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9 October 2012

The new Secretary of State for Health has started his tenure in office by saying all the right patient-centric things at the Conservative Party Conference today.

Whilst Labour, at its own conference, shooting from the hip, made the faux pas of proposing yet more structural change showing up its inability to grasp the detail of what patients want.

21 October 2012

Has not the use of the NHS for social engineering and gatekeeping at times been a disgrace? Surely over the past week the Daily Mail has done the nation a service by bringing issues about the Liverpool care pathway fully into the public domain and has not BBC Radio Five Live done it another by amplifying ordinary people's concerns about it last night?

Disquiet not approval was the overwhelming sentiment in the latter's programme. No ideological defenders emerged at all.

Would this pathway be declared unconstitutional if England were in the United States?

The NHS is regarded by quite a few there as practising something akin to euthanasia. The healthcare debate is transatlantic and ideas from elsewhere cannot be dismissed because they are foreign or potentially expensive to implement. They frequently have merit.

The NHS has not yet got its house in order. It cannot be considered a model for anything, least of all a putative national care service. Within the 2012 Bill can be found the means to get the culture changed.



Wander into a large 1930's block of flats somewhere in central London like Bloomsbury and chances are you will find a large entrance lobby with a porter's desk and a porters' room nearby and since this physical layout has been there for three-quarters of a century and no one has seriously challenged the basic organization implied by it, you will also find porters sitting there or busying themselves around the building.

Make your way to a modern block and you may find a much smaller lobby with old-fashioned keys and electronic entry systems defining entry. There are no porters. If anything security and privacy are better.

The conclusions that might be drawn here are not only that architecture is much more powerful in defining how we live than we often imagine but that gatekeepers, engaging characters though they may be, are there on a kind of cultural sufferance. Gatekeeping, in many cases, may not be necessary at all.

Britain has two major problems that affect its citizens. One is economic, the other the underperformance of the National Health Service.

The first resulted in a 7% drop in GDP by 2009, the second might be costing citizens months or years in average life expectancy.

Proposals for systemic changes to economic structures emerge from time to time (even your reviewer could produce some) but fewer are floated for systemic changes to the healthcare system.

Whatever its record since 1946, Labour now seems to have no communicated vision of how the NHS can be improved beyond maintaining the status quo.

The NHS was created during the post-war years of rationing on almost military lines as far as patients were concerned. You took what you were given, you obeyed orders, the system would decide what was best and it would seek to do what was best for all.

It was because of the last of these that it received tacit consent even when it did not truly seek informed consent from patients.

The case for treating the population like the conscripted has disappeared.

The concept of doctor's orders is becoming quaint outside Britain in the 21st century.

Setting aside the question of payment, as not everything can be reduced to money, and comprehensive insurance does exist, the Continental citizen temporarily in Britain can visit a U.K. private hospital for diagnostics, own the report and diagnostic material handed over to him, decide himself what to do on advice or otherwise, jump on the Eurostar or an aeroplane to return to his own country, select a specialist of his own choosing without the intermediation of a general practitioner and get further treatment within days in an establishment of his choice.

Since the British citizen pays for healthcare through general taxation, his trajectory is likely to be quite different but should he lose the real elements of decision making, ownership, information capture and speed found in the example for possibly worse (or better) outcomes?

Too often the personnel of the NHS fall back into a default position of giving no meaningful information to patients, of obfuscation, of denial of effective choice, of discouraging questioning and of suggesting the patient talk to the gatekeeping general practitioner instead.

This cultural myopia militates against the maintenance of effective standards.

It may be related to the lower life expectancy than in many other European countries.

Although the Council of Europe's Convention on Bioethics, Article 10, makes provision for people's wishes not to be informed to be observed, it positively states that:

Everyone is entitled to know any information collected about his or her health.

Philosophy is there to be applied.

Philip Pettit has written (Joining the Dots in Common Minds. 2007):

Respect cannot be conferred only commanded.

The NHS cannot fully respect its patients if it has the role of dominus or master in its relationship with them.

A 'conscripted' patient or one under its direction is no good for respect.

The patient has to have the means of commanding the respect of the medical practitioners, as in the example of the Continental patient by, for example, in his case, having the ability to take the report of one set of practitioners to another or by being able to reserve to himself decisions.

In turn, the aware patient may not wholly respect or, worse, wholly trust, practitioners who preserve for themselves too much of the gatekeeper role because, in practice, this is cutting corners.

The NHS has always been an odd animal to behold because of its tendency to treat patients as conscripts. It probably needs to shed its gatekeeping roles fast to move on as a good service for Britain.


Postscript 1 September 2012

One can be in a fair degree of agreement with the BMA's recently elected chair of council Dr Mark Porter's fears about rationing of treatment in the NHS without for a moment thinking that this has been the intention of current ministers. Unlike some who have stated that the NHS has always been a rationed service, they are not making a case, actual or implicit, for rationing. Reform in the NHS set off with the intention of reducing rationing not increasing it and the NHS needs to be held to a continuing change in outlook.

This review was written before the health and social care bill was passed and is essentially a critique of the situation that already existed under Labour with its plan for efficiency savings and its stated position at the general election of intending to cut spending on the NHS (presumably the NHS in all parts of the UK).

England no longer spends less than the rest of Europe on healthcare. It will not in the near future as the NHS budget is protected in real terms for the rest of this parliament.

The rationing is partly due to very poor management in many parts of the NHS. Dr Porter's members are less to blame than some others for this. Wherever you go NHS staff make up rules or interpret local or national rules, not laws, in a way that fobs off patients, makes them wait, covers up, rations them and often makes ill use of resources. One can often not know if resources are scarce because multiple layers of procedure and administration stand between them and delivery to patients.

The Continental tendency is not to question what the patient wants except on medical grounds and those grounds have to be stated by the equivalent of Dr Porter's members and not by anyone else.

Better treatment for patients for the same amount of money is often achieved by governments setting scales of charges that medical practitioners and establishments must largely adhere to, by allowing relatives much greater access into hospitals including, at times, into operating theatres and by a culture that wants to say 'yes, you can have what you need' to patients.

The clinical commissioning groups have got to start off with a low bureaucracy, fewer rules, 'we'll help the patient even more' outlook from the outset not the old NHS culture.

2004 On the campaign trail