Category Archives: Commissioning

Hospital chief says family time would give patients a better end to life

The end of most of our lives will not be planned or expected for long. The “handover” from oncology and chemical treatment to attempt cure, and palliative and then terminal care, is not good enough. Those in charge of the former are reluctant to give up and hand over to the latter. The result is a lot of unnecessary discomfort and stress, and often in rural areas, of travelling long distances to achieve very little. The interface between these specialities would be best facilitated by a GP, preferably one with a palliative care interest. 

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Advanced directives would also be helpful, and other countries are showing us the way.

Sarah Kate Templeton on June 25th in the Times reported: Professor Marcel Levi: Dying should shun treatment and take final holiday – Hospital chief says family time would give patients a better end to life

Patients who are dying should be allowed to go on a final holiday rather than be subjected to gruelling treatment, according to the boss of one of Britain’s largest NHS trusts.

Professor Marcel Levi, a practising doctor and chief executive of University College London Hospitals, said the NHS is wasting time and money treating dying patients at the end of their lives.

He said: “I often think, ‘You would be better going on holiday with your family and you may have a little shorter but a lot better end of your life.’”

Levi, who is Dutch and was previously chairman of a leading hospital in Holland, said: “I do not find the discussion, ‘Which patients should we not treat any more at the end of their lives?’ very well developed in the UK.

“The patients do get anti-cancer treatment when the oncologist, probably the patient and his or her family know it is not going to contribute a lot and it may cause a lot of safety problems and harm.

In Holland, Levi said it is common for patients to state they have had enough treatment and do not want to go back into intensive care.

In the UK, however, he said patients are automatically continuing with treatment in the absence of an honest discussion about what is going to be achieved.

“Patients who are 85 years old do not have to expect a lot of gain from haemodialysis [kidney dialysis], but they still go there three times a week. They feel terrible on the day of dialysis, they feel terrible the day after dialysis. That is six out of seven days of the week,” he said.

“Somebody should at least discuss with them, ‘Is this useful for you? Are you really having any gain of quality of life by doing this?’

“They have a very short life expectancy and we are actually spoiling the last weeks of their lives instead of making them comfortable and them spending quality time with family and friends.”

About 43% of NHS spending goes on the over-65s, according to the Nuffield Trust healthcare charity. This age group also occupies about two-thirds of hospital beds, National Audit Office figures show. Between 10% and 20% of the NHS budget is spent on people in the last year of life, a government-commissioned palliative care funding review found.

Dr Gordon Caldwell, a consultant physician at Worthing Hospital, West Sussex, agrees that British doctors — himself included — often avoid frank discussions about letting patients die.

He said: “Often, as doctors, we hold on to hopes of marginal benefits — ‘You could live 30 days longer, perhaps to three months’ — but omit, ‘This will involve 60 days attending hospital, so you could not go to see Snowdon and Anglesey with your grandchildren.’

“We have relatives demanding, ‘Do everything, doctor.’ Those same relatives, when the patient dies, ask, ‘He didn’t suffer, did he?’ Well, if we were honest [we would say], ‘Yes, he did because you asked us to do everything.’

“I strongly suspect many patients would want less medical interference, such as tests, treatments, last-ditch attempts at chemotherapy.

“Doctors must learn to be honest about the true likely effects of their tests and treatment — a marginal benefit in a few patients at a lot of opportunity loss. A day spent having chemotherapy is a day not with the family.”

Levi said it is up to physicians to broach the subject and it is often welcomed by patients and their families.

“It is the doctors who start the discussion. It was a bit tricky when we did this [in Holland] but it actually turned out that many, many patients and their families were extremely supportive,” he said.

“There were many families of patients who died of cancer who said, ‘If I knew before this was going to happen, we would not have done this operation or this chemotherapy.’”

Professor Karol Sikora, former chief of the World Health Organisation’s cancer programme and chief medical officer of Proton Partners International, a private cancer and healthcare specialist, said there are now more than 25 cancer drugs available that cost more than £50,000 for one year’s treatment and in most cases these would prolong life for only an extra three months.

He added: “There is so much pressure to be active, driven by the pharmaceutical industry and the breakthrough mentality. Giving patients permission to let go has got a lot harder over the last decade.”

However, Baroness Finlay, a crossbench peer and palliative care consultant, believes patients must be given the options of treatments that could help them live longer.

“Sweeping judgments about a person’s quality of life are dangerous,” she said. “Anyone can refuse or cease treatment and that wish must be respected but it becomes dangerous when people are not given the options that might help them live longer and live well.”

Judith Kerr, 94, the children’s author and illustrator who wrote The Tiger Who Came to Tea, has already made her preparations. Last year she told The Sunday Times she keeps “a little piece of pink paper signed by the doctor, saying ‘Do not resuscitate’.”

She added: “Having had a good life, to go through this misery, and at great expense to everybody else — expense not only in money but in emotion.”

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions.

Selecting doctors, and portfolio careers crossing from primary care to Hospital.

Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts..

The Canadians shame us with their plans for end of life care

Cancer patients given new drugs that won’t help them. GPs needed in oncology clinics…

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Bradford staff: government breaking its promises….. This needs to be a nationwide rather than a local solution.

If we look at pensions as a promise of  future payment, and we assume that the English Health Service, along with the other 3 dispensations, has a “ponzi” scheme type of pension fund, then it is not surprising that Trusts and their boards of directors try to escape future commitments that they cannot fulfil. The whole of the former NHS (when we had one mutual) is funded on this basis, but by denial of the long term problems, politicians are forcing locally based solutions, inequity, and poverty in their workers old age. In effect they are breaking their promise… just as the Greeks had to …. The problem needs a nationwide solution so that the pain if felt equally. The earliest Trust sare those most likely to get away with it, and some already have. The result is post-code rationing by ethically and legally dubious means….  In any event, the whole state as well as health worker pension situation needs review….

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Unison website reports 8th July: Bradford hospital staff strike to stay in the NHS and picket lines will begin

BBC reported 14th August: Bradford Teaching Hospitals staff to strike over outsource plan

and Susie Beever of the Yorkshire Evening Post reported 1st August that there would be a two week strike over jobs 

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The History: Bradford Hospital has a track record. Simon Freemna in the Times 27th November 2004: Hospital’s rescuers charge £160,000 for the privilege

Sarah Kate-Templeton in the Times 2016: Safer births campaign: Shamed hospitals blame high stillbirth rate on the mothers

Rhys Blakeley in the Times 19th August 2019: Plea for state pension age of 75

 

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The reality that Health and Social Care are not either of them free, has not sunk in to the politicians yet. We cannot have “Everything for everyone for ever” and for free, and in their denial, both houses thus conspire to avoid the important debate that Mr Stevens called for on 4th June 2014, almost exactly 5 years ago. If Social Care is means tested, why not Health Care? 

The unedifying spectacle of two potential leaders trying to bribe 160,000 older and richer people who happen to be their members, is the reality of todays politics. No wonder so many people dont vote. We need an honest party to speak “hard truths” to the nation. NHSreality believes the first party to do this, and be understood as honest and working for the overall good of us all, fairly, will eventually win a landslide. It will also win the hearts and minds of the medical professionals….. and they are trusted, and speak to many people daily.

Our political (moron) representatives need to permit commissioners and trust boards to ration overtly, so that their citizens know what is not available. Initially this will have to be by post code, but national guidelines from NICE would help. Eventually, for those services and treatments that none of us can afford, cancer and big operations for example, there can be a National Health Service again, and for cheap and cheerful, high volume low cost services, we can have local post code rationing if we still want it…

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BBC News reports 4th July: Social care: Hunt and Johnson urged to consider NHS-style free service

Public Service Executive reports: Peers call for NHS-style free social care system and an extra £8bn to tackle funding crisis

and the Guardian today also reports the Peers asking for an extra £80m for “vulnerable elderly people”. 

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

New and higher taxes will never solve the problems of health and social care…

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the CQC …

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

The reality of the post-code lottery and rationing of health and social care. It will just have to get worse before the “honest debate”…

A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. The media failure, and political denial can only get worse..

Nov 2016 NHSreality: NHS funding and rationing: The debate (and the denial) intensifies… It’s going to get worse..

Reality is a word rarely used in Health debate and discussion. The Economist comments on post election realities..

A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this. (U tube 4th June 2014)

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The “Economist” acknowledges health rationing, but does not recognise that it is covert…. More and more anger to come.

How long will the UK citizens put up with untruths? How long will it take for the proper debate to begin? The Economist recognises rationing, Enoch Powell in “A new look at Medicine and Politics” recognised rationing in 1966. We cannot go on without knowing what (for us) will be unavailable. It is surely a human right to be able to plan for your own health, your family’s health, your death, and illnesses. No wonder citizens are getting more and more angry..

If we want to win the cooperation and hearts and minds of medical staff we need to find out the truth about what they think. BMA conferences full of retired and burnt out doctors may reject the “long term plan” but there is no link with the doctors at the coal face.

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Not only is devolution a failure (certainly in Wales) but the 4 different systems allow different language of obfuscation, different methods of rationing, and outcomes. The anger will be the same.

The East Anglian daily Times shows how angry and dissatisfied the citizens are becoming. If you multiply the figures up over 200 health staff are attacked daily in the UK.

NHS GPs Economist 0619 Whats up Doc June 2019

Enoch Powell 4 Supply and Demand – Rationing  Minister of health for 3 years 2nd Edition 1974

Toni Hazell 28th June in GP mag: Here are two potential problems with primary care networks.  Huge hurry, and who takes responsibility?

Andrew Papworth reports 30th June 2019 in the East ANglian Times : “NHS staff aren’t punchbags”: Shock as six workers a day attacked in Suffolk by patients.

BMA ARM: Doctors spurn NHS long term plan

NHS patients ‘face more treatment rationing since coalition restructuring’

Wales is bust, and cannot pay for its citizens care. Devolution has failed. This is the thin end of a very large wedge..

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Endgame for the NHS? Warrington and Horton Trust are bust – same as Wales. Two waiting lists, one for Wales, and one for England.

Just as Wales cannot afford (without central intervention from Westminster treatment for North Wales patients in CHester.  ( Solved by Loan or grant we wonder?) the services their patients need, Warrington and Horton are trying alternative methods to ration by encouraging purchase schemes. They forget that the average DGH has more complications than a private hospital, and if you are paying you might as well ensure safety, quality and a consultant of your choice. (The default operation consent allows any of the team to do your operation). Quite rightly, Helen Salisbury questions whether there us anything that can be done to stop the financial decline. If the 4 health services are to remain free at the point of need, (as opposed to want) we need to ensure that need is not defined by the patients themselves! Now it would be interesting if Chester patients were to demand care in Wrexham, but with longer waits and lower standards this wont happen. Wrexham would be delighted as the money moves with the patient. Chester and Oswestry will have two waiting lists, one for Wales, and one for England.

Helen Salisbury opines: Endgame for the NHS? (BMJ 2019;365:l4375 )

Since its foundation, the NHS has been committed to providing treatment according to clinical need. The distinction between want and need is important—there may be treatments that patients want but don’t need, such as cosmetic surgery. In these cases, they have to go to the private sector and pay up front or through insurance. This is set out in the first two points of the NHS constitution,1 which state that the NHS provides a comprehensive service, available to all, and that access is based on clinical need, not a patient’s ability to pay.

This week Warrington and Halton Hospitals NHS Trust was in the news for its published list of charges for 71 procedures.2 This is not entirely new: starting with an initial offer of varicose vein surgery in 2013,3 the scheme was relaunched in September 2018 with a hugely expanded list of procedures and has only now hit the headlines. This list appeared under the banner “My Choice—by the NHS, for the NHS,” next to the NHS logo. This is very confusing and would leave many people asking, “Is this an NHS service or not?” The list included prices for cataract surgery (from £2251 (€2523; $2872)), knee replacement (from £7179), and hip replacement (from £7060), all of which are beyond the means of most people served by these hospitals, given Warrington’s high deprivation.4

The justification given by the trust is that these procedures have been limited by NHS commissioners.5 Operations on this nationally generated list were initially referred to as “procedures of limited clinical value” and are now “criteria based clinical treatments.” If patients don’t meet the criteria but still want the surgery, they will have to pay.

This makes a mockery of the NHS constitution: either patients have a clinical need, in which case they should receive timely NHS care, or they don’t need the surgery, in which case it’s not in their interests to have it, and it shouldn’t be done by the NHS.

What this programme reveals is that access to procedures with a proven track record of safety and efficacy, which patients need in order to see clearly or move comfortably, is being denied. The “criteria” for many patients are increasingly stringent: the Royal College of Surgeons raised the alarm in 2017 about restricting hip and knee surgery on the basis of arbitrary pain and disability thresholds rather than clinical assessment.6 And cataract guidelines from the National Institute for Health and Care Excellence explicitly state that commissioners should not restrict access to surgery on the basis of visual acuity,7 yet that’s what happens to patients covered by over a third of clinical commissioning groups.8 These decisions are not about optimising outcomes for patients but are a reaction to inadequate funding, requiring patients to be significantly visually impaired or disabled before they’re treated.

Even more worrying is that an NHS trust is explicitly offering a two tier service, with earlier treatment if you can pay. We should resist this transformation from a single, comprehensive system, where all are treated equally, to one where rich patients have rapid access and poor patients struggle to be referred and then languish on waiting lists. Bevan must be turning in his grave.

Methods of rationing in 1966. Warrington shows that we have since invented many more….

Wrexham.com suggests the problem of Welsh patients being seen in Chester is resolved. What nonsense. The financial solution is opaque indeed… and will be so for the foreseeable future.

Manchester, Liverpool, Hartlepool: Death rates in your local DGH are too high..

 

Methods of rationing in 1966. Warrington shows that we have since invented many more….

A new look at Medicine and Politics: chapter 4 –  J Enoch Powell 1966. We have invented many more since Enoch Powell’s day, and the latest from Warrington is how rich or poor you are…

The answer for this post-code lottery is for GPs to send all their patients elsewhere. Since the money moves with the patient, Warrington and Horton will get none.

https://www.sochealth.co.uk/national-health-service/healthcare-generally/history-of-healthcare/a-new-look-at-medicine-and-politics/a-new-look-at-medicine-and-politics-4/

METHODS OF RATIONING

The preceding pages have been devoted to examining how the medical profession is affected by the system that has been adopted for the purchase by the state of a certain quantity of medical care outside the hospitals. That quantity, as already explained, is indirectly fixed by the remuneration the state offers, which determines in the longer run the number and quality of those contracting to provide that care.

Thus, outside as well as inside the hospitals the figure on the supply side of the equation is fixed at any particular time by those complex forces that determine the state’s decisions on expenditure. With this figure demand has to be brought into balance. Virtually unlimited as it is by nature, and unrationed by price, it has nevertheless to be squeezed down somehow so as to equal the supply. In brutal simplicity, it has to be rationed; and to understand the methods of rationing is also essential for understanding Medicine and Politics. The task is not made easier by the political convention that the existence of any rationing at all must be strenuously denied. The public are encouraged to believe that rationing in medical care was banished by the National Health Service, and that the very idea of rationing being applied to medical care is immoral and repugnant. Consequently when they, and the medical profession too, come face to face in practice with the various forms of rationing to which the National Health Service must resort, the usual result is bewilderment, frustration and irritation.

The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted. This is not possible where its very existence has to be repudiated.

In the hospital service probably the most pervasive, certainly the most palpable, form of rationing is the waiting list. The waiting list is a complex phenomenon in itself. One component can be likened to a reserve of working materials: if the hospital resources are to be continuously used, there must be a waiting list. The simplest case is that of a consultant available (let us suppose) during a two-hour session. If there were no queue in the out­patient waiting-room, there might be gaps between one consultation and another when the consultant would not be productive— not, at least, in that sense. So it is always arranged that there shall be plenty of people waiting when the great man arrives, so that there is no danger of the expensive mill even momentarily lacking grist. Similarly, if the capital and resources represented by operating theatres and their staffs are to be intensively used, there must be, so to speak, a cistern from which a steady flow of cases can be maintained.

This element of the waiting list is only incidentally a rationing device, though even here time is serving as a commutation for money: a consultant in private practice can accept the dis­continuity of work implicit in a good appointments system, because his patients are in effect buying his waiting time as well as his consultation time or, putting it another way, the patient finds his own time worth more to him than the consultant’s.

Waiting lists, however, normally exceed the minimum related to full employment of the medical resources. They are then directly rationing in their effect. For example, they ration demand for the more able, experienced or celebrated advice and treatment compared with the less: the waiting lists of consultants in the same department of a hospital can differ greatly in length. It is sometimes said that consultants regard a long waiting list as a status symbol and preserve it with the same care and pride as an Indian would a string of scalps. Certainly, consultants are very possessive about their waiting lists. But the taunt is as uncomprehending as it is uncharitable. There has to be some differential rationing for different qualities of an article, and if not price, then, for example, time: better surgeon, longer wait, and vice versa. No wonder consultants, family doctors and patients too resist equalisation of waiting lists, which would mean that rationing by time would have to be replaced by some even less rational or intelligible form of rationing, such as rotation or the initial/letter of the surname.

Generally, the waiting list can be viewed as a kind of iceberg: the significant part is that below the surface— the patients who are not on the list at all, either because they are not accepted on the grounds that the list is too long already or because they take a look at the queue and go away. Naturally, no one knows how many these are. Indeed, the very question is rather absurd, as it implies some natural, inherent limitation of demand. But the part of the iceberg above the water is doing its work, directly as well as indirectly, by attrition as well as by deterrence.

It might be thought macabre to observe that if people are on a waiting list long enough, they will die— usually from some cause other than that for which they joined the queue. Short of dying, however, they frequently get bored or better, and vanish. Here again, time on the ‘waiting list is a commutation not only for money— measurable by the cost of private treatment with less or no delay— but also for the other good things of life. It is an interesting phenomenon of the waiting lists for in-patient treatment that at the holiday season and around Christmas time it may be necessary to go quite far down a lengthy waiting list to get patients willing to accept the long-awaited treatment in sufficient numbers to keep even the temporarily reduced hospital resources fully employed.

I  cannot  but  reflect sardonically  on  the  effort  I  myself expended, as Minister of Health, in trying to ‘get the waiting lists down’. It is an activity about as hopeful as filling a sieve, although this is not to deny that some of the measures applied and pressures exerted might conceivably have had some useful side-effect in improving, in a slight degree, the direction of effort. There were the circulars enjoining such devices as the use of mental hospital beds and theatres, or of military hospitals. There were the stiff cross-examinations of staffs and hospital authorities in the endeavour to discover what contumacy might explain their continued non-compliance with the official exhortations. There were the special operations to ‘strafe’ the waiting lists, urged on the fallacious ground that a stationary waiting list is not evidence of deficient capacity— otherwise it would lengthen —but of a backlog which, once ‘cleared off’, ought not to be allowed to recur.

Alas, the waiting list that melted under an assault of this kind was back again to normal before long. There were always special, local and temporary explanations that could be cited, such as a sudden coincidence of staff off duty through leave, sickness or change of post. But all too evidently the causes at work were general and deep-seated. There was a mean around which the figures fluctuated, but that was all. Naturam expellas furca, tamen usque recurret: though you drive Nature out with a pitch­fork, she will still find her way back.

In a medical service free at the point of consumption the waiting lists, like the poor in the Gospel, ‘are always with us’. If at any moment of time they do not exist, they have to be re-invented, or rather they reproduce themselves effortlessly and automatically. Ministers come and Ministers go: the hospital service spends a rising fraction, or it spends a falling fraction, of the national income; but the ‘waiting list at 31st December’ in the Ministry of Health’s annual reports still stays the same, a reliably stable feature in an otherwise changing scene. On New Year’s Eve 1959 it was 442,519; on New Year’s Eve 1960 it was 475,643; I962, 474,353; 1963, 470,297; 1964, 475,863; 1965, (oh dear!) 498,972. And what had it been, pray, on New Year’s Eve 1951, back in those early, primitive days of the National Health Service? Why, 496,131.

At the same time, Ministers of Health are broadly truthful when they say that for cases diagnosed as urgent or critical the waiting list, practically speaking, does not exist. This is far from disproving the function and necessity of the waiting list as a rationing device. For one thing, ‘urgent’ and even ‘critical’ are not objective magnitudes; on the contrary, they are assessments that have already taken the volume of supply into account. In any case, there is no clear-cut dividing line between the ‘urgent’ cases, seen or treated at once, and the ‘non-urgent’ cases on the waiting list— or, as the case may be, not on the waiting list at all. The latter are squeezed down— or off— by the former. To point to the fact that no ‘urgent’ case goes untreated as evidence that supply and demand can be brought into balance without rationing is like arguing in a famine that because nobody dies of starvation, there need have been no rationing system.

A  DOUBLE  STANDARD

In the last resort the waiting list, or the queue in the general practitioner’s surgery, is one aspect of rationing by quality. In the days of the reform of the poor law and abolition of outdoor relief for the able-bodied, this used to be known as the principle of ‘lesser eligibility’. What are called the ‘deficiencies’ of the National Health Service— the large number of patients per general practitioner, the age and quality of many of the hospital buildings, and so on —are not deficiencies in the literal sense of the word, that the service falls short to a measurable extent of an objectively definable standard. They are those consequences of the quantity and quality of medical care being purchased by the state that help to equate the demand with the supply. The supply of medical care of all kinds through the National Health Service is rationed by forcing the potential consumer to choose between accepting the quality and quantity offered or declining the care offered. If he declines the care offered, he can either renounce or defer treatment altogether or he can endeavour to purchase it outside the National Health Service.

This is why it is absurd to declaim against a ‘double standard’ of medical care, inside and outside the National Health Service respectively. The standard inside is that which balances demand with the amount supplied by the state; the standard outside is that at which the supply and demand for medical care balance in the market, given the existence of the National Health Service. The standard in question is not necessarily one of purely medical treatment, if indeed the purely medical aspect of care can be divorced from the others. For example, it may well be that a patient acutely ill or gravely injured may be treated as skilfully, efficiently and safely in a National Health Service hospital as in an expensive private hospital or ‘nursing home— often, I would guess, more so. But the paradox is capable of rational explanation. The ancillary aspects of medical care— amenity, privacy, attention in convalescence, a degree of freedom, choice and individual self-assertion—may be valued no less than the essentials that affect life and limb. Indeed, they are sometimes valued more highly, surprising though that may seem. There can also be an element of pride, prejudice, snobbery— call it what you will— that values the identical article more highly when it is purchased than when it is received gratis.

The principle of lesser eligibility has always been applied, cannot help being applied in some form, wherever provision is gratis. It was applied before the National Health Service started in the voluntary and municipal (ex-poor law) hospitals and, indeed, from the beginning of time wherever medical care was rendered free at the point of consumption. Since eligibility is a form of rationing, we naturally find that it, like the waiting list, is also used to establish an order of priority. This is the reason why, for instance, the geriatric and long-stay mental hospital wards are, and have always been, the most ineligible in the service. The priority accorded to the demands of acute illness requires that rationing be applied more severely to the chronic.

Two instructive contrasts outside the National Health Service will illustrate the rationing function which lesser eligibility performs in it. One is the striking contrast between the two forms of old people’s accommodation: the workhouse and the new-style old people’s home. The former was designed to meet a legally unrestricted duty to admit; the latter corresponds to a discretionary and highly discriminating right to admit or not to admit. Consequently the poor law institution had to ration by ineligibility, and still in practice does if it continues to exist, while the new-style home explores ever-rising standards of amenity and care under the shelter of a rationing system of a different kind. Similarly, the paradox of the relatively high standard of the subsidised local authority house, although it is subsidised, is explained by the fact that the demand is tailored to the supply by the discretionary waiting-list itself, and consequently the supply can be rendered in a relatively eligible form.

Parkinson’s Law

The fact that the necessity for these covert forms of rationing springs from the very nature of the National Health Service and not from any particular level of supply attained in it is borne out by ‘Parkinson’s law of hospital beds’, which asserts that the number of patients always tends to equality with the number of beds available for them to lie in. Thus, the ratio of hospital confinements to total births ranged in 1965 from as low as 53.8 per cent in East Anglia to 78.4 per cent in Wales—the national average   was  69.8  per cent. Yet the pressure on maternity accommodation was at least as high in the latter part of the country as in the former. Again, the number of hospital beds for acute disease in the North-West of England is almost twice as great as in the South-East: in 1961 there were 3 per thousand population in East Anglia against 5.6 in the Liverpool region. Yet the pressure of demand, as evidenced, for example, by length of waiting lists, shows no comparable variation. There is, as has been said above, no reason to suppose that an increase in the quantity or quality of care provided by the National Health Service would reduce the need for rationing. On the contrary, every increase in eligibility must involve an intensification of the other forms of rationing, such as waiting.

It is unfortunate that the nature and the value of rationing by waiting and by ineligibility in the National Health Service are not recognised, at least by the professions. For these are the features that make it possible to avoid invidious discrimination in administering the service and, at the same time, secure a certain rational allocation of priorities. Instead, these features are treated as evidences of ‘inadequacy’ and as blemishes that it lies within the power of politicians to remove, given the insight and the will.

Martin Bagot in The Mirror updated 2yh June reports Warrington’s plans to charge 20K for a hip replacement. It would be cheaper and safer to go abroad.

 

 

Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding? If we don’t keep the gatekeeper role for GPs the system will get constipated.

A recent report in the Times (Not on line) opines “Gatekeeping by GPs called into question. This is not new, as you can see from the debate following Matthew Paris’ article in 2015. The problem is not referrals, but the 90% who do not need a referral. Allowing others, less trained in dealing with uncertainty, will lead to more referrals, longer waits and a constipated system. The useless 111 service where there has seen no reduction in GP workload is another attempt to wriggle off the hook of under capacity and poor manpower planning. In his Imperial College funded report, Geva Greenfield and others report: “Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding?”.

One solution is to make patients pay for their GPs and let them have appointments free with the nurses and paramedics. A two tier system by design. Lets see the comparisons in referral rates, expense and survival!! The result would be anarchy.. (sic) Geva Greenfield says “There is a trade-off that needs to be found between GPs serving as hgatekeepers to secondary care, and at the same time allowing patients to see a consultant when they wish”. We are trying to treat patients, and the governement are treating populations. Money matters, and the services are all rationed. (covertly)

Image result for money and NHS cartoon

Image result for money and NHS cartoon

This is the sort of thinking “outside the box” of current opinion that we have to get to talking about openly.

On November 26th 2018 Chris Smyth reported in the Times: Bypassing GPs could help to diagnose cancer sooner

In Pulse 2015: GPs should give up their Gatekeeping Roles

Matthew Paris on June 16th 2012 reported in the Times: GPs – little more than glorified receptionists

In this age of medical specialisation, if family doctors didn’t exist we wouldn’t feel the need to invent them

Next Thursday, family doctors plan to strike. Striking doesn’t suit the profession’s humanitarian image. Interviewed, doctors’ leaders struggle to insist (on the one hand) that nobody needing medical attention will be denied it, without implying (on the other) that few will suffer if doctors aren’t there.

How much, though, would we suffer? If family doctors had not existed, would we today have found it necessary to invent them?

We pay general practitioners more than we pay airline pilots, but they are becoming glorified gatekeepers: a portal to the more specialist medical care that our health service offers in growing measure. As GPs have receptionists, so the NHS itself uses GPs as its receptionists. Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?……..

……..Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. Walk-in and appointment clinics are becoming more common, especially evening clinics. Sexually transmitted disease, family planning, coughs and colds, eye, ear nose and throat … in all these fields specialist practices staffed by nurses and pooled doctors, rather than personal GPs, are where we’re going.

The only question is how fast. Let’s hope next Thursday’s strike prompts us to speed this thinking up. Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The response June 18th 2012:

Sir, Matthew Parris (Opinion, June 16) is not quite correct in describing GPs as “becoming glorified gatekeepers”. We have already had that role (among others) for decades.

It is true that part of this role is to refer to secondary care, but he seems to miss the corollary of this; that we also judge when not to refer, thus saving patients, and the country, the burden of over-investigation and over-treating. The internet has expanded everyone’s access to specialist knowledge, but has not, perhaps, increased our ability to apply that knowledge appropriately. We know more, but understand less.

Mr Parris also fails to acknowledge that GPs have a vital role in the other direction of travel; from specialist care to the community. In this past week I have picked up the care of patients after their discharge from heart by-pass surgery, psychiatric in-patient treatment, dermatology, gynaecology, child autism and palliative care clinics.

In addition, we need to manage patients whose symptoms and conditions cover several specialties, as well as those who have exhausted all secondary care investigation without any diagnosis being reached.

“A decent grasp of the whole thing” is exactly what GPs need.

Dr Jonathan Knight
GP, Ipswich

Sir, Matthew Parris assumes that his interaction with his GP is typical of the work that GPs do. I have been working in general practice since 1987 and my experience is very different. We spend most of our time managing long-term illness such as high blood pressure, diabetes, kidney disease and asthma. When I was in training in the 1980s these conditions were managed in hospital but are now managed mainly in primary care. Of course I do not profess to be an expert in everything so I may refer to colleagues for opinions about aspects of a patient’s care, but they are then usually discharged to my care.

Allowing less-qualified health professionals to manage patients has never been shown to be more cost effective than using GPs.

It is this system of every patient having a GP, enshrined in Bevan’s original vision for the NHS, that other health systems around the world have strived to emulate. We should not discard it lightly.

Steve Charkin
London NW3

Sir, Matthew Parris says that he believes he could refer himself appropriately to a specialist, but he is not our typical patient. GPs’ time is predominantly taken up with the very young and the elderly, particularly those with chronic, complex and multifaceted medical conditions. For these folk, it is their GP who sees the “big picture”, the context and impact on the individual and their family, while each specialist focuses in on his own area of expertise. Approximately 90 per cent of healthcare needs are met in the community, by GPs and their practice nurses, with only 10 per cent of care being hospital-based, at far greater expense. It is true that a GP’s role includes “gate keeping” access to expensive specialist opinion, but I would suggest this is essential.

As Mr Parris concedes, most GP consultations do not lead to a referral to a specialist. His vision of a future without GPs to manage the majority of our health concerns would be financially unsustainable and bewildering to many. Would a woman with lower abdominal pain and back ache refer herself to a gynaecologist, urologist, gastroenterologist, oncologist or orthopaedic surgeon? Does she need a specialist at all if it is just a urine infection? How does she know?

While a single day of industrial action will cause no more inconvenience than the extra bank holiday for the Diamond Jubilee, Mr Parris belittles our role at his peril.

Dr Isabel Cook
Reading

Sir, Before getting rid of GPs Matthew Parris might be wise to wait until he is a bit older when he may have to see more than one specialist at the same time. He will find that the treatment for one condition often aggravates another and he will then be grateful for a generalist’s opinion. He will also find it more efficient to keep seeing the same GP so that he does not have to keep repeating his past history.

Dr Richard Stott
Epsom, Surrey

Sir, As a GP I know Matthew Parris is right. A lot of what GPs do is pointless or could be done by others. So there is a simple solution: stop giving us work.

John Booth
Middlesbrough

Sir, There is overwhelming evidence that GPs deliver highly effective, cost-effective care to our patients. Moreover, we do so with the trust of our patients, and with care and kindness.

I invite Mr Parris to sit through a surgery with me at any time, where he will see first hand how GPs care for the elderly, the frail, the disadvantaged and the ill. I’m sure that afterwards his perceptions of general practice will be different.

Professor Clare Gerada
Chair of Council, Royal College of General Practitio