I support the NHS without reservation. I support the junior doctors in their industrial dispute with the government, and I hope that they win their high court action against Jeremy Hunt.
These things go without saying – I trained to be a doctor in the NHS because I could not imagine a healthcare system in which receiving medical care and treatment depended on one’s ability to pay. As I progressed through my years of postgraduate training I met and worked with doctors from the US who had trained and expected to work in a very different system – a system that certainly can offer the very best treatment in the world to some patients – treatments that are not always available in the UK – but also a system in which at least 32 million people remain uninsured. I have spoken to US colleagues who somehow manage to reconcile these facts, but I know that I could not.
Nevertheless, this government wants to take our healthcare in the direction of the Americans. It has, at the heart of its ideology, a determination to shrink the State. The NHS is a potentially bottomless pit for any government; medical advances and an ageing population have combined to increase our society’s expectations of medical treatment. The medical profession is collusive with this as doctors seem more reluctant to face up to the reality of eventual death (as are their patients). This government would prefer to de-nationalise the NHS, replacing it with some form of insurance system. In fact the 2012 Health & Social Care Act, steered through parliament by Andrew Lansley, has facilitated movement towards privatisation. It has to be said that the Blair-Brown governments did nothing to stop the development of the internal market in the NHS, which marked a major change in the way in which healthcare in this country is delivered.
The internal market has been responsible for a huge shift in medical practice. Instead of being able to do the best that one can do, in a holistic way, for the patient who is sitting in front of you, practice is determined by targets and budgets. Budgets have become so crazy that clinical commissioning groups fine hospital trusts for breaches of targets, thereby increasing the debts of the hospital trusts, which in turn makes them less able to deliver services within target. Time has become an even more precious resource than previously, and anecdotally I have heard that many GPs tell their patients to bring only one problem to a consultation. My own specialist pain service was a casualty of the internal market several years ago, when both the hospital trust and the (then) PCT agreed that the service was needed, but neither could agree about who should fund it.
Over the past ten years I have observed clinicians becoming more compartmentalised in their medical practice. It is no longer possible to ask another clinician to see your patient – instead they must be sent back to the GP with a request that the GP refers to the person that you want that patient to be seen by. In fact it may be impossible to refer to a named doctor, instead the patient may have to be referred to a particular service – even though I might think that a particular consultant would have a personality that suits my patient (or not!) Instead of one consultant delivering holistic care to the patient it has become common for the consultant to be a ‘conductor’, orchestrating the patient’s dance round various specialist nurses, physiotherapists, healthcare support workers, phlebotomists and others. It seems almost frowned upon to suggest that a patient should develop a therapeutic relationship with their doctor – indeed clinical commissioning groups commonly try to contractually limit the number of follow up appointments that a patient has in secondary care.
The internal market has, at the same time as it introduced waiting time targets, also created further delays in the system. A recent experience with someone that I know (who I will call AB) illustrates many of the failings of the current system. At the beginning of January AB was admitted to a district general hospital and diagnosed with right heart failure and pulmonary hypertension. Multiple investigations were performed at both the admitting hospital and a teaching hospital. After four weeks AB was discharged to the care of relatives. Because AB had been admitted to a cardiology (heart) ward, little attention had been paid to AB’s lungs or nutrition – even though AB was grossly underweight. The investigations had not shown any cancers anywhere to account for weight loss so it was ignored. A letter suggesting referral for further investigations at a teaching hospital was sent to AB’s GP. However, AB had been sent out of hospital to live with relatives who were 100 miles from AB’s home, outside the catchment area of all the hospitals involved. Furthermore, as AB was not expected to be fit to return home for some months they had registered with a GP practice local to the relatives. An appointment was made with a local cardiologist who arranged referral to a specialist team at a different teaching hospital. After a short admission under the care of this team it was decided that AB’s main problem was with the lungs and that a referral should be made to a local respiratory physician. The relevant letters were sent to AB’s old GP, not the new GP. This was only detected because the relatives were doctors. AB was then seen by the respiratory consultant, who admitted that she was ‘running late’ during the consultation. One change of medication was recommended, the possibility of home oxygen was mentioned, as was the option of lung or heart-lung transplant. A follow up appointment was made for ten weeks later. An appointment (made at AB’s request) with the specialist respiratory nurse, to answer some questions, failed to answer any.
So nearly four months after admission to hospital in a critical condition, AB has seen four cardiology consultants, one respiratory consultant, one GP (twice) and one respiratory nurse specialist. Numerous investigations have been performed. A diagnosis has finally been made. No treatment plan has been made. Nobody has addressed AB’s nutritional status (which has improved) despite the fact that NHS Choices suggests that patients with a BMI less than 16 will not be considered for transplant. Nobody has spoken to AB about the fact that they live alone, nobody has asked about employment status or intentions. Nobody has addressed any questions that AB might have about transplantation; nobody has addressed AB’s emotional or psychological or spiritual needs.
In short, nobody has seen AB as a whole person, living in a social context. AB has not had bad medical care, but there has been no joined up care, no holistic care. Instead of consultants talking to one another informally, everything has followed predefined pathways. At the end of the day none of this is likely to make any difference to the medical outcome, but I believe that medicine is about healing as well as treating/ curing. Healing means treating the whole person, not individual organs. The internal market has encouraged fragmentation of care as healthcare budgets have been devolved to different parts of the service. Privatisation of healthcare may mean that fragmented care becomes no care for some people, and bankruptcy for others.
We must fight to save a publicly funded NHS, free at the point of delivery. We must not let care become even more fragmented.