Fear of death is not as great as fear of dying. Dying without support, a comforting and competent carer, and without pain relief, is a return to the standards for the uninsured pre 1948. Aneurin Bevan was trying to replace fear when he published In Place of Fear A Free Health Service 1952 (Chapter 5 of In Place of Fear), and he conducted open debates on exactly what the purpose of his new service would be. Some of his speeches can be re-read, and some are even on film. It is cynical, and so tempting, for the de-commissioning GPs and Health Boards to ration the care of those who will never vote.
When Dennis Campbell in the Guardian 13th March 2017 reports on the King’s Fund opinion we should all worry: Dying patients waiting hours for pain relief in NHS funding shortfall – Overworked district nurses struggling to care for dying patients, with one in seven posts cut in two years, warns King’s Fund
Dying patients are waiting up to eight hours to receive pain relief because of cuts to district nursing services during the NHS’s unprecedented budget squeeze, a new report has revealed.
Severe financial pressures on the NHS are leading to longer waits for treatment and a short-sighted and growing rationing of care that is storing up problems for the future, according to a study by the King’s Fund health thinktank.
The report quotes one unnamed manager of a hospice saying: “The district nurses working at night are not able to give effective response times; you can wait up to eight hours … for patients experiencing pain and discomfort in the last two to three days of their life, it has a massive impact. It’s a frightening time for patients.”
The King’s Fund research has found that district nursing and sexual health services are among the areas of care most affected by six years of the NHS in England receiving annual budget increases of 1.2%, far less than its historic average of 3.7% rises.
It highlights how the diminishing number of district nurses are struggling to give patients prompt high-quality care because they are increasingly overworked.
The need to balance budgets and the smaller numbers of district nurses are prompting some NHS bodies to restrict their eligibility criteria for patients seeking help, refusing it for those with serious mobility problems unless they are completely housebound.
“We heard some examples of providers attempting to limit access. This was mainly through tightening referral criteria, particularly in relation to patients being ‘housebound’. Increasingly, if patients are able to visit their general practice (even if doing so is challenging), they will not be eligible to receive care from district nurses,” the report states.
The past two years have seen a loss of one in seven (14.8%) district nursing posts. “There is a significant gap between demand for district nursing and the available resources in terms of funding and staff numbers,” researchers found. Heavier workloads are contributing to 20% vacancy rates in some places.
The report also warns: “Pressures in district nursing are affecting the quality of patient care. Staff are increasingly rushed. Visits have become more task-focused, and there is less opportunity for thorough assessments. This dilution of quality may damage patient experience and outcomes.”
Many services provided by acute hospitals have been “relatively protected” despite the lack of investment in the NHS in recent years, the authors say.
However, genito-urinary medicine services have been hard hit, with cuts of up to 20% in 2014/15-2015/16 in some places in the budgets for testing for and treatment of sexually transmitted infections. “This has resulted in fewer clinics and reductions in staff in some areas, while there have also been cuts to prevention and outreach services. This could put patients and the general population at greater risk of infection,” the report adds.
The number of hip replacements has also started to fall, despite growing demand for them caused by the ageing population. Slightly fewer were carried out in 2015-16 than the year before as NHS clinical commissioning groups (CCGs) sought to save money by making surgery conditional on losing weight or giving up smoking. Waiting times for the procedure have also lengthened and more patients are waiting longer than the supposed maximum 18 weeks.
“It’s a disgrace that as a result of the Tory funding squeeze many elderly people are forced to live in prolonged agony and without independence because they are denied a hip replacement in reasonable time,” said Jonathan Ashworth, the shadow health secretary.
“Patients are unfairly suffering the consequences of a deliberately underfunded NHS at breaking point,” said Dr Mark Porter, chair of council at the British Medical Association.
The King’s Fund warns that rationing of care will become ever more common. “Although NHS funding growth began to slow in 2010/11, it appears to have taken some time for financial constraints to impact on patient care, and our data suggests that these impacts will spread and intensify,” the report adds.
The Department of Health has told CCGs not to ration care, despite the tight financial constraints it has imposed. NHS England said only: “Ultimately these are legally decisions for CCGs, but informed by best evidence and national guidance where appropriate.”