The NHS needs reform, not amendments.

They do not know what they are doing nor have they any idea of the consequences of their action.

Lord Owen Independent April 3rd 2011 writing about the Government’s NHS reforms

The Health and Social Care bill is so flawed that it is not fit for amending.

Those parts of that may be of benefit, such as greater clinician involvement in decision making are too tightly hitched to the most damaging parts, such as the purchaser-provider split and the external market. The damaging parts of the bill are so dangerous that no amount of amending can make it safe.

The NHS is in need of reform. There are problems that urgently need to be improved.

1.Improve collaboration. Community, primary care and hospital specialists need to work together. At present shared care is on the whole poor to non-existant, though there are patchy exceptions. Hospital doctors need to know what they can expect from the GP once their patients are discharged so that they can confidently share responsiblity. They need quick access to the detailed clinical and personal information held by GPs. They need to be informed of problems and clinical complications in order to improve standards of care and help avoid unnecessary referrals and admissions. GPs need to have flexible access to hospital specialists for advice. For 40 years we could phone our local hospital and speak to a consultant, but now because of the purchaser-provider split, we have to set up a contract and pay for an advice line, which is far less convenient than the old infomal service. We need to know when our patients are admitted and discharged. Many times I’ve turned up to visit someone only to find they’ve been admitted to hospital and all too often there are long delays between discharge and my receipt of their records. Both hospital specialists and GPs are aware of huge variations in clinical practice, but without good communication and collaboration, little or nothing is done. Evidence from the US Mayo clinic and others shows that when clinicians collaborate (rather than compete) costs and clinical errors are reduced and quality increases.GPs and hospitals need to be able to feed back concerns about how their patients were treated, and patients need to be able to do the same, all with the knowledge that when appropriate, changes will be made.

The close collaboration that is needed cannot happen with a multitude of providers. It depends on GPs working with local specialists and getting to know them personally. At present we meet, personally with our local psychiatrist, psychologists, district nurses and health  visitors, specialist diabetic and heart failure nurses and others. We know some of our local consultants well and have worked out several effective joint services. A multitude of providers will make close relationships impossible. For our most vulnerable, complex patients this is potentially dangerous.

2. All providers need to share responsiblity for the health of a defined population.We must abandon the purchaser-provider split. GPs are providers of health care. If GPs are purchasers there is no way to avoid the potential for conflict of interest. The purchaser-provider split damages relationships between GPs and specialists and hinders rather than facilitates joint responsiblity for patient care because GPs are trying to reduce medical interventions to save money at the same time as hospitals and others are trying to increase interventions to earn money. It is an absurd situation.
3. Continue to invest in NICE and improve the dissemination of and monitor the use of guidelines. There is a great deal to be gained from better adherence to clinical evidence. Guidlines are all too often not followed because of lack of familiarity rather than clinical reasoning.

4. Measure outcome data more effectively. The outcome of health care is health gain. It is very difficult to measure health gain because of the huge numbers of variables, the social determinants of health, the subjective nature of health, the variable time-lags between interventions and outcomes and more. If we are to become more efficient, then we need also to agree on how to measure efficiency.
5. Federate GPs in a geographical area so that they work collaboratively to share resources and take responsiblity for peer performance. The failure of PCTs and the GP profession to manage underperfoming GPs is inexcusable. It is part of the political justification for competition on the assumption that it will drive out poor quality despite there being no evidence that competition between GPs will do this. Because of their long history of independence GPs are not used to working with their peers. This situation is not sustainable and urgently needs to change. The Royal College of GPs has proposed this in the past. This is an excellent idea, but will need firm leadership, expert management and a range of incentives if it is to succeed.
6. Reduce health inequalities. Having worked in deprived and affluent areas I know that general practice in deprived areas is far more clinically challenging and less financially rewarding. There are serious inequalities in the resources available, the quality of care and the incentives for GPs. The govt has made a serious error in assuming that inequalities are not an issue. Proposed funding allocations will widen inequalities and threaten the financial viabilty of general practice in areas with the greatest health needs. Efficient care depends on efficient patients and the impact of markets on inefficient patients will result in the Inverse Care Law. The appalling capitulation to alcohol and junk-food manufacturers under the guise of public health policy is an indication of the government’s failure to take seriously the social determinants of health. Strong public health leadership and close collaboration is essential here. See the recent BMA recommendations for public health reform.

Other important areas for improvement are greater financial and clinical transparency and accountablity. Greater patient involvement. Improved multidisciplinary teamwork between doctors, nurses and other allied health professionals. Better management training: for managers and clinicians.

The proposed reforms will worsen the existing problems of poor communication and collaboration in the NHS. They will fail to address poor standards and they will widen inequalities.

Reform is desperately needed and it can address the major problems the NHS faces, but the health and social care bill needs to be rejected. Belief that it can be amended is naive and dangerous.

5 responses to “The NHS needs reform, not amendments.

  1. Also in today’s SIndy:

    ‘Exclusive: Cameron signals retreat on NHS reforms: Health Secretary’s plans have been put on hold as PM has yet again signalled an embarrassing about-turn By Matt Chorley and Nina Lakhani’

  2. It is a tragedy that so much time and money has already been spent building consortia and rebranding PCTs as independent commissioning hubs. Meanwhile creative caring NHS underlings – who supported the kind of joined up reform you propose – have been discarded.
    Add their redundancy pay to the consultancy fee taken by KPMG and just think how much we could have spent on the kind of shared care GPs really want.
    Having been to several interprofessional workshops locally, I know good clinicians want the kind of reforms you propose. Sadly the so-called reforms will do nothing to bring about cost-effective clinical improvement.

  3. As a patient (with a chronic condition) I want my GP to be at the centre of my care. This surprises my leftie colleagues because they say I should be against “GP commissioning”. What I am against is the line in the white paper that says “GPs should align clinical decisions with the financial consequences” because I want clinical decisions, I do not want my GP to see me as a financial drain. I want my GP to be my advocate, my friend. I do not want him to see me as a bottomless pit into which his profit sinks.

    Multiple providers is a waste and it makes more likely people falling between the cracks. With my own care I find that multiple providers want to provide monitoring. I have asked them to stop contacting me because my local hospital does that monitoring and they say they cannot without my consultant writing to them. Sorry, but that is just touting for business, so I do not turn up to their appointments. Wasteful.

    I want my GP as the point of contact throughout my treatment. Rather than my GP simply handing me off to the hospital for treatment and then taking up the baton once I have been discharged, I want my GP to be involved throughout. If I have a query, or an issue with my care, my GP should be the point of contact.

    All of this can be sorted out through greater collaboration, and that means providers putting the patient first rather that making surpluses or profits their primary aim. (Actually, I would *require* that any provider taking NHS cash should have to invest any surplus into healthcare – particularly removing health inequalities – and removing totally the possibility of making profits from NHS cash.)

    Further, I would like to see a “family doctor service” rather than have “primary care providers”. Labour changed the law to allow companies like The Practice plc to be created. These companies are not community based. A family doctor – by necessity small scale and community based – will be closer to the community and better placed to understand the health issues of that community. Small is good.

  4. Not a doctor, so general points to excellent analysis above (NB highly recommend Julian Tudor-Hart’s book):

    – time for salaried GPs – no place for this bribe in C21 healthcare system; at present, doctors could also profit from Lansley proposals:; maybe this is why some GPs already formed themselves into groups/’consortia’ – see below.

    – need emphasis on prevention (of ill-health) as much as treatment (pt 6 above). Diabetes (& diabetic blindness), obesity, chronic heart disease – just a few examples of largely preventable conditions which place an enormous burden on NHS. Birmingham’s ‘Gym for free’ showed recently how improved cardiac health/decline in obesity, therefore lessening burden on NHS, can be achieved through intelligent, commonsense preventive health measures.

    But as worrying as Lansley’s proposed changes themselves is the undermining of the democratic process which is going on in parallel, see eg Telegraph 3 April:

    ‘NHS reforms ‘gone too far already to be undone’:

    As Health and Social Care bill hasn’t yet been passed by parliament (and might be rejected by Lords or fall at its 3rd reading if the 57 LIbDem MPs reject even the amendments proposed by David Owen), how can the ‘reforms’ have gone ‘too far’? Part of the answer must lie with some GPs/PCTs playing the ConDem game (former have already begun to form themselves into groups/’consortia’, the latter to disband. Ironic that doctors could be said to be complicit in this undermining of the democratic process.

  5. Great post. Agree collaboration is essential to provide good healthcare.
    You seem to focus on those with chronic or longterm illnesses i.e. patients you come into contact routinely but what about the majority(at present) who don’t need all that care or come into contact with GPs far less.
    If for example someone who was registered at your surgery became injured whilst playing sports would it not be advisable for that patient to go straight to sports injury clinic/physio rather than go to A&E/GP?
    Of course with the ageing population this will dramatically change in a decade or so.

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