The Health and Social Care Bill is a necessary step in the evolution of the NHS because of major challenges posed by changing demographics and turbulent economic conditions. Unfortunately, the Bill is handicapped by a lack of clarity about the long term impacts which would result from a shift in funding policy. It also misses the opportunity to address the fundamental flaws in the configuration of the health system.
Furthermore, the title of the Bill is a misnomer as its social component omits a much needed review of the ties between the benefit system and the NHS. Its present linkage to the NHS not only constrains the effectiveness of the NHS but it also conspires to undermine proposed reforms of our pensions and welfare system.
Apart from transferring financial responsibility to GP consortia, the other subsidiary principles of the Health and Social Care Bill are valid – the reduction of bureaucracy, the repositioning of decision-making processes and revision of social care provision.
With over 30 years of experience in the NHS, it is possible for me to track the changes that have contributed to the success and failure of various health policies. The most significant of these is the greater separation between primary and secondary care that has come about recently and exacerbated by the monetisation of medical procedures. The situation has become so ponderous that, unsurprisingly, hordes of clerical and managerial staff are required to negotiate and monitor contracts with their complicated financial arrangements.
The variability of human responses to a multitude of illnesses and diseases means that it is virtually impossible to standardise all aspects of medical procedures and treatments. It is also paradoxically inefficient to do so in many instances. The introduction of targets and pricing for waiting times, at Casualty Departments from arrival to admission or discharge, inpatient stay and the arbitrary episode cost and trim points and resolution of outpatient referrals, etc., has subverted clinical common sense and decisions.
Despite assurances that they would be reviewed and removed, it seemed that New Labour philosophy has become entrenched and accepted. A few days ago, a lung cancer patient due to attend a brain scan had deteriorated but he was told he could not be admitted from the Radiology Department onto the ward as he was only booked for scanning. His GP could admit him onto the ward but he would then lose his place on the scanning queue!
Rigid adherence to protocol driven and cost-based direction of medical activities are behind all this inefficient behaviour and it detracts from giving appropriate and compassionate care.
Patients know about the rush to get them out of hospital beds and commonly attribute it to bed shortage but are not aware of the other reasons such as the financial parameters of bed occupancy. In contrast, they are perplexed by long waits for outpatient follow-up appointments that are often only 2-minute perfunctory consultations just to confirm the clinical condition with nothing substantially achieved. Unknown to them, however, are the financial deals between the Primary Care Trusts and Acute Hospital Trusts. Acute Hospital Trusts will do all they can to suck income from Primary Care Trusts while the latter will try to reduce their out-sourcing requirements to contain expenditure. This format results in public misunderstanding, doctor frustration, managerial burden and unforeseen negative financial impact.
Just last weekend, patients throughout a Midlands county experienced unusually long waits to see a GP. Two weeks into running the out-of-hours contract, a private firm finds that many of the regular doctors have lost their motivation to work in those positions and stayed away while casual locums have not been altogether reliable in turning up for duty. Many out-of-hours primary care centres offer a poor service.
That is just the tip of a more insidious iceberg which is the damage to professional ethos and morale from the unceasing barrage of audits, surveys, reports, appraisals and refresher courses of the same topics repeated at short intervals. This micro-management by people converted to the ‘New Labour’ way emanate mainly from administrative non-medical quarters.
As for the medical profession taking on commissioning responsibilities, the cost of getting them ready to undertake financial decisions is added to the redundancy payouts to thousands of clerical and managerial staff in the PCTs as these are being faded out. The irony is that these commissioning doctors are trained to develop the very financial mindset that has been the cause of so much of the problems.
This therefore raises a serious question – has it ever been considered that in healthcare with particular emphasis on medical services that, perhaps, it is not granting financial control to doctors but ensuring a return of professional autonomy to all those skilled groups that work under its banner that is the route to a better NHS?
Apart from its health scope, the proposed Act misses the opportunity to deal with wider social aspects that impact on health and the national economy. Recently, the Department for Work and Pensions identified 1.5 million people on incapacity benefit to test their ability to work. It was also reported that almost 30% of those who took the test during pilot schemes in Burnley and Aberdeen were declared fit to work. Incredibly, “early indications showed 70% of incapacity benefit claimants had the potential to work.” Why is that figure so high? Is it because the condition that originally formed the basis of such certification had been successfully resolved, or could it possibly be variation in the threshold for initiating such certification? Have GPs got it so wrong that 1 in 3 long-term sick notes have no validity for financial support?
The answers to these questions lie to a significant extent at the interface between the claimant and the certifier, namely the GP. Certainly, the association between the patient and the GP is too close to avoid compromises in many cases. There are also those cases of sickness claims that have their origins in industrial disputes or employment grievances – cases of stress at work or unfair treatment awaiting arbitration – but have become ‘medicalised’ and given certificates.
At the 2003 Policy Forum on Health, Andrew Lansley (then newly appointed Shadow Health Secretary) was the guest speaker. He was presented with various proposals. The issue of accountability to patients, effecting seamless care and enhancing professional satisfaction that included learning opportunities and performance monitoring could all be addressed with the introduction of integrated multidisciplinary units based on a clinical chamber model. Indeed, genuine competition among such units would result quite naturally and spontaneously.
In the area of funding, some basic questions need to be answered – is the NHS about treating illness and diseases, or does its remit have to extend beyond such a function to include the wider role of a moral custodian? Where should the responsibility lie for management and education of drugs addiction, including alcohol and cigarettes? There were also recommendations to hybridise healthcare funding with incentives that are consistent with personal financial autonomy. Finally, does the state have a direct responsibility for the health of its citizens or is it politically acceptable for it to behave as a mega-insurer giving out subcontracts to private firms? Is the Beveridge Report not relevant anymore?
The above issues and questions could be advantageously explored during the temporary suspension of the Health and Social Care Bill. Inclusion of some of the proposals could make a significant difference in advancing the Bill and eliminate some of the deeper shortcomings and longer term risks associated with changing the fundamental complexion of the NHS.