Now, since the “reforms” to NHS dentistry resulted in it becoming harder to see an NHS dentist…
Given that Bradshaw has threatened “failing” hospitals with closure or privatisation…. (Just as Education minister Balls has threatened “failing” schools – his list included schools that the inspectors had given good marks.
FIRST, let me declare my prejudice: I’m a GP. Second, let me set out my ambition: to warn you of the delicate health of the NHS. Scaremongering? Well, once upon a time you saw an NHS dentist; perhaps, in the not-too-distant future, you’ll recall the days when you saw an NHS GP.
Let’s start with some pertinent history. The NHS was established in 1948. At that time, hospital consultants became public sector employees, but the Government of the day could not afford to buy out GPs and so they remained self-employed practitioners. This continued to the present day and until recently GP partners retained a monopoly of primary healthcare, because their practices provided cover 24 hours a day, 352 days a year. In the beginning, this wasn’t too onerous, because calls were infrequent and often tea and sympathy were all that could be prescribed.
However, half a century later things had changed. Mobile phones and the internet had transformed the temporal landscape. Sunday was no longer a day of rest and the worker rats were running faster and further on their spinning wheels. Medicine did not miss the beat. Clinical possibilities increased, patient expectations rose and politicians promised more and more. By the 21st millennium, GPs were suffering from chronic fatigue. And so, in 2003, we reached a watershed.
That watershed was called the New Contract and, as some would argue, it transformed exhausted GPs into rich, lazy millionaires. In return for giving up out-of-hours care, they were rewarded with performance-related pay in the form of the Quality and Outcomes Framework. All they had to do was focus on new targets, code the information for audit and Bob was your uncle. No one mentioned that those unlucky enough to be ill with unfashionable diseases might lose out.
Given the constraints of 10-minute consultations, software was developed to flash up warnings regarding QOF-related omissions as a patient approached the consulting room door, thereby enabling health professionals to juggle QOF requirements with the patient’s own wayward agenda.
For a few months, all seemed well and GPs lived in paradise. Then they began to wake up to the fact that the New Contract was more akin to a Faustian pact with the devil. The Government had driven a wedge into the provision of primary healthcare from which GPs were unlikely to recover. The monopoly was lost forever and the door had been flung wide open for alternative, competing providers. Choice became the watchword, the be all and end all of the Government’s policy-making machine, and patients benefited enormously – or so ministers wanted them to believe. But the problem with the choice agenda, identified by those with more discernment, was that it seemed to bear little relation to equity of provision or improved health outcomes. In fact, it seemed to be driven by economic imperatives (reduce public spending), ideology (individual rights are more important than social imperatives) and political expediency (politicians thinking they are more likely to get re-elected if people believe they have given them want they want, even if it’s not necessarily what they need).
The problem is that “alternative providers” actually means creeping privatisation. This was introduced by Margaret Thatcher in the 1980s. Gone are the long-stay hospitals for the frail and elderly. These have been replaced by private residential homes. Access to NHS dentistry and optical services also declined under the Conservatives. What is new and shocking about the current scramble for alternative provision is that it has been zealously pursued by the present Labour Government. This means that neither of the two main political parties in Britain is prepared to champion a publicly-funded, equitably-distributed NHS. So why has there been no rumpus?
Labour has been cunning. So far, the Government has only allowed healthcare commissioners to contract for-profit companies to provide NHS services. In other words, patients don’t pay directly from their own pockets – yet. But that squeaky clean new treatment centre round the corner owned by South Africans and serviced by professionals from eastern Europe is funded by British taxpayers. A Trojan horse has arrived and healthcare is being outsourced to private companies from across the globe.
Does it matter? If we’re happy getting gas from Russia, nuclear fuel from France and cars from India, then buying healthcare from China may not be such a big deal. Except there’s a hitch. By definition, for-profit organisations need to make a profit, so their service provision is more expensive than that of the not-for-profit public sector.
The Government does not agree with this simple arithmetic. It insists that public service is stuffed with dead wood and that consequently it is inefficient and extravagant with funds.
But can we afford to be persuaded by this assumption? Consider the privatisation of the railways. Think Northern Rock. Private companies fail regularly and, when the stakes are high enough, politicians readily forget their scruples and plunge their hands into the public purse. When the alternative healthcare providers fail, the British taxpayer will be expected to bail them out.
And it’s worse. In its haste to limit spending from the public purse and dodge its social responsibilities, this Government has offered private sector providers more favourable contracts than those enforced in the NHS. Combine this with the fact that private companies do business first and healthcare second and you’ll understand why they have rapidly cherry-picked the more lucrative services. If you have a chronic or relapsing condition or you’re on the far side of your date of birth, start to fret. In the future, you may be dumped into what’s left of the NHS with the intractable, high-risk, challenging stuff that doesn’t make a profit – unless you’ve got health insurance. But beware: insurance is slippery stuff. You’re never quite sure what you’ve got until you actually claim. Did you forget to read the small print? Did you understand the small print? Did you realise that the more you need it, the more it costs? So don’t get ill or relapse and don’t get depressed or stressed. It’ll be like trying to get house insurance after flooding.
Which brings us back to those rich lazy millionaire GPs. They’re feeling as if they’ve been zapped with a Taser. For the first time in half a century, they understand what it means to be self-employed in a competitive market. And they’re on the back foot. Most GPs are just clinicians. In the past, this has not really mattered. But now they have businesses to run, too, and they’re not sure how that works. And they don’t have the time. So now they employ business managers instead of practice managers and clinical meetings have been abandoned in favour of updates on QOF and the provision of time for the administration required for the new forensic audits. Many GP partners, while retaining their NHS status, have also started joining private companies. They’re not quite sure what joining a private company means, but they’re fearful for the future so they’ve started diversifying.
From the outset, “new” Labour – bent on the transformation of social healthcare into a market – dispensed with intelligent or philosophical discussion. Instead the Government used carrots and sticks. The carrots for GPs included reprieve from punitive 24-hour care. The sticks were mainly in the form of threats to livelihoods: “Do this or someone else will”. More recently, the sticks have become batons. Earlier this year, GPs were required to vote for a continuation of their current practice for less pay or extended and less desirable hours for less pay. There was no third choice and the first option was strongly discouraged by the threat of alternative provision. GPs are beginning to feel like dentists.
But forget for a moment the possibility that your NHS GP will become as rare as a dodo. The transformation of healthcare means a heavier price will be paid – by patients. In its eagerness to open up the market and provide choice, the Government has progressively and systematically fragmented primary healthcare.
Once, the grand symphony was conducted from general practice. Although there were a few fluffed notes, everyone knew which part of the score to play. District nurses and pharmacists had solos, but there was an attempt at harmonisation. Now the score has been shredded. Now we have a plethora of uncoordinated overlapping services, a multiplication of opinions and confusion regarding responsibilities. Throw alternative providers waiting for your custom on railway stations and in high street stores into the mix and you’ve got a great big noise. And noise is wasted energy and expensive. So we’ll all pay – even if we get to pay less in tax and more directly from our own pockets.
Interestingly, there is a model for this transformation of our healthcare system. It’s in the developing world where there is a panacea of possibilities on the pavement alongside spiritual healers and shamans. Multiple opinions will lead to multiple diagnoses and multiple prescriptions and this could be dangerous.
The Government thinks it will overcome this with a national medical database. It has already spent a lot of money trying to get this up and running, but so far there hasn’t been a lot to show for it. Sadly, even if it ever works (and it isn’t stolen or left on a train,) the database won’t prevent the multiplication of diagnoses and prescriptions. There’s only so much that one human being can process in 600 seconds.
So it’s back to the future with the commodification of healthcare, abandonment of continuity of care and dawn of the age of choice. Tomorrow you may be able to hobnob with the community pharmacist, take tea with the community matron, pop into the treatment centre or take out some health insurance. Confused? Beginning to wonder if Jamie Oliver is responsible for your healthcare? So is your GP.