Sir Bruce Keogh has published a report on the first stage of his review of urgent and emergency care in England. You can read more about the review as it progresses on NHS Choices.

There are various potential causes of the current A&E problems. One reason might be that many people anecdotally seem to have trouble in getting a ‘routine’ GP appointment.

Labour says the crisis has been made worse by job cuts under this Government — such as the loss of 6,000 nursing posts since the election, and decisions to axe NHS Direct and close walk-in centres.

Sir Bruce says the current system is under “intense, growing and unsustainable pressure”.  This is driven by rising demand from a population that is getting older, a confusing and inconsistent array of services outside hospital, and high public trust in the A&E brand.

Invariably, the response, from either those of are of a political inclination, or uneducated about macroeconomics, or both, is that “we cannot afford it”. This is dressed up as “sustainability”, but the actual macroeconomic definition of sustainability is being bastardised for that purpose.

Unite, which has 100,000 members in the health service, said this year that it wanted the “Pay Review Body” to “grasp the nettle” of declining living standards of NHS staff.  “The idea behind the flat rate increase is that the rise in the price of a loaf of bread is the same whether you are a trust chief executive or a cleaner. Why should the CEO get a pay increase of more than ten times that of the cleaner, as would be the case if you have a percentage increase,” said Unite head of health Rachael Maskell.

According to one recent report, the boss of a failing NHS trust was awarded a £30,000 pay rise as patients were deprived of fluids and forced to wait in a car park because A&E was full. Karen Jackson, chief executive of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, is reported to have accepted a 20% increase last year, taking her salary from £140,000 to £170,000.

Even if you refute that the global financial crash was due to failure of the investment banking sector, it’s impossible to deny that the current economic recovery is not being ‘felt’ by many. Indeed, some City law firms have unashamedly reported record revenues in recent years. Many well-known multi-national companies have yet further managed to avoid paying corporation tax in this jurisdiction.

Sir Bruce Keogh has himself admitted that extra money and “outsourcing” of some services to the private sector will be used to attempt to head off an immediate crisis, but will say the whole system of health care needs to be redesigned to meet growing long-term pressures.

This is on top of an estimated £3bn reorganisation of the NHS which the current Government has denied is ‘top down'; in their words, it is a ‘devolving’ reorganisation; similar to how the ‘bedroom tax’ should be a ‘spare room subsidy’ according to the Government and the BBC.

A poet who uses language far better than either the current Coalition or the BBC is Samuel Taylor-Coleridge. One of his poems, “The Rime of the Ancient Mariner”, relates the experiences of a sailor who has returned from a long sea voyage.

The poet uses narrative techniques such as repetition to create a sense of danger, the supernatural, or serenity, depending on the mood in different parts of the poem.

Water, water, every where,
And all the boards did shrink;
Water, water, every where,
Nor any drop to drink.

Like the manner of this poem, the mood of the NHS changes with the repetition of certain language triggers such as ‘sustainability’.

More than £4bn of taxpayer funds was paid out last year to four of Britain’s largest outsourcing contractors – Serco, Capita, Atos and G4s – prompting concerns that controversial firms have become too big to fail, according to the National Audit Office.

But according to the National Audit Office, increasingly powerful outsourcing companies should be forced to open their books on taxpayer-funded contracts, and be subject to fines and bans from future contracts in the event that they are found to have fallen short. The report estimates that the four groups together made worldwide profits of £1.05bn, but paid between £75m and £81m in UK corporation tax. Atos and G4S are thought to have paid no tax at all.

“[This report] raises some big concerns: the quasi-monopolies that have sprung up in some parts of the public sector; the lack of transparency over profits, performance and tax paid; the inhibiting of whistleblowers; the length of contracts that taxpayers are being tied into; and the number of contracts that are not subject to proper competition,” said Margaret Hodge, chair of the public accounts committee, who commissioned the NAO to carry out the study.

As for the NHS, Keogh describes it as ‘complete nonsense’ that his proposals are a ‘downgrading’ or ‘two tier system’. As an example, Keogh says there has been 20% increased survival rate in major trauma by treatment in a specialist treatment on the basis of his 25 designated trauma centres. Keogh’s focus is on major trauma, stroke or heart attack.

This is a perfectly reasonable observation, in the same way that the existence of the tertiary referral medicine centres for clinical medicine, such as the Brompton, the Royal Marsden or Queen Square, for highly specialist medical management of respiratory, palliative and neurological medicine should not be interpreted as the NHS Foundation Trust ‘tier’ offering a second-rate service on rare conditions. Developed after an extensive engagement exercise, the new report proposes a new blueprint for local services across the country that aims to make care more responsive and personal for patients, as well as deliver even better clinical outcomes and enhanced safety.

Keogh advocates a system-wide transformation over the next three to five years, saying this is “the only way to create a sustainable solution and ensure future generations can have peace of mind that, when the unexpected happens, the NHS will still provide a rapid, high quality and responsive service free at the point of need.”

But it is highly significant that this ‘beefed up system’ is building on the rocky foundation for the NHS since May 2010, where the Coalition has ‘liberalised the market’. Far from giving the NHS certainty, the Health and Social Care Act (2012), as had been widely anticipated, has liberated anarchy and chaos.

There are many more private providers delivering profit for their shareholders.

However, the National Health Service has been propelled at high speed into a fragmented, disjointed service with numerous providers not sharing critical information with each other let alone the public.

Only this week, Grahame Morris, Labour MP for Easington, warned yet again about how private providers are able to hide behind the ‘commercial sensitivity’ corporate veil when it comes to freedom of information act requests. This wouldn’t be so significant if it were not for the fact that ‘beefing up’ the NHS 111 system is such a big part of Keogh’s plan.

NHS 111 was launched in a limited number of regions in March 2013 ahead of a planned national launch in April 2013. This initial launch was widely reported to be a failure. Prior to the launch the British Medical Association – affectionately referred to by the BBC as “The Doctors’ Union” – had sufficient concern to write to the Secretary of State for Health requesting that the launch be postponed. On its introduction, the service was unable to cope with demand; technical failures and inadequate staffing levels led to severe delays in response (up to 5 hours), resulting in high levels of use of alternative services such as ambulances and emergency departments. The public sector trade union UNISON had also recommended delaying the full launch.

The service has run by different organisations in different parts of the country, with private companies, local ambulance services and NHS Direct, which used to operate the national non-emergency phone line, all taking on contracts last year. The problems led to the planned launch date being abandoned in South West England, London and Midlands (England). In Worcestershire, the service was suspended one month after its launch in order to prevent patient safety being compromised. The 111 non-emergency service has faced criticism since a trial was launched in parts of England last month. Some callers said they had struggled to get through or left on hold for hours.

Andy Burnham, Labour’s shadow health secretary, at the time accused the Government of destroying NHS Direct, “a trusted, national service” in an “act of vandalism”. “It has been broken up into 46 cut-price contracts,” he said. “Computers have replaced nurses and too often the computer says ‘go to A&E’.”

Clare Gerada, also at the time, said that the introduction of 111 had “destabilised” a system that was functioning well under NHS Direct and called for non-emergency phone services to be operated in closer collaboration with local GP services.

“The big problem about 111 is of course money,” she said. “It was the lowest bidders on the whole that won the contracts… If you pay £7 a call versus £20 a call you don’t have to be an economist to see that something’s going to be sacrificed. What’s sacrificed is clinical acumen.”

Keogh is keen to put a different gloss on the situation now. He admits that people wish to talk to clinician if they are worried, rather than an “unqualified call handler”. He says that this is possible ‘but we need to put the infomatics in place’. 40% of patients need reassurance, according to Keogh. Keogh then argues that, if there is a concern, an ambulance can be called up, or a GP appointment can be arranged.

However, for this system to work, people offering out-of-hours services will not just be dealing with a third degree burn in the absence of any previous medical history at all. There will be patients with long-term conditions like diabetes, asthma and chronic heart disease, who might not have to use A&E services so frequently if they were supported to manage their health more effectively.

Some of these patients will be ‘fat filers’, where it’s impossible to know what a medical presentation might be without access to complex medical notes; e.g. a cold in a profoundly immunosuppressed individual is an altogether different affair to a cold in a healthy individual. Likewise, individuals with specific social care needs will need to be recognised in any out-of-hours service.

The aim of ‘beefing up’, as Keogh puts it, the ‘National Health Service’ was to make it a coherent service across all disciplines, with clinicians – as well as top CEOs – adequately resourced out of general taxation.

As it is, it is pouring more money into people who have not delivered the goods thus far.

The solution to failed outsourcing cannot be more failed outsourcing. As one interesting article in ‘Computer Weekly’ explained recently, the “NHS 111 chaos is a warning to organisations outsourcing”.

The report has also made a case for improved training and investment in community and ambulance services, so that paramedics provide more help at the scene of an incident, with nurses and care workers dispatched to offer support in the home, so fewer patients are taken to hospital. This can work extremely well, provided that resources are allocated to such services first, and there is a proven improvement in quality (which seems very likely.)

And if somebody tells you it’s all about sustainability – tell them there’s water water everywhere, and there’s not a drop to drink as this recent event provoked.