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.