17 October 2009

The Grumble Credo

In its bricks and mortar, people and services, the NHS embodies something which is truly great about Britain. That something is equity: the spirit of fairness for all and the equal right of everyone regardless of age, background or circumstance to get the healthcare they need.

Those words are a bit cloying but it is what Dr Grumble believes. After all Dr Grumble has been described by overseas commentators as a socialist blogger. Praise for the NHS is what the Grumble readers expect as a general election draws closer. So let Grumble continue:

The NHS really is one of the most precious gifts we enjoy as British citizens.

Perhaps by now you have realised. These words are too sugary to be Dr Grumble's. Can you guess who wrote them? The writer believes them. He has good reason to write these words. Personal reasons and political reasons. The writer is, believe it or not, David Cameron.

Unfortunately people close to David Cameron probably do not think of the NHS in quite the same way.

Here is a clue to the way the Cameron henchmen are thinking:

Despite believing that market mechanisms work, [Labour] have failed to open up the market for the provision of NHS care so as to drive up standards.

You can find all this in the Conservative's NHS Improvement Plan (pdf). Here they laud Labour for privatising parts of the health service, recognise that this policy has failed and imply that the solution is to throw even more NHS services out to the market wolves. The failure of the market is recognised yet the response is to propose more of the same. There is no recognition of the vast sums now being spent on running the costly market processes. There is no mention of how the well heeled bureaucrats employed to commission the services are sucking up the billions that we all know are no longer reaching the front line. Despite all that has happened in finance as a result of the present government leaving things to a market free-for-all (encouraged it would seem by the opposition) there is still the widespread blinkered view that markets will somehow solve the problems of the NHS. It is just not true. Markets are causing the problems.

There are those elsewhere who think even more misguidedly. Take this quote which begins with a wonderful pun:

Focused eye surgery centres, heart health and orthopaedic hospitals, for example, can streamline processes and deliver far higher output and quality than the hotchpotch of services provided in general hospitals.


This fails to recognise that operating on elderly people with multiple pathologies in a streamlined highly efficient centre is not a good idea. General hospitals are not places where you have general doctors who have a stab at anything and do nothing well. They are places where there are teams of experts so that individuals can get the full range of expertise they need. When you fracture your hip and go into heart failure it is really not a good idea to have the heart doctors in their own streamlined centre across town. We need bigger hospitals not smaller. NHS patients have suffered too much already being transferred from one hospital to another because of failures to provide the full range of what patients may need all under the same roof.

Here is another nonsense:

At present, the NHS locks in inefficiencies due to two antiquated models: the general hospital and the general practice – both designed a century ago when medicine lacked evidence-base and was largely intuitive. Far more productive, now that we can make definitive diagnoses in many cases, would be to integrate the diagnostic work across the two, and hive off many procedures that occur after a definitive diagnosis to specialist centres.


This makes little sense to Dr Grumble. Whatever does the author think happens now? If you need your stitches taken out it makes sense for your GP's nurse to do it. If you need your appendix removed this is no longer done on the kitchen table. You go to the hospital. And what about today's news on the increase in children's admissions? What's the betting that that is the consequence of the loss of the antiquated 24/7 care that used to be the responsibility of individual GPs?

Here's more:

Real reform should thus look at the demand side too; at breaking PCTs up into groups of competing social insurers, as already exists to great effect in many European states such as France, Germany, the Netherlands and Switzerland. This is not a threat to universal and comprehensive ideals. With the state paying for, or topping up, premiums for those that cannot afford health insurance or with chronic conditions, these ideals are preserved – just as Europe. The difference is that healthcare premiums are paid direct to insurers, rather than to the state through taxation, and people are able to choose between them on the basis of quality and price. If service is poor, or insurers fail to back innovative providers, declining custom gives a powerful incentive to improve.


Anybody who thinks this will make healthcare more cost effective than the NHS used to be before the recent meddling is clearly living in cloud cuckoo land. But then a lot of people do, it seems, live in cloud cuckoo land.

Dr Grumble agrees that large improvements in funding in the NHS over the past ten years have not brought matching improvements in services. There are all sorts of reasons for this. One major factor has been the cost of running a failed NHS market.

19 comments:

Anonymous said...

Sorry Dr. Grumble, but you are seriously out of touch with what happens in a hospital setting in this day and age.
Partialists?, generalists? - mostly partialists. If you are admitted with a possible cardiac condition and this is not found, you will be sent home. It does not matter whatever signs and symptoms you are presenting with - if it's not cardiac, home you go!
If your head exploded whilst on the ward, home you go as it's not cardiac!
I am seriously thinking of packing it all in as 'doctoring' is a very dangerous game to be playing in a hospital setting!
I really do not think it makes a difference of who is governing our wonderful country.

Dr Grumble said...

I agree with your points anonymous.

The diagnosis of 'not cardiac' is common and is not a diagnosis. But it would be even more like that if we had the streamlined cardiac centres proposed instead of general hospitals.

I would also agree that general physicians are becoming a thing of the past and hospitals are assemblies of specialists (or partialists if you want to be pejorative).

I also seriously think of packing it in. We are not the only ones.

And I certainly agree that it matters not a jot who is going to run our wonderful country because their policies are all essentially the same.

Things are very bad politically at present. The problem is that there is no politics any more. We have the red team, the blue team and the yellow team. The colours on their lapels are the only thing that distinguishes them. That is the real reason for the disillusionment with MPs. It is the fact that they are being MPs to earn a living from their allowances and not because of any underlying political conviction. The public know this. Sorting out MPs allowances will not deal with the fundamental problem which is the total lack of political vigour and choice for the electorate.

You should read the Witch Doctor's blog for her cryptic messages about where we are heading as we enter the post democratic era. The politicians are disappearing and being replaced by an elite operating largely out of sight.

It is time we all woke up to this but what we can do about it I really do not know. Why are young people no longer interested in taking to the streets to protest?

Dr No said...

In passing, I am not sure I agree that "not cardiac" is not a diagnosis. A distinction has been made between a cardiac cause and a non-cardiac cause for the patients symptoms. But the real problem here is not the diagnosis but the management once the "not cardiac" diagnosis has been made.

What is more to the point is the number of us (doctors) who are thinking about packing it all in, which suggests we really are fed up, and so presumably have some pretty strong feelings about the matter, and the severe lack of comments to this post. If we remove Dr G's comment (because he is the OP) then there is only one, and then mine in 24 hrs. Contrast that to the KW posts.

I suspect this is indeed because of apathy. Its all very well us bloggers telling the profession and the public what is going on but maybe they don't want to hear.

The latest edition of GMCtoady (sic) screamed "93% and rising" - 93% being the number of doctors who have said they want a licence. But as I said in Faceless Men in Black, that's missing the real story - which is what’s happened, and going to happen, to the seven percent who haven’t responded?

Then add in the low morale, the we're ready to leave mindset; and then add in revalidation. There is going to be a huge exodus from/cull of the profession.

And yet no one seems in the least bit concerned! Bonkers - or should that be bizarre?

Dr Grumble said...

Its all very well us bloggers telling the profession and the public what is going on but maybe they don't want to hear.
***********

While I think the public don't really want too much meddling with their NHS they are not really prepared to protest about what is happening to it. When they really find out about the consequences it will be too late. They certainly come out in force when their local hospitals are under threat (even when this is the right thing to do).

When it comes to using their vote the public has no choice. It is either vote for Labour who have created the problems we have now or vote for the Conservatives whose main line seems to be that Labour is heading in the right direction but has not gone far enough.

Many out there do believe in private markets and fail to recognise their limitations when it comes to healthcare despite all the recent problems in the world of finance.

And the oddest thing of all is that while we are moving more towards an American system, in the US they are moving in our direction because their system has patently failed.

There are problems that none of the parties has addressed such as keeping the lid on demand. But possible ways of dealing with this such as payment are politically unacceptable. To some extent the public has tied the hands of the politicians over some aspects of the NHS and paying is one. So we have the nonsense of wealthy pensioners going to their GPs for free shampoo.

The demand side does need addressing because if you give people a good service and take away waiting there will be no way of limiting what the NHS (or the impoverished taxpayer) has to provide.

Dr Michael Anderson said...

Possibly the only good thing that came out of the near-collapse of the global finance and the current recession was that those who kept saying that free-markets are the only way to run healthcare finally shut up as all we saw what fools they were and what pain lies down that road.

It seems that the fools never learn, they're back saying the same things as they said before.

Dr Grumble said...

Yes, Michael. For a brief moment I thought society had learnt its lesson about markets but the worship of markets is so deeply ingrained it seems that the recent disaster that we are all going to have to pay for for the foreseeable future has already been forgotten.

Certainly there seems to be no widespread understanding that you could have cost effective quality healthcare without introducing a market - despite the fact that that is what we had in the NHS until recently.

dearieme said...

The notion that the NHS embodies some special moral merit, while the systems of Canada, Iceland, France, Australia, Singapore, and so on are morally inferior strikes me as childish, or superstitious, or just plain silly.

Witch Doctor said...

You can read here why the NHS is morally indefensible.

Apparently.

http://www.imprint.co.uk/books/brassington.html

Dr Grumble said...

Clearly Dr G is misguided, WD.

Dr Grumble said...

It seems from snippets of this book I have read online that the argument goes that the NHS is morally indefensible because if we think a public health service is morally warranted we cannot stop with a national health service - it has to be bigger and include other nations.

No One said...

Dr G

Really I think you should give up defending the status quo, or indeed defending an impossible Mao style NHS

The current NHS is top to bottom broken and I for one hope the Conservatives do the blommin obvious and put the real decision making in the hands of the patients as the only proven way of forcing up standards in any consumer fronting business

Julie said...

Real reform should thus look at the demand side too; at breaking PCTs up into groups of competing social insurers, as already exists to great effect in many European states such as France, Germany, the Netherlands and Switzerland. This is not a threat to universal and comprehensive ideals. With the state paying for, or topping up, premiums for those that cannot afford health insurance or with chronic conditions, these ideals are preserved – just as Europe. The difference is that healthcare premiums are paid direct to insurers, rather than to the state through taxation, and people are able to choose between them on the basis of quality and price. If service is poor, or insurers fail to back innovative providers, declining custom gives a powerful incentive to improve.

Yep, just as I predicted. Turn the not-for-profit social insurers into competing market insurers. I just didn't think of the primary care trusts in England being included in that.

It may interest you to know that the person who put forward the European Cross Border Directive was one John Bovis of the Conservatives. He's now resigned as an MEP, but his heritage lives on after him. Think I will have a look to see where it's got to..

Sam said...

"And the oddest thing of all is that while we are moving more towards an American system, in the US they are moving in our direction because their system has patently failed."

Everybody is moving to meet in the middle Dr G. 'New world order' meanz 'New World Health' too .. the future is 'medical tourism', you outsource to get cheaper, otherwise systems are not sustainable as they are now! It's the only way to solve the problem of the ever increasing demand because we're living longer .. that's why alternative providers in internal markets have to stay .. not for Britain only but for the whole world! ... IMO :-)

Dr Aust said...

Talking of Ian Brassington, I'm mildly surprised he hasn't been over to comment about the ethical issues in the KW case, Dr G. As you spotted, Dr G's blog has been signposted for him.

Most of the ethicists I have ever come across strike me as the sort of people who like a good argument (Prof John Harris comes to mind) - but I also have the impression they tend not to argue with the clinicians but more with other ethicists and with the public. Any views?

Dr Grumble said...

The failure of the lawyers and others to engage in discussion with us is quite strange, Dr Aust. As you say, at least some of them know we are here.

Dr Grumble said...

Sam, you are right that whatever you look at we are all meeting in the middle. And it is to do with the post-democratic era and the New World Order. You can't have an NHS in one country and insurers in another. And in the third world no healthcare at all for most. That's the argument anyway. NHSs cannot be expected to work across borders. Insurers can. Businesses can now be bigger than countries and they are determining the way things go as democracy gets ever weaker and organisations like Common Purpose find ways for the elite to get what they want.

It's easy to think that the proposals you favour will save money but it is not what has happened in the US where the market rules more than anywhere else. Quite the opposite in fact. The reason for this is that private organisations always want to sell as much as possible for as much as possible. It is very clear that that is exactly what happens in US healthcare. More tests and more treatments. But more is not necessarily better though the patients seem to think it is. Cheap solutiions to healthcare costs running out of control such as quality general practice are not favoured by such systems.

Outsourcing healthcare abroad is not very realistic. People fall ill where they live. They have chronic illnesses where they live. They die where they lived. They want operations where their relatives can visit them and where any complications can be dealt with.

A better case can be made for independent providers as home (fly in the cheap labour if you like) but so far experience of this alongside the NHS has not been wonderful to say the least. And certainly it hasn't been cheap.

It grieves me very much that people do not see that the way to deal with the unsustainable increases in healthcare costs is using a system along the lines of the NHS that we had until recently. That was a system that minimised investigations and minimised treatments and focussed on general practice. People knew it wasn't perfect. There was no choice and no thick pile carpet and there was waiting and open wards. But it got the job done at minimum expense. It really did.

But your children will be alright in the new system which will inevitably come. In systems like that the best paid tend to get more and the worst paid get less.

Contrary to what some believe, the affection many of us show for the NHS is not to do with self interest as employees. It to do with trying to get the best bang for our buck as taxpayers and patients.

Sam said...

"It's easy to think that the proposals you favour will save money but it is not what has happened in the US where the market rules more than anywhere else."

I did not say I 'favour' internal markets or not! I don't know much about how they work within the NHS to decide. Only I do not mind the involvement of the private sector to introduce competition to drive up quality, precicely because the public sector tends to stagnate and waste resources when left to function on it's own - this happens all over the world and not just in Britain - employee cares only about the pay packet at the end of the month and no ownership or loyalty to the establishment itself, hence ineffeciency!

You see, having done both, public as well as the private sector, I can not understand why the irrational fear by some groups in the NHS because of the introduction of 'minimal' competition; like GPs and the polyclinics for example - they will 'destablise' general practice in this country! - wot?! 150 of them?!!! So, what would they do if they were in a 'proper' competitive industry like airline or travel? What do you do if you want to book a ticket to New York? ... that's competition! And in comparison, the polyclinics are just a 'tickle'! I now believe they will help improve effeciency as well as support GPs too - let's wait and see the GPs being grateful they exist!

And, I am not afraid of the private sector, and it doesn't worry me in the least that my children may have to compete in an open market once fully trained because I expect them to adapt - as for who makes more money than the other, this is not my concern, I just hope they will be able to make a decent living to sustain a dignifying life style suitable to the hard work they have put in. If they make more, then, jollyyyy - indulge - they worked hard for it, so, enjoy! :-) But money as the sole aim in life is only fo the foolish IMO and I hope none of my children will fall into that trap.

And, as you know, I also happen to firmly believe that introducing competition to doctors 'in training' is foolish too! Because it is 'unfair competition' - look how many 'good' doctors did flee the country because of MTAS!

Sam said...

Outsourcing healthcare abroad is not very realistic. People fall ill where they live. They have chronic illnesses where they live. They die where they lived. They want operations where their relatives can visit them and where any complications can be dealt with.

=====

Sure, no one is suggesting the closure of our system and outsourcing the lot! :-) but anything that can be outsourced will be encouraged ... dentistry ... lots of plastics .. lots of ortho paedics .. etc - you know what I meant Dr G!

"A better case can be made for independent providers as home (fly in the cheap labour if you like) but so far experience of this alongside the NHS has not been wonderful to say the least. And certainly it hasn't been cheap."

=====

I fully agree with you on this one Dr G! Let's also add the current doctor/nurse 'blurring of roles' to the equation! Both are not solutions but a very costly hinder to quality and driving up effeiency on the long run!

=====

"the way to deal with the unsustainable increases in healthcare costs is using a system along the lines of the NHS that we had until recently. That was a system that minimised investigations and minimised treatments and focussed on general practice."

:-) Isn't that what Darzi is about?! Cutting down waste in the system while improving effeciency to drive up quality? Why 'La resistance' then?!!! You yourself did not come across as supportive of his initiative that apparantly 'now' speaks the same language as you do Dr G! Why?

Anonymous said...

'NHS that we had until recently. That was a system that minimised investigations and minimised treatment.'
before the Labour twits introduced nowinnofee and 'cover your ass'became essential.
how many lawyers are in parliament?

hughev