#JuniorDoctors How About we Liberalise Medicine Just a Bit…

I need to be absolutely clear on this, I bloody love doctors. They are awesome! When I was a boy I got a thing called testicular torsion. I won’t bore you with the gruesome details, but what I will say is that it was ****ING painful!! But guess what? One of those wonderful doctor people fixed me right up and now my testicles are all shiny and perfect again…

So it should be quite clear that I don’t want to see doctors mistreated in any way. I hope that they get paid well and don’t have to work arduous hours. I want what they give to society to be rewarded with the good life…

The thing is though, I do feel awfully sorry for Jeremy Hunt. And that’s not just because his name rhymes with runt… Poor Jeremy and a few bureaucrats are in a rather ridiculous position. They have to negotiate the pay and conditions for almost all the doctors in the country.

Just think about that for a second… Jeremy Hunt has to work out a package of pay and conditions that makes almost every doctor in the country happy. Most small companies fail at this and they might only be doing it for 10, 20 or 30 people. Little old Jeremy is set up to fail, it’s an impossible task.

The way doctors’ pay and conditions are negotiated is insane. Imagine some poor sod was responsible for negotiating the pay deals for all the estate agents in the country… And for one reason or another they had to cut their car allowance. No longer could Terry the Estate Agent of Foxtons afford his BMW 1 Series or his Audi A1… What do you think would happen? There’d be cocaine fuelled pandemonium, society would collapse and ISIS would invade…

Thankfully though no one is responsible for setting the wages of all the estate agents, because that would be mental… But here’s the rub, the imaginary estate agent example I’ve provided is exactly what happens with doctors and teachers and various other professions in this country and it’s completely ridiculous. Every so often we have to go through these pandemonium phases because no one can agree what a doctor or a teacher or a nurse should be paid — or the hours they should work. But no one ever asks how a centralised system is meant to agree on this.

So while I do bloody love doctors it would be nice to see just one of them ask for the liberalisation of the medical profession in terms of pay and conditions. How about the #JuniorDoctors ask for all the pay bands and universal contracts to be scraped..? Why don’t they ask that instead of negotiating their wages and hours with one man they negotiate directly with their employer — the hospital or practice they work at.

In this scenario individual doctors could more easily find a deal that suits their needs. Maybe they negotiate less pay for better hours, or even more pay for less sociable hours. They and their employer work it out between themselves — just like the rest of us…

Then poor old Jeremy doesn’t have to be called a Cunt everyday because he has a silly name and a ridiculous job…

General Practice “won’t get any more sustainable”

A former Bradford GP lambasts the NHS GP system in a letter to Pulse:

I [left General Practice to work in a Hospice] for several reasons. Gone is the relentless pressure to move onto the next patient. I have taken a significant pay cut, but I don’t care, this job at least does not treat me like something you scrape off your shoe. I start at 9am, get a lunch break, and I get to lavish time on my patients.

What would it take to induce me to return to general practice? Even as I ponder the answer, I know it’s futile. The job won’t get any more sustainable with seven-day opening, and a dwindling number of colleagues. No. I’m done.

Read the whole thing.

Why is the National Health Service in crisis?

I’ve been discussing the NHS A&E issue that’s been in the news of late with the medically knowledgeable and NHS-aware members of my family and thought you might be interested in their background information, so have written it up while the conversations are still fairly fresh in my mind. I summarise, then give my own thoughts at the end.

The immediate cause of the NHS A&E issue being such a story in the media at this time (other than the upcoming election, of course) is simply that at Christmas a great many staff take holidays. The resulting shortfall exposes long-term trends in an area under pressure. There is no other immediate cause, as distinct from long-term trends: these problems have been growing for 15 years and more as follows.

1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort – delaying release and also using up time of staff in non-health work – and costs money.

This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years – “If the NHS were a patient, she’d be on the critical list” – was caused by this and the resultant bed-blocking more than any other one cause.

A more recent context is over-regulation of local councils’ social services leading to declining throughput, unrealistic expectations for their visit times, etc., and their have also been some social services cuts by said councils. These also have an impact on a hospital’s ability to get people out of the back-end to free up beds for A&E incomers.

2) The new 111 service is sending many more patients to A&E.

2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.

2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. This 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).

3) Regulation prevents fixing the problem as well as causing it. A Birmingham hospital (Queen Elizabeth in Edgebaston IIRC), said to be very efficient as such things go, tried to create a low-level care unit precisely to solve the problem. Because of the regulations, the attempt had to be abandoned – they just could not tick all the boxes.

4) Back in the early-80s, when my sister (a doctor) did her elective in A&E, she loved it. Now, doctors are avoiding A&E as a speciality because they know how brutal is the pressure there. So the problem is beginning to compound itself.

There is a great deal more one could say, but the above are what my informed relations see as the key immediately-relevant causes. So far my summary. Now some thoughts of my own.

What I observe has most changed in the last two decades in these either left-leaning or were-left-leaning people is firstly their belief that “No party can fix it”. (This I heard from a previously definitely-left individual who would probably still cut her hand off before it voted Tory and whose heart wavered between Labour and [Scots] Nats although her head despises Nats ideas and despairs of Labour.) There is an expectation that no likely government will do anything other than talk of reform while actually causing yet more regulation. Some of this in some of them might be a reluctance to think that the side of politics they’ve loved to hate in the past might be the place to look for an answer (I am reminded of Gore Vidal in 1979, “I feel the despair of coming to think that the Soviet Union may be as despicable as the U.S.” – quoted from memory) but it also reflects their opinion that the Tory-led coalition has failed to reverse any of the above trends, and this opinion I fear is not mere prejudice but has a basis in their experience of the last three years, just as much of the above reflects their experience of the last 15 years.

Secondly, they report a widespread belief within the health service that this time “a bit of money can’t fix it”. There is no expectation of an ocean of money (and – I sense – awareness that the NHS already consumes an ocean of money, so can hardly demand another ocean of money even as a righteous goal, however impossible to arrange).

Lastly, I know that behind all this inefficiency of regulation, there lurks a compounding problem of looming social trends. The number of patients who have no family ready to help is rising. The promise that the state will look after all has led more people to lead lives that make no other arrangements. But these long-term trends are not the reason the NHS operates much worse now than two or three decades ago.

 

by “ARC” via Samizdata

 

Red meat for the 35%

Well, that was a drab affair. There was not much energy or excitement around the Labour conference and this year Miliband was not able to find the same spark as he had in previous speeches; those that led to a resurgence of spirit in the Labour ranks and surprised the public, the punditry and the party. They were rife with big ideas, big slogans and door step friendly sound bite policies that led to a post-conference poll bounce. I doubt that there will be any significant movement in the polls as a result of this conference. Ed Miliband has consistently surprised me with his ability to give great speeches, and right when he is under pressure too. Not that his policies or ideology attract me but I had to admit to being impressed when he managed to enrapture an audience without notes and capture the attention of the public. This time he fell short, it was not a good speech and it revealed just how narrow an election campaign Labour plans to run. Gone was the whole notion of “one nation” or any attempt to meet issues such as the economy and immigration head on. This was all about throwing enough scraps of red meat to their loyalists, activists and core tribal voters; they are now the party of the 35%.

Ed Balls speech the previous day was even worse. It was uninspiring and did not address any concerns over Labour’s management of the economy. Ed Balls swung from left-wing populism, designed to get the seals to clap, to token disclaimers about the reality of Britain’s financial situation. It seems that the Labour Party is willing to nod its head towards the vast deficit and national debt but is not brave enough to explain what it plans to do about it. Ed Balls announced the already leaked plans to raise the minimum wage, axe the “bedroom tax” and put the top rate of tax back to 50p. Clear answers to the issue of “difficult decisions” were absent, he said labour would maintain the child benefit restrictions, saving a meagre amount of money in the grand scale of things. Given that the state of Britain’s finances is nothing less than a national crisis, making hollow concessions about the need to make ‘difficult decisions’ while planning to put in place new punitive taxes that will bring in meagre amounts of money is a pathetic response. The Raising of the top rate is a counter-productive populist policy for the electoral base, it might excite the 35% but could lose the treasury revenue.

Ed Miliband’s speech was chock full of the kind of fool’s gold idealism and flatulent progressive language that so excites the left. He used the word “together” an absurd amount of times, to convey the image of Labour as the party of social solidarity. They are the party for the many, and their movement is a collective endeavour… the usual socialist hot air. All eye rolling bilge of course, especially from a party with an electoral strategy to limp over the no. 10 threshold with only the votes of their core supporters and a few lapsed Lib Dems. The speeches highlights involved bashing the rich and the Tories, linking them all together with predatory big business and oligarchs. He played to the electorate’s perception of the Tory Party as being representative of the privileged few, contrasting the Conservative ‘leadership that stands for the privileged few’ with Labour’s leadership that fights for you’. Such lines hit the target but were drowned out amidst the tiresome anecdotes in an overlong speech of vague aspirations that failed to make Ed Miliband seem any more prime ministerial.

The Labour Party are on the retreat because Ed Miliband no longer seeks to unite one nation, instead he plans to cobble together a majority by pandering to the party faithful. Left wing populism for the 35% target that ignores thorny issues like the welfare state, spending cuts, immigration and constitutional reform. We now know that the key policies of the campaign will be the plan to raise the minimum wage and invest in the NHS through the “Time to Care Fund”, true Labour populism. Although raising the minimum wage will inevitably lead to job losses and increased difficulty in the job market for the young and unskilled, no matter, it’s a great sound bite and the activists will have a spring in their step when they knock on doors. Investing in the NHS and pledging to hire more nurses, doctors and midwives by clamping down on the tax avoidance schemes used by evil corporations, taxing properties worth more than £2 million and raiding the tobacco companies is a great red meat policy for the party base. Still, it is essentially a foolish avoidance of NHS reform; this behemoth of a health service, creaking and overstretched, that teeters along the edge of insolvency will eventually need more than cash injections from the tax payer.

Labour are ducking the most serious issues and this failure is thankfully likely to keep them out of power. Ed Miliband “forgot” the part of his speech when he was meant to talk about the deficit; basically he bottled it and instead clung to his comfort blanket. For this folly he will be ravaged in the in the media and rightfully so. The economy is the number one issue and the public are wary of Labour’s record yet Miliband was silent and Balls unimpressive on the topic. The potential future Prime Minister forgot to talk about the economy! This is not someone to lend your vote to; there is no sign that the £75 billion in spending cuts that are needed are being contemplated with any seriousness. Maybe I’m wrong, perhaps they will get away with it, perhaps by rallying their loyalist troops and benefiting from their fixed electoral advantages Labour will manage to form a weak majority government. Then we all get to see the British François Hollande swing into action, with his dismal cabinet behind him, ready to implement his ten year plan to realign Britain to Milibandism. Ugh.

Don’t jump to conclusions on Ashya King case

As an NHS GP who ultimately gets his income from looted fund via the government I feel compelled to offer some commentary before condemning the doctors involved in Ashya’s care.

It appears that the initial social services and subsequent police involvement was triggered by Ashya leaving the hospital, without staff knowing he was leaving or where he was going. This is a significant event and does need a timely response in a child who is severely ill and would need hospital care within a short period of time. The hospital would call social services, to raise concerns, and the police, as rapid contact with Ashya was needed.

Doctors involved in care are legally and professionally bound to raise safeguarding concerns in children or vulnerable adults. When this has not been done the doctors can, and have been, disciplined and struck of by the General Medical Council, as well as the usual vilification in the press and by politicians. Baby P was such an example.

It is highly unlikely that a child cancer centre, which deals with complex children and their families in extremely difficult circumstances, would flippantly aim to remove a child from their parents due to hurt professional pride or a difference in opinion, especially when this would involve multiple staff to make this decision, not just one ‘rogue’ doctor.

Once the acute concern (finding Ashya) had been dealt with it is not the doctors who determine what happens next. That is up to social services. What happens in Spain once the family are met is up to Spanish police in liaison with Hampshire police.

Just because the initial raising of the alarm led to a heavy handed police response doesn’t mean the initial action from the hospital was at fault. Bear in mind the difference in professional views that occur however (and I have first hand experience of this): doctors may feel patients are ill unless otherwise proven; social servies believe parents are bad unless otherwise proven; police think people they encounter are lying criminals until otherwise proven.

Taking an ill child abroad, without even letting the hospital know they were leaving, is a cause for concern, in a society where the current consensus is that the state has a role in protecting the vulnerable. I am liberty orientated yet on many occasions have raised concerns to social services, including in cases of unexplained injuries in the vulnerable, as well as cases where the parent is a feckless substance abusing disaster, yet is still the most responsible carer holding the baby, other family and partners having left or been kicked out for domestic violence.

Doctors disagree with patients, parents, nurses, the media, other doctors and themselves every day – it is part of the job. Vaccines are not compulsory for children in the UK and the cases where treatment is mandated by a judge are rare indeed. Much as I’d like to refer to social workers when I see a child with a head moulding helmet for plagiocephaly (they grow out of it – have you seen many adults with misshaped heads recently?) this isn’t part of medical culture in the UK.

In summary I would be cautious over the facts of this story. Every similar story I have first hand experience is reported poorly. I would also differentiate between the initial alarm and the subsequent treatment by Spanish police of the family.

As to when others can intervene in the case of vulnerable children – that is perhaps the subject for someone else to post on, yet an absolute position that acknowledges parental rights only does has demonstrable problems.

I wish Ashya and his family all the best.

NHS knew on Friday where Ashya had been taken

This is the video message dated 30th August in which the father of a child with brain cancer appeals to the authorities to stop chasing him around Europe. Why did he end up a refugee? Because he dared to ask for a different medical treatment for his son, one which might stop his brain being damaged by radiotherapy treatment. The Southampton based doctor stonewalled requests for medical information from a Prague based practitioner and in an unrelated conversation (about chemotherapy) threatened to get a court order to keep the sick child’s parents away from him. Instead of remaining a victim of that system, Mr King took responsibility and removed his child from that system on the afternoon of the 28th.

On the 29th the public were told that this father had snatched the child from the hospital, with the press hinting at religious reasons, and a manhunt was launched in France and Spain. We were told about a snatching and a ferry journey to France, while the court were simultaneously authorising law enforcement to pursue them in the Czech Republic:

court-order-extract-ashya-king

Why the Czech Republic? Perhaps because Prague, where Mr King was liaising with a radiotherapy practitioner for advanced proton beam technology, is the capital city of the Czech Republic. If so then this is a smoking gun that shows a police chase and European Arrest Warrant was issued for a case in which a father was known to have sought treatment outside the NHS. He was not a mad religious nut snatching his kid away from scientifically rational NHS doctors; nor was it a parent who did not understand the gravity of the situation; it was straightforward case of NHS care not being good enough for Mr King. The NHS knew this with enough notice to correctly guess where Mr King was going and file a lawsuit accordingly.

Was Mr King right? That is not for a court to decide. It is Mr and Mrs King who have responsibility to their child and a practitioner with a different opinion to Mr King has a duty of care to persuade him of the better course – not the other way around.

Your NHS GP is a Libertarian, but doesn’t know it

‘Getting to see you is like trying to get tickets to see a rockstar’ a retired lady observed yesterday in clinic. This was probably the most polite expression of a patient’s frustrations around access to a GP that I’ve heard in my career, and it summed up the plight of UK general practice perfectly.

You see in a system where 1 million patients are seen in GP surgeries daily, where demand for such services is increasing yearly, and where no money is exchanged directly by the patient for this service, there are only 3 ways to allocate appointments: a lottery system (who can get through first when the phones open); a waiting list; or an assessment of ‘need’.

Now in the case of my practice I see about 30 patients daily, for 10-15 minutes each, as well as checking all results, running the practice, keeping my knowledge up to date, visiting patients at home, developing innovative service models and supervising and training other staff. After 12 hours of this I can’t safely do any more work. So why don’t I employ more doctors?

To understand this one has to understand founding history of the NHS. Aneurin Bevan famously said that he persuaded the doctors to join the NHS in 1948 by ‘stuffing their mouths with gold’. Less well understood is that the general practitioners (GPs) declined this offer and have remained independent contractors to the NHS ever since. This currently translates to a flat fee to the practice to provide medical services, with some incentives around chronic disease management, which amounts to approximately £100/patient/year, regardless of the number of appointments. Average consultation rates are approximately 5 primary care appointments / patient / year.

© Dalius Baranauskas

© Dalius Baranauskas

What’s this to do with rockstars? – one might ask. Well, the main issue facing me and my colleagues is we’re too good at our job. As our practice offers extra services, such as warfarin monitoring, specialist diabetes nurses, extended opening hours and 15 minute appointments, we attract more local patients with complex conditions, as they are most incentivised to find a good practice. These patients require a lot of clinical time, yet are still paid at the above flat fee which is still less than the cost of yearly hamster insurance. Thus the financial incentives in primary care penalise those who provide the best care.

Despite this doctors remain the most trusted profession (Ipsos Mori polls) and as such the machinery of government, education and business has started using GPs as a kind of cut price notary service for all aspects of someone’s life.

The kind of life events that are now medicalised, mostly as a completely rational response to external pressures by individual patients, include: unfit for work; unemployable; bereavement; conflict at work; requests for housing; requests to move house; requests to stay in the country; requests to bring family into the country; not fit for exams; didn’t do well in exams; too anxious to work; proof of existence.

In essence much of what we do, and much of our patients’ responses, are affected by our unsought role as a judge of need. This is explicit of course in the NHS founding aims: free at the point of use; meeting everyone’s needs; based on need not ability to pay.

This superficially laudable concept probably sounded good at first, but like the Twentieth Century Motor Company, rapidly deteriorated into a perverse system that, in the case of the NHS, penalises self-care, encourages dependence and creates resentment between patients. Commentators, media, politicians, patients and doctors can all be found espousing the same views that somehow poor access to services is due to patients attending A/e, GPs, hospitals, walk in centres when they ‘don’t need to be seen’.

Call me a lightweight, but I find the concept of deciding who is ‘ill’ difficult enough after 15minutes of history, examination and investigations, and I’m paid to do this. Then try and ‘judge’ competing claims for appointments amongst self-employed builders with work injuries; unemployed depressives whose benefits have just been stopped; patients who need a medical review before going abroad at short notice next week; those who think they are dying; those who probably are dying and it’s no surprise that often access is decided by he who shouts loudest. And, as my receptionists known, there is a lot of shouting.

Fortunately there is hope. The same profession of GPs who declined becoming salaried employees of the state in 1948 retain an independent streak today. GP training and research in the UK has a long history of emphasising the personal interplay between a GP and the individual sitting in front of them, from Balint in 1957 through to Pendelton in more recent decades, the role of the GP and patient working in partnership for mutual benefit is one that can be viewed as consensual trade. The work of others such at Berne’s transactional analysis (1964) has also been used, with the understanding that the default state should be doctor and patient interacting as adults, rather than one taking on the role of parent and the other child. My own views on liberty have been developed and sharpened at work by witnessing both the benefits of these adult-adult transactions and by noting the real disabling nature of systems that treat us as children.

GPs also remain businessmen and women, which probably explains how £100/patient has lasted so long without complete implosion of the system! And, alongside many libertarians, we don’t like being told what to do.

So where is the opportunity in this industry that affects all 60+ million people in the UK, is a £7 billion sector representing 8.4% of the entire NHS healthcare budget yet accounts for 90% of all NHS consultations?

The obvious answer would be to free up this sector, which currently crowds out all other low cost healthcare. A ‘medical home’ (primary care) is recognised by the World Health Organisation as particularly important for good healthcare yet there are few private GPs in the UK. The GP role is important – whilst private or public hospital specialists might have incentives to promote their own treatments (usually involving a tube in an orifice or a cut with a knife) there is a need to build on the trusted medical expert skills of the GP. A good GP can help patients avoid unnecessary, dangerous and expensive hospital care, and help manage the risk and uncertainty that is unavoidable in life and health. These skills are particularly necessary given the increasing morbidity as we manage more long term conditions into old age.

3 massive barriers to private GPs exist however.

The first is NHS prescriptions. Only NHS GPs can issue NHS prescriptions. As prescriptions can costs thousands of pounds a year privately, yet should only cost a maximum of £120 / year in total for those not exempt, all but the wealthiest are incentivised to keep an NHS GP.

Secondly, only NHS GPs can refer to NHS secondary care. Whilst many pick and choose for elective secondary care, paying for one time operations privately, they still wish to use NHS services for catastrophic care and long term conditions, especially as the ‘free’ healthcare crowds out alternatives. Again, this makes having a private GP more hassle than it saves.

Thirdly, existing NHS GPs cannot offer any added or extra services to their own registered patients.

Thus three actions that could instantly allow the market driven development of improved, more accessible, GPs would be to allow private GPs to issue NHS scripts and refer to NHS consultants on the same terms that NHS GPs do, and to allow NHS GPs to offer extra services to their patients.

This would instantly improve extended hours access, continuity of care, improved use of IT for communication and encourage the self-care agenda that leaders in the NHS constantly talk about, without understanding why this doesn’t occur.

A spontaneous change to the rules would be preferable, but perhaps a patient could influence this change via a legal challenge to their ‘right’ to NHS care, or a private GP could gain access to NHS services via competition rules.

Many models of care would arise, from concierge medicine paid like a gym membership with guarantees regarding maximum GP list sizes, through to pay as you go services to be used as needed.

For the GPs they would take back their autonomy and, instead of feeling that queues to be seen were a sign of failure, would instead see their services being properly valued, and would thus strive to improve them further.

For patients they would gain control over their health and would take a more active role in their own health.

And perhaps over time, seeing that the system didn’t implode, and that they were still alive and healthy, the whole country would feel a little bit more free, a bit less like a hamster and, maybe, even a little bit more libertarian.