Having worked in various NHS positions since the late 70s, I listened to the Prime Minister's speech at Guy's Hospital on June 14th with great anticipation, only to feel disappointed by the end of it. Later that afternoon, I attended a GP Commissioning Consortium (GPCC) board meeting which was more crowded than usual with non-executive directors and lay observers. The meeting dragged on but the decisions which were finally reached would have been no different had the non-board members stayed away. Of course it is important that all interests are considered at such meetings, but this and other current processes are mere tinkering of the much larger national problem which the Government must urgently tackle – how to achieve successful integration within the behemoth that is our NHS.
Leicester has one of the busiest Accident and Emergency (A&E) Departments in the country. A large proportion of its attendees have minor ailments that should be dealt with by their GPs. Such inappropriate use of the A&E is not entirely the fault of the doctors and nurses or the architects and planners. Getting those members of the public to co-operate with advice and improve the situation has not worked and has sometimes backfired. The addition of a hospital doctor, nurse and more lay people to the GPCC would not make any significant or beneficial difference to this type of problem. A primary care led consolidation of services would more easily resolve such difficulties. Integration will.
Yesterday, my 87-year old patient who attended the hospital for a hernia operation was turned away. She thought she could have the surgery under general anaesthesia, spend a few days recuperating as an in-patient, and return home when she could look after herself again. The surgeon wanted to operate on her as a day case using local anaesthetic, so she contacted the social services for an enhanced care package but she was denied assistance. The social worker phoned me to say that “the patient failed the eligibility test as she could do all the things according to the social services checklist at the time of her assessment“ and added she was able to go to town with her friends! Evidently, no consideration was given to the patient’s post-operative condition. Has bureaucracy stopped managers from being human? And with the social worker’s supervisor away, no alternative decision could be made for at least another two weeks! People like this lady will welcome the Prime Minister’s vision of a “seamless journey through the health service.“ To make that a reality, health and social care needs to be integrated.
Integration of primary and secondary care therefore offers the rare opportunity to include tertiary care and other areas of health provision in the proposed reform. If the Prime Minister pursues a total reversal of the existing fragmentation of services, a wholesome environment can return in which future generations of doctors and nurses will be able to learn about the virtues of holistic care. It is important that such training continues to nurture compassion and intellectual expansiveness as these are essential to the advancement of health and social care. If health policy reduces the administrative burden of doctors and nurses, they will be able to concentrate more on the clinical aspects of care.
Unfortunately, integration relies on the co-operation of the local authorities, mental health agencies and the commissioning consortia to work together. There is substantial resistance because these entities operate from their respective funding pools. That is why the Health Secretary should retain ultimate responsibility, not only to ensure that integration succeeds but also to oversee service delivery, such as local processes of design and execution of patient pathways, interactions between hospital doctors and GPs, and local variations in the detailed specification and standards of facilities.
Any failures or deficiency of these delivery units – in quality, timeliness and cost – are sometimes wrongly ascribed to policy failure but detailed analyses often reveal a variety of reasons, such as bad management and poor implementation of the regulations. The way to deal with these problems is to improve the management, not to privatise or to increase the size of the management. There also needs to be a system of feedback that is responsive to clinicians’ input so that good care is facilitated and clinical quality is enhanced.
Only from successful integration will sustainable economic efficiencies and a seamless service be delivered. However, the Prime Minister’s plan for the integration of primary and secondary care is inconsistent with his simultaneous insistence that competition should prevail. How can an integrated service compete against itself? Why is “competition” promoted as the magic solution to the problems in the NHS?
Fundamentally, competition in the free market sense only works for distinct and mutually exclusive entities. The NHS, however, is the exact opposite of this. It is one unified body so asking it to compete with itself it like asking a human to use his right arm to cut off his left. Competition will therefore prevent us from achieving successful integration of the NHS. If the objective is cost reduction while preserving quality, the exercise is not competition; it’s realignment. Therefore, the stripping out of some services from the hospital setting and transferring them into the GP setting will not only reduce costs but also allow some hospitals to concentrate on high-end complex services such as cardiac and transplant surgeries, and allow some hospitals to be closed where services could be delivered well in other settings. However, we have seen political pressure being applied to prevent closure of hospitals even when there are economic justifications for such closure. Will such closures now be allowed?
I believe proponents of competition, which has no place in an entity such as the NHS, fail to draw the critical distinction with competitiveness, which should be nurtured in the NHS in the same way as competitiveness is nurtured within a school – pupils compete for excellence and recognition based on merit and dedication. Competitiveness, which ensures high quality, can in the context of the NHS encourage sensible pricing pressures. This is what we need to bring back to the NHS. The NHS is about people – the medical, nursing and allied professions and the patients who deserve the compassionate care which this country has for decades been renowned for delivering
In contrast, offering “the choice to get treated where you want, the way you want“ is regrettably a stale political mantra that is neither ethical nor professional. As as the technology involved in some advanced forms of treatment requires exacting clinical environments, it would be irresponsible to recommend otherwise. Similarly, announcing that in the case of “treatment for cancer you can choose to have your drug treatment at home at a time that suits you“ is irrational as most patients understand the strict regimes of drug treatment are tailored by clinical criteria and not personal whim.
Financially, it is neither efficient nor viable to have a block contract payment for any given service by existing NHS hospitals and at the same time have settlement for fee-per-item bills of an identical service from other providers. It is therefore hard to believe in either the honesty or the sustainability of promising anything and everything to all patients when those with responsibility for spending NHS funds are reminded of the need to save £20 billion out of an annual budget of £100 billion. This must be one of the most bizzare examples of double bind.
In the drive to achieve savings, younger doctors are becoming less able to exercise clinical decisions based on scientific judgement and compassion. The more experienced doctors feel mounting tension as a result of this challenge – humanistic values are pitted against the tide of economic pragmatism while defensible medicine has to yield to defensive medicine to avoid complaints and litigation. Homogenisation of clinical cases is now matched by a similar assault on intellectual autonomy and the resultant curtailment of free thinking has led to some disastrous consequences.
Of course, demand management and rationing has always been part and parcel of the service delivery. The government must now not flinch from setting out an explicit list of services available and those which are excluded from state provision. This transparent format of selectively excluding certain service items (referred to as priority setting) is not incompatible with the basic tenets of the NHS, and I believe the opportunity should also be taken to incentivise personal autonomy while guaranteeing state responsibility.
I have previously outlined on ConHome some of the measures the Government should take in order to move firmly away from the vicious cycle of crises. At the same time, we must also avoid a repeat of previous reform endeavours – spending a lot of money and time on reorganisation, slimming down bureaucracy only to re-inflate it and in the process losing the plot for good intentions.
We have now reached a watershed in the evolutionary history of the NHS, a health system that embodies worthy principles and values that are still as valid and as relevant today as when it was first conceived. We can and must achieve a sustainable health system that will thrive well into the future despite demographic pressures and economic exigencies.