio who often forget how many calls we are juggling every day.

When your call comes in, it is coded via a computer system. If it’s red 1, that means cardiac arrest. Red 2 could mean chest pain, breathing problems, fitting, or an unconscious patient. We try our best to get the nearest resource to you as quickly as possible and are set a target by the government to be on the scene within eight minutes of these most serious calls. We don’t always manage that.

Other calls will be categorised in the green 1 or 2 category – this might be falls with an injury, broken bones, road traffic collisions, headaches, or bleeding, for example. In most cases, these requests for help are held with me until I can allocate an ambulance. If your call is categorised as a green 3 or 4 – this might be non-injury falls, abdomen pain, headaches – you’ll most likely get a call back from a clinician to arrange the most appropriate help. Heartbreakingly, if you’ve fallen, that means you could wait on the floor for hours before we manage to send someone to help.

There is a shortage of resources and the unions that represent paramedics put even more pressure on dispatch teams. They argue that a paramedic who will have to work 30 minutes past the end of their shift to see the patient and potentially take them to hospital should not have to take an emergency call. This means that some may not go on a call for the last hour or more of their shift. We might have to send a team that’s an hour away, when there is an available ambulance much closer, because of such rules.

Our guidelines state that we should rarely use paramedic cars for less serious calls – they should mainly be used for red 1 and 2 calls that are subject to government targets. But an incident that was initially low risk can easily become more serious, and this delay in sending help is having dire consequences. We continue to see an increase in fatalities from calls coded as green once our crews arrive.

These incidences are not reported on, because there are no targets for these calls. Every time it happens, we dispatchers are left wondering if we did everything we could, if we could have found a car to send to you sooner. If we had done so, perhaps you or your relatives would have had a better chance. Paramedics will often get feedback when there is a serious incident, but we rarely hear anything. We also never see changes implemented to prevent such incidences in the future.

The pressure in my control room has become so severe that it is damaging staff wellbeing. Our concerns for patient care are rarely listened to by management and the overall morale is incredibly low. There’s a high turnover of staff and many of my colleagues end up off sick with stress.

I’m an NHS ambulance dispatcher. I am overworked and undervalued. I try to do my best for you, but I’m sorry my service often fails when you need it the most.

This series aims to give a voice to the staff behind the public services that are hit by mounting cuts and rising demand, and so often denigrated by the press, politicians and public. If you would like to write an article for the series, contact kirstie.brewer@theguardian.com

Talk to us on Twitter via @Guardianpublic and sign up for your free weekly Guardian Public Leaders newsletter with news and analysis sent direct to you every Thursday.

I"m an NHS ambulance dispatcher and I know my service is failing you

Has government learned the vital lessons of public service failures?

From the failure at Mid Staffordshire NHS foundation trust that led to the mistreatment of hundreds of patients, to the Rotherham children’s services scandal, we have seen been high-profile crises in public services that have had direct and disastrous effects on people’s lives.

Managing failure is a vital skill, and new research from the Institute for Government aims to understand how government can best respond to – and learn from – such events more effectively. It focuses on failures in four key public services, hospitals, local authorities, children’s services and schools, and ways to restore services quickly. A few common themes emerge:

The first lesson is to avoid some of the most common responses to failure, including blame and restructuring. It’s human instinct to find an individual to blame: 70%-80% of inquiries across a range of industries and professions attribute tragedies to the error of particular individuals. But this instinctive response usually fails to understand or to address why it was that an individual thought it best to act in a given way. The impulse to restructure in the wake of a crisis has a similar appeal – it feels like you are at least doing something – but will be effective only if linked to the actual causes of failure, which are frequently rooted in behaviour or culture.

One example is Doncaster metropolitan borough council, which was found to be failing by an Audit Commission inspection in 2010. by the Audit Commission. The communities secretary, John Denham subsequently appointed commissioners and service quality improved. They were withdrawn a year earlier than planned, in 2014.

Related: May’s Whitehall reshuffle shows disregard for evidence and expertise

In Doncaster, the turnaround was based in part on reconnecting the council with neighbouring authorities. It had become insular, and as it detached from its peers, it lost its sense of what good looked like.

This was a common phenomenon across our case studies; one teacher, appointed to a school just weeks before it was tipped into special measures, recalled that it was absolutely crystal clear the second they walked in that building that the school was failing. “What was terrifying was that it wasn’t clear to the people inside it.” To overcome this insularity, organisations began rebuilding links with their peers, including them on improvement boards or by making use of sector-specific services such as the Local Government Association’s peer challenge tool.

Doncaster also avoided the risk of pursuing an unsustainable recovery based on temporary appointments or relying on external support. The commissioners were clear that ownership should remain with the council. The test for ending the intervention was not whether services had returned to a good standard, but whether commissioners were confident that the council could reach that point without further external support. In contrast, in Tower Hamlets in 2014, the commissioners sent in by then-communities secretary Eric Pickles formed an executive board and replaced the council in the day-to-day running of services.

Failure is not going to go away, but at least we can minimise its impact if the government is prepared to learn lessons from the past. There is plenty of scope for improvement.

Oliver Ilott is a researcher at the Institute for Government.

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Has government learned the vital lessons of public service failures?

When VCs Stroll By way of The Door Customer Service Flies Out Of The Window

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Is this a harsh factor to say, or is there a semblance of truth in it? Or even worse, is this the norm? Many firms declare in their mission statements or advertising materials that their consumers are at the heart of their ethos and operations. Even so in nowadays&rsquos planet with organization [...]

When VCs Stroll By way of The Door Customer Service Flies Out Of The Window