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.

A market based answer to the Care.Data medical records fiasco

Big data has always been important in health care research. John Snow famously used epidemiological data to identify the source of the Soho Cholera outbreak in 1854. Aggregated case reports are used to classify disease and improve our collective understanding of illness so that we can treat it. I myself spent happy hours as an undergraduate researching original contemporary case reports of the ‘insane’ in the 17th century, printed alongside tables of numbers, symptoms and demographic data.

The UK government now wishes to use the 15 + years of highly detailed individual patient GP records for research, by any organisations that wish to use it.

Jeremy Hunt stated in an interview recently that GPs should use public trust to sell the benefits of the care.data programme.

I’ll not dwell on the irony of the current health secretary trying to use the trust in GPs he has consistently tried to erode, nor will I discuss the implications that government doesn’t have enough trust itself to trade for the public’s data!

How complex must it be for government – how can they reconcile individuals’ thoughts on privacy, support for medical research, and trust in the system storing and protecting the data?

Fortunately there is a market answer. Simply invite all those registered with a GP to submit a ‘lowest acceptable price’ for the use of their data over the next 3 years. Make the scheme opt-in rather than opt-out. The government then selects a price point that meets the number of patients they need and pays all qualifying patients this price.

It would even be possible to randomly select a cohort of patients who will be offered much higher prices for their date, to provide a control group for the possibility of the wealthier being less likely to part with their data at the chosen price.

This would be a true consensual trade, and would make both government and individuals aware of the true value of our personal data.

Could Direct Care shame the NHS into reform?

Direct Care or “Concierge Medicine” is a reformed way to pay for health care that is gaining in popularity in the United States, there is even a SitCom about a Direct Care practitioner in the wealthy Hamptons but this is not only for royalty. This model has the potential to create a new health-care sector accessible to all classes, and, as such, to embarrass, out-compete and denormalise the NHS.

harley-street-craftivist-collective

© craftivist collective

The traditional US model is comprehensive “insurance” which includes cover for catastrophes and accidents, as well as pre-payment for the kind of common ailments that may just require a little advice and some medicine to manage: everything from minor infections, stitches for your sports or domestic injury, or help managing your blood pressure or diabetes. Insurance for the routine “family” medicine. Of course, as proponents of private health care we will have all heard of the mandatory insurance benefits for frivolous items, and the shrill controversy over subsidised birth-control.

Paul Hsieh makes this comparison clear in Forbes:

What most people consider health “insurance” is actually genuine insurance combined with inefficient pre-paid medical care. Contrast that with standard car or homeowners insurance policies. Those plans protect us against unlikely but expensive events, such as a bad car accident or a house fire. But we don’t use car insurance to cover routine predictable expenses such as oil changes.

Another part of this traditional system is the “co-pay”: small additional payments for care designed to be an obstacle to insurance claims, to share some of the accountability for health care with the recipient. We all worry that the UK system of tax-payer accountability encourages reckless obesity and hard-drinking here, the co-pay is designed to solve a similar problem of over-claiming on insurance.

Wikipedia Contributors note:

Insurance companies use copayments to share health care costs to prevent moral hazard. Though the copay is often a small portion of the actual cost of the medical service, it is meant to prevent people from seeking medical care that may not be necessary (e.g.: an infection by the common cold). The underlying philosophy is that with no copay, people will consume much more care than they otherwise would if they were paying for all or some of it. In health systems with prices below the market-clearing level in which waiting lists act as rationing tools, copayment can serve to reduce the welfare cost of such waiting lists

Concierge doctors in the states are continuing to experiment with co-pays, but the direct model dispenses with this system and works more like a gym membership, or perhaps a little like broadband. You pay a standard price (though often a discount applies) and you get unmetered access to the pool of health facilities. In the Direct Care scenario that means you can make as many appointments as you wish, and even consult over the phone. Interviewed by The Objective Standard direct care practioner Dr. Josh Umbehr explains:

A per-visit cost encourages patients to make a difficult decision based on cost. When you remove the per-visit cost, you enable him to maximize the care he receives. When you maximize the care, you maximize the potential for good outcomes, saving him even more money downstream. A diabetic can come to me every day for a week or until the condition is truly under control, with no additional cost to the patient.

I also prefer routine costs in other fields. I don’t want to talk to my lawyer or my accountant if it’s going to cost me $50 a pop. But I might make a decision that isn’t as wise as it could be and that may cost me thousands because I didn’t want to spend $50 to talk with my attorney to clarify something. I think the same is true with health care. When you level the payments, just like a gym membership, you remove that obstacle. You have no idea how much the people are going to use it, but if you maximize their opportunity to use it, you maximize your potential value to them and the benefit of their unlimited access to care. I think this best serves the patient’s long-term health goals.

The sales pitch is compelling. Unlimited access to a doctor who wishes to maximize the value he offers to me. This would be a thousand times better than being asked to jump through bureaucratic hoops to access rationed specialists or getting funnelled down standardised treatment pathways in the NHS. Or worse, being trained to lie about the urgency of your need in order to get an appointment while you are still sick.

This last problem is a serious one for casual workers and honest businessmen, because if you cannot work you might not be paid. OK so we could accept having to lie to work the system as a trivial cost to society, but I suspect (and please excuse me if this seems a stretch) that a national institution that you must lie to in order to gain anything from has a serious design flaw and one that is corrupting of the society it exists to serve. But I digress. For people like me who shoulder the risks of ill-health themselves the real issue is staying at your desk. Paul Hsieh explains how this new model can help:

[Doctors] are establishing “concierge” or “direct pay” practices, where patients pay a monthly or annual fee for enhanced services, including same day appointments, 24/7 access to their doctor, e-mail consultations, and longer appointment times.

The national average wage is equivalent to £100 daily. If you are a plumber, a casual labourer, retail worker, shop owner, freelancer, a skilled consultant or an entrepreneur then that wage is conditional on your being fit to work on any given day. If an NHS appointment is only available after a 7 day wait then you could be better, without help, before you even see a doctor but you would have lost at least £500-700 pounds. In contrast, if some access to medical advice saves you from spending the whole week in bed, and gets you back into the office for Friday then you will be £100 richer than you would have been. This is exactly what happened to me after a lingering bout of food poisoning. It cost me a well spent £40 on a private GP, and some non-prescription medication worth less than a tenner.  Compared to where I was when I made that decision I was at least £400 better off, and this was for a relatively simple problem. If I had a chronic condition to manage I might face that kind of trade-off regularly.

The pricing of Josh Umbehr’s AtlasMD service is comparable to a gym membership or daily coffee, $50 per month for any adult via a company policy. Let’s assume we do not get the benefit of the exchange rate and this is likely to cost you £50 a month. Yes you would still pay for the NHS, it’s mandatory, but the more you earn the higher the probabity this kind of support will pay off economically; and of course the pay off is twice as fast if your spouse is nursing you and has similar circumstances. On average, for a single adult, the payoff would be 6 days. For me – a backend web developer – the payoff would be there if less than 2 days were saved in the year. Of course, this doesn’t cover major catastrophic illnesses, but I would be able to rely on the NHS for that. I’m thinking of incremental reform, and also in terms of triggering a debate about NHS quality.

This is what I’d like to see happening. At the moment, I am able to find just one GP offering a service on a monthly fee in the UK and that is in the rural out-of-hours niche. I’d like this to be commonplace, and available all-day. It would not need to be the dominant form of healthcare, but merely to be available for about the price of a gym membership to 10% of the population. We can then start to use this kind of care as a counter example to the sainted NHS. To get there, we need to stimulate demand. We need to talk about this idea with friends and talk about the various ways in which this would be more pleasant and more convenient than the GP service we get from the NHS. We would then be able to talk about the NHS as something like a safety net for very serious medical catastrophes, not something we rely on every day for every kind of medical assistance.