Now that the NHS is going to be run along business lines to improve efficiency I’ve been thinking about the role of my patients. Policy bods think about the role of systems. It’s my job to think about the role of patients.
Health is distributed according to socio-economic status so that my patients, who are on the whole severely deprived, are also pretty sick and in need of a lot of care. So under an NHS that plans and delivers care according to need, they would get more care than patients who are better off and more healthy.
But under the new NHS that doesn’t plan care, but delivers it according to business principles, I’m worried that my inefficient patients will get less care.
Why are they inefficient?
1. Many of them cannot read or write so they have trouble understanding appointments, diseases, treatment regimes etc.
2. Many have mental illnesses including severe anxiety, depression, schizophrenia, dementia so that they are forgetful and chaotic.
3. Many are addicted to drugs and alcohol, so they are unpredictable and chaotic and frequently present to hospitals at a point of crisis.
4. Many are socially isolated, especially the people described above, the elderly, single mums, immigrants and so on. They present very frequently for company and reassurance.
5. Many have complicated mixes of different chronic diseases such as diabetes, heart disease, arthritis, renal disease, and so on, frequently compounded by mental illness, so they need a lot of care.
6. Many are very poor, over 50% do not have a car and many struggle to pay to travel to appointments, so often don’t attend, or don’t collect prescriptions if they have to pay.
7. Many of them don’t attend appointments for all the reasons above, so we cannot look after them effectively or perform all the checks for which we are paid.
8. Lots of them don’t take their medications, and so we struggle to get their diseases under control and then don’t get paid when their blood pressure (for example) is too high.
9. Many have very unhealthy lifestyles for which there are medical consequences, but little in the way of medical solutions, so they don’t get better no matter what we do.
10. A lot don’t trust doctors. And stay well away or ignore whatever we suggest.
These patients need looking after. They need a lot more care than patients who are better educated, wealthier, and more secure. Because they do not, cannot behave ‘efficiently’, their GPs and hospitals will appear to be inefficient. And the market solution for inefficiency is, either to become more efficient, or be closed down or taken over. Lansley has said for the NHS market to work, inefficient providers must not be bailed out.
The Inverse Care Law, coined in 1971 by Julian Tudor Hart is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served, This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.
Doctors and patients work together as ‘co-producers’ of health. Efficiency in health care is therefore a joint effort. This is most clearly explained in Tudor Hart’s latest book published in September last year: The Political Economy of Health Care. It is absolutely essential reading.
The risk that these reforms pose to vulnerable patients is particularly grave.
To preserve an NHS where patients, not profits come first: