Downton Abbey – Dreadfully Subversive!

As a suburban family man I do enjoy sitting down in front of my HD TV on an autumn Sunday evening to watch that exquisite example of English, class obsessed, period, property porn that is Downton Abbey. Thoughts of medicine, politics and economics are usually far from my mind during this time.

However towards the end of the 11th October episode I was surprised by two separate scenes:

The first was Lady Crawley discussing her lady’s maid Anna’s emergency procedure (cervical cerclage) done for her repeated miscarriages.

Lady Crawley: I’m so grateful for you coming out here at dawn.

Gynaecologist: Don’t worry – it will be reflected in my bill.

Lady Crawley: Of course.

It itself this wasn’t that exciting, but it woke me up a little so I was prepared for the extraordinary anti-government speech delivered by the fiery Dowager Countess of Grantham, Violet Crawley (played by the excellent Maggie Smith). In this scene the ladies are discussing the proposal for the village hospital, of whom the Crawleys are trustees, to merge with another larger hospital.

Lady Rosamund Painswick: Is it really so important to see the Crawley’s in command mama?

Violet Crawley: That is my sole motive is it?

Isobel Crawley: Isn’t it?

Violet Crawley: No, no it is not. For years I’ve watched government take control of our lives, and their argument is always the same – fewer costs, greater efficiency – but the result is the same too. Less control by the people, more control by the state, until the individual’s own wishes count for nothing. That is what I consider my duty to resist.

Lady Rosamund Painswick: By wielding your unelected power?

Violet Crawley: You see the point of a so called ‘great family’ is to protect our freedoms. That is why the Barons made King John sign the Magna Carter.

Isobel Crawley: I do see you argument was more honourable that I had appreciated.

Lady Rosamund Painswick:  Mama we’re not living in 1215, and the strengths of great families like ours is going. That’s just fact.

Violet Crawley: Your great grandchildren won’t thank you when the state is all powerful because we didn’t fight.

 

High drama? Libertarian propaganda? Veiled criticism of the BBC by ITV? I’ll let you decide.

Should Libertarian doctors strike?

Intimidation, damage to property, civil disobedience and scared children – I am pleased to say none of these things were present when I attended the junior doctors’ march in London on 17th October, in support of my junior doctor wife and colleagues. This was the first public political protest I have attended and I left with mixed feelings.

As I approached Waterloo place, just west of Trafalgar Square, on a mild dry Saturday, the first signs of the protest were the ubiquitous Socialist Worker supporters handing out various red and black top pamphlets. They were far older than the bulk of the crowd, which consisted of Junior Doctors (those who are not consultants or GPs) mostly aged between their early 20s and early 40s, and their families. My instinctive scowl at the Socialist Workers was changed to a wry smile when I saw a stall manned by those notorious market making capitalists – Locum Agencies!

We were directed to the other side of the square where we loitered with the children, occasionally bumping into friends or colleagues, and tried to hear what was being said on the stages. I’m told it was all quite rousing, although all I could hear over the PA system was ‘hmm mm brr ggg mm sqqqll bzzz NHS! NHS!’ and a few cheers. After an hour or so we slowly walked back towards Trafalgar Square, brandishing our placards and occasionally chanting ‘Hunt must go’. The placards varied: ‘We’re quite annoyed’; ‘I’m not a gynaecologist but I know a Hunt when I see one’; ‘Not Safe Not Fair’; ‘Save our NHS’.

Saving the NHS. That is where I found things difficult. You see the doctors are correct in opposing the contract changes, which will result in significantly worse terms, conditions and pay, especially for those doctors already working lots of nights and weekends. The only reason the government would push for these changes, if I discount them wanting to precipitate a fight with the world’s weakest union, the BMA, is to save money. They wish to save this money as there is not enough money out of tax alone to run a safe, effective NHS. The problem is that doctors are already taking individual action, even with the current contract, and are leaving the UK, changing careers, locuming or cutting down their hours. This is expressed as unfilled rotas and rising locum rates.

Should doctors threaten strike action? I am aware that some on the political right believe doctors should not strike as they knew they were entering a state industry. This is ridiculous. The reasons for entering medicine are complex, and at the time of entry the quality of life in a hard, demanding yet fulfilling job was still attractive for many people. Those skilled doctors who work in the NHS would be the same doctors working in any other system. As a monopsony employer the use of collective bargaining is a legitimate market response for the self-interested worker. Forcing others to strike or operating a closed shop would be illegitimate, but freely bargaining as a collective does not, in my view, make one a socialist.

The real danger, however, is that workers trying to come an agreement on pay, with an employer that wishes to have a single contract for all similar staff, will seek out those who agree and support them. Thus industrial militancy in this usually quiet cohort of professionals can end up with a movement to the political left if their concerns are dismissed.

Regarding the NHS, the most dishonest thing for doctors to do would be to accept a new contract without fighting, as this would leave to falling staff numbers and worsening quality of care. By maintaining a strong contract that may be unaffordable under the current taxpayer funded model, they will precipitate the discussion that politicians keep avoiding. 90% of the public trust doctors to tell the truth; 16% trust politicians to tell the truth (IPSOS MORI 2014). That is because doctors will tell you bad news. Here is some bad news. There is not enough money in the NHS to maintain safe services today. This applies to private services as well as NHS ones – NHS trusts are in deficit; Circle handed back their Hinchingbrooke Hospital contract; GPs I know are closing their practices.

Accepting the truth of the lack of money in UK healthcare would enable the next conversation to take place: where should the extra money come from? When asked honestly the Great British Public may surprise politicians, who look to the past more than the future. Extra taxation seems impossible in the current economic state we are in so that solutions such as co-payments or top up payments, the first step on the road to reducing government interference in healthcare, must be permitted.

One quote for those who would condemn potential strikers. It comes from Atlas Shrugged and remains prescient today as we witness professionals taking their own industrial action by leaving the country or their chosen profession. In my view a day or two of industrial action, if it is a real signal from those who might actually leave for good, is not inconsistent with its message:

“I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.” Dr Thomas Hendricks, Atlas Shrugged

 

 

When NHS charges come, please do it the right way.

I was pleased to see this briefing from the Chartered Institute of Public Finance & Accountancy examining NHS health finances.

The NHS’s own Five Year Forward View, despite its retro 60s communist sounding title, is honest enough to identify a £30billion funding gap from now until 2021, leaving £21bn in ‘efficiency savings’ to make. The official political establishment view during the election was that these new efficiencies can easily be found, and that only £8bn of extra funding is needed.

The reality however is that services are at the point where productivity does not need to increase – it actually needs to fall. Safety and quality of services are constantly under pressure due to permanently running at minimum staffing levels, without the capacity in the system for the expected pressures of epidemics, winter, staff illness and staff turnover. This leads to problems with retention of existing staff, subsequent spending on last minute locums, and a state of constant crisis. This is not just a failure of state providers in this free at the point of use system – Circle Holdings withdrew from their Hinchingbrooke Hospital contract and the rate of GP surgeries handing back their NHS contracts is rising rapidly.

Healthcare workers themselves realise this and many make the choice to withdraw their labour, not as a strike, but by reducing their NHS work, changing careers, working privately, locuming or leaving the country.

Thus in order in improve quality, and retain the skills of those who might otherwise not work at an unsafe intensity, productivity needs to fall, as more resources are put towards an individual’s episode of care.

The CIPFA report states: ‘It will be necessary, to underpin that agenda, either to add further to the NHS budget, charge users more, or reduce services. To choose none of those is not a realistic option.’

Given we are on the cusp of the next financial crisis the only acceptable option is to bring in user charges. This could easily be done in the part of the NHS where 90% of consultations occur, primary care. GPs already take money for various non NHS services, and most patients have a choice of GP practices such that competition could occur.

These charges however must be allowed to be set by the market for each individual practice. A blanket fee would only be taken back into central NHS coffers and would lead to a clamour for means tested exemptions such that the squeezed middle and working poor would take the brunt of the charges. This would damage further attempts to move away from sole government funding.

In contrast, freely floating charges would enable a mixture of providers to compete. Product differentiation, that magical process that fills in the left of the supply/demand curve, would occur, with patients choosing between options including: bespoke concierge medicine; a regular GP service with payments for convenience; services with better IT access, such as asynchronous secure messaging; a cheap system where all contacts are pre-triaged by a GP who decides which health professional will deal with your problem as per clinical need, not convenience. The NHS could continue to fund part of this according to illness burden – there are various risk profiling tools that accurately predict the health usage of cohorts of patients in various risk bands. These could be used to allocate supporting state funds for now.

Looking at the comments on social media sites such as Doctors.net and Pulse there is a real appetite for this amongst clinicians. Personally I would relish the chance to provide an excellent service with the extra funds this would draw in.

Governments nowadays don’t create policy, they adopt that of think tanks. If HMG wishes to follow the logic of the CIPFA report, they need to embrace NHS charging in the freest sense.

 

 

Image © Chris Yarzab

The last patient

‘Sir we’ve found him!’

Sir Winston Johnston Roxville’s hearing, at the age of 72, was as good as it was at 27, yet the only thing he could think to say at that exact moment was, ‘Pardon?’

‘The last patient, we’ve found him!’ exclaimed Jenkins, the parliamentary undersecretary for the NHS.

Sir Roxville stood from his chair and walked to the sideboard where a whiskey decanter stood invitingly. He poured a double for himself, then a double for Jenkins, then gave the decanter a contemplative look before downing his glass in one and pouring another double for himself.

A small LED on the sideboard started blinking red and Sean Connery’s voice piped up from a hidden speaker, ‘Sir Roxville, you are entering binge drinking territory, please be aware your BUPA premiums are at risk of rising.’

Without warning Sir Roxville turned on the hidden machine. He picked up a metal paperwork of a ship’s anchor from his desk and attacked the wood panelled cover concealing it. ‘Put down your weapon, you have twenty seconds to comply’ the machine barked at him as Robocop, yet still Sir Roxville smashed the casing and the underlying machine. Various other historical celebrities told him off as he continued his assault until finally all that could be heard was the long retired Prime Minister David Cameron warning him, ‘as long as you obey the law we’ll leave you alone’ accompanied by the sobs of Sir Roxville, the NHS Chief Surgeon, as he slumped to the floor of his office.

 

2 weeks later Ernold Harris arrived at the entrance to St the Mary-George-Thomas and Peter NHS Foundation Hospital in the shadow of the London Eye at Waterloo. He was driven there is a shining 2015 vintage ambulance, accompanied by one male and one female paramedic, both chosen for their looks as much as their clinical skills. As they approached the hospital Ernold looked out of the window at the cheering crowds who had come to see his arrival. Once there he was wheeled through a set of double doors marked ‘NHS only’ to the side of the public entrance where cardiac patients in hospital gowns chose their food from the well stocked vending area (‘One Big Mic for E£1* (*+health premium tax as per your insurer)!’).

In the lift to the operating suite Ernold passed a television and was amused to see the back of his head as the newscaster told the world about ‘the amazing story of Ernold Harris!’

It seemed all too brief once up there as he changed into his gown and met the operating team. The senior registrar, Miss Blenchamps, gave him a 20 page consent form to sign, ‘Operation: total abdocolectomy; hemi cardiopulmonary osteonephrostomy; deinfibulopartialvesico-lympadenocorticovestibular shunt; appendicectomy. Indication ‘Mr Lehman Frist Weber’s disease – type II’.’

From there he taken to the anaesthetic room, where his last thoughts were of his interview with the veteran broadcasters Ant & Dec.

 

Sir Roxville paused as the patient was brought into theatre. 4 surgeons, 5 scrub nurses, 3 anaesthetics, 2 perfusionists, an irritable robot, a film crew, 3 operating department assistants and a cleaner heard his speech:

‘Today we are privileged to operate on this extraordinary man. Throughout his 92 years he never smoked; he never drank too much, nor too little, alcohol; he was never stressed.  He worked, not to excess, yet was not slothful. He ran and swam, yet avoided marathons. He paid his taxes and took his immunisations. He drunk milk with a positive mental attitude. His house was free of asbestos, yet not too clean. He walked when possible yet conserved his joints. In winter the gas was on at an appropriate 19 degrees at all times. He has no known venereal diseases and his mental wellbeing never failed. He has never been sunburnt. His condition has no genetic basis and he never broke the law. He has no parking tickets. He had a small amount of semi skimmed milk in his tea twice a day. He attended the dentist every year and took an aspirin and statin daily. His BMI is 22.’

‘He is the last eligible NHS patient. Let’s treat him well.’

 

 

 

 

 

Image © COD-Newsroom