You are hereBlogs / dr-no's blog / If It Walks Like a Duck...

If It Walks Like a Duck...

Posted by Dr No on 29 April 2011

its_a_duck_2.jpgDr No has no doubt that the most devastating blow to be wrought by the Tories on the National Health Service in their Health and Social Care Bill is the abolition of the Secretary of State’s duty to provide a comprehensive health service. At a stroke, it removes ministerial responsibility and accountability, and so renders the NHS as an army without a chief, a supertanker with no one on the bridge, a body without a head. And when mayhem arrives, as it surely must, when the troops run wild, or the tanker strays off course, there will be no one in charge, no one on whose door we can knock, and demand redress. So long as the Secretary of State has ‘acted with a view’, an invidious wording blessed with the legal slipperiness of a bar of soap, he can profess to have done his duty, and declare, even as the tanker hits the rocks: ‘not my problem’.

Decapitation is of course a brutish but undeniably effective way of killing off the comprehensive national health service, but what about the other central tenet of the (N)HS, that it is free at the point of delivery? The Tories, naturally enough, make loud claims that this sacred cow of Modern Britain shall never be slaughtered, and indeed the Bill appears to support this. Or does it? Once again, scrutiny of past versions of the Act, and the wording proposed in the new Bill, reveals a subtle change. Where previous versions had ‘The services so provided shall/must be free of charge…’, the phrase ‘so provided’ linking the absence of charge to the comprehensive health service provided by the minister, we now have ‘The services provided as part of the health service in England must be free of charge…’

On the face of it, this apparently minimal change might appear a necessary uncoupling, given that the Bill removes the duty of the minister to ‘so provide’ a comprehensive national health service. But it also does something else. It defines a subset of services provided, that subset provided as part of the health service, and so there are some that are not provided as part of the health service. If we then add the removal of the duty of the minister to provide a comprehensive health service, we can see that another subset – possibly quite a large subset, given the absence of a duty to provide a comprehensive service, possibly not – of services might now exist: those services not provided as part of the health service.

Now all this might appear pedantic nit-picking by Dr No, but he begs you indulge his fancy for just a moment longer. Whether intentionally – the conspiracy version – or accidentally – the cock-up version – other better known parts of the Bill will transform the our health service into a system that closely mirrors the American health care system – a system, we might add, that costs almost twice as much (16% of GDP compared to our 9%), for worse outcomes (infant mortality/1000 live births is higher, at 6.06, compared to our 4.62 and life expectancy at birth is lower, at 78.37yrs, compared to our 80.05yrs).

Where the Americans have healthcare maintenance organisations (HMOs), often large private corporations, that insure ‘enrollees’ and ‘manage’ their healthcare with providers chosen by the HMO, we shall have large privately run (general practices, remember, are self-employed businesses – the so called independent contractor status) commissioning consortia, all too often enthusiastically assisted by American HMO back-room boys, managing our healthcare delivery by ‘any willing/qualified provider’ chosen, we should note, not by us, but by our commissioning consortia.

As the saying goes, if it walks like a duck… The core feature – HMOs contracting with their choice of provider – of the American system will be in place. And if it walks like a duck and swims like a duck, before too long it might start quacking like a duck. Although consortia will be statutory bodies, and so have statutory functions, given the vacuum created by the removal of the minister’s duty to provide a comprehensive health service, there is no bar that Dr No can discern to the establishment of a parallel insurance based health care system; the once registered NHS patient reborn as an HMO enrollee…as long as they, or their employer, can afford it.

Far-fetched, even preposterous? Dr No thinks not. We already have a dental service run along these lines: glossy private practices funded mostly from insurance, alongside a destitute and creaking NHS funded service – and already that makes use of top-up payments. And then consider what has happened in higher education: once free tuition, now increasingly topped up by fees. The precedents are all too plain to see.

The Health and Social Care Bill, if enacted in its present form, will not only kill of the golden NHS goose, it will also pave the way for an American duck – or does Dr No mean turkey? – of a health care system, a system in which the rich buy frivolous care, while the uninsured poor suffer in destitution and depravity.

9 comments: could be goose?

Or a dodo? could even turn out to be an Argentinian racing pigeon!

But Dr No thinks he knows an American turkey when he sees one.

I would disagree that a central tenet of the NHS is that it should be free at the point of delivery.

IMHO, the central tenets of the NHS are that it should be:
1. Universal, i.e. covers everybody
2. Comprehensive i.e. covers a wide range of illnesses, and
3. Fair

Now, 'fair' does cover issues such as the ability to pay, as well as the rationing of limited resources but that does not imply that is must be completely free of any charges at the point of delivery. We already have prescription charges (in England, anyway) and it has been suggested many times that patients should pay at least a small fee to limit the abuse of the service.

Yoav - a good point that may turn out to be the crucial one.

Dr No says free at the point of delivery is a central tenet because it was enshrined in the original Act, and has since remained central in the Acts.

Your point is I think in essence about equal vs equitable treatment. We can for example say that all parents whether paupers or princesses get £10pw child benefit per child. That would be equal - and so presumably laudable - treatment - but it might not, to use your word, be fair.

The old (pre-Hacksaw) NHS subconsciously embodied the concept of need. Sick patients got treated; the well-to-do worried well were booted off to pay their guineas to Harley Street (and that includes the private wing of NHS hospitals). That, in it's way, produced a mechanism for fairness.

The problem we now have is that, thanks to Hacksaw and her subsequent clones, health care is seen as grocery shopping - and that means the consumer must have choice...and Respect.

And so our ability as doctors to meter fairness is castrated by marketeers.

The time may have come to challenge the government on the distinction between equal and equitable health care (difficult to do) as well as drawing a clear distinction between patients and clients (also difficult to do). Nowadays, governments of any colour will never give up on trying to make healthcare profitable, and they seem to be prioritising the prevention of illness (clients) rather than its treatment (patients). Indeed, NICE recently has challenged “The Rule of Rescue” against the advice of their “Citizen’s Council”

i.e “The presumption that saving the life of someone in imminent danger of dying is more important than improving the quality of life of someone else whose life is not in immediate danger, or of saving hypothetical future lives through prevention efforts.”

This was picked up in Oregon, USA. They have themselves changed their rationing priorities to reflect a drift towards “politically popular” care to the extent that treatment for tobacco dependence, or sterilization is now prioritised before the management of severe or moderate head injury, Type 1 diabetes, torsion of the testis, or Addison’s disease.

There is the potential in the new Health and Social Care Bill for much profitable madness.

There is already an inequality/inequity (I'm sorry, right now I can't work out the difference although I get the gist of what people are saying about it).

A close relative of mine is currently in hospital and due to be discharged any minute. The nursing team has told me he has alzheimers and I just have to accept it, but you get a different story from each nurse. The doctors don't talk to me. OT spent a lot of time asking if I could care for him but when told that I can't, still said they'd send him home to me. The social workers won't assess him because his needs are not critical. (Er, how do you determine that someone's needs aren't critical without assessing their needs?) They won't assess my needs because they've deemed he is not eligible for his needs to be assessed. The NHS care team that were looking after him in the community before he went in have decided that their services are no longer needed.

I am disabled myself with day and night care needs. I am hallucinating and manic. But I am not stupid. I know when people are passing the buck. I know when everyone wants someone to be dealt with by someone else's team and someone else's budget.

I also know that he won't get care unless someone calm and articulate and knowledgable with the right connections and sufficient determination advocates for him. I know that I won't, either.

Or to put it differently, the welfare state favours people able to fight the system, not ordinary people, least of all those with chronic, unsexy needs.

Anonymous - there is a name for your experience - it is called the collusion of anonymity.

The term was first used by Michael Balint to describe what happens when a GP refers a patient to hospital consultant (he was writing a little while ago!) and then the hospital consultants passed the patient from piller to post, with no one doctor taking responsibility (the collusion of anonymity); as a result patient fell between the gaps. Nowadays, with plethora of teams (and so team members as well as different teams) on offer, the opportunities for collusions of anonymity are boundless.

This is one of the reasons why Dr No is not over-impressed with teams in healthcare (of course they have a place, but they are far far away from a panacea). Patients need one clinician (usually a doctor, but it doesn't always have to be) to be in charge, and in today's political correct times being in charge doesn't go down well. The end result is that with no one in charge, no one takes responsibility, the collusion kicks in, and patient falls between the cracks.

In the old days, GPs did most of this being in charge most of the time, (indeed that is why consultants are called consultants: the GP consulted the consultant, but the patient remained his) and good ones, sadly increasingly rare these days, still do: they are the articulate and knowledgeable someone with the right connections you describe; and good doctors, whether they would put it like that or not, always see themselves as advocates for their patients.

As doctors, especially GPs, increasingly become GMC style cloned team-docs (not being a ‘team-player’ is a mortal sin these days – and so doctors increasingly prefer to be team players, rather than be awkward and stand up for their patient), patients, and their carers and relatives, risk (not all do, of course) getting a shoddier, more disintegrated, perhaps even non-existent service. And as you observe, those who know least about how to fight the system are most at risk.

Dr No has struggled with this problem for a while, and he does not have an easier answer. Putting the doctor (GP) back in charge (and so responsible) again goes against today’s politically correct love of team playing, and so will not be easy. It is almost as if there is a need for a skilled patient/carer/relative advocate, an ‘articulate and knowledgeable’ individual who can help the patient/carer/relative navigate the system. But it seems so absurd to have to reinvent the wheel when not so long ago the GP did just that – and if they pulled their grubby fingers out of their team-playing asses could still so do.

The problem with teams is that to work well, as well as having their own individual expertise and experience, the members have to:

Like each other
Co-operate rather than compete
Have to be physically based close to each other and meet face to face frequently (usually informally every day.)

Unlike the teams caring for patients in the past, today’s teams are often the antithesis of the above and simply don’t work. Gaps appear, responsibility evaporates, there is infighting, they become talking shops, important aspects of patient care are omitted and there is lack of attention to detail.

The other problem is that today’s teams go hand in hand with protocols.

One of the first posts on Witch Doctor addressed was the perniciousness of “The Protocol.” These tick boxes are often a means of an establishment attempting to abdicate from responsibility.

However when things go seriously wrong eg a patient dies tragically because of some omission, it is usually the senior doctor that is fingered to take the blame. This may result on him/her being struck off and even jailed. And so, doctors cannot ever escape from being responsible for their patients no matter how much of their work is delegated to others by themselves, managers, administrators, think tanks and governments.

So, a good starting point would be to get back to the old system where the GP has explicit overall responsibility for the patient in the community, the GP has explicit overall responsibility to refer the patient directly to the most appropriate consultant, and that consultant has explicit overall responsibility for the patient when seen at a hospital outpatient department or during admission.

Anonymous 12 May, If you are a patient or you are acting on behalf of a patient, is your right to ask to see the consultant. There will have been a consultant responsible but he she/may have been in hiding - in committee rooms spending hours coming up with no sensible decision about anything, attending a leadership course when they should already have been leading the care of their patients, or they may have been collecting their little grateful “Thank you” letters for patients and putting into a folder for their next appraisal session, – all done during working time paid for by the taxpayer - Time which would have been better spent doing the job he/she spent many years being trained to do.

But Anonymous, it is not your fault that you find it difficult to fight the system for the benefit of your relative. We doctors, who know the system well, find it difficult too when our relatives or ourselves are on the receiving end of healthcare today. That, I think, is why some doctors have started to blog and why we are so fearful of the proposed changes contained in new healthcare reforms. They will undoubtedly carve up responsibility for patient care further until it is no longer exists.