A Better NHS

Most people agree that the point of the NHS is to provide health care free at the point of delivery. Doctors for Reform are notable exceptions, arguing that you should pay to see your GP, but they are considered by most in the profession to be a right wing fringe even if they do appear to have Lansley’s ear. Free care may be one of the principles of the NHS, but it is not the most important.

More importantly, the point of the NHS is to distribute health care according to need.

As John Lanchester describes in his gripping guide to the world of finance and the economic crisis, “Whoops!”

“Capitalism is not inherently fair: it does not, in and of itself, distribute the rewards of economic growth equitably. Instead it runs on the basis of winner takes all and to them that hath shall be given. For several decades after the second world war the western liberal democracies devoted themselves to the question of how to harness capitalism’s potential for economic growth to provide better lives for ordinary people. The jet engine of capitalism was harnessed to the ox-cart of social justice. This was the cause of much bleating from advocates of pure capitalism, but the result was that western liberal democracies became the most admirable societies the world has ever seen. Not the most admirable we can imagine, and not perfect; but the best humanity had as yet been able to achieve. Then the Wall came down, and to various extents  the governments of the west began to abandon the social-justice aspects of the post-war project. The jet engine was unhooked from the ox-cart and allowed to run off at its own speed. The result was an unprecedented boom, which had two things wrong with it: it wasn’t fair and it wasn’t sustainable.

Notwithstanding the contraversial (to some) link that Lanchester makes between the collapse of the Berlin Wall and the unhitching of social justice from the economy, the gross and widening social-economic inequalities over the last 30 years are beyond reasonable dispute.

The Tory Health White Paper, like the New Labour policy that preceded it is based on the ideological conviction that the ox-cart of the NHS is holding back the jet-engine of commercial healthcare.

The historian Tony Judt gives the unhitching a more detailed analysis in his recent book, ‘Ill Fares the Land‘

Markets follow the money. Goods are distributed not where they are needed but where the money is. Consider any commodity, food for example. There is plenty of food to feed everyone on the planet, but while rich countries are facing an obesity epidemic and throwing away millions of tonnes of food every year, millions of people in poor countries are still dying from diseases related to malnutrition. See the excellent book “Stuffed and Starved” by Raj Patel, or take a trip to Hoxton market near my surgery (4 jumbo bags of Dorito’s for £1) and Broadway Market in a ‘nice’ part of Hackney (organic truffles £1 each).

Markets lead to crap for the poor and indulgence for the wealthy. Too little care for those who need it, too much for those who don’t. Bevan knew this over 60 years ago when the NHS was born, under worse economic conditions than we’re experiencing now. Bernard Shaw knew it a century ago:

And every hypochondriacal rich lady or gentleman who can be persuaded that he or she is a lifelong invalid means anything from fifty to five hundred pounds a year for the doctor. Operations enable a surgeon to earn similar sums in a couple of hours; and if the surgeon also keeps a nursing home, he may make considerable profits at the same time by running what is the most expensive kind of hotel.

Meanwhile the sickly poor had to make do with charity or nothing.

There is another point to the NHS, of less obvious importance than free care distributed according to need, but of profound importance to our society. The NHS binds us as a society together. Everyone who contributes to the NHS can feel condident that no matter how we feel about the work we do, roughly every 11th hour we work can be considered our contribution to the care of people who need it. We can be (or could be) assured that people less fortunate than ourselves, thanks to us, are being treated by the NHS. Because of the government’s ideological conversion of the NHS from a public service to a commercial business, the NHS will become nothing more than a brand. There will be no NHS care any more. The money, instead of being spent on care for people who need it, will be given to a commissioning organisation that will pay private companies and give them the right to use the NHS brand. Our money will go to private companies who will divide it between care and shareholders, keeping the maximum possible for their shareholders. We will loose an institution that binds us together. As Sir Ara Darzi said in his resignation letter to Gordon Brown last year:

“The NHS is the greatest expression of social solidarity found anywhere in the world: it is as much a social movement as it is a health system. It is not just that we stand together but what we stand for: fairness, empathy and compassion. It is for these reasons that we all care so deeply about its future; and it is why I stand ready to contribute to ongoing efforts to invest in and improve the NHS, in any way I can.”

Imagine you’re a gastroenterologist working in a large PFI hospital with a multi-million pound PFI debt. Your hospital is a foundation trust and therefore contractually obliged to make  a profit. You’re aware (albeit dimly) that somewhere in the health white paper it says that if your hospital can’t turnover an operational profit you’ll be either closed down or more likely taken over, perhaps by Sainsbury’s.

Your managers are leaning on you (and every other department) to work more efficiently in order to raise cash for the hospital. Last month (for the 10th month in a row) the general surgeons won the prize for income generation thanks to their busy gastric band and bypass service.

Your next patient comes with a short letter of referral from their GP saying that their acid reflux wasn’t settling after treatment with 2 different acid suppressants and testing for helicobacter was negative. Could you give some advice and perhaps perform an endoscopy?

Most GP’s who want an endoscopy refer direct to the nurse specialist. She is making plenty of cash, no time wasted listening to the patient’s story, just a busy production line with a patient in and out every 35 minutes, a generous tarif for every scope and next to no complications. Easy. Running a general outpatient clinic is different however. Up to 60% of patients in hospital outpatients have medically unexplained symptoms (MUS). What about them?

This patient seems more straightforward however. Not so long ago, faced with a patient with heartburn, you would have taken a history, examined the patient, repeated some blood tests, done an endoscopy and referred back to the GP with advice about future management. Now, forced to fill the yawning hole of debt and catch up with your more ‘efficient’ colleagues you’ve had to completely change your practice. Every test you arrange, every procedure you carry out, every colleague you refer this patient to for another opinion generates money for your hospital. The GP gets the bill. (Actually presently the PCT gets the bill and then shows the GP how much money they’ve spent. If the white paper goes through, the GP will be billed directly.)

Acid reflux is frequently difficult to treat and fails to respond to the usual medications which is why you still get a few referrals. Heartburn can cause chest pain so you could ask for a cardiology opinion. In some cases reflux can cause a chronic cough  so you could ask your respiratory colleagues if they’d be so kind as to arrange some tests for asthma. Reflux can cause a sore throat, so you could refer to your ENT colleagues to check his pharynx and perhaps arrange a scan of his neck. You could arrange an ultrasound of the patients abdomen and perhaps if they have gallstones you could as for the surgeons to consider removing them.

Remember, every test, every procedure and every referral gets billed to the GP and the hospital gets the cash.

You swallow down some of the professional pride that’s protesting and fill in forms for blood tests, endoscopy, ultrasound, ECG and opinions from your ENT, Cardiology and Respiratory specialist colleagues, each of whom is also under pressure to perform as profitably as possibly. Each of them will be forced to think about the patient in terms of how much income they can generate for the hospital.

You don’t believe it’s got anything to do with efficiency any more. Its obvious to anyone that if you’re efficient you’ll do less and earn less. There are patients who’ve seen every specialist and are still being passed around having more and more money extracted from them. These are the ones at the more severe end of the medically unexplained symptom spectrum, doctors used to call them heartsinks, now the managers call them ‘cash cows’ because no matter how much work you do on them, you can still do more. People with medically unexplained abdominal symptoms are 3 times more likely to have their gallbladder removed, twice as likely to have their appendix or uterus removed and 50% more likely to have back surgery compared to a matched control group. They are also significantly more likely to commit suicide after surgery.

There is a growing body of research on how best to manage patients with medically unexplained symptoms. For the last few months I’ve been involved with psychotherapists and psychiatrists at the Tavistock to see how better to look after these unfortunate people. For years they’ve been treated as heartsinks, timewasters and nutcases. What is beyond doubt is that people with MUS are really suffering and they are harmed by excessive medical interventions and helped by an enduring supportive relationship with a clinician. And thanks to work with the Tavisock and others the awareness of MUS and how better to identify patients and care for them the situation might improve. However …

Both the incidence of MUS and the associated harm is higher in healthcare systems with ‘perverse incentives’ (financial drivers of clinical activity) like the US. The health white paper marks a decisive and deliberate change towards a system of perverse incentives, in which profitability is the bottom line and the possibility of continuity of care is being destroyed by the twin tyrannies of patient choice and multiple providers.

Sir David Nicholson came to Hackney last week, after his infamous, ‘if you don’t like it get out now’ speech. He was presented with a case very similar to that outlined above and was speechless. It hadn’t occured to him that this was the kind of disaster awaiting us if the commercialisation of our NHS goes ahead.

We have to hope we’ve made an impression.

Please spread the word. This white paper will destroy the NHS.

From Ehealth Insider Primary Care

Sir David told the NHS Employers conference last week that the NHS faced the “biggest management of change exercise in the world” and that the changes outlined in the government white paper Equity and Excellence: Liberating the NHS would have to be managed alongside the £20billion savings already outlined for the service.

He said he himself had “gone through a whole series of emotions about the service and how we take things forward” but that staff currently working in the NHS could be divided into three groups.

He added: “There are those people in the service who essentially hate all this. My view is that they should go.”

Nicholson told the conference that 2000 people had already left through the Mutually Assured Resignation Scheme at a cost of £40m but generating savings in a year of £70 million.

He added: “For all sorts of reasons that’s a good deal and we need to think about how we expand that in future.”

The NHS chief executive said a second group of staff, those who did not want to be part of the new structures but were prepared to support the transition, should be given some certainty over what will happen to them.

He said the third group of people, who he defined as those who supported the ideas in the white paper, should be helped to learn new skills if necessary and moved into new positions as quickly as possible.

So… doctors and nurses who hate the white paper can leave to join private providers…. and then be re-employed to do the work they used to do for the NHS… without any of the employment rights or pensions they were entiled to. Alternatively they could stay… and then be taken over by the a private provider and then be re-employed to do the same work etc. etc.

David, its time for your medicine, now come quietly…

Thanks to a review of the recent Commonwealth Fund report for 2010 by Paul Corrigan.

Members of the public were surveyed from 11 countries; UK, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the US.

They were asked that if they looked at the health system as a whole, do they think it needs minor changes in the system; fundamental changes; or do you think it should be rebuilt completely.

3% in the UK think the system needs to be rebuilt completely (the lowest in the world). 34% think there needs to be fundamental changes, and 62% think that only minor changes are needed. The UK public think their health care system needs changing less than any of the other countries surveyed.

There is very little professional appetite for the government’s proposals in the health white paper. Because it is a gift to private enterprise, the enthusiasts are very often GP entrepreneurs who have, or are planning to set up private companies like The Practice or Chilvers Mcrae. In a debate I had with Civitas the opponents (Steve Smith from Imperial in particular) made great play of how desperately awful the NHS was and how much it needed to change. That the NHS is either far too expensive or unpopular is a common theme from the privatisation advocates, but it doesn’t stand up to international comparisons. Julian Le Grand (another privatisation ideologue) is fond of saying that health systems should be judged by patient satisfaction, I hope he’s read the Commonwealth fund report.

As Paul Corrigan says,

If I were a Government about to embark on the biggest change in the health care system since the war this would give me pause for thought.

At the moment the public don’t think their system needs big changes.

I am not saying whether they are right or they are wrong, but their opinion could politically be very important.

Because if you start a revolution the public think isn’t necessary – and mess it up – they are likely to be pretty angry with you.

The idea that there is anything other than fringe support for the government’s reorganisation of the NHS needs to be exposed as propaganda and we doctors should take courage that if we take on this fight against the health white paper we will have the support of our patients and the wider public.

The majority of GPs are supportive of the new Chair of the Royal College of General Practitioners Clare Gerada who recently publicly announced her opposition to the government’s health white paper.

In areas with the greatest health needs GPs are most acutely aware of the social determinants of health and the desperately wide (and widening) inequalities in health and health care provision and so perhaps the objections are strongest, yet even at a recent British Medical Association Meeting there was almost unanimous opposition to the white paper.

It is becoming increasingly clear that GP entrepreneurs and the ‘circling wolves of the private health industry’ are the only ones with anything to gain from the white paper proposals. Patients, doctors, nurses and other health professionals are joining forces in their opposition and Lansley is looking more and more isolated.

At a recent meeting in Hackney of almost 100 GPs there was near unanimous opposition to the White paper. The same happened in neighbouring Tower Hamlets. The letter below is from Jackie Turner, Chair of the Tower Hamlets GP forum addressed to the Royal College of General Practitioners.

Hon Sec.

I am writing in support of Clare Gerada our new Chair.

It is entirely predictable that officials within the Department of Health will seek to rubbish her disquiet over the proposed NHS reforms, but she should not buckle under the pressure. We need more outspoken opposition to the White Paper from our leadership. Sir John Oldham claims that her comments are at odds with the profession she represents, if this is what he really believes then it is him that is out of touch.

I attended a London Regional Meeting of the BMA on 4^th November to discuss the White Paper. The feeling of grass roots doctors from the floor was very much against the reforms. An indicative vote was taken demanding that the BMA council call a Special Representatives meeting to discuss the White Paper, (something that they are refusing to do). The vote was overwhelmingly for the motion, with only two voting against. The vast majority of the speakers from the floor expressed grave concerns that the reforms signal the break up of the NHS, that GPs are being set up to fail, opening the door to the private sector, ushering in a US style health care system.

This is not what doctors that I talk to want. I am Chair of Tower Hamlets GP Forum. We held a special meeting in July to discuss the White Paper. There was standing room only. Nearly one hundred local GPs came. Not one of them welcomed the reforms.

We need our leadership to speak out against the White Paper. We need to protect the NHS as the provider of health care, irrespective of ability to pay, from cradle to grave. We do not want a multi-tiered health care service where the poorest in society are left to die on the streets because they can’t afford the insurance or the fees.

I support Clare Gerada and urge her to go further. I urge her to lead the profession in opposition to these reforms because together we can stop them.

A Department of Health spokeswoman said: “Our reforms will indeed mark a new era for the NHS – one where patients and clinicians are at the heart of the service. Our reforms aren’t an option, they are a necessity….” Guardian 19.11.2010

The perception most GPs have is that no amount of appeals to the Department of Health or the Commons Health Committee will change what is being described as a “done deal”. The fear is that if GPs don’t become the commissioners, private corporations will be bought in to do the commissioning for them, and it is this fear which is driving many to go ahead with the Health White Paper proposals they despise.

“NICE is accountable to the public,” Lord Crisp – the former NHS chief executive – advised Parliament last week. “What we don’t need is to import American style private sector rationing where individuals find themselves the victims of decisions made in private by individual insurance companies where nobody is accountable.” Health Service Journal

What is more, in the not too distant future, uncapped university fees will lead to newly qualified doctors with unprecedented debts who will then be easy prey for insurance companies who will offer them a salary and structured debt repayment they’ll find hard to refuse…but at what cost?

According to a thought provoking article by the eloquent David Loxterkamp, The Dream of Home Ownership

In the summer of 1984, no primary care physicians were employed by our local hospital. In the past 5 years, physicians who left or retired were all self-employed; contracted physicians took their place. The medical staff is now mostly on hospital payroll. This trend is neither isolated nor inexplicable. Graduates of private medical schools carry a median debt of $180,000; the burden of public school graduates is only slightly smaller at $145,000.00.³ Large corporate and hospital-owned systems are poised to invest heavily in recruitment incentives, loan forgiveness programs, higher salaries, and freedom from administrative worry. But at what cost for primary care?

The culture of group practice was studied in 2003 by Curoe, Kralewski, and Kassi.⁸ They found that 2 factors—size and ownership—were pivotal. The authors surveyed 547 primary care clinicians from 148 Midwestern clinics and analyzed their data using contingency and complexity theory. They found that clinics owned by private or hospital-based systems had “less organizational trust, less identification with the group practice, and less collegiality among physicians.”

We can expect the end of independent GPs. We will become the salaried employees of corporations and the bottom line will be profits, not patients. Medicine will be protocol driven with a loss of clinical freedom and less patient centred care, less commitment to our practices and our patients, and the loss of trust upon which our work depends.

As Dr Loxterkamp concludes:

Together we must demand a broader, more-farsighted, and compassionate view of the business of medicine. I am reminded here of another Christmas classic, and words uttered equally to the point:

“Business!” cried the ghost, wringing its hands again. “Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business.”¹Dickens, C. A Christmas Carol. Boston, MA: The Atlantic Monthly Press; 1920:33.

As we indenture our labor, mortgage our homes, lease our cars, and live on borrowed time, let’s at least own our conscience and the decisions about whom we serve. And work to create systems and structures that dignify and promote human relationships—the very foundation of primary care. We cannot afford to relinquish the dream. Ownership, by which I also mean a sense of commitment and empowerment, begins at home, in the medical home, at the heart of medicine.

Guardian letters Monday 22.11.2010

• It was timely to read that Clare Gerada “leads doctors against the white paper”. In doing so she echoes the sentiments of Sir Michael Marmot, the president of the BMA, who hit out at the government’s spending cuts last month, claiming that its insistence that its proposals would create a fairer society were a “grotesque parody of the word fairness”. They both speak for growing numbers of health professionals opposed to the health white paper, many of whom have joined organisations like the NHS Support Federation and Keep Our NHS Public.

The gross and widening inequalities in health and healthcare provision cannot be justified in a society as rich as ours which prides itself on universal health care. A commitment to put patients before profits and defend the principles of the NHS will restore trust in medical professionals and ensure care reaches those who really need it.

Dr Jonathon Tomlinson, Dr Mel Sayer, Dr Ruth Silverman, Dr Jens Ruhbach, Dr Alison Gibb, Dr Helen Godwin

A refreshing and timely replacement for Steve Field, Clare Gerada takes over as chair of the Royal College of General Practitioners.

Pulse

Dr Clare Gerada, who takes over as RCGP chair this week, has signalled an abrupt shift in the college’s relationship with the Government by warning she will directly oppose key elements of the NHS white paper.

Pulse: Video of interview with Clare Gerada

Guardian: Doctors warned to expect unrest over NHS reforms & Opponent of NHS refroms driven by grim memories of 60s

“I think it is the end of the NHS as we currently know it, which is a national, unified health service, with central policies and central planning, in the way that [Aneurin] Bevan imagined,” said 51-year-old Gerada, who represents Britain’s 40,000 family doctors. Lansley’s shakeup will lead to a much greater role for private healthcare companies, the likelihood that England’s health system will look more and more like America’s, and GPs being blamed for things such as the NHS’s inability to cope with a winter crisis, long waiting lists and the decommissioning of services to save money, she added.

Bed blocking of an altogether different order as furious pensioners threaten to stage hospital sit ins at a recent meeting in Camden.

National Pensioners Committee general secretary Dot Gibson said: “This coalition government is throwing down the gauntlet to those who uphold social justice. We must mobilise, organise and fight.

“We, as pensioners, remember what it was like in 1945 and 1948. We are facing it again – and it is our responsi­bility to take forward the struggle.”

Having just read Alone in Berlin by Hans Fallada, (whilst in Berlin) I was struck by Hannah Arendt’s reflection that evil is banal, committed by ordinary people just doing their jobs. Those responsible were very often petty careerists who refused to think about the wider impact. The resistance, on the other hand, was carried out by extraordinary people who thought of themselves as ordinary, who couldn’t avoid thinking about the wider impact of their actions.  People like Dot Gibson and Wendy Savage will always be part of the resistance.

We should all be inspired.

http://www.camdennewjournal.com/news/2010/nov/occupy-wards-threatened-closure-say-oap-leaders

A march organised by the British Medical Association last night erupted in scenes reminiscent of the student protests. A horrific climax resulted in a protester setting fire to himself outside the front door of the Tory HQ. The British Medical Association condemned the violence.

A recent analysis of the governments proposals for Universities by Stefan Collini in the London Review of Books raises the serious and under-reported fact that:

Browne wants to see universities attracting customers in a competitive marketplace: there will be a certain amount of public subsidy of these consumers’ purchasing power, especially for those who do not go on to a reasonably well-paid job, but the mechanism which would henceforth largely determine what and how universities teach, and indeed in some cases whether they exist at all, will be consumer choice. There are, naturally, some well-meant nods towards ‘quality assurance’ and ‘safeguarding the public interest’, and the report has a few good ideas for mitigating some of the harshest financial effects of its scheme on individual students from less advantaged backgrounds. But what is of greatest significance here is not the detail of the financial arrangements but the character of the reasoning by which they are justified. Britain’s universities, it is proposed, should henceforth operate in accordance with the tenets of perfect competition theory.

It’s not the cuts (stupid) its the markets.

Which of course is the plan for the NHS.

Tony Judt explains how we’ve got here with greater passion, articulation and historical analysis than I ever could in his new book ‘Ill Fares the Land’, and in the essay, ‘What’s Living and What’s dead in Social Democracy?’ which was the inspiration for the book.

The Goldsmiths lecturers were of course right, the real violence (the violence inherent in the system) is the government’s ideological bonfire of public services with the intent that markets’ will rise from the ashes to take their place.

And by the way. Don’t worry. We doctors are such political invertebrates we’d never protest, let alone catch fire.

A colleague has started providing primary care services to international students based in London. She was shocked to discover that not only American, but many other European female students with experience of health insurance expect to have an annual smear, pelvic ultrasound and hysteroscopy.

I’m horrified by the medical-industrial conversion of a young woman’s pelvis into a site of potential pathology, the profiteering and waste of medical resources on the healthy young and the risks associated with such a high risk of false postive results in screening, but I think we’ll be seeing a lot more of it over here before long.

Previous post: https://abetternhs.wordpress.com/2010/05/12/the-medical-industrial-complex/

In Hackney another established practice has taken over a list from a failing practice that has suffered years of substandard care. Over the years many of the patients have chosen to register at other local practices. Due to the density of housing, practice boundaries often overlap in urban areas and this enables a limited choice. Typically there is a choice of 2-4 practices and patients usually choose by word of mouth or personal recommendation.

The patients who did not leave were disproportionately old, housebound, mentally ill, and suffering from long-term/ chronic diseases. They were too ill, disorganised, frail, uneducated or immobile to change GP. Some patients had been advised to change GP by their hospital specialists. One advantage of a local hospital (in contrast to the proposed model of multiple willing providers) is that once consultants have been in post for a while they know which practices take better care of their patients and they can (and not infrequently do) recommend patients change.

Choice is exercised according to your levels of motivation, education, flexibility and economic and social status. In fact the more our patients need to be looked after and the greater their health needs, the less empowered they are likely to be to make choices. Furthermore patients who are less empowered are more likely to say that they have not been offered the choices they want.

The downside of choice is that it risks widening health inequalities because of the Inverse Care Law. This states that: “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” (Hart, 1971).

A recent review of patient choice in the British Medical Journal concluded that choice of treatment was more important to patients than choice of provider. A typical GP consultation is full of choices about different treatment options, but provider choice is rarely necessary because even once patients are referred to the local hospital they expect to be able to discuss the treatment options again with the specialist. There is a world of difference between the treatment choices of patient-centred medicine and choice of provider as a market lever.

When Mary comes in to ask whether she should have a tube placed directly into her stomach so that she can be fed during another 7 cycles of radiotherapy for her throat cancer… when Alfred comes to tell me that he absolutely won’t take insulin for his diabetes and wants to know the alternatives… when Sally wants to discuss vaccinations because her neice almost died after an anaphylactic reaction… what my patients need is a doctor they know and trust, someone who is experienced and sufficiently qualified to help them make serious choices about their care.There are many ways in which doctors’ behaviour can be improved, but as the example above shows, simply widening provider choice will leave those who most need care without it.

Many doctors who object to the proposed NHS reforms have been criticised for denying patients choice. I do believe in patient choice. For all of my (now 15 year) career, I have involved patients as partners in discussions about their care. There is not doubt that this is what patients want. But what I also believe is that choice has risks as well as benefits.  The risks of patient choice as a lever in healthcare markets is that those patients who are least able to exercise choice will be left with the worst care when they are the ones who need the best care, most of all.

“The White Paper’s proposals are ideological with little evidential foundation. They represent a decisive step towards privatisation that risks undermining the fundamental equity and efficiency objectives of the NHS. Rather than “liberating the NHS”, these proposals seem to be an exercise in liberating the NHS’s £100 billion budget to commercial enterprises” Lancet Oct 6th 2010

University of Liverpool Dept of Health Inequalities and Social Determinants of Health (Whitehead, Hanratty, Popay) Lancet 2010. The lead author, Professor Margaret Whitehead is the W.H. Duncan Chair of Public Health, and is also the Head of the World Health Organisation (WHO) Collaborating Centre for Policy Research on the Social Determinants of Health

Memorandum of evidence for Health Committee’s inquiry into Commissioning.

Summary.

The aim of any system of universal healthcare is to distribute healthcare according to need, hence avoiding the ‘inverse care law’ which states: “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” (Hart, 1971)

Evidence about health inequalities shows that the inverse care law still holds true today, and yet the aim of distributing care according to need has been replaced with the aim of distribution according to market forces. Economists as diverse as Freidrich Hayek, Adam Smith and Amartya Sen, all recognised that markets are blind to need. Whereas healthcare distributed according to need may be efficient, the converse is not true; for example refusing to treat someone may be cheaper than treating them and screening low risk populations can be highly profitable.

1. Commissioning increases the role and effect of markets in the NHS and will therefore exacerbate health inequalities. As GPs our primary duty as codified by the General Medical Council is to our patients. Mentor, the body set to oversee commissioning will add the conflicting duty to behave competitively and efficiently. Well educated, motivated patients with uncomplicated needs that are amenable to medical solutions can be looked after efficiently and will therefore attract more resources. Complicated patients with high levels of socially determined health needs, complex medical problems, low literacy and chaotic lifestyles cannot be looked after as efficiently and we will lose resources even though their needs are greatest. It is important to note that the very best quality care may not be efficient. Patients in primary care very often need a doctor who listens, who is considerate, understanding, and sympathetic and who gives a clear explanation and reassurance. It is hard to see how, if at all, visiting a bereaved patient or taking time to discuss a serious diagnosis can be deemed efficient. Up to 30% of patients in primary care and 50% in secondary care consult with medically unexplained symptoms. The evidence is that these patients benefit from continuity of care and are harmed by excessive investigations. British general practice has a universally admired tradition of continuity of care but this will be undermined by a plurality of providers and payment by results rewards excessive investigations.

2. The serious choices patients have to make, such as when to stop chemotherapy, whether to die at home or in hospital, whether to continue with an unwanted pregnancy depend on continuity because they are best made with a doctor they know and trust. These choices are far more important to patients than the choice of hospital.

3. GPs in affluent areas with low levels of need are already supplementing their income by offering cosmetic treatments, whilst in deprived areas GPs still lack the resources to manage serious physical conditions, psychological problems and drug or alcohol addiction.

4. Forcing providers of health within the NHS family to compete with one another instead of collaborating is a great threat to the provision of integrated care. My patients with serious long term conditions depend on close collaboration between primary, secondary and community care. The purchaser provider split and payment by results are already damaging the relationship between GPs and their hospital colleagues; GPs are suspicious that their hospital colleagues see patients in order to earn money even when they could be managed in primary care and hospitals worry that GPs are working beyond their expertise by holding onto patients in an attempt to make savings.

5. The abandonment of practice boundaries enables young, mobile patients with few health needs to join practices designed for them, leaving other practices to look after higher concentrations of complex, elderly patients. Historically, GPs have been able to afford to manage their complex patients because they have a balanced population, including an income from young people who only consult occasionally.

Summary.

The conversion of the National Health Service into a fragmented system of competing providers based on profitability marks the end of universal health care planned and distributed according to need.

Supplementary Memo

I thank the Health Committee very much for the opportunity to speak today.

There are just three comments.

1. One of the last questions from the committee was on the cost of commissioning. The questioner referred to the cap on administration costs.

Presently my PCT receives £33 per patient. We have been told that our commissioning group will receive just £9 per patient.

My reply informed the committee that the administration and transaction costs of running a market are higher than running a non-competitive system. Not only will we (City and Hackney GPs) have to take over PCT functions on a fraction of the budget, but we will be expected to take on the significant, additional costs of managing a competitive market. This is not recognised in the White Paper.

2. Efficiency is aimed at maximising profit. It’s essential that we don’t confuse maximising efficiency with responding to clinical need. If Dr Charlson sets up a blood testing enterprise on the doorstep of my surgery he may well be enterprising and efficient (blood tests are easy to organise efficiently), but he’s not responding to patient need, because we already do our own blood tests. Our patients need more drug and alcohol rehab provision, but under the proposed system it is not going to be provided unless it is profitable, in spite of the desperate need.

3. The other speakers objected to my comparisons with the US system. In my defence I will explain the similarities and I include the quote I read out and a reference.

The White Paper proposes that NHS services become social enterprises and hospitals become foundation trusts. These processes will allow the transform of the NHS from a publicly owned service into privately owned businesses. Secondly the intention to remove practice boundaries and allow patients to register with commissioning consortia is based on the US Health Management Organisation (HMO) model. Thirdly the conversion of the NHS into competitive markets converts medical care into a commodity in trade. Finally and most importantly, the major private companies competing to provide services to the NHS (like United Health) are US health care companies. It is for these reasons that I believe that comparisons with the US are vital if we are to understand our future prospects.

Quotation.

“The US devotes a much larger fraction of its GDP to health care than other advanced countries—nearly twice their average. We spend, in US dollars per person, two and a half times as much as our counterparts in Europe. The most important reasons for the uniquely high costs are its commercialization and the effects of business incentives on the provision of care. The US has the only health system in the developed world that is so much owned by investors and in which medical care has become a commodity in trade rather than a right.” Health Care: the disquieting truth<http://www.nybooks.com/articles/archives/2010/sep/30/health-care-disquieting-truth/?utm_medium=email&utm_source=Emailmarketingsoftware&utm_content=229811853&utm_campaign=September302010issue&utm_term=HealthCareTheDisquietingTruth>

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Opposing the White Paper – defending the NHS

Monday 11^th October, 7pm* – 9pm

Boothroyd Room, Portcullis House, Bridge Street Westminster (opposite Houses of Parliament), SW1

*arrive early, allow 20 minutes to get through security

Speakers include: Frank Dobson MP; Caroline Lucas MP, Gail Cartmail, Unite; Dot Gibson, National Pensioners Convention; John Lister, Health Emergency; Jonathon Tomlinson, GP; Wendy Savage, co-chair, Keep Our NHS Public; John Lipetz, Keep Our NHS Public (chair) and others.

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“The most important reasons for the uniquely high costs of the US health system are its commercialization and the effects of business incentives on the provision of care. The US has the only health system in the developed world that is so much owned by investors and in which medical care has become a commodity in trade rather than a right.”

Health Care: The Disquieting Truth Arnold Relman New York Review of Books

Little clots of blood float around the cloudy pink liquid in the jam jar Henry’s placed on the desk in front of me. The medical student beside me has in mind half a dozen possible, mostly serious causes of frank haematuria (visible blood in the urine) and I can see her jotting them down. Like too many men, Henry was hoping ‘things would sort themselves out’ for several weeks and only after his wife noticed the blood-stained toilet bowel could she cajole him to come in.

Nevertheless what Henry really wants to talk about is his son, just out of prison on a methadone script and looking for rehab. I was hoping to discuss Henry’s worsening renal failure – a consequence of his uncontrolled diabetes and high blood pressure. His wife wants to talk about his depression and worsening memory. The jar of bloody urine stands on the desk momentarily stalling any conversation while we sit waiting to see who will speak first and about what. Nine minutes remain of the ten minute consultation.

General Practice has developed during the last 60 years of the NHS to allow GPs a monopoly over the provision of primary health care. Because of this we are able to develop lasting therapeutic relationships with our patients that can extend over lifetimes and generations. It is possible for me to look after Henry and his wife for the rest of their lives, guiding Henry through what will, quite soon, be his final illness, his wife through her bereavement and their son through his drug detox and subsequent relapse. The long-term relationships that GPs have with our patients result in continuity of care. This allows us not only to manage ongoing ill health but also to be prepared for serious illnesses. How Henry might react to a diagnosis of prostate or bladder cancer and how we might then manage it cannot be understood without knowing about how he has managed (or failed to manage) his diabetes; how his wife aids him and helps with his medication and appointments; how his depression affects his behaviour and how the chaos and distress their son brings affects them all. A familiarity with the latest guidelines for managing haematuria is essential but negotiation and adaptation are essential if I am able to help Henry.

I’ve decided to focus on the bloody urine for now, but take time to arrange to see his son 15 minutes before my Thursday afternoon surgery (I’ll be glad of an excuse to miss the end of the meeting in which various imaging corporations pitch their services). I send an email to our practice nurse to ask if she can fit Henry into the next diabetic clinic before bringing the conversation around to the jar in front of us. Six minutes remain.

I test the urine sample and decant some into specimen pots to check for cancer cells and infection. I ask about other symptoms and perform a physical examination. My 10 minutes are up, but he still needs a referral. At the heart of the Coalition’s ideology is ‘patient choice’ so instead of referring Henry to the local hospital, I am obliged to spend valuable time guiding him through a range of private and voluntary providers offering services for his bloody urine. Meaningful choice needs to be informed and considered, but Henry doesn’t know what most of the 14 tablets a day he takes are for, he can’t recall whether his blood pressure is too high or too low and he only comes to appointments if his wife reminds him on the day. Usually when I ask him why he has come to see me, he says, “I don’t know, you’re the doctor!” In so many ways he is like my own father who despite being considerably more affluent and educated is equally ignorant of his treatment, happy to trust his GP and my mother ‘to worry about all that’.

The new commissioning organisation has made the job a little easier by restricting us to a short-list of ‘approved, value for money providers.’ The provider I believe to be in Henry’s best interests, – the local hospital – is not approved, but may be ‘negotiable’. Negotiation will involve spending valuable time writing letters trying to convince the commissioners that because of Henry’s depression, diabetes, renal failure and long history of missing appointments he needs to have his care at the local hospital. Unfortunately I later discover that the urology department has been ‘decommissioned’ for being too ‘inefficient’. The ‘one-stop’ heamaturia clinic has become ‘two-stop’ because a private company has the contract for day-surgery and the cystoscopies (bladder scopes) are being done at another hospital, while the local operating theatres are concentrating on more profitable gynaecology. I no longer know what is in Henry’s best interests.

What Henry wants, and more importantly needs, is to be looked after, but he’s told he must ‘take responsibility and choose’. As his advocate I must help him choose and also fight to keep the services he needs. As his GP my days may be numbered. More efficient providers will move in to provide convenient care for young healthy people who will choose not to spend time waiting to see a doctor whose clinics run late because of complicated patients like Henry. Instead of waiting they will register with Virgin, or any number of competing providers who know healthcare is most profitable when the patients aren’t really sick.

I’ve been recommending this new, significantly revised edition ever since Julian sent me a copy last year. He is able to explain better than any living doctor or politician, how vital politics  are to health care, even down to the intimate relationships between doctors and patients. Most GPs are exhausted with the effort of dealing with our patients and the management of our practices. We lack the time and knowledge to understand our work in its political and historical contexts. We need to read this book.

This book however is written not for doctors, but for patients. Patients have always been the greatest supporters of the NHS whilst doctors, concerned about their own class based interests have at times been its bitterest opponents. Now we face what may be the end of the NHS . The Coalition’s Health White Paper far from being a radical document, is a predictable stage in a 20 year process of converting the gift economy of the NHS into a market economy.

Just as the NHS depended on the will of the people for it to be created, its future depends on us all. This book is a history  of the struggle and a call to arms.

The second edition of Julian Tudor Hart’s Political Economy of Health Care
is published on September 1st 2010.

Sir Ian Gilmore, President of the Royal College of Physicians of London,
writes:

“This is a remarkable book by a remarkable man.  Anyone who professes to
believe in patient-centred care (including our most recent two
governments) need to read it to understand that to be patient-focused you
must also be public- and population-focused, challenging markets and
tackling inequalities.”

Graham Watt, Professor of General Practice at Glasgow University Medical
School, writes:
“Julian Tudor Hart’s example was not only to imagine but also to deliver
integrated care for all his patients over 25 years, using epidemiology
to measure what he did and to show what could be achieved. For health
care systems round the world, facing problems of fragmentation,
spiralling costs and increasing inequity, the gauntlet he threw down is
to develop similarly integrated systems for the societies they serve.”

John Frey, Professor of Family Medicine at the University of Wisconsin
School of Medicine and Public Health, writes:

“Rather than writing from an abstract view of general practice, Hart
brings a life time of experience among his patients to bear on the history
and changes in the NHS.   He raise cautions as well as provides a vision
for the future. In the end, he sees general practice in the context of
community as a testing ground for ideas that should reshape  the NHS. Hart
has been recognized  around the world as one of the great scientists of
community health. His ideas are born from his work in practice in the
deprived where he practiced combined with his broad knowledge of the
mistakes and confused policies of the past that have delayed getting
proven care to the  those who are most at risk in any community. This book
brings Hart’s distinctive, passionate voice to bear on  his personal
journey through his 60 years of the NHS and carries his tempered optimism
that we can all do better.”

It seems that despite the best efforts of an unlikely coalition of the wise, the cautious and the ideological of all political persuasions, the majority of GPs, thanks in large part to the appeasement efforts of the BMA, will go along with the Health White Paper.

Richard Holloway, ex-bishop of Edinburgh boiled down the Christian message to 3 principles in his book ‘Doubts and Loves, What’s left of Christianity’:

Stand up for the oppressed, stand up to authority and seek understanding rather than judgement.

These seemed like 3 sound guiding principles for a doctor of medicine. Sadly my peers are prepared only to stand up for their patients in the confines of a clinical relationship but not in the more general context of the social, economic and political reality in which they live, and which, as we all now know, is not only getting worse, (and here and here)

…but more importantly determines their health far more than any of the medical interventions we have to offer.

Unless we have a [moral] revolution which leads to a majority (a significant minority do this already) of doctors prepared to challenge the systems that lead to the social determinants that cause their patients illnesses, we’re unlikely to see doctors voting for a change that puts the needs of their most vulnerable patients first.

We need to examine the white paper in the context of widening health inequalities and the needs of our most vulnerable patients, which means we have to prioritise:

continuity of primary care, not the endless choice of a healthcare market

Better collaboration between primary and secondary care, not the competition of commissioning

stability of services, not the continual birth, death and rebirth of market driven services,

diversion of resources to the most deprived areas taking into account not only the clinical needs but also the complexity of caring for people with socially determined problems, not simply the diversion of resources to the most efficient/ easily run areas

Psychology, chronic disease management and drug and alcohol services, not homeopathy and other choices of the not terribly ill

Longer appointments with expert clinicians, not any time, any where appointments with any clinician

Better use of NICE to ensure a raising of clinical standards and far more widespread adherence to best practice guidelines, not increased clinical freedom: the failure to adhere to guidelines is far worse than the rare, but highly publicised cases where quite reasonably clinicians may wish to deviate but cannot.