A Better NHS

The now ex-chair of the Royal College of General Practitioners in offensive and ill considered form telling poor people to take more responsibility, especially since the RCGP also backed the recent report on inequalities. He doesn’t point out the fact that unhealthy behaviour is associated with inequality and rising inequality (article in the week’s BMJ) worsens unhealthy behaviors.

The best worded criticism is from Oscar Wilde, The soul of man under socialism:

The virtues of the poor may be readily admitted, and are much to be regretted. We are often told that the poor are grateful for charity. Some of them are, no doubt, but the best amongst the poor are never grateful. They are ungrateful, discontented, disobedient, and rebellious. They are quite right to be so. Charity they feel to be a ridiculously inadequate mode of partial restitution, or a sentimental dole, usually accompanied by some impertinent attempt on the part of the sentimentalist to tyrannise over their private lives. Why should they be grateful for the crumbs that fall from the rich man’s table? They should be seated at the board, and are beginning to know it. As for being discontented, a man who would not be discontented with such surroundings and such a low mode of life would be a perfect brute. Disobedience, in the eyes of any one who has read history, is man’s original virtue. It is through disobedience that progress has been made, through disobedience and through rebellion. Sometimes the poor are praised for being thrifty. But to recommend thrift to the poor is both grotesque and insulting. It is like advising a man who is starving to eat less. For a town or country labourer to practise thrift would be absolutely immoral. Man should not be ready to show that he can live like a badly-fed animal. He should decline to live like that, and should either steal or go on the rates, which is considered by many to be a form of stealing. As for begging, it is safer to beg than to take, but it is finer to take than to beg. No; a poor man who is ungrateful, unthrifty, discontented, and rebellious is probably a real personality, and has much in him. He is at any rate a healthy protest. As for the virtuous poor, one can pity them, of course, but one cannot possibly admire them. They have made private terms with the enemy and sold their birthright for very bad pottage. They must also be extraordinarily stupid. I can quite understand a man accepting laws that protect private property, and admit of its accumulation, as long as he himself is able under these conditions to realise some form of beautiful and intellectual life. But it is almost incredible to me how a man whose life is marred and made hideous by such laws can possibly acquiesce in their continuance.

The proper aim is to try and reconstruct society on such a basis that poverty will be impossible.

After 20 years of building therapeutic relationships between doctors and patients, patients present to the surgery when they need to and the doctors time is spent productively. This is rational, needs based care. It takes a long time to build up relationships with patients, to give them the confidence to manage problems themselves and to work out the best way to use the expertise of the general practice team. This works better with continuity of care, which we are continually trying to improve, but in an urban practice like ours where there is a 30% per year list turnover it is a never-ending task.

A walk-in centre opens up next door, and forced to see 40 patients a day, they try whatever they can to get patients through the door. They are incentivised to see patients as often as possible, rather than help them manage problems themselves. This is the effect of perverse incentives and is typical of market driven healthcare.

Before long patients are popping in to the walk-in centre for second opinions from nurses with a fraction of the experience of the patient’s own GP, with itchy toes, furry tongues, odd smells, and a sore throat that started on the way to work. In short, anything. All that matters for the walk in centre is that the patients, now rebranded as consumers, come in through the door.

What the Torys think:

Philip Blond, “Cameron’s Crank” (Jonathan Raban, London Review of Books) on the Moral haze last night:

19.50 “There is a distinction between the state as facilitator and the state as provider, and I think the state as provider really is now a bankrupt model”

25.48 “Redistribution on the basis of income has failed, what I’m arguing for is distribution, the ‘asset effect’. It was our idea, the ownership state, that argued for the mass mutualisation of public services, that is continuing apace, that will give people a stake, low paid workers, often women a stake in a business enterprise that is mutual that they’ve never had before, it is exactly my idea and the ideas of those associated with us that will actually transform the lives of the poor, whereas ‘Statism’, redistribution along the lines of income has failed that’s why we offer radical transformation, and that’s why you should support it”

There you have it. The NHS is no longer to provide healthcare, instead it will commission care from private providers aka social enterprises. The old NHS staff will presumably no longer have a stake in the new NHS (unless they’re commissioners) but will have a (probably low paid or voluntary, part time) position with a private provider.

Government announce £4 million boost to give patients control of their health care

Sidney: Hello doc

Doc: Hello Sidney, how are you today?

Sidney: I’ve been spending some of my personal health budget

Doc: Are you feeling any better?

Sidney: They were lovely at the alternative therapy diabetic foot centre, I got scented oils, massages the lot. You should try it, the hours you work, it might relax you

Doc: Thanks Sidney. What else have you spent it on?

Sidney: Well you know that fancy place you sent me to get my heart scan? They offered me a cancer screening body scan, so I got one of them as well, they said I qualified because I had bowel cancer before

Doc: ! Sidney, you had your annual colonoscopy last month, what did you have a scan for?

Sidney: They was checking for everything

Doc: So did they find anything?

Sidney: I don’t know, they said I had to come and see you

Doc: And how much is it costing to see me?

Sidney: Eh? I don’t have to pay to see me own doctor! I wouldn’t have to pay if I was sick, would I?

I mean, what if I’d run out of money?

Conservatives put Dumb and Dumber on the health select committee

Following my previous post, I’ve come to realise that the White Paper, described even by Tory think tank Civitas as a dog’s dinner will be scrutinised by Health Committee morons Nadine Dorries and David Trednnick.

Blooming marvellous.

What about continuity of care?

Sidney: I’d like to see doctor Tomlinson please

Receptionist: Is it about a pre-existing or a new problem?

Sidney: Eh? I just wanted to see my doctor

Receptionist: I won’t be a moment sir, just a few questions. Now is it about an old problem or a new one?

Sidney: Old, I suppose

Receptionist: Very good. Would you describe it heart and circulation, lungs and breathing, or ‘other’?

Sidney: Couldn’t I just discuss it with doctor Tomlinson?

Receptionist: Won’t be long sir, now was that heart, lungs or ‘other’

Sidney: It’s about my diabetes

Receptionist: I was just coming to that sir, you’ve jumped ahead, but nevermind. Now you have several exciting choices

Sidney: Couldn’t I just choose to see my doctor?

Receptionist: I’m sure that won’t be necessary sir. Now, would you like to go to the Britania skip-fit diabetic weight-loss class, the Little Chef healthy eating course, the Clark’s soft and comfy footwear clinic, the Specsavers Retina Chekka, the Dyna-rod renal one-stop or the counsellor? If you’ve paid into the United rapid access fund you get the first choice for appointments

Sidney: What the hell? Where’s doctor Tomlinson

Receptionist: I’m afraid he’s not here sir

Sidney: Well when is he back? I’ll wait.

Recptionist: He won’t be coming back here sir, but you might be able to see him at the 24/7 patient satisfaction drop-in centre once he’s finished his efficiency management course.

Extraordinary changes demand extraordinary justification backed up by extraordinary evidence

The top three challenges for the NHS are

1. Improve clinical outcomes

2. Abolish health inequalities

3. Save money.

The extraordinary changes proposed in the white paper could only be justified if there was evidence that they would solve these 3 challenges

If it did so there would be an  electoral mandate

But there’s no evidence that it will do that. In fact, what little evidence there is suggests the opposite.

We don’t live in a democracy any more, and yet we passively aquiesce. As Nobel Prize winning physicist Niels Bohr said when asked why he kept a lucky horeshoe over his door, “Of couse I don’t believe in lucky horeshoes, but apparently they work even if you don’t believe in them!”

It’s the same with our relationship with democracy

Health Inequalities.

One of, if not the top priority for health ought to be to reduce health inequalities by the redistribution of resources to those with greatest health needs and to take into account the damage of market rewards where those whose needs are greatest present the greatest challenge to efficient provision.

Choice

Despite the rhetoric the emphasis is all about choice of provider, for which there is little evidence of public enthusiasm and absolutely no evidence of any relationship with quality of clinical outcome. One has to assume that this is simply a means of diverting patients to the private sector. My patients today who came to discuss whether to start insulin or continue chemotherapy had far more important choices to discuss than where to be treated.

Patient centred Vs patient led

The two terms are used interchangeably in the white paper. Patient centred healthcare was part of my medical curriculum in the early 90’s, it has helped make enormous improvements in doctor-patient communication even though it remains too often merely an aspiration. Patient led healthcare is political confusion, akin to letting the lunatics run the asylum.

Effective healthcare is a partnership; patient centred and physician guided with shared decision-making.

GP Commissioning

It’s near impossible for GPs within a single PCT to work together, and yet consortia of 500-600 GPs are expected to joint commission across areas of extremes of social and ethnic diversity and health and economic inequality, e.g. three soon to be abolished PCTs: City & Hackney, Tower Hamlets and Newham, would have to be combined.

GP fundholding widened inequalities between practices because entrepreneurs profited and the less business savvy lost out; it seems likely the these inequalities could be increased in proportion to the enormous difference in scale proposed by GP commissioning. The government’s own Health Committee published a highly critical report about commissioning in March this year, which raised very serious concerns about the poor value for money;  scaled up to the level now proposed is fiscally irresponsible.

Efficiency

Rewarding efficiency will widen health inequalities because 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 will lose resources even though their needs are greatest.

This White Paper fails to address our most pressing health needs despite costing an estimated £20 billion a year to implement, its a great opportunity wasted.

In anticipation of the white paper that will propose handing commissioning power to GPs it’s worth considering who is advising parliament.

The Health Committee is “appointed by the House of Commons to examine the expenditure, administration and policy of the Department of Health and its associated bodies”. You would be absolutely right in thinking that a doctor on the committee would be a great asset, essential even and yet if you look at the political interests of the Chairs of different Commons Select Committees a lack of specialist knowledge or political interest would appear to be the single unifying qualification.

The new Chair of the Health Committee is Stephen Dorrell who true to committee form, lists only economics and foreign affairs as his political interests, in spite of being Conservative Health secretary 1995-1997. By contrast, the Chair of the Education Committe, Graham Stuart lists “Older people, mental health, welfare… community hospitals.. and education” among his political interests. Nowhere on the parliamentary website is there any evidence of any committee Chairs with actual experience of working in the fields they are reporting on.

Apart from expertise, independence of thought (in contrast to party political line towing) is a virtue we would wish from the Chair of a cross party committee, but obviously this rarely happens. The previous Chair of the Health Committee was a retired consultant rheumatologist and an independent MP, Dr Richard Taylor; an excellent Committee Chair who I had the privilage of seeing in action at the house of Commons last year, and who oversaw the last highly critical report about commissioning which is essential reading.

All of this pales into insignificance with the news that Conservative MP David Tredinnick is on the health select committee. The link takes you to the wonderful Badscience website. Having David Tredinnick on the health committee is akin to having a creationist on the science and technology committee, or inviting the BNP onto the race relations committee.

Is there any hope left for democracy?

Dispatches from the Emergency Room by Teri Reynolds describes the experience of an emergency room physician (Accident and Emergency doctor) working in Oakland County hospital in the US. She describes in vivid detail the consequences of a system of healthcare that leaves people without access to comprehensive primary care.

As the coalition accelerates New Labour’s conversion of the NHS from a public service to a competitive market we will see people who require care that cannot be provided profitably left stranded like those that frequent Dr Reynolds’ emergency room. The coalition plan to use personal health budgets and GP commissioning to hand over responsibility for rationing care for populations down to individual patients and groups of GPs. It is patients who will suffer the consequences acutely once their money has been spent. If you or I as a patient are given money for our diabetic care but chose to spend our personal budget on scans for our more symptomatic back pain and headaches (shamelessly promoted by private healthcare providers) presumably we’ll be left to the same fate as Dr Reynolds’ patients with only A&E departments willing or able to provide care.

The NHS is there to care for those who cannot care for themselves. My consulting room is full of people who are not only physically or mentally unwell, but they’re also illiterate, uneducated, destitute or intoxicated, abused and isolated -just like Dr Reynolds’ patients.

Friends and family are coming and going from and to Iraq and Afghanistan, not as I did, as a medical volunteer with Medcins Sans Frontiers, but with the armed forces. Like our political leaders I have great respect for their bravery and professionalism in the face of extreme and unpredictable danger.

What they report is of relevance to the subject of this post: the growing replacement of state employed professionals by private contractors. There is a balance between those functions performed by the state and corporate employees. What my friends and family report is that increasingly the balance is swinging away from the state towards the private sector. Their belief is that civilian costs -financial and human- are not counted as they are for the armed forces, which plays well politically because less soldiers need to be paid and civilian contractors are not reported in the press when they are killed in action. Private contractor profits are enormous, and in these times of economic hardship, are an increasing contribution to our ailing economy.

The changing balance means that the time is rapidly approaching when the wars in Afghanistan and Iraq contribute so much to the corporations that influence political policy that our chance of ending these wars is fading. Perhaps we will see the day when they contribute more to our economy than our involvement in the war is costing.

An effective NHS will minimise the demand for medicine by increasing the health of the public, but profit-driven health care needs to increase demand and consumption. There is no other market that doesn’t depend on ever-ending growth. After the economic collapse we were told that we needed to shop more, not tighten our belts.

The more the balance at home changes from NHS providers to private providers the greater the government costs and private profits will increase. The evangelical zeal that our politicians have for market solutions seems to completely ignore the cost of healthcare in other rich countries and the inevitable market need for expansion.

Andrew Lansley has so far committed himself to the continued transformation of the NHS into a competitive market. Perhaps he should look to Iraq and Afghanistan for inspiration.

Put better than I possibly could,

Iona Heath was her usual perspicacious self in last weeks British Medical Journal:
“What is needed is a political context that maximises the amount of time that clinical professionals have available to spend in direct patient care; provides an environment within which trusting human relationships can develop and flourish; minimises perverse incentives; avoids the wholesale medicalisation of populations by situating preventative interventions at the level of the society rather than the individual; avoids duplication of effort and expenditure; is prepared to scrutinise the potential futility of interventions towards the end of life, especially in extreme old age; enables primary and secondary care professionals to pool their complementary expertise in the care of patients; and, overall, provides a better balance between the transactional  and relational aspects of care. If any party is offering this, just let me know and my vote is yours”

To all the private health industry nobs at the CIVITAS debate last month, I re-emphasise.

The NHS is not for you!

This doesn’t just mean that your market based intrusion is unwelcome, but just as importantly;

Patients are not like you and me.

They are more likely to be very young or very old, have chronic mental and / or physical illnesses, be on multiple medications, have personality and mood disorders including chronic anxiety, be illiterate or poorly educated, not speak English, to be poor, and suffer social deprivation including unemployment, poor housing, lack of space and exercise, to smoke and drink excessively, abuse drugs and so on. That’s why 10-20% of our practice list accounts for 80-90% of all our appointments.

Patients; those people for whom the NHS has greatest responsibility, are a vulnerable subset of the population and they lack the autonomy –determined by knowledge and power- that the rest of us have.

Markets convert citizens into consumers and lead to a social divide in which the autonomous rise to the top. If you create a market in healthcare, then patients –those who need healthcare- will fall to the bottom and the social divide –which has worsened considerably over the last 30 years (see Steffan Collini: Blahspeak London Review of Books April 8^th 2010) will be mirrored by a widening health divide.

Its a hot topic and there are three conferences coming up. Given the amount of market intrusion it may appear to be an example of closing the stable door afer the proverbial, but nevertheless I think they could be valuable.

April 14th BMA round table discussion. No longer open.

June 1st MEDACT AGM The Latest Pandemic: Global trends in the privatisation of health services. Speakers include Allyson Pollock, Proressor of International Health Policy, University of Edinburgh and Anna Marriott, Health Policy Advisor Oxfam.

email MEDACT for if you wish to attend. Only £60 to non-members, including lunch. I’ve previously worked as a volunteer at MEDACT and they have hosted excellent meetings in the past. I’d thoroughly recommend this AGM as it’s likely to be a rare opportunity to hear from health policy experts who are thinking independently rather than advocating for the medical-industrial complex.

July 1st The LANCET Health of the Nation Summit

-a rather astonishing £300 or thereabouts. With a line up of medical-industrial proselytising lobbyists you’d have thought they’d be able to sponsor the costs. How they manage to make it 5 times the cost of the MEDACT confrence, I don’t know. Nevertheless I’ll be going.

The most telling part of the Civitas debate was when Charlie McEwan, the head of a not for profit health insurance firm said, “these days  with the internet, nobody needs a gp, you just look it up” Professor Smith suggested the same thing, advocating for direct access to consultants.

There was laughter after Charlie’s comment, but after the Prof’s suggestion there were murmurs of approval.

What was telling was that people still agreed with them, even after I explained that 1 in 3 people will develop dementia, 1 in 10 will be on at least 10 regular prescriptions, 1 in 5 will have heart disease, 1 in 7 will have diabetes and so on. In short, most of us will have a range of complex interacting chronic diseases. The pin-stripe suited advocates of markets in the room were so wedded to their ideology (or, more likely future personal profits) that nothing could shake them from their conviction that they’ll remain healthy and autonomous to the end.

They’re designing a health service for themselves, their future and their profits. They’re dining with politicians.

We’re not.

Vampire doctors has now been published and is subject to copyright. You can read it in the British Medical Journal.

This house believes that a market will deliver quality and efficiency in healthcare better than central planning ever could.

The NHS has been increasingly subject to market principles for the last 20years during which time costs have risen faster than in any comparable period in its history without a comparable rise in efficiency.[1] Central planning has given new benefits such as NICE and QoF which have increased quality and reduced health inequalities.[2][3] At the same time, due to their independent contractor status, GPs have always been able to tailor their services to meet the needs of their local community.[4] Quality and efficiency in healthcare though vital themselves, are not enough; we must include public health measures to manage the social determinants of health, which remain as urgent as ever. Unless we choose to abandon 60 years of universal healthcare, we must insist upon the redistribution of healthcare resources because poorer areas have a greater burden and complexity of health needs.[5] [6][7] Markets lead to monopolies of power and resources in global corporations such as United Health who are bidding for UK general practice surgeries.[8][9] Markets are inappropriate for the provision of healthcare, or for that matter any human necessity because they are driven by profits not human needs.[10]

As a result of markets in food more people than ever before are dying prematurely from obesity related diseases while billions of people remain starving. Profits are made from selling luxury foods to the rich, junk food to the poor and withholding food from the very poor.[11] Exercise has become increasingly subject to the market and there is a strong correlation between deprivation and lack of exercise.[12] My poor patients cannot afford to join the gyms my wealthy patients patronise.[13] Exercise on prescription, like the NHS, has been devised to compensate for the failure of markets to provide for the poor.[14]

Housing markets started the present global economic crisis. We are in a situation where rich people have second or third homes (or more), purchased for holidays and investments whilst more people than ever are unable to buy their own homes because the cost is too high. Prices are whatever the market will tolerate, not what is needed to house the population. [15]

Central planning is a feature of markets more than ever and in the recent wake of Cadbury’s take over by Kraft and the US government bail out of the US health insurer AIG (the world’s 18^th largest corporation) and our own government rescue of HBOS we now know that international businesses are bigger and more powerful than many states. As far as central planning is concerned, markets are the problem not the solution.  Major global corporations are too big to fail; huge banks, power stations and hospitals cannot be allowed to close. If they collapse, the government picks up the pieces. [16]

The World Health Organisation has said that health inequalities in lower and middle income countries are widened by markets and publicly financed healthcare is the preferred policy option. There is every reason to believe that this is the case in the UK[17]

I believe that we have a duty to care for our fellow citizens and that the NHS may be “the greatest expression of social solidarity found anywhere in the world”.[18] We cannot abdicate our responsibility to the market.

Jonathon Tomlinson

Feb 23^rd 2010

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[1] For details about the privatisation of the NHS see the BMA campaign www.lookafterournhs.org.uk/ Keep Our NHS Public http://www.keepournhspublic.com/index.php and my blog www.abetternhs.wordpress.com See also Julian Tudor Hart: The Political Economy of Healthcare: A Clinical Perspective Policy Press 2006 (the second edition is out very soon) and John Lister: The NHS after 60, for patients or profits? Middlesex University Press 30^th April 2008

[2] Using NICE Guidance to cut costs in the downturn http://www.nice.org.uk/aboutnice/whatwedo/niceandthenhs/UsingNICEGuidanceToCutCostsInTheDownturn.jsp Accessed 23.02.2010

[3] Doran et al. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. The lancet Vol 372Issue 9640, Pages 728-736 30 August 2008 doi:10.1016/S0140-6736(08)61123-X

[4] For an excellent analysis of local autonomy and corporate healthcare in the US see David Loxterkamp, The Dream of Home Ownership,, Annals of Family Medicine www.annfammed.org/ his other essays in the Annals of Family Medicine are highly recommended.

[5] House of Commons Health Committee Health Inequalities Third Report of Session 2008-9 http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/286/286.pdf Accessed 23.02.2010

[6] Julian Tudor Hart. Inverse care Law The Lancet Feb 27 1971 www.sochealth.co.uk/history/inversecare.htm

[7] Marmot Review: Strategic Review of Health Inequalities in England post 2010

[8] Raj Patel: The Value of Nothing. Portobello books 2010 www.rajpatel.org/

[9] http://en.wikipedia.org/wiki/UnitedHealth_Group Accessed 23.02.2010

[10] For a really deep and engaging review of the history of medicine, public health and socialised medicine, see all the books by Henry Sigerist, especially Medicine and Human Welfare, Yale University Press 1941.

[11] For a thorough investigation of global food systems see Raj Patel, Stuffed and Staved. Portobello Books 2007

[12] Elizabeth Dowler. Inequalities in diet and physical activity in Europe. Public Health Nutrition: 4(2B), 701-709 (2001) DOI: 10.1079/PHN 2001160

[13] Bodywise training. www.odywisetraining.com

[14] For a history of the NHS see Julian Tudor Hart, The Political Economy of Healthcare It’s worth waiting for the very soon to be published second edition.  See also: Webster, C The NHS: A Political History, Oxford OUP 1998

[15] Very simple graphs showing trends and affordability are at www.mortgageguideuk.co.uk/housing/housing-stasistics.html Accessed 21.01.2010

[16] John Lanchester, It’s Finished. London Review of Books Vol. 31 No. 10. 28 May 2009

[17] World Health Organisation Commisson on Social Determinants of Health. Closing the Gap in a Generation. Final Report Chapter 12 http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

[18] Professor the Lord Darzi of Denham KBE; resignation letter to Gordon Brown. July 13^th 2009

March 17 6.30 to 9pm

The think tank Civitas have decided to stage a joint Socialist Health Association/Civitas debate around the market and the NHS following their latest publication, ‘Markets in health care: the theory behind the policy’

The motion will be:

‘This house believes that a market will deliver quality and efficiency in healthcare better than central planning ever could’

17^th March, in the evening (6.30-9pm), inc. a drinks reception afterwards in the conference room at Civitas’ offices (address below).  James Grubb and Steve Smith, CEO of Imperial are proposing the motion and Neal Lawson from Compass and myself are arguing against it.

Its an odd motion because markets lead to monopolies -(HBOS, Barclays, Kraft, Nestle, United Health, Atos Origin etc.) and central planning can allow local autonomy (your local GP).

I’d like to think that the debate might lead to some new ideas about how to improve quality and efficiency rather than be a hammer and tongs argument about markets. Perhaps I’m being naive…?

If you want to come along please contact Civitas.

CIVITAS: The Institute For The Study Of Civil Society

First Floor
55 Tufton Street
Westminster
London
SW1P 3QL

Tel: +44 (0)20 7799 6677
Fax: +44 (0)20 7799 6688

General enquiries: info@civitas.org.uk

Removed for the time-being to protect patient confidentiality. Although there was no patient identifiable data or even demographic details it’s possible that patients who were seen in that surgery might have recognised themselves. I’ll use a surgery from a few weeks ago to reduce further the risks and rewrite it soon

Jonathon

In 1974 Julian Tudor Hart established that patients with high blood pressure were much less likely to die from complications if he asked them to come back to have it checked rather than waiting for them to return to the surgery the next time they felt unwell. This radical finding he called ‘planned care’ and changed forever how GPs worked.

Not that he needed any extra work. At that time up to 300 patients a day were coming to see him. But he knew that reactive care, the model for the previous 2000 years of medical history, whereby doctors sat at their desks waiting for patients to come in, could be radically improved.

In his book, The Political Economy of Healthcare which is shortly to be published in a significantly redrafted second edition, he proves false the assumption that what patients want exceeds what they need, which exceeds the resources of a healthcare system.

As our population grows older the burden of chronic disease increases and most people will spend the last quarter of their life with a number of chronic diseases such as hypertension, diabetes, ischaemic heart disease, chronic kidney disease, dementia, incontinence and even cancer, since so many cancers are treated and monitored long term now. Most of the time these conditions are asymptomatic even when they are irreversibly damaging your most delicate organs. To wait until you feel unwell before visiting the doctor is to invite catastrophe or death.

The rational way to care for people with chronic diseases is to plan their care, to regularly monitor, educate, negotiate, treat and review their lifestyle, medication, organ function, ability to care for themselves and so on. This kind of care requires a relationship between doctors (and others involved) and patients. This is ‘continuity of care’. It is in contrast to the instant access healthcare and multiple provider choice that is the contemporary political obsession.

We have the resources abundantly in a country as rich (albeit indebted) as ours and we know what patients need -planned care. By focusing instead on what we think they want -instant access and choice, we’re wasting our precious resources on a model of unplanned reactive healthcare that should have died when it was conclusively proved wrong in 1974.