A Better NHS

Medically unexplained symptoms

In 2004 I spent 8 months working in a rural clinic in North West Afghanistan supervising 2 local doctors and seeing up to 100 patients a day in a tiny concrete room. The area was desperately poor. There was no clean drinking water, sanitation or electricity. Approximately 3 quarters of children were chronically malnourished, almost half died before the age of 5 and the chance of dying from the complications of childbirth was over a thousand times that of dying from childbirth in this country. Malaria, typhoid, dysentery and tuberculosis were seen daily. Among the misfits, missionaries and mercenaries that work in places like Afghanistan are a fair few doctors who believe that in places with such overwhelming levels of poverty and disease, doctors must spend all their time dealing with genuinely sick patients instead of the chronically anxious, so called ‘worried-well’ that demanded their attention at home.

Imagine their surprise and disappointment then to discover that up to half the patients who attended the clinic had ‘medically unexplained symptoms’. Studies of primary and secondary care in the UK have shown that between 40 and 60 percent of patients have medically unexplained symptoms. This is not to say that their symptoms cannot be explained; a 23year old mother of 3 surviving children who has seen 3 of her own children die in infancy, who lives in a cramped, smoke filled mud house with the sound of constant hungry crying, whose husband is 3 times her age and whose parents were both killed in the war that constantly threatens to reignite, is bound to suffer, and given the presence of a doctor whose purpose is to relieve suffering, it should be of no surprise that she comes to see what he has to offer. It is usually a surprise that the proportion of people in whom there is no medical explanation is the same in such different places as rural Afghanistan and urban England. The history of medicine is interesting. The ancestors of modern doctors were priests, shamen, sorcerers and healers. They had not developed our biomedical model to categorise illnesses and so were far less likely to deny suffering on the grounds that it could not be explained.

The risk of reducing suffering and the causes of suffering to a biomedical model is that only those that fit the model are legitimized. And when health is commodified, only what is legitimized is paid for, and when healthcare is subject to the market, only what is paid for gets cared for.

Science deals in the general, it is a process of sorting the world into categories such as those types of suffering that can be medically defined, for example; what may be divided into infections, growths and degenerative processes. Art deals in the specific, the personal subjective nature of suffering; the library is a better place to study human suffering than the laboratory.

Medicine is art guided by science and doctors are presented with the subjective experience of suffering and the measurable effects of disease every day. We separate what we can of the illness from the patient:

“On a psychological level recognition means support. As soon as we are ill we fear that our illness is unique. We argue with ourselves and rationalise, but a ghost of the fear remains. And it remains for a very good reason. The illness, is an as yet undefined force, is a potential threat to our very being and we are bound to be highly conscious of the uniqueness of that being. The illness, in other words shares in our own uniqueness. By fearing its threat, we embrace it and make it specially our own. That is why patients are inordinately relieved when doctors give their complaint a name. The name may mean very little to them; they may understand nothing of what it signifies; but because it has a name; it has an independent existence from them. They can now struggle against it. To have a complaint recognised, that is to say defined, limited and depersonalised, is to be made stronger.” John Berger: A Fortunate Man

Naming the illness doesn’t make the patient disappear, and in most cases the relief described above is short-lived; the depression becomes the patient’s exhaustion, loss of libido and insomnia; the cancer their loss of career, hair and fertility. The 50 percent or more of illnesses that cannot be named and the degenerative diseases of our time cannot be cured or separated from the patients’ experience of life lived. A great deal of what we do was described by Voltaire; ‘The art of medicine consists of amusing the patient while nature cures the disease’. The art of medicine is not what we do once our science has been tried and found wanting, nor is it mere amusement; as a result of the therapeutic relationship that develops between a carer (be they doctor, nurse or other) and a patient, we develop trust, relieve anxiety, make sense of fear, anger, hopelessness, frustration, sorrow, guilt, and shame and support. And that is how we care for our patients throughout their suffering.

Kant, Human dignity and the subjective nature of suffering

One hundred years after Voltaire, Emmanuel Kant defined dignity as the intrinsic worth of a person. Human beings, unlike things, have a kind of intrinsic worth that should be respected. Unlike relative worth which has a value which may be exchanged for something else, intrinsic worth can have no equivalent. A commodity has relative worth, a person has intrinsic worth.

Respect for human dignity requires that we cannot generalize a patient’s subjective experience. Respect for dignity also means that one should “Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end”. To treat others as beings who have ends is to be motivated by their ends as well as our own, so that their interests become our own. The logical conclusion from this is that we have a duty to help and care for others.

Commercial healthcare

When healthcare is commercialized, human health is commodified; that is, people are broken down into diagnostic categories and biological parameters that can be quantified, i.e. given a relative worth which is given a financial value.  So doctors are paid for reductions in the weight or blood pressure of their patients, for diagnoses made and for tests carried out. The relief of suffering becomes a secondary end, achievable only if it occurs as a consequence of treating the illness. Many treatments, such as drugs to treat hypertension and high cholesterol, screening for breast cancer and immunisations cause as well as relieve suffering. Though their ultimate aim is to prevent future suffering, the markets for preventative services (screening, statins and so on) are greater than those for curative services because far greater proportions of the population are ‘at risk’.  This results in a shift of emphasis from cure to prevention, i.e. from caring for the ill, towards medicating the healthy[1].

According to the logic of capitalism, only commodities count because only they can be counted. When a patient comes to see me I am reminded by my computer of a list of biometric data that I need to collect. If I fail to collect the data my practice will lose money. You may wish to discuss your failing memory or the side effects of your chemotherapy, but we’re only going to get paid for measuring commodities, not for listening. Listening is too hard to measure, but not time; if I keep you waiting I’ll be fined, and if I give you the time you need I’ll be fined for keeping the next patient waiting.

For Kant, an act should be done for the sake of duty. It must be done out of a concern for what is morally right; not out of some self serving motive. It must be done for what is right for the patient, not what pays.

[1] Disease mongering is the increasingly widespread practice of widening disease parameters and thereby extending treatment thresholds ‘in order to expand markets for those who sell and deliver treatment”. Selling Sickness: The Pharmaceutical Industry and Disease Mongering. Ray Moynihan, Iona Heath, David Henry. BMJ 2002;324:886-891

Practice Based Commissioning means that once a quarter we have to sit down and look at how much we’re spending/ being charged for our patients attending hospital. I’m not sure what the difference is, its an interesting point. Like our patients who cannot choose whether or not they are sick -if they have dreadful disabling Parkinson’s disease, Colitis or whatever, they need to see a specialist and we have no choice but to refer them. I suppose that if we think they need to be seen in hospital, we’re think we’re spending, but if we don’t think they need to be seen, -say they pitch up at A&E repeatedly because they’re very anxious, ill, or shambolic, then we think we’re being charged.

We have to find innovative ways of keeping these patients away from A&E and of making absolutely sure all our referrals could not have been managed in primary care in order to save money. Not necessarily a bad thing.

Junior doctors see patients they’ve operated on in outpatients for follow up. When we receive the letters they usually say, “I saw your patient and they were fine, all yours now, yours sincerely”, so it looks like the surgeon just saw them and waved goodbye, and in fact that’s usually what our patients report, so we’ve been campaigning for these patients not to go back to hospital because it costs us money (about £100) and our patients time. If the letters gave an indication (or if we had better relationships with the hospital) we might be aware of how important it was for young surgeons to know what proportion of their patients had complications and we’d be happier that the money was well spent.

The tarifs can be problematic. The tarif for midwives is about £180 for each patient that the midwives from the hospital see in our surgery. We organise the scans and blood tests so they can concentrate on talking to the patients. They see 2-3 patients an hour costing us £360-540 per hour. If we hired midwives independently we could make enormous savings by undercutting the hospital which cannot change the nationally set tarif. We’re £80k overspent this year… what should we do?

There are innumerable similar examples.

The consequence is that we’re forced to save money while the government encourages competing providers whilst tying hospitals to a set tarif. If we stick with the hospital we run out of money for our patients, if we don’t use the hospital they’re no longer financially viable.

Ditto also diagnostics, the PCT buys a job lot of scans and we can refer to scan.com without using our PBC budget, but if we refer to the local hospital it comes out of our budget. The hospital loses patients and money.

If you wanted to run down local hospitals and destroy integrated community care you’d be pushed to design a better system.

“Science deals in the generic and art in the specific”[1]

I went to the launch of the new Centre for The Humanities and Health at Kings College London this evening.

I asked Professor Howard Brody, Director of the Institute for the Medical Humanities at the University of Texas what the centre could offer to a profession that has lost the ability to develop relationships with patients and students because of a loss of continuity. I pointed out the fragmentation of primary care, the effect of working time directives on hospital training and the lack of mentors, using the counter-example of apprenticeship shown in Kurosawa’s epic, Red Beard to show what a teaching relationship could achieve. Humanities, I said, had to be part of caring for real patients. He thanked me, but didn’t answer.

Mark Slouka recently argued in Harpers Magazine that the humanities are necessary precisely because they are political and dangerous.[2] The social determinants of health and patient experiences have more to do with health than the micromanagement of biological parameters. And if you grant, as I do that this micromanagement is also necessary, then it’s far more effectively done if you understand how your patients live and how they think. And you do this far more effictively with continuity of relationship.

Medical humanities must be political. And in the political situation we find ourselves they must be subversive and they must act to transform medicine –including the medical, nursing and paramedical professions into more patient centred professions.  I hope this is not an academic centre producing PHDs about Middlemarch, I hope it is far more dangerous than that.

“Medicine is a social science and politics is nothing more than medicine on a large scale”[3]

Most of the posts here are about continuity in some form or another…

[2] Slouka, Mark. Dehumanized; When Math and Science rule the school September 2009 http://www.harpers.org/archive/2009/09/0082640

[3] Wirchow. Quoted in Sigerist, Henry. Medicine and Human Welfare 1941

Continuity of care.

The political restructuring of the NHS is increasing the range of hospital and community health care providers[1]. This fragmentation of care risks what Michael Balint referred to as the “collusion of anonymity” in which different parts of the patient’s health are cared for by different specialists and consequently important aspects are neglected because they fall outside the specialist’s remit. [2] Consequently, now more than ever, a comprehensive, generalist primary care physician providing continuity of care, is essential.

Continuity of care is the care of an individual patient over time. Various attempts have been made to define continuity, many of which try break down comprehensive continuity of care into subsets of continuity, for example, informational, management and relational continuity.[3]

All subsets are essential components of patient care. Continuity of information on the electronic record and continuity of management through the use of shared guidelines and protocols get more attention because they are more easily assessed than relational continuity which is complex and difficult to measure. Relational continuity is the basis of the doctor-patient relationship and requires doctors and patients to understand each other’s personalities and remember past experiences and not simply recognise professional roles and clinical features. [4]

I would define relational continuity as the therapeutic relationship between a doctor and a patient, developed over time in which the doctor takes responsibility for coordinating the patient’s care.

In measuring the effects of continuity of care, the question might not be, “Does continuity of care make a difference at a population level?” but rather, “Are there specific sub-populations for which continuity of care is especially valuable?”For most healthy, wealthy, young individuals, contact with aphysician is unlikely to have a measurable impact on their already good health.[5]”

Approximately 75% of all GP consultations are with people over the age of 70 and 75% of these people have multiple chronic conditions. In a deprived inner city environment where we work, the incidence of serious mental illnesses, drug and alcohol addiction and chronic stress due to social determinants such as unemployment, poor housing, crime and violence results in high re-attendance rates from a significant proportion of our practice population. For these people relational continuity is particularly important. [6]

Multiple conditions interact in ways that fall outside the remit of clinical guidelines. For example deterioration in mental health or social stress may result in a patient with diabetes neglecting their diet and medication with a subsequent loss of diabetic and hypertensive control. Regaining control of one disease is inextricably bound up with recognising and supporting them as they deal with the others. A frail patient with multiple problems may appear to a clinician with whom they have a relationship to look seriously unwell or their usual frail self the moment they walk through the consulting room door depending on their usual appearance and levels of stoicism or distress.

“The implicit choice between personal continuity and modern care is false; what evidence there is suggests that patients prefer services providing personal continuity, and this may also reduce the use of investigations and admissions to hospital” [7] There is also evidence that improved continuity of care results in better preventative care and lower costs. [8] Other benefits include:

1. Greater efficiency due to better communication and trust, facilitating information gathering.
2. Increased safety because communication and awareness of subtle changes not included in the electronic record or clinical guidelines. Many critical incidents we have investigated involve lack of continuity and have resulted in changes to improve relational continuity.
3. Higher patient satisfaction because of better reassurance and confidence in care. In patients with serious mental illness this is particularly important because the individual nature of the illness.

I believe that continuity of relationship is essential to organise and coordinate the increasingly fragmented care that patients receive. Continuity of relationship is most important in the care of patients with multiple chronic diseases, mental illnesses and social distress. These are the greatest users of the NHS. Prioritising speed of access and choice of provider risks damaging continuity of care for those who most need it.

Jonathon Tomlinson October 7^th 2009

Update December 2014. We have put in place measures to improve continuity of care at my practice where we have 12 part time GPs and nearly 14000 patients. This year, 80% of appointments were with the patients’ usual GP, up from 50% in 2012.

See also: Boosting continuity of care could save millions Pulse 10.04.2012 (source link £)

[1] Our Health, Our Choice, Our Say. Department of Health White Paper 2006

[2] Balint, Michael. The Doctor, His Patient and The Illness. 1954

[3] Haggerty JL, Reid RJ, Freeman GK, Starfield B, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219-21.

[4] Greenhalgh, Trisha. Narrative based medicine in an evidence based world. BMJ 1999;318:323-325 ( 30 January )

[5] Christakis, Dimitri A. Continuity of Care: Process or outcome? Annals of Family Medicine 1:131-133 (2003)

[6] Guthrie et.al Continuity matters. BMJ 2008; 377: a867

[7] Guthrie B, Wyke S. Does continuity in general practice really matter? BMJ. 2000;321:734–736.

[8] Saultz, J. W., Lochner, J. (2005). Interpersonal Continuity of Care and Care Outcomes: A Critical Review. Ann Fam Med 3: 159-166

Depth of the Patient-Doctor Relationship and content of consultations. BJGP Nov. 2014

Better continuity of care associated with fewer hospital visits for elderly with multiple conditions Annals of Family Medicine March/April 2015

Continuity of Primary Care. To who does it matter, and when? 

Defining and measuring interpersonal continuity of care. Annals of Family Medicine Sept 2003

The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? American Journal of Public Health 1998

The Kings Fund: Continuity of Care Report by George Freeman, Emeritus Professor of General Practice, Imperial College London, and Jane Hughes, an independent researcher.

Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey BJGP July 2013

The patient’s perspective on the importance of knowing your GP. Diaryofabenefitscounger.

A tragic tale, rich with personal tesimony but unfortunately lacking in substance.

The only comprehensive, highly recommended essential analysis of Independent Sector Treatment Centres is: Confuse and Conceal: The NHS and Independent Sector Treatment Centres.

Review  here:
Confuse and Conceal: The NHS and Independent Sector
Treatment Centres
Stewart Player and Colin Leys, Merlin Press, 128 pages, ISBN 9780850366099,
£10.95.
in The Spokesman, No 99, 2008, Russell Press, Nottingham ISBN 9780851247533
This is an excellent and important book, which should be widely read. It exposes how a succession of New Labour Health Ministers, advisers, senior civil servants and staff recruited from the private sector operated in the Department of Health to restructure the private health care sector with a network of Independent Sector Treatment Centres (ISTCs). Equally important, it chronicles the failure of scrutiny. The House of Commons Health Committee failed to investigate the real aims of the ISTC programme or to challenge the Department of Health when it refused to provide financial information.
The ISTC saga is clearly set out in three parts. The first part explains the launch of the ISTC programme and the first wave contracting process, which led to nine private healthcare companies being allocated 1.3m procedures over five years. By June 2007 twenty-four ISTCs were operational although some centres in the second wave of the £5.6bn programme may now not proceed.

ISTCs were presented primarily as using resources in the private healthcare sector to shorten waiting lists for elective surgery and diagnostic tests and to introduce greater choice. But the underlying aim was also to empower the private sector and to develop a NHS market. At least a quarter of the work carried out by first wave ISTCs was not additional work but ‘transferred activity’ which would otherwise have been carried out by the NHS.
Since the book was published more evidence has emerged to support the Player and Leys analysis. Department of Health figures for ISTC Phase 1 centres show that only four centres were working at 100% of the value of the contract and four had under 60% contract utilisation (end of September 2007). Yet these ISTCs were given guaranteed contracts requiring the government to pay the full cost irrespective of how many patients are treated.

The second part examines the House of Commons Health Committee’s investigation of ISTCs in 2006. This highlights many important issues, at least four with wider relevance. Firstly, New Labour’s public sector transformation strategy requires the mainstreaming of commissioning and the creation of contestable markets. The ISTC programme highlights the sham of devolution and local control. Primary Care Trusts ostensibly contracted with ISTCs but the programme was centrally controlled. Democratic accountability has been virtually non-exitant. Secondly, the use of ‘commercial confidentiality’ to block disclosure of financial and performance information severely limits the degree of scrutiny. ‘Commercial confidentiality’ is widely used to limit the transparency of Public Private Partnerships and will become commonplace as commissioning leads to more outsourcing. So how can there be any meaningful ‘community engagement’ if the public, community organisations and trade unions are denied access to information on policies and performance? Thirdly, it demonstrates that Key Performance Indicators (KPIs), value for money and quality and contract monitoring will be marginalised by the market making activities and partnership with private health care companies. Most of the KPIs were process and not outcome indicators. It appears that there was never any attempt to assess the impact of the ISTC programme other than the extent to which it contributed to the development of an NHS market. Finally, the ISTC programme is classic ‘partnership’ in which public service principles and values are made subservient to commercial interests.

There is only one criticism. The analysis of the development of the NHS market in Chapter 3 would have benefited from placing it in the context of what is happening across the public sector. Player and Leys do an excellent job in showing how Health Ministers and the Department of Health planned to marketise healthcare and the extent they will go to manipulate and conceal the real use of public assets and resources. Other government departments, local authorities and public bodies are undertaking similar market making strategies in the rest of the public sector and welfare state. Sector studies, for example in health, education, housing and criminal justice play a key role in building an evidence base. However, there is an obligation to set each of these studies in the wider context so that common impacts can be identified, lessons learnt and alternative policies and strategies devised. Those who believed that there would be a change of policy under Brown have been proved right – the drive to marketisation and privatisation has intensified! The words ‘lies’ and ‘deceit’ would be more accurate in the title of the book reflecting the depths to which markets and neoliberal ideology drives political ambition and greed.

Dexter Whitfield, Director, European Services Strategy Unit and Adjunct Associate
Professor, Australian Institute for Social Research, University of Adelaide and author
of New Labour’s Attack on Public Services.

Iona Heath, writing in the British Medical Journal BMJ 2009;339:b3735 described the failure of Camden PCT to hold a meaningful consultation process,

This consultation is a travesty and provides a close and dispiriting encounter with the realities of accountability and transparency in today’s NHS. It begins by inviting agreement with a series of very broad local health priorities, which include reducing health inequalities and improving mental health services. It then asks: “Do you support our plan to expand primary health care in Camden through our polyclinic programme?” It offers no alternative policies and goes straight on to ask: “Which services should go into our local polyclinics?” This is not consultation, it is manipulation. A later question asks “Do you support the development of a range of services at the new GP led health centre?” but fails to mention that the services have already been tendered. There has been no attempt to survey public opinion or the views of health professionals working in Camden in a way that could be considered statistically valid or defensible. The powerlessness of ordinary people to affect local policy in the unfortunate English part of the NHS is profoundly depressing.

In Hackney, with other members of Keep Our NHS Public I’ve spoken at public meetings and stood in the streets handing out leaflets and answering questions. We’ve been doing the work of the PCT, informing people that the PCT have been forced by the Department of Health to offer private corporations the opportunity to run NHS services including GP led health centres, walk-in centres and diagnostic services. People are usually shocked and respond by saying that the government would never do this, and if they tried it would be all over the news. A tiny minority of people say that they don’t care what happens. No-one, ever has said that they had heard about what was going on as a result of a PCT consultation. Even people we’ve spoken to who’ve responded to consultations deny being informed that NHS services were being offered to private companies.

The lack of democratic process and lack of regard for public opinion cannot be explained by the genuine difficulty of holding a comprehensive consultation. Iona Heath goes on:

As soon as you begin to question where the real power lies, you discover what could be a quagmire of real or potential conflicting interests. In June, Mark Britnell, the NHS’s director general for commissioning and system management, who has been instrumental in opening up the NHS to for-profit companies and the driving force behind “world class commissioning,” left the NHS to join the private company KPMG. Britnell also created the “framework for securing external support for commissioners” (FESC). On its website UnitedHealth UK proudly declares that, under FESC, it is “a preferred supplier by the Department of Health to support Primary Care Trust commissioning capabilities,” while it is, at the same time, applying to provide commissioned services. Mark Hunt, the managing director of primary care services for Care UK, was previously responsible for designing policy in the strategy unit of the health department. These are just two of the ever growing number of civil servants and politicians leaving the department to take up lucrative positions with the private companies that are profiting from the policies they have helped to create.

As disastrous as I believe a market driven NHS will be, as a citizen I consent to democracy.

I have written to my MP on several occasions and spoken at the House of Commons. The extraordinary response of my own MP, Meg Hillier and from Ben Bradshaw (last year) was to bluntly deny that there is any process of NHS privatisation.

If the process of forcing markets into the NHS is not democratic and the democratic avenues are closed with bare-faced lies and flat denials, then the question arises, how should one proceed?

The health policies of all the main political parties emphasize:**

(a) the need to reduce public responsibility for the
health of populations;

(b) the need to increase choice and markets;

(c) the need to privatize medical care;

(d) a discourse in which patients are referred
to as clients and planning is replaced by markets;

(e) individuals’ personal responsibility
for health improvements;

(f) an understanding of health promotion as
behavioral change; and

(g) the need for individuals to increase their personal
responsibility by adding social capital to their endowment.

See: What we mean by social determinants of Health. Vicente Navarro Speech to the Eighth IUHPE European Conference, September 9, 2008

The sum of all these is an ideology that will widen health inequalities, destroy the precious and vital therapeutic relationship between patients, doctors and other care-givers, make impossible the effective integration of primary, secondary and social care and massively add to the burden of suffering that presents to whatever’s left of healthcare.

This should be contrasted with the ironically ideological article by Andy Burnham’s new chief political advisor Keiran Brett: Against Ideology which argues in favour of individual empowerment and against state intervention; classic neoliberal ideology.

Will we notice when the Tories have won?

*Ross McKibbin. The London Review of Books, September 24th 2009

“Then there is the sad story of ‘choice’, from which the Tory leadership has learned little over the last 30 years. Much of the energy of recent governments has been expended on trying to create markets where markets cannot operate – particularly in education and health. One perverse consequence of this has been a huge increase in managerial bureaucracy in every sphere where ‘markets’ have been devised. Another has been to encourage a free-for-all, which favours, as one would expect, the well-connected and the well-to-do. ‘Choice’ has consistently undermined both the efficiency of the Labour government’s high levels of social expenditure and its worthy attempts to eliminate inherited disadvantages. How far a Cameron government would attempt to further marketise the NHS we don’t know, since Cameron is clearly nervous about upsetting the status quo. When it comes to education, however, Gove has been extolling choice and diversity (every man his own school). If carried out, this policy would probably wreck the state education system by shifting resources to the most energetic and best-placed parents. Since resources are finite, the result of ‘choice’ is that one parent’s gain is another parent’s loss. But the Labour Party has been almost as reluctant to admit this as the Tories. It is unlikely, therefore, that a Cameron government would make much difference. It will simply make the same mistakes; and perhaps a few new ones.”

**correct me if i’m wrong and I might vote.

NEWS FROM THE CENTRE FOR INTERNATIONAL PUBLIC HEALTH POLICY
Prof Allyson Pollock, Centre for International Public Health Policy
PFI interest rates by bailed-out banks unjustified

http://bit.ly/Qtbe5
http://www.health.ed.ac.uk/CIPHP/

The UK government is allowing banks to restore their profits by charging unjustifiably high interest rates for health service private finance initiative (PFI) projects, a study claims.

An opportunity to negotiate better interest rates is being missed, researchers suggest, now that two banks providing investment for new hospitals are partly owned by the government.

As a result, say researchers at the University of Edinburgh, the quality and financial performance of NHS services are being impaired.

The study analysed the 149 major PFI hospital projects that have been signed by the NHS so far. The researchers found that two banks in which the government is the major shareholder – Royal Bank of Scotland and Lloyds – have provided senior debt (the low interest portion of the borrowing) to 38 projects and have equity in 16.

The researchers say that these projects have raised £12.27 billion under PFI – but that over the next 30 to 60 years, the public sector will pay a total of £41 billion for the cost of capital alone.

Prof Allyson Pollock, of the University of Edinburgh’s Centre for International Public Health Policy, said: “Instead of using the opportunity of the taxpayer bail-out to reopen the contracts and negotiate better rates in favour of the public sector, the UK government is allowing the banks to restore their balance sheet by charging relatively high rates of interest for PFI schemes.

“The increased costs of servicing the debt are met from annual budgets of the NHS, and result in reductions in the money available for services.”

Prof Pollock said that the policy of using private finance is used to disguise public expenditure liabilities, since it takes capital investment off the government’s books. International accounting rules that would have required government to put PFI back on the balance sheet are being ignored.

She added: “The policy is expensive; compared with conventional government borrowing and procurement, PFI is associated with high costs of borrowing which include high rates of returns to the investors.

“There is a risk that reductions in public expenditure could provide a new political impetus for using PFI regardless of whether the policy is socially and economically beneficial and this will continue to be at the expense of major reductions in public services and public expenditure cuts.”

The news that patients should be allowed to register with any GP practice is apparently supported by all the political parties. It suits the modern conception of people as solipsistic consumers, increasingly motivated by convenience and satisfaction.

Lawrence Buckman interviewed on Today this morning said most of what needed to be said. The Government’s enthusiasm for adding bureaucracy to the NHS might make it possible.

What Dr Buckman didn’t say was that a great strength of GPs presently is their level of local knowledge frequently built up over many years. In the 6 partners in my practice we share 79 years of experience working in South West Hackney. We have an in-depth knowledge of the NHS and voluntary sector services, which work well and which don’t, who to call where and when, who’s worth referring to, and who ought to be avoided. We know the streets and the estates where our patients live and work. We know the relationships between generations of local families.

We know that most of our patients’ experience of life, illness and suffering are bound up in their relationships with other people and with their environment. We know how to work as part of a large and complex team of primary care, social services, voluntary sector and hospital specialists. We are local experts for our local patients. If we are to look after anyone from anywhere we can’t be that kind of expert for everyone.

PCTs are now carrying out tendering exercises for new GP led health centres, Polyclinics, Urgent Care Centres, GP surgeries, physiotherapy, radiology etc. etc. The costs are enormous and yet nobody can say how huge they are.

For example a PCT has to stage a tendering exercise for a GP led health centre. There are 50 applications for the first stage, each submitting a 70+ page document. Once these are analysed, a process taking up to 2 months, a short-list of, say 5 are invited to submit a final, much longer tender. Many of these applications are from local GPs who will, on the whole complete the applications themselves either on days off, or considering the amount of time required, by taking time out from when they would normally be seeing patients. They may have to employ locums to see their patients, or at even greater cost they could employ someone to write the tender for them. The overall cost to a GP surgery can be in the region of £40k plus all the additional human costs in terms of patients being unable to see their own doctors, lack of senior clinical support, weekends and evenings away from families and so on. And at the end of this, only one bidder will win the tender. For a small business, as most GP surgeries are, tendering is far too great a risk. They simply can’t afford the financial or human costs.

The cost to the PCT for a tender such as this is unknown. Unofficially I’ve been told it us up to £3 million. I’d be very happy to see evidence to the contrary. This is £3million that could have been spent on front line staff; there are still desperate shortages in many areas.  Most PCTs are being forced to carry out several tenders a year with millions of pounds going on administration. Meanwhile thousands of hours of clinician time are taken away from patients as GPs struggle to keep services in the hands of people who are still committed to the NHS.

Once a GP practice has lost a tender or 2, bidding will become financially unviable and the costs to existing patients unacceptable. Soon only massive private companies will be bidding, and, given enough time there will be a handful of corporate interests running NHS primary care. More and more money will be swallowed up on administration and transaction costs and less and less on caring humans.

We already have the most parsimonious universal healthcare in the world, and yet it is possible to make it more efficient by ending the market driven reforms, not by forcing more.

In last weeks BMJ privateers Julian Le Grand and Zack Cooper came to the underwhelming conclusion that “The reforms have not had a deleterious effect on the equity of waiting times for elective surgery in England” On the strength(?) of this they followed up with an article in The Guardian(!), “The NHS can cut costs and still care” followed by letters, including from Peter Fisher, president of the NHS consultant’s association and then a pointed response from Le Grand and Cooper.

Before I summon the energy to respnd to their BMJ article (my baby cryeth upstairs) Here’s my response to an article Le Grand and Cooper wrote in the BMJ news in May:

“As the great sage Jagger said, “You can’t always get what you want!”” House.

According to Zack Cooper and Julian Le Grand, writing in support of patient choice and provider competition in the BMA News in May 2009, “the true test of how a health service is performing is whether patients are satisfied with their care”.[1] It seems extraordinary that this should be the ‘true test’ of healthcare rather than for example, better health. Never mind better diabetic control or better mobility and pain control after orthopaedic surgery, or a reduction in mortality after angioplasty, or any other clinical outcome for that matter. A brief reflection on the parallel system of private healthcare in the UK is explanatory. In the UK people pay for private healthcare in order to have direct access to a consultant specialist, to be seen at a convenient time such as an evening or weekend, to guarantee a private room or for other non-clinical hotel comforts such as carpets or luxury menus. Unsurprisingly the costs of having a specialist at your beck and call and staying in luxury accommodation after your operation vastly exceeds the costs of equivalent NHS care. Satisfaction rates may be higher, but there’s no evidence for any difference in clinical outcomes. At my surgery in Hackney, East London patients have to fill in ‘satisfaction questionnaires’ every year and the responses are one of our ‘performance indicators’ which determine how much we are paid. Frequently there are complaints about our lack of beverage facilities and the quality of reading material in the waiting area. More seriously, of the 26 key performance indicators for Independent Sector Treatment Centres (ISTCs) only 8 are clinical indicators of any kind and only one can be considered a ‘pure clinical outcome indicator’.[2] Whilst I would never deny that I want my patients to be satisfied, I know that quite frequently what they want (viagra) is not the same as what they need (a test for diabetes)

One hundred years ago Bernard Shaw wrote in the Preface to the Doctor’s Dilemma, “Please do not class me as one who “doesn’t believe in doctors.” One of our most pressing social needs is a national staff of doctors whom we can believe in, and whose prosperity shall not depend on the nation’s sickness, but its health”

Satisfaction is the ‘true goal’ of private medicine because satisfied consumers keep coming back for more.

One of the many questions we now need to ask is, are these patients who are being seen quicker, healthier as a result?

[2] Player S, Leys C Confuse and Conceal: The NHS and Independent Sector Treatment Centres

The NHS is about care, not markets

Downsizing the workforce is a business response to loss of profit – but it doesn’t account for the NHS goal of universal healthcare
Allyson Pollock The Guardian 04 September 2009

Read online: http://www.guardian.co.uk/commentisfree/2009/sep/03/nhs-business-markets

The core goal of universal healthcare and services planned on the basis of need and not ability to pay is being jettisoned by the turnaround teams and management teams brought in to manage anticipated reductions in NHS budgets. Downsizing the workforce is a traditional response of business to loss of profit where businesses have to pay the costs of operating in a market and earn surpluses for shareholders. Unlike Scotland and Wales, the NHS in England is continuing to pursue market-oriented healthcare in its reform of the NHS. So it should be no surprise that management consultants firm McKinsey have come up with market-oriented solutions to anticipated budgetary shorfalls<http://www.guardian.co.uk/politics/2009/sep/02/nhs-advised-to-lose-workers>. They have advised ministers to cut 10% of the NHS workforce in England by 2014, a reduction that will affect services provided primarily to the old and the poor who have among the highest healthcare needs. But strategies to reduce the NHS budget need to pay attention to the role of market structures and how they reduce the ability of the NHS to pool the risks and costs of care across its population.

The diversion of health spending from patient care to paying for a market are not apparently McKinsey’s concern<http://www.guardian.co.uk/politics/blog/2009/sep/03/mckinsey-nhs-sarah-palin>. Take for example the costs of the new market bureaucracy; for more than 40 years administration costs were in the order of 6% of the total budget a year, they doubled overnight to 12% in 1991 with the introduction of the internal market. We have no data today for England, but what we know from the US is that the introduction of for-profit providers increases administrative costs to the order of 30% or more.

So why hasn’t McKinsey advocated making savings along the lines of Scotland<http://www.scotland.gov.uk/Topics/Health/NHS-Scotland> and Wales<http://www.wales.nhs.uk/> by reintegrating trusts into area-based planning structures and thereby abolishing billing, invoicing, the enormous finance departments, marketing budgets and management consultants, lawyers, commercial contracts? In this way one could project savings of anything from £6-24bn a year for England.

A second set of savings would be the high costs of PFI<http://www.guardian.co.uk/politics/pfi> where the taxpayer, having bailed out the banks, is now paying almost twice as much as it should for some PFI hospitals through high rates of interest and returns to shareholders. The total money raised from private finance so far is £12.27bn but the NHS will pay out £41.4bn for the availability of buildings and a total of £70bn over the life of the contracts. The irony is that the patient and the public are rebuilding the banks’ balance sheets using scarce NHS funds intended for patient care and staff, especially in community-based services.

A third saving could be made by cancelling the contracts for the £5bn ISTCs programme<http://www.dh.gov.uk/en/Healthcare/Primarycare/Treatmentcentres/index.htm> – research in Scotland extrapolated to England has shown as much as £1bn has been wasted by giving money to for-profit ISTCs for work that was not carried out in the first wave.

Then there are all the other contracted out services including the pharmaceutical bill of £14bn. Are these contracted out elements part of the McKinsey scrutiny? It is doubtful since the company travels the world advocating market solutions.

And here we run up against the fundamental problem of retaining marketeers to advise on healthcare. Markets mean reducing the capacity of the NHS to pool the costs of care across the whole service, substituting instead hospitals, clinics and practices that have to pay their way like businesses and, like businesses, can fail. Needs-based planning, once the hallmark of the NHS in England, is being replaced by strategies to deal with artificially created market failure.

Solutions are sought from outside consultants and turnaround teams using unsubstantiated assertions that the NHS is inefficient and can increase productivity. What the selective use of data and evidence mask is the failure to view the system as a whole and to remember that its core goal is universal healthcare, not concocted operating surpluses.

In contrast to Wales and Scotland, England has established hospitals and services as competing trusts or firms operating in a market; competition has replaced the mechanisms which enabled health authorities to monitor and respond and direct resources to the needs of the populations that are being served. But markets create winners and losers – and the unpublished McKinsey report is an attempt at refereeing.

The moral is that if the Department of Health in England commissions private management consultants that derive their profits from markets you will get market solutions. It is the commissioning, not McKinsey’s report itself, that should give offence

http://www.guardian.co.uk/commentisfree/2009/sep/03/nhs-business-markets

Replies (best of):

“lespetroleuse

03 Sep 09, 8:31pm

Burdened as it is with the weight of market-based reform, I find it remarkable that our NHS still performs so well.

Just 2 years after cuts in staffing imposed by a turn around team of top managers, my local hospital Trust has once again lost control of its finances and needs to find £13million ‘savings in the budget.

Patients, apparently, are in hospital for too long, due not to them being poorly, but rather, it seems, to poor systems and communications preventing them freeing up their beds earlier.

Having put the squeeze on the workforce by a moratorium on using agency staff, the Trust has now invited them to come up with suggestions for savings. Savings mind you, not cuts.

The longstanding objective of attaining the golden uplands of foundation status – the dominant and abiding corporate mission for at least 3 years – has been ditched for the time being as an unnecessary distraction that must not deflect from getting the new PFI extension completed and operational on time.

This unique outbreak of common sense is read by staff to mean that the Dept of Health has simply said Foundation status? – with that financial black hole? – no chance matey

Meantime, striving to earn its spurs as a world class commissioner, the separate local patient care trust (PCT) which serves the same people has split itself into two new entities; one for commissioning NHS services and one for providing them directly to the people.

All the top bods are, of course, on the commissioning side; amply supplemented, by the way, with experts in market intelligence, contract specification, bid evaluation, and procurement. Job titles come ready-prefixed with the term strategic.

The regional strategic health authority (SHA) which also deals in strategy, but of an undoubtedly higher order, doesnt much like direct provision.

This, I understand, is where the existing workforce and managers successfully bid to carry on doing what they do but offering improvements and economies over the years ahead.

Oh no, the SHA much prefers private health care operators to come in and do precisely the same thing with one minor difference.

They like to insist that the workforce leave behind their NHS pensions as a small token of their personal commitment and gratitude at working for a reformed NHS but with a private sector employer.

The icing on the cake was the PCT conjuring up legal advice to say they couldnt award a service contract to the in-house team (despite them submitting the best bid) only for the provider part of, (yes, I know) the same organisation, to counter with separate legal advice saying, precisely the opposite – that they could.

And all the while the overwhelming majority of NHS front line staff simply get on doing the best that they can for the people they care about.

Both staff and patients of the NHS deserve better than this.

Keep up the good work Allyson Pollock”

nicita

03 Sep 09, 10:00pm

lespetroleuse: all excellent points clearly spoken by somone with experience!

a few more:
* Foundation Trust Status: the Holy Grail, but who will drink form it: the directors of the new FTs, (who until recently got paid less than £100k per year but now have doubled their salaries).
*Watch pensions and grading for lower paid staff be the first to suffer in the cuts
* Watch Cameron carry on where the consultant driven incompetents of new labout have left off… what are hospitals but lage gotels anyway? Make Alan Sugar the new CEO of the NHS.
Staff and patients will need to find some new solidarity to opose and redress this nonsense, but I fear the socialist foundation of the NHS has been already holed below the waterline by a labbour government.

RogerINtheUSA

03 Sep 09, 11:53pm

The moral is that if the Department of Health in England commissions private management consultants that derive their profits from markets you will get market solutions. It is the commissioning, not McKinsey’s report itself, that should give offence.

Why did the bureaucrats at the had of the health system bring in McConsultants?

Ya do it for the same reasons you bring in a pro from Chicago when ya need some moak wacked in St Louis, or a guy from Vegas to ice a rival in Brooklyn. You bring in an outsider so the locals don’t take the heat. In the Sopranos they even brought in paisans from Naples

So you got the government telling you that you absolutely gotta save 20 billion then obviously something has to give. Painful choices.

So you bring in Yank hit men so that nobody says that the UK government is penny pinching and saving 20 billion to spend on Trident, and so nobody says that the NHS wants to fire your beloved GP – It’s the damn Yanks.

The Mac-something consultants. They do the work of Tony’s hit men from the Camorra, but with obnoxious Yank accents.

The other reason to bring them in is to produce a report that will create outrage – “if you cut our budget by 20 billion we will have to get rid of your GP and your nurses”

Huge commotion, recriminations all around, government drops plan, takes the Trident money out of Education instead, NHS officials return to status quo ante

From what I can tell the report says nothing about marketing or market-oriented systems. It just lists things to cut if the elected British government insists on cutting 20 billion out of the health budget.

Nothing to do with profit. Does the NHS make a profit? No. It has a budget. If London cuts its budget what happens?

Also, the UK spends far less on health care than the more compassionate countries on the Continent.

So you are going through all this commotion to save £333 per capita? Screwing up your already parsimonious system to cut a further amount equal to about 2 months health insurance in the US or maybe 3 months insurance in Germany?

Your health, your choice.

Excert from Patients not Profits.

The Kantian imperative, “you can because you must”, has been inverted to become; “you must because you can”[1].This has happened with the NHS mantra, ‘Your health, your choice’[2][3]. In other words you must be healthy, (and slim and beautiful), because you can. Fat or thin, sedentary or active, smoker or non-smoker, whole foods or junk-foods, in short, whether you are in control of your life or not, according to ‘Your health, your choice’, it all comes down to a matter of personal preference. Health differentials based on social class and circumstances out of your control are blamed on lifestyle choices.[4]

In developed countries such as ours, there is a social gradient in health, which means that the lower your socioeconomic group the greater risk you have of suffering from almost all types of illness, especially cardiovascular disease and most types of cancer. As the level of inequality increases, as it has done over the last 30 years, the social gradient widens even if the level of absolute poverty stays the same. As the rich get richer, the poor get relatively poorer and consequently become more socially excluded as the costs of participating in society increase. The health gradient “cannot be attributed, in the main, to diet, smoking or other determinants of ‘lifestyle’”[5]

The result of the government’s failure to protect health by increasing social inclusion through education, employment, and housing, is to shift the burden of responsibility onto patients who are expected to improve their lifestyles, and doctors who have to spend more and more time promoting healthy choices. Corporations are encouraged by the Government to offer a market driven culture of dependency; your choice, you choose yourself the products you need to be healthy.

The naive consumerist position is based on the imaginary construct of an ideal consumer based on rational choice theory which assumes that people are fully informed and fully able to understand the information, are rational and not subject to bias, are self interested rather than altruistic, in other words, fully autonomous.

This position assumes that society consists of equally autonomous individuals making rational choices in their own best interests. Autonomy is not equally distributed; it’s strongly associated with educational and financial empowerment so the least educated, poorest and unhealthiest are also the least autonomous. Illness undermines autonomy in several ways. Though mental illness most obviously adversely affects our judgement, most of us recognise that we think less clearly when we’re suffering from any illness. When chronic illness such as diabetes or heart failure is compounded by depression as they frequently are, your reasoning skills are seriously impaired. Physically disabling illness causing pain, breathlessness or visual impairment restricts your ability to choose where to go for your treatment because travel is so difficult. Chronic illness is financially disabling, resulting in unemployment or high costs for care or adaptations, so that choices that incur additional costs are closed off. People with learning difficulties and many elderly people find choices difficult and anxiety provoking and they value quality and continuity rather than choice.[6] Some people’s poor health and other difficulties are themselves testament to their failure to make rational choices that serve their best interests. It seems absurd to encourage them to continue to rely on their proven poor judgement for something as important as their healthcare, indeed it is a paradox that people’s poor health is blamed on unhealthy lifestyle choices in the first place and then they are told to choose how to improve their health.

When people are ill and hence most vulnerable, they need doctors who know them well enough to understand how illness robs them of autonomy, doctors who are skilled enough to step in and take care of their patients by sharing the burden of responsibility at a time when it weighs most heavily. In contrast the commercial health industry exploits illness and anxiety with advertising and fear-mongering to encourage people to choose and consume their products.

I opened the window of my consulting room wide in the hope that the smell of cigarettes would fade before the evening clinic. I had just been to visit SD at her home which was always thick with smoke and the 1970s decor –memories of my own childhood, was stained yellow like an old pub. For the last 2 years I’d been visiting her to check on her blood pressure and give her a general check up. She was well aware of the risks of smoking and hypertension and had guessed rightly that she had suffered a stroke during the night, but wanted to see me before calling an ambulance. She had started smoking 60 years ago as a 15 year old. Then she smoked Lucky Strike because that’s what everyone was smoking, but for the last 20 years or so she’s smoked whatever was cheapest at the local store. That’s what everyone smokes these days. You can even buy single cigarettes for 30 pence if you can’t afford a packet. Disabled by severe arthritis, she rarely goes out, but she’s always cheerful and denies being lonely. She has tried giving up cigarettes on a few occasions, and managed for a couple of years before her husband died, but started again afterwards to help fill the gaps in the day. She tried again after a chest infection shortly after we first met, but became depressed and rapidly returned to her cheerful self when she started smoking again. She gestured to her flat and the estate around, “when you live somewhere like this, it’s not like where you live doctor, we don’t mind smoking here”

Even in the absence of market pressure, the assumption underlying choice is that people like SD and doctors like me are equally able to take control of our lives and define ourselves by our choices. It assumes, wrongly, that providing information is enough to empower people to choose a healthy lifestyle. Offering choice without addressing the conditions within which people live their lives, the experiences that affect their decisions, and aspirations which shape their vision of the future, widens inequality by empowering those ready to make those choices and alienates those people who have very different priorities.

RT has pain in her knees and ankles, she starts telling me about them as we walk from the waiting room to my consulting room. She is also morbidly obese and eats to cope with her emotions. She finds herself overwhelmed by first comfort and then remorse as she cries throughout her eating binges. She has spent thousands of pounds on countless diets including one from a private clinic that injected her with amphetamines and resulted in a psychotic episode. She has spent hundreds of pounds on gym-memberships and bought dozens of self-help guides, none of which have had a lasting effect. Recently we discussed referral for gastric bypass surgery but the thought of the risks and future complications frightened her. She rarely goes out except to work or to collect her daughter from school. For a long while she stopped going to the doctor, because whatever she wanted to talk about, all they seemed interested in was her weight, “it was like they stopped seeing me as a person”.

[1] Zizek. S. You May! London Review of Books 18^th March 1999 http://www.lrb.co.uk/v21/n06/zize01_.html (accessed 2.2.9)

[2] http://www.nhs.uk/Pages/homepage.aspx

[3] http://www.nhs.uk/choices/Pages/Aboutpatientchoice.aspx

[4] Heath, I. A Mystery of General Practice in Matters of Life and Death, Key Writings. Radcliffe Publishing 2008, 97

[5] Marmot, M. Status Syndrome, How your social standing directly affects your health. Bloomsbury 2005, 249

[6] BMA News May 23 2009 p.10

Annemarie Mol’s wonderful book, The logic of Care. Health and the Problem of Patient Choice discusses in detail the complicated relationships that are necessary between health professionals and patients and highlights important differences between care and choice that are not discussed above.

The Essence of General Practice

Dr Jonathon Tomlinson
On December 29th 2007 Lord Darzi, in an interview in the Guardian gave an example of a patient with abdominal pain who required a scan for diagnosis and an operation for a cure.
The essential problem with the NHS, Darzi argues, is not a lack of funding or expertise, but the way different parts connect. Patients in search of treatment must navigate a maze – and may not end up at the door of those best equipped to treat them. “Take the example of a patient in London who develops abdominal pains in the evening,” he says. “They tolerate the pain overnight, then they go to see their GP, who says they need to see a consultant…” What follows is a time-consuming and costly back-and-forth: to the consultant, to the hospital for an ultrasound scan, to the consultant to discuss the results, to the hospital for a surgery pre-assessment, to the hospital again for an operation, back to the GP with a wound problem. “I mean, if you did your shopping this way… If Tesco provided you with that service, you wouldn’t go there. If you booked your flights that way you’d be all over the place.”[1]
He then went on to explain that he was going to change primary care services to reflect the needs of patients like this. I responded with a letter to the Guardian because it was immediately obvious to me as a GP that this wasn’t remotely typical of general practice. I see several patients with abdominal pain every week, but in nine years only a tiny minority have needed a scan and even fewer an operation. None of these have had an unnecessary delay. Just as everything looks like a nail to a man with a hammer, only a surgeon would advocate the reorganization of primary care on the basis of patients that need operations. And yet it was with that in mind that his plans were conceived.
More typical of general practice was a 50yr old man who came to see me with abdominal pain 2 weeks ago.
He was accompanied by a friend who said she was there to help him because he never came to doctors and he was really anxious. He looked anxious; he was also very overweight, slightly tremulous and pale. His friend explained that he’d been worrying about stomach cancer ever since his father died from stomach cancer last year. He wanted a scan to see if he was alright. He confirmed that this was the case. I spent a few minutes reassuring him and asking a few general questions about his health. Soon it was clear that he didn’t have any symptoms suspicious of stomach cancer. I examined his stomach and checked his weight and blood pressure.
His blood pressure was 224/124, extremely high, though not altogether surprising.
I checked a urine sample which revealed glucose, (probable diabetes) and signs of kidney failure (associated with high blood pressure and diabetes)
I asked him about his smoking (40 a day for 30 years) and family history of heart disease (his father also had a heart attack) He’d been experiencing pain in his arm on walking upstairs for the last few months, but had put it down to sleeping awkwardly.
He was beginning to relax because, I suspect, the level of attention and concern he was getting was more than he was used to, and because I hadn’t yet broke the news about the significance of what I’d already discovered.

He asked his friend to leave and asked me if he could have some Viagra. Unsurprising really that someone with diabetes, hypertension and kidney disease should have impotence.
He asked if he could also have some sleeping tablets.
Not really surprising then, that he also admitted that he was depressed
Up to 50% of people with chronic illness are depressed and insomnia is a common symptom of depression
Not surprising either when he admitted that he was drinking excessively.
Perhaps he might have something wrong with his stomach after all, an ulcer? Pancreatitis? Or even cancer

One by one I talked through his problems with him.
What he wanted when he came in was a stomach scan, some Viagra and some sleeping tablets
What he needed was looking after. He needed a doctor who was prepared to take responsibility for his care.
For this he needs continuity, a doctor who he could see regularly and develop a relationship of confidence, trust and understanding
He also needs a comprehensive service. With so many associated problems he needs to be seen by a doctor willing and able to manage all his different conditions.

What the changes proposed for primary care offer is the opportunity for people to be seen in a range of places other than their usual GP including walk-in centers, urgent care centers, and GP led health centers. What is lost by this is the opportunity for them to be seen by one GP who is able to take responsibility for them and offer continuity.
The unbundling of primary care services offers patients a choice of providers to provide care for each of their conditions. What is lost is the possibility for one doctor to provide comprehensive, holistic care in one place.
The changes to primary care are ideally suited to young people who occasionally get sick, whose wants are closely allied to their needs and for whom prompt convenient care is more important than continuity or comprehensive care.
The people for whom the NHS is most important are those who are much less able to identify their actual needs, people who need not so much choice, as looking after.
Jonathon Tomlinson
GP
The Lawson Practice
Hackney
London
June 8th 2009
[1] http://www.guardian.co.uk/politics/2007/dec/29/publicservices.uk

Post Script.

“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.”

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

We live in an age where rights are the ethical trump card, though there’s no rational justification for the ethics of rights to trump the ethics of duties,virtues, justice, consequences, or difference, all of which are useful ways of thinking about how best to provide health care. Rights are not the best (and are certainly not the only) ethical defence for health (or the environment for that matter), but they’re so dominant that they appear to be the blunt instrument taken from the ethical tool box every time.

Why is that?

On June 29th 2009 Gordon Brown announced that he was going to use Human Rights not simply to allow people to access private health care, but to force PCTs to send people to private providers.

He announced that patients are to have “six new rights to health” and “Primary Care Trusts will be forced to send people to a hospital in another area or, in extreme cases, for private treatment if they cannot deliver it in NHS facilities.”

No New Labour/ corporate health statement has failed to emphasise that choice is at the heart of how things will be in the new NHS. This makes a lot of sense when you consider that ‘choice’ and ‘rights’ are the ethical pillars on which corporate healthcare is justified. Choice and Rights are invoked because they are automony-dependent faculties and corporations like people to imagine that they are free agent consumers. This free-market ideology of capitalism is the model on which most western governments,  under corporate guidance are forcing upon every aspect of civic life.

Rights as a concept go back to Roman times; it was rights over slaves that really got the Romans going, but the modern conception of rights, and the one that’s so appealing to corporate interests is the version of rights laid out by the Geneva Convention after the second world war to protect individuals from the abuse of repressive states. They have risen as the dominant ethical paradigm since then (coincidnetally since the inception of the NHS) hence its no surprise that they also been widely used to justify the behaviour and legal status of corporations. The World Health Organisation has stated that far from individuals needing protection from the state, an effective state is essential for healthcare provision.

One serious problem with rights is that they are much less effective for anyone who really needs them (the sick and the powerless) whilst being relatively superfluous to the powerful (who can have everything they need, and can get what they want without having to appeal to rights)  “The Rights of Man become the rights of those who have no rights, the rights of bare human beings subjected to inhuman repression and inhuman conditions of existence. They become humanitarian rights, the rights of those who cannot enact them, the victims of the absolute denial of rights” Jacques Rancière

How can the ethics of care, duties, values, consequences, or difference add to a useful conception of health care, its provision and application?

To be continued…

We Brits fail to recognise just how deeply ingrained the American spirit of individualism, entrepeneurship and self-reliance is. For millions of Americans (and many here in the UK) there is a belief that justice is something that happens naturally, not something to be distributed by a state.  At this ideological level I don’t believe people will be converted from one side of the debate to the other, and therein lies Obama’s biggest problem. No matter how much evidence you present about the benefits (or otherwise) of sharing the burden of healthcare costs by progressive taxation and distributing it according to need guided by scientific evidence, the argument will be won or (more likely) lost on moral grounds. Things are, of course more complicated than that as i’ve already said, but like most debates, this has already degenerated into hammer vs. tongs.

Of course the confusion caused by attributing moral values to material facts is by no means restricted to Americans, though being a vast and varied country its quite easy to find examples. One of the more extreme, but nevertheless infuential and wide ranging is Prosperity theology. According to this reasoning success is a sign of God’s approval and failure a sign of His disapproval. Hence the successful deserve wealth because they are good and the unsuccessful deserve poverty because they are bad. Newspapers and politicians who would most likely choose to distance their politics from prosperity theology, still share the same moral reasoning. The secular version lies at the heart of Social Dawinism which has been enormously infuential in American and right wing European politics, based on the principle that social stratification will happen according to natural merit so long as governments don’t interfere.

The shocking conclusion of this way of confused moral reasoning is that despite the advances of science and modern theology illness remains as much now as it did in ancient times, a divine punishment for evil and according to simple capitalist rationale, if you’re sick you deserve to pay for it.

“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.”

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

When London GP Iona Heath introduced an article for the British Medical Journal criticising the effect of markets on health care she began, “The UK National Health Service is designed as an expression of social solidarity and provides universal access to health care funded through general taxation and free at the time of need.”[1] She was criticised for her “socialist parody of how real markets function”[2] This is the usual retort whenever doctors criticise the real or potential effect of markets. Hoping to avoid this charge I am presenting the evidence about the effects of real markets on two essential components of the NHS; equity, and efficiency.

Equity is the ability to distribute resources to those who most need them; people who are overwhelmingly and increasingly elderly, disabled, mentally ill, and suffering from multiple chronic diseases, rather than those who are the most demanding, articulate, enabled consumers.

Efficiency is the ability to use resources most appropriately; to ensure that patients are not inappropriately screened, scanned, medicated or dissected.

Equity

There is a social gradient in health, meaning that the less wealthy you are the lower your life expectancy and the higher your burden of disease. A report by diabetes UK this month showed that the UKs poorest had the highest risk of diabetes and its complications.[3] Poor people are more likely to have unhealthy lifestyles due to lack of education, hope and self esteem. Despite this, the differences in mortality and morbidity persist even when lifestyle factors are corrected for.[4]

Research by a colleague at my surgery in Hackney, East London of the highest attendees at the local A&E department shows that these people are more likely to be elderly, have multiple chronic diseases, have psychological co-morbidities, in particular anxiety and/or abuse drugs or alcohol.

Policies such as user fees, like the £20 fee to see a GP proposed this month by the Social Market Foundation shift the financial burden of healthcare onto the sickest and poorest in society so widening the health divide.[5] There are alternatives. Our practice is working with the local A&E department and out-of-hours service to develop shared care planning for the highest users in order to treat them more appropriately, so increasing both equity and efficiency. User fees would do the opposite.

Equity and choice.

The growth of markets in the NHS is linked to the increased emphasis on choice. Being able to make a choice and see it through is related to your level of autonomy. Because poverty, lack of education and ill health all undermine autonomy, unregulated choice also results in a widening of health inequalities.[6] [7]

Efficiency

Submission to the BBC Today programme request for suggestions for cost cutting in the NHS on June 30^th 2009:

According to the WHO Committee on Social Determinants of Health:

“In middle-income countries, higher levels of commercialization are systematically associated with worse and more unequal health-care access and health outcomes (HSKN, 2007). In low-income settings, unregulated fee-for-service commercialization is particularly damaging to health outcomes. In terms of health equity, publicly financed health care, regardless of ability to pay, is the preferred policy option. (See Chapters 9 and 11: Universal Health Care; Fair Financing)“[8]

Administration costs and transaction fees in the NHS have increased from 5-6% in the mid 1970’s to over 20% today. This is due primarily to the introduction of markets within the health service and a massive management expansion including the use of external consultants. Before long it may reach the extraordinarily inefficient 34% common in the US for profit hospitals unless the privatisation agenda is abandoned[9]. A fully publicly funded NHS could reduce administration costs to below 10%, saving the £10bn a year that’s required, without any reduction in services, indeed services would improve without the duplication and inefficiencies that competition has introduced.

The NHS spent £350 million on external management consultants in the last financial year. More than £273 million of this was not related to direct patient care and equates to the cost of 330 fully staffed medical wards, each with 28 beds.[10] Latest figures suggest the cost may be nearer £500 million and Labour ministers and high ranking civil servants are profiting.[11]

And the costs for IT have more than doubled to at least 15 billion so far with estimates that it might increase to over 30billion.[12]

The PFI initiative means that for an investment of 10bn, private companies charge the NHS over £50bn in rental over the next 25 years. The PFI companies are borrowing money from the same banks that we own, and then we are paying their profits (rent) as well.[13]
A few years ago I started a project with MEDACT to look at making the NHS sustainable. The possible savings for the NHS would be phenomenal if money was invested in making hospitals more energy efficient. The Royal Free in Hampstead invested in a combined heat and power plant and is saving over £1million a year with all savings going back into clinical services. [14] There are over 1000 hospitals and clinics in the UK, representing a potential billion pound a year saving. Other energy efficiency and waste reduction measures, in an organisation the size of the NHS could save millions.

GP led health centres.

Every PCT in the country has been forced by the DoH to build a GP led health centre. They have been given up to 7 times the amount of funding per patient than GP surgeries they are in competition with. “With the cost of GP-led health centres averaging three times as much as GMS practices, and rising to as much as seven times the price, serious questions must be asked over value and affordability” [15]

Independent Sector Treatment Centres

These were introduced to increase capacity in the NHS but at least 25% of their staff has been taken from the NHS. Their contracts mean that almost all the clinical and financial risk burden is still on the NHS. In spite of this the Department of Health own research has shown that the cost of care in the first 20 ISCTs is 12% higher than in the NHS.[16]

Commissioning and the Purchaser Provider split

Recently PCTs (Primary Care Trusts) have been forced to separate into commissioning and providing arms with the eventual aim of transforming the entire NHS into a commissioning organisation that pays competing private contractors to do the work. The claim is that competition between providers will drive costs down and increase efficiency. One example in Hackney is that a private company, InHealth has been paid a lump sum by the PCT (Primary Care Trust) to provide ultrasound scans, MRI scans, and various cardiology investigations. Because they are paid a lump sum it doesn’t matter how many investigations they perform, they still get to keep the money. If Hackney GPs refer to them it doesn’t come out of our PBC (Practice Based Commissioning)/ referral budget, but we refer to the Hospital it does. Many practices are tens of thousands of pounds overspent with their referral budget already because of the arbitrary pricing procedure so they are effectively blackmailed to send their patients to InHealth instead of the local NHS hospital, in our case the Homerton. The Homerton, like all hospitals now, is contractually bound to make a profit, by selling services (like scans and cardiology tests) to GPs, but it cannot compete with InHealth because their scans don’t come out of our budget. The risk, of course, is that our local hospital goes bust.

The US experience.

The US spends more per person per year on health than any other country as a result of greater administration costs, defensive medicine (over investigation and treatment due to fear of litigation), greater use of branded drugs and high-tech equipment and so on.[17][18][19] New medical technology such as complex scanning devices and chemotherapeutic drugs tend to be a lot more expensive than existing treatments. The costs are continuing to rise as new treatments become available and an aging population needs more health-care. The costs of operating a market – the costs of promoting and advertising insurance plans and providers’ facilities, of making contracts between insurers and providers, of accounting and invoicing for every individual treatment, of recording payments and chasing non-payments, of auditing and litigation – are huge. In US public hospitals in 2004 administrative costs accounted for 22.9 per cent of total costs; in private non-profit hospitals they accounted for 24.5 per cent; but in for-profit hospitals they accounted for 34 per cent.[20]

The US surgeon Atul Gawande recently examined healthcare in Mc Alpine a small Texas town on the Mexican border where the average per-capita healthcare costs exceeded the average annual income. [21] The costs there were the second highest of any US town. The main reason was a result of “financial incentives that drive unnecessary care”.

“Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.”

Postscript.

Complaint submitted to BBC Newsnight on July 27^th 2009

Dear BBC,

I am writing to complain about bias in the programme Newsnight (July 27^th 2009) The programme was billed as a serious report on ways to cut costs in the NHS but instead you presented a platform for advocates of privatisation.

The two health ministers, Mike O’Brien, Labour and Steven O’Brien, Tory started the program by stating their commitment to the purchaser-provider split and an internal market, joined by private hospital cancer specialist Karol Sikora who started off by saying that neither of them were going far enough with privatisation.

You then interviewed David Locke a barrister MP who lost his seat to Richard Taylor MP, a doctor that campaigned to save Kidderminster hospital.

You also interviewed someone from Doctors for reform, an organisation dedicated to profiting from privatisation of health services.[22]

I have submitted evidence about the increased costs and damage to equity and efficiency of markets in the NHS to your programme and the Today programme which has not been disputed.

I was very disappointed by Newsnight’s extraordinary bias. You didn’t have anyone who actually worked for the NHS or anyone committed in any way to preserving the NHS as a publicly funded organisation.

[2] Black, Stephen, Myths about markets and health, rapid response to Heath, Iona, Only General Practice can save the NHS, BMJ  2007;335:183 (28 July), doi:10.1136/bmj.39286.704722.59

[3] UKs poor twice as likely to have diabetes and its complications. Diabetes UK July 27^th 2009 http://www.diabetes.org.uk/About_us/News_Landing_Page/UKs-poorest-twice-as-likely-to-have-diabetes-and-its-complications/

[4] Marmot, Michael. Wilkinson, Richard. The Social Determinants of Health. Oxford University Press 2006 Second ed.

[5] From Feast to Famine: Reforming the NHS for an age of austerity. Social Market Foundation. July 20^th 2009

[6] Marmot, Michael. Status Syndrome. How Social Standing affects our Health and Life Expectancy. Bloomsbury 2004

[7] Sen, Amartya. Development as Freedom. Oxford University Press 2001

[8] 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

[9] New England Journal of Medicine vol 336 1997, pp 769-74

[10] NHS spending on management consultants in shoking. Royal College of Nursing May 10^th 2009 http://www.rcn.org.uk/newsevents/news/article/uk/nhs_spending_on_management_consultants_is_shocking

[11] Millions spent on NHS management consultants with Labour links Telegraph 23.08.2009 http://www.telegraph.co.uk/health/healthnews/6073354/Millions-spent-on-NHS-management-consultants-with-Labour-links.html

[12] NHS programme for IT http://en.wikipedia.org/wiki/National_Programme_for_IT#cite_note-15

[13] New hospitals ‘could drain NHS’. BBC Health http://212.58.226.17:8080/1/low/health/8081936.stm

[14] Estates Manager, Royal Free Hospital London. Rob Speight. Thursday 20^th March 2003  Society Guardian http://www.guardian.co.uk/society/2003/mar/20/hospitals.publicvoices

[15] Cost of GP led Health Centres. Pulse Editorial comment July 1^st 2009 http://alternativeprimarycare.wordpress.com/2009/07/01/one-year-on-is-the-cost-of-darzi-centres-too-high/

[16] http://www.publications.parliament.uk/pa/cm200708/cmselect/cmhealth/1190/1190w118.htm

[17] Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., and David U. Himmelstein, M.D. Costs of Health care Administration in the US and Canada. New England Journal of Medicine. Volume 349:768-775 August 21^st 2003 http://content.nejm.org/cgi/content/short/349/8/768

[18] The US Health Care system, Best in the world, or Just the most expensive? Bureau of labor Information, University of Maine, Orono, Maine. Summer, 2001 http://dll.umaine.edu/ble/U.S.%20HCweb.pdf

[19] Why does US health care cost so much? New York Times November 14^th 2008 http://economix.blogs.nytimes.com/2008/11/14/why-does-us-health-care-cost-so-much-part-i/

[20] Woolhandler and David Himmelstein, ‘Costs of care and administration at for-profit and other hospitals in the United States’, New England Journal of Medicine Vol. 336, 1997, pp. 769-74.

[21] Gawande, Atul. The Cost Conundrum, What a Texas Town can teach us about health care. The New Yorker. June 1^st 2009 http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=1

[22] http://www.keepournhspublic.com/pdf/Reform.pdf

The US doesn’t have a National Health Service. Instead there are dozens of different models of healthcare provision, some much better than others and some perhaps better than ours. The US surgeon, public health expert, philosopher and writer Atul Gawande has been finding out which aspects of US healthcare provision we might benefit from emulating.

His articles, published in the last couple of months in the New Yorker and the New York Times have shown that high quality, low cost healthcare is possible in the same country that has some of the most extravagantly expensive, averagely effective healthcare in the world.

The Best.

The Mayo Clinic in Northern Minnesota offers exemplary care at $8000 less per person each year than McAllen (its Medicare costs are in the lowest 15% of costs for the whole US) It does this by removing financial incentives from clinical decision making, by paying staff salaries or fixed fees instead of linking pay to procedures and by significantly improving the level of teamwork by facilitating communication and collaboration between all the professionals involved in patient care. Costs were reduced and there were less unnecessary investigations and less clinical errors. The Mayo clinic isn’t the only example he gives of affordable excellence, there are others, all non-profit hospitals with excellent levels of communication that offer care with higher quality care and lower costs than average American towns.

The Worst.

Gawande contrasts this with the US most expensive healthcare in McAllen, Texas. Here the extraordinarily high costs are due to doctor-owned, for-profit hospitals that have financial incentives to investigate, medicate and dissect as many patients as much as possible. As Bernard Shaw said in his preface to The Doctor’s Dilemma, “That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.” He was speaking at a time before the link between cutting off legs and making a profit was broken by the NHS; in Shaw’s day private doctors to the wealthy indulged them with all kinds of nonsense to make sure they came back for more. According to the same logic nowadays private health advocates most frequently quote patient satisfaction rather than clinical outcomes as a measure of their success.1

What are we doing in the UK?

Far from following the example of the Mayo Clinic, we’re following the example of McAllen. Established by the Department of Health in 2003, NHS Foundation Trusts must be run as businesses and make an annual financial surplus. Payment by results forces providers to compete for patients making the link again between cutting off legs and making a profit. Financial competition for patients and a free market in providers makes it extremely difficult for hospital departments and GPs to communicate effectively and collaborate in the best interests of their patients because they’re forced all the time to consider who is getting paid to do what rather than what’s in the best interests of the patient.

How on earth did we get McAllen instead of Mayo?

In the UK, US prvatisation advocates such as Tony Blair’s advisor Simon Stevens, now CEO of US Health insurance giant United Health have been lobbying and advising the UK government about healthcare reform for the last 20 years. I won’t repeat the details because they have been thoroughly documented in the essential books, ‘The NHS after 60’ by John Lister and ‘Confuse and Conceal, the NHS and Independent Sector Treatment Centres’ by Colin Leys and Stewart Player. What these books reveal is the depth to which profit seeking US corporations have influenced healthcare reform in the UK. The new book by Leys and Player, The Plot against the NHS brings the details up to date (edited 14.4.2011)

Instead of fawning over the NHS and abusing the US system, we ought, like Atul Gawande, to carefully examine what factors lead to the most effective, equitable and efficient healthcare in the UK and we need to ask why our politicians are not standing up to the private health insurance lobby as Barack Obama is.

1No Turning Back, BMA news May 23rd 2009 p.15