JOHN LISTER looks at three recent academic papers and a book relevant to NHS campaigners, the Nordic Health emergency and the French policy of hospital at home

The importance of action to address the causes (“social determinants) of ill health and improve public health as part of any plan to improve and expand the NHS is widely accepted in words, and a crucial assumption of the NHS Long Term Plan in England, so any books or articles that remind us of the health consequences of austerity and inequality must be welcomed.

This summer has seen not only another interesting free access article demonstrating the impact of financial crisis and austerity on health in Andalusia, but also open access to an entire 290-page book on Health in Hard Times, focused on the British context and in particular the north east of England.

Both make important points and remind us of some of the long term effects of austerity as a policy option implemented by governments. But both also have surprising weaknesses.

The study on Andalusia, the large southern region of the Spanish state that suffered especially brutal repression under General Franco’s fascist rule published in the International Journal for Equity in Health, notes that it was one of the regions most damaged by the economic crisis triggered from 2008 by the banking crisis.

The impact was exacerbated by the subsequent brutal austerity regime imposed on Spain, as well as Ireland, Portugal, and most infamously Greece by the “troika” of the European Commission, the European Central Bank and the International Monetary Fund.

Andalusia faced a much heavier reduction in health budget than other regions of the Spanish state (13.9% compared with an average of 9%) as well as closure of several services, loss of hospital beds, the axing of over 7,000 health care jobs, the imposition of co-payments for prescriptions for pensioners and those on high-incomes, and changes to the health care system to make coverage dependent on social security contributions, ending NHS-style entitlement based on residency.

Waiting lists for treatment have grown, the quality of care has fallen, primary care and prevention have been cut back – at a time when falling living standards and growing unemployment was also undermining public health. The study reports on interviews in which people from different social layers – the poorest and most vulnerable, the middle class and “upper social class” express their experience and reaction to the changes that have taken place.

For the poorest, the focus is much more on survival: access to a basic diet and their ability to afford medicines, especially for children. For the middle class the preoccupation is much more focused on mental health, the increased pressures, and the lack of resources in health care.

By contrast the wealthiest groups “did not consider that the crisis had directly affected their health, yet they were very aware of how it had impacted Andalusian society in general.”

Missing from this interesting account is any mention of one of the more discriminated against and vulnerable communities in Andalusia, the marginalised Gypsy population whose limited access to education and employment  increases their need for assistance from the State health service – or indeed any discussion of ethnic minorities.

Nor, in a region which in January saw an end to 36 years of socialist control and the establishment of a new right wing government propped up by the far right, is there any discussion of the ways in which regional government action might have addressed some of the problems, or now make them even worse by further cutting taxes (and thus government revenue), further reducing welfare benefits and support for disabled people, and further increasing levels of discrimination.

Similar weaknesses also spring out from the new book Health in Hard Times, even though its Foreword promises to provide “a vivid illustration of how health inequalities are largely the result of political choices.”

The book is edited by Clare Bambra, Professor of Public Health at Newcastle University, who summarises it on Twitter as demonstrating “the impact of austerity on health inequalities using mixed methods research”. It seeks to go beyond limited analysis of inequalities based either on composition of the local population or the specifics of the geographical context to bring in political-economic factors and a historical view. In doing so it offers a wide range of useful and alarming information, identifying the impact of key measures (p13).

The book is primarily focused on just one north east town, Stockton on Tees. We learn that there is a staggering 15-year gap in life expectancy between the most and least deprived areas of the town, which are just two miles apart. Stockton in this respect is typical of some of the more deprived areas of the north of England, where as one new campaign has pointed out “over half of the North has a lower life expectancy than the worst area in the South.”

But in other ways Stockton is very untypical. In particular, along with much of the north east it has very low proportion of non-white residents: ONS figures show that it has less than half the English average of Asian and British Asian population, around a quarter of the English average of  Black or Black British, almost 10% fewer non-white people. The book’s focus on this one town means that scant attention is paid to the health impact of health inequalities and racial discrimination on ethnic minorities.

A focus on just one town also serves to understate the scale of the problem, which is especially acute in Britain, but a wider issue across Europe: “European Union-level analysis suggested that the costs of health inequalities amounted to EUR 980 billion per year, or 9.4% of gross domestic product (GDP) – as a result of lost productivity and health care and welfare costs.

“… Analysis has also suggested that increasing the health of the lowest 50% of the European population to the average health of the top 50% would improve labour productivity by 1.4% of GDP each year – meaning that within five years of these improvements, GDP would be more than 7% higher.” (p247).

However this also highlights an elephant in the room which the entire book ignores: despite Stockton’s massive vote to leave the EU, along with much of the north east, the word Brexit appears only once in 290 pages, and the issues it poses are not addressed at all – even in a book published in June 2019, amid mounting public and media concern over the dangers of a no-deal Brexit.

The likely post-Brexit recession would impact very heavily on the economy of the Brexit-voting north east and therefore once again on the health of its people.

And despite repeated reference to political economy, there is very little explicitly political assessment, even though it’s clear that action on any scale sufficient to address health inequalities requires a full scale change of government and policy – from actively making things worse since 2010, to seeking to address problems that have been created.

Clare Bambra and colleagues know it is not an accident that levels of child poverty and homelessness have increased since 2010, and are far worse overall in the north than the south. The book states several times that austerity policies are a choice and not an inevitability. But it pulls its punches.

The lack of any current political analysis and the silence on Brexit underline the fact that, with the partial exception of Clare Bambra’s concluding chapter, much of the book also reads as already seriously out of date, although this is possibly a result of publication delays rather than all of the chapters coming from academics.

Much of the information in the edited chapters that make up the majority of the book appears to rely on relatively dated

Nordic health emergency

Another free access paper giving an interesting sidelight on problems we face in England comes from Norway. Emergency department crowding and length of stay before and after an increased catchment area takes a familiar story: the merger of four hospitals on the outskirts of Oslo to form Oslo University Hospital, followed by closure of some of the previous capacity, including (unlike England) closing a University Hospital (Aker).

About 150,000 inhabitants which had Aker as their local hospital, were transferred to Akershus University Hospital, now the biggest emergency department in Norway.

“Thus, the catchment area of Akershus University Hospital increased by 44% from Jan 1st 2011, from 340,000 to 490,000, the latter approximately 10% of the Norwegian population.” The hospital had already, been struggling with bed capacity, with a high bed occupancy level.

The study reminds us NHS commissioners and their management consultants do not have a monopoly on half-baked plans. In Norway, too, inadequate resources lead to delays: length of stay (LOS) increased by 20.9% as admissions increased by 41%, with neurology admissions up 46.5%.

“Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input.”

Even in wealthy Norway: “The increased catchment area … aimed to reduce costs and increase quality.” However “Increased LOS and crowding is often a sign of the opposite, as a longer stay in the ED increases the risk of adverse events and decrease patient safety.”

Hospital chez vous?

“Hospital at home” (HAH), like mergers and reconfiguration, is a concept that is often trotted out by NHS bosses in England, although they tend to be stronger on the long term promise than on the actual delivery of services.

Few NHS commissioners or providers pay much attention to the aspect of “hospital at home” that has been investigated by another free access paper in The experience of patients and family caregivers during hospital-at-home in France.

It shows that HAH is already established as a significant factor in French health care:

“HAH is a model of care that provides acute-level services in the patient home and can also in some cases be set up in a nursing home. HAH is a less expensive way than conventional hospitalization with an average cost of 198€/day in the French health system.”

41% of French HAH providers are public sector, 41% non-profit, and the remainder is provided by profit-seeking companies. HAH accounted for 4.6% of the total of bed days in France with payments totalling €913 million to 308 HAH institutions in 2015.

The study uses interviews with patients and caregivers, all in the Paris area. It found that “HAH remains widely unknown among patients and caregivers, who rarely are at the origin of the admission, and lack information before the return home.”

It reveals some of the stresses and strains on caregivers, pointing out that the extra work could lead to a real deterioration of their relationship, but also of the caregiver’s health. The study raises a “fundamental” question that needs to be asked of the NHS:

“Can we, ethically, favour patient’s well-being over caregiver’s suffering?  If HAH is beneficial to patients but strongly impacts caregivers, should we deprive the patient from a better care to relieve the caregiver? Or should we force the caregiver to bear the situation in the name of “good care”?”

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