Desperate NHS needs a desperate remedy – care is already rationed

if I was an overworked GP I would be tempted to go “part time” and close the doors. There are just not enough of us, and a reasonable defence mechanism is to reduce the pressure.  Philip Collins does not seem to appreciate that his local Health Service is already rationed, but covertly, and in a differential post coded manner. He has not recognised that several other countries who initially tried to imitate the 1948 model, have abandoned it. (NZ and Scandinavia). The ironic laughter with which the profession saw the Olympic Ideal portrayed in London needed to be seen by politicians. It is too late for a “turnaround” because the goodwill has gone, along with many of the staff. It has to get worse now, and a new model of care will evolve. It looks like being a two tier system with insurance or private care for those who can afford it, including emergencies. The care tsunami will overwhelm us..

Image result for care tsunami cartoon

Philip Collins opines in The Times 15th Jan 2017: Desperate NHS needs a desperate remedy – If the medical profession continues to cry out for more money, the health service will have to start rationing care

When Theresa May said, at prime minister’s questions, that the Red Cross had been “irresponsible and overblown” to describe the state of the NHS as “a humanitarian crisis” she was right. The Chelsea and Westminster hospital is not Aleppo. But the Red Cross has devalued the debate more than that. It has encouraged the pretence that the crisis is sudden and government-inspired. In fact the crisis is truly chronic.

Simon Stevens, chief executive of NHS England, told a committee of MPs that the health service is under severe pressure while the prime minister, who is in danger of falling out with a civil servant she really needs, is said to believe that the crisis is no more than the typical winter discontent. An iron law of politics applies: in any political argument it is more than likely that both sides are right.

The situation is both severe and typical. The NHS will now be permanently “in crisis”. Every so often there will be a flashpoint such as the junior doctors’ strike or a winter surge. December 27, 2016 was the busiest day in the seven-decade history of the NHS; the number of elderly patients waiting on trolleys has trebled. If the prime minister is tempted to take the attitude of “Crisis, what crisis? she would be foolish. Real people are suffering, some of them fatally.

It helps nobody, though, to pretend that this is all the fault of Jeremy Hunt, the health secretary. His intentions for the NHS, despite the wild accusations of some critics, are nothing but good. The problem is much bigger than the identity of the minister or the political complexion of the government. The Office for Budget Responsibility (OBR) has calculated that unless the current productivity rate in health improves, the cost of the NHS will push the national debt to more than 200 per cent of GDP by 2060. We cannot pretend that we can keep finding enough money. As Giuseppe di Lampedusa wrote in The Leopard, “If we want things to stay as they are, things will have to change”.

The first change is to recognise that the National Health Service is not really any of those three things. Variations in quality mean the NHS is a regional service with a national logo. Second, the nature of modern illness, which depends so much on diet, means that health is looked after at home; the NHS is an illness checker and fixer. Finally, the NHS is not a single service. The current problem with A&E occurs because GPs, happy recipients of a crazy contract, are closed or there is no local minor injuries centre, which would be a much better place for many of the people in A&E. Hospitals cannot discharge the elderly because local government cuts — the falsest economy in the sorry history of austerity — have turned a poor social care service into a shameful one. The NHS is the repository of problems, not the cause….

Yet we are sickly sentimental about it. To provide health care by need rather than by ability to pay is a noble principle which should remain the centrepiece of the system. But too often it functions as a sign that warns off trespassers: “No reform here.” It’s too late for that; winter is upon us.

The NHS budget has been protected, at least relative to other services. The much bigger problem is that demand is racing ahead. The country is older than it was and getting older. In 2015 there were three times as many people aged over 85 as there were in 1990. Medical science can do more than ever before, and in a system in which people are not rationed by cost they understandably want all the care they can get. Inflation in the NHS is in the region of 7 per cent per annum, just to achieve the same results.

If we really want to defend the principle of the NHS then we have to countenance unpopular measures. The first is a campaign to close hospitals. Routine problems such as hip replacements no longer need to be done in the district hospital. Victims of heart attacks, coronaries and strokes are better treated in small specialist units. Ultrasound can now be done by GPs. Some acute care can be offered at home. The day of the all-purpose district hospital has gone.

The NHS was designed in an era when care was done to patients by doctors. That is no longer true. Two thirds of the NHS budget goes on the 15 million people in the country who have a long-term condition. Patients with dementia, diabetes, arthritis and hypertension take up half of all GP appointments, two thirds of outpatient appointments and 70 per cent of inpatient beds. Moving their treatment out of hospitals could save £4 billion a year. Most chronic care is administered by the patient him or herself. It is worrying that a 2010 Commonwealth Fund report compared seven health systems. The NHS came top for effective care and efficiency. On putting the patient in control it came bottom.

Next, politicians, especially on the left, will have to stop screaming “privatisation” at every reform. At the moment less than 8 per cent of the NHS budget is spent on private providers. Competition has lowered costs for cataract procedures, MRI and knee replacements and shortened waiting time for hip operations. If it increases capacity and quality without demanding a payment from patients, people need to get over themselves on private provision.

One person under no illusions about any of this is Simon Stevens. NHS England’s Five Year Forward Review set out a bold reform programme to replace the “factory model” of the NHS. It is obvious what will happen if reform does not follow. There will be charges. Instead of rationing by queue the NHS will begin to ration by price. The only alternative will be to define a core NHS offer that applies to all taxpayers and charge for additional treatment. None of these is a good option but this is where we will end up if critics and the profession simply cry for more money.

I shall not hold my breath. The British Medical Association is every bit as hostile to change as the RMT but much more adept at preventing it. It is posing as a friend of the NHS when it is its unwitting enemy. Whatever happens now, this will not be the winter of discontent in the NHS. That line is always misunderstood. Shakespeare meant that the discontent was coming to an end. In the NHS it has hardly started.



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This entry was posted in A Personal View, Nurses, Rationing, Stories in the Media, Trust Board Directors on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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