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April 7, 2011

Welsh Institue of Health and Social Care Blog
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» STRESS TEST THE NHS

Another contribution to the fierce debate on the reform of NHS England is published in today’s Guardian from WIHSC Emeritus Professor, Morton Warner. Andrew Lansley cut a lonely figure as he announced a “natural break” to review his NHS reforms. (Guardian … Continue reading

February 17, 2011

Welsh Institue of Health and Social Care Blog
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» Why GPs Should not Commission Specialist Health Services

Contrary to manifesto promises and most informed opinion, the UK government is imposing a radical, expensive and ideologically driven restructuring on the NHS in England.  The central feature is the proposed delegation of the £80 billion annual budget for hospital and specialist services to consortia of GPs.  Although these changes do not apply in Wales and the other devolved administrations, they will have serious repercussions across the UK. 

This policy is misguided for many reasons.  First, it reinforces the misconception that hospital and specialist services are the core of the NHS.  However, only ten per cent of GP consultations trigger referral to a Consultant. 

Primary care is internationally recognised as the essential foundation of any effective national health-care system.  UK primary care, in which GPs play a leading part,  is amongst the best.  However, it is still not good enough. 

Choosing a GP is the most important decision a patient has to make.  Unfortunately, there is no credible public information on which the quality of a GP practice can be judged.  Many GPs are excellent.  Others are unacceptably poor.   

GPs are independent contractors to the NHS, not employees.  They determine how they spend their time, including private interests.  This pragmatic arrangement has generally worked well since 1948.  A clinically independent and trusted GP is important for patients.  The drawbacks include professional isolation, variable quality and a tendency for some GPs to confuse their personal interests with those of their patients.

 Advancing technology has progressively enhanced the diagnostic and treatment capacity of primary care.  However,  many GPs have abdicated from services traditionally associated with the holistic ‘family doctor’.   These include maternity, some disabilities and chronic conditions, home visits, preventative services and mental health. 

Despite the introduction of ‘NHS Direct’, many patients, particularly in deprived areas, still find it difficult to access acceptable GP services.  This has not been helped by GP withdrawal from  ‘Out of Hours’ services.  This has led to clinical discontinuity and, in some cases, negligent incompetence by substitute doctors. 

Many such changes have occurred during successive renegotiation of the national GP contract.  GP remuneration is fundamentally based on ‘capitation’ (the number and types of patient on a GP’s list).  However, this principle has been gradually eroded by supplementary ‘ fee-for service’ payments.  It is difficult to avoid the impression that GPs continue to be paid more for doing less. 

GPs are trained in the convergent skills of diagnosis and treatment of individual patients.  They do not necessarily have the skills required for leadership, long-term planning and development of comprehensive services.  GP involvement with commissioning is not new.  ‘GP Fund-holding’ was introduced with the NHS ‘internal market’ by the Thatcher government in the 1990s.  Most GPs were not interested in the scheme which was expensive to run and brought marginal improvements.  GPs have continued to be intimately involved with commissioning in the English Primary Care Trusts which the government now intends to abolish. 

The fundamental problems lie in the perverse, financially orientated and divisive  incentives of the ‘internal market’.  English PCTs have consistently found it difficult to balance the interests of patients against the self interest of service providers, particularly GPs whose (frequently undeclared) business interests are not always congruent with the needs of patients. 

Conflicts of interest are likely to become even more significant in future.  Probity requires public money to be entrusted to a properly constituted and transparent statutory body which is elected, or otherwise selected to be broadly representative of local interests.  A consortium of independent contractors to the NHS cannot possibly constitute a valid authority, either for distributing public money or monitoring their own performance.  Such bodies must also harness the experience of all health professions, and valid representatives of patients and public. They must not be hostage to any particular professional group.

The government’s (under)estimate of the costs of this upheaval is £1.4 billion, during a time when public services are being decimated.  After experienced NHS managers have been sacked, GP Consortia will be obliged to employ commercial consultants to fill skill gaps.  This will further inflate management costs and diminish public accountability.

In future, in England, it will be possible for NHS services to be delivered by ‘any willing provider’.  GPs are the government’s stalking horse for further fragmentation and privatisation.  On past performance, GPs may not choose the best quality or most cost effective options. Longer term considerations (such as training) and less powerful interests (such as mental health) are likely to take a back seat. 

The budgets available to Consortia will be cash limited.  Demand will continue to rise.  Consortia will overspend.  Ministers will blame GPs for the inevitable unmet demands.  GPs will be obliged to ration services but the basis for their decisions may not be  transparent.  The relationship of trust between patients and GPs (which is currently untainted by financial considerations) is likely to be damaged. It is also likely that GP practices will progressively merge.  

International evidence unequivocally demonstrates that markets in health care increase costs, reduce quality, distort access, increase inequalities and diminish choice.  They corrupt professional practice with financial considerations and increase the incidence of inappropriate, dangerous and ineffective treatment.  A former member of the Thatcher cabinet aptly described the introduction of the NHS internal market as “a triumph of ideology over experience”. 

The NHS is one of the most equitable and cost cost-effective systems in the world.  If the government wants to improve it, it should commission a comprehensive assessment of health challenges and consider NHS achievements in comparison with other systems.  The UK faces dramatically increased prevalence of many complex, chronic and debilitating conditions.  Many are closely associated with longevity but several, such as stress, obesity, substance misuse, diabetes, heart disease, cancer, mental illness and accidents have links with the environment and personal behaviour.  None will be resolved by simplistic market ideology which damages professional cooperation and patient interests.  

Effective medical interventions require the sound foundation of competent, multidisciplinary primary care, underpinned by locally integrated, but nationally coordinated, secondary and tertiary specialist services.  An independent review of the adequacy and funding of the totality of primary care services would be a good place to begin evidence-based consideration of the future direction of the NHS. 

The blinkered commitment of UK politicians to market solutions for social problems threatens the very existence of the NHS.  There is a better way.  In Wales, the internal market has now been abolished.  Local Health Boards (the Welsh equivalent of PCTs) and NHS Trusts have been combined into single authorities which are now accountable for the integrated development of all local NHS services.  Community Health Councils have been strengthened.  Scotland is further down a similar path.  Both countries should be confident that their chosen route will prove more cost effective, equitable and true to the founding values of the NHS.

Written by David Hands, Visiting Professor in Health Policy and Management

February 9, 2011

Welsh Institue of Health and Social Care Blog
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» History teaches us that working together works

It’s useful, now and again, to look back on our past successes. 

This is not just to make ourselves feel good – although a little bit of that now and again does no harm – but to learn the lessons of the past.

To twist a phrase, those who don’t learn the lessons of history are doomed not to repeat them.

Almost at random, let’s look at three different successes which NHS Wales (and its partners) can justly claim from recent years, and see what they might teach us about the future.

First, learning disability services:

Almost a generation ago, the NHS and social services in Wales changed the face of services for this client group. Working together, they moved people out of Victorian institutional warehouses into housing in normal streets up and down the country and put services in place to support them there.

At the heart of this success was the sort of genuine joint working that we need now across most of health and social care.

The agencies overcame their many differences and worked together on a common goal because the Welsh Office (as it then was) made joint working all but compulsory and provided clear cash incentives to do so.

Secondly, the abolition of waiting times:

This massive achievement in our current decade is of historic proportions.

Within a few years, people’s biggest and oldest bugbear about the NHS – inordinate waits for treatment – was ended. Why? Because for once we bent every sinew to the task, we matched this with resource and we stuck at it until the task was achieved.

Thirdly, the 1,000 Lives campaign:

This is still very much in progress – in the guise of the five-year, 1,000 Lives Plus programme – but it has already achieved impressive improvements in the quality and safety of care in pretty much every hospital across Wales.

The lesson here is that if you can find a cause which unites both the professionals and the managers, you’ve got a good chance of getting somewhere.

The win-win – better care and greater efficiency – must also be good news for patients and taxpayers too.

You could also add to this happy trio the huge improvements in dental health we’ve seen over the last couple of generations – most children now have no fillings, compared with the serried rows of grey metal in their parents’ mouths – and the huge growth in GP and community services.

These two examples show what can be achieved when we get patients and services to work together, for example applying fluoride each day and regular visits to the dentist, and by lining up the resources and incentives in GP services.

So what does this teach us for the future?

Five lessons of great relevance – make joint working unavoidable; get patients and professionals to work together; find common ground for clinicians and managers; line up incentives and resources; and choose a small number of priorities and stick with them.

History tells us this is all possible.

A quick glance through the rest of this newspaper tells us that it’s now more necessary than ever before.

Written by Professor Marcus Longley, Director and Professor of Applied Health Policy

This blog is reproduced from Marcus Longley’s column in the Western  Mail on 7 February 2011

http://www.walesonline.co.uk/news/health-news/2011/02/07/history-teaches-us-that-working-together-works-91466-28123802/

March 24, 2010

Welsh Institue of Health and Social Care Blog
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» Out of dependency…

The dominant model (I don’t say the only model) of doctor-patient consultation privileges one viewpoint: the doctor’s. The relationship is a power relationship in which the doctor remains largely unquestioned and the patient is mostly powerless.

Whether benign or not, the balance of this relationship may be shifting, indeed has to change, if we are to deliver world-class health outcomes for users of health services in Wales, and to do so within the financial constraints the NHS is facing.

Last Tuesday’s Times (16 March 2010) published a letter (We must treat our minor ills ourselves) signed by a number of doctors and related professionals bewailing the fact that the ‘worried well’, half of them of working age, now represent approaching 20% of GP time. The ‘catastrophic impact of this dependency’ is detailed in the accompanying full-page (3) article (Workforce wimps cost NHS billions)which ‘demonstrates’ the huge costs of attending to the minor ills of half of those making 51.4 million visits for colds, headaches, back pain, indigestion etc: £2billion annually. (This is not to ignore the fact that, in a few cases, the presenting minor problem masks a deeper more serious disease or condition.) 90% of those visits for minor ailments resulted in a prescription.

In one way, the perception that patients, by and large, are powerless, might be challenged when we see them as having the capacity to drive the NHS this way. But GPs speaking about their own ‘victimhood’ behaviours, in an unreasonably demand-led culture of service use, does not change the central fact of the relationship that people have with their health professionals. If they have learned to be sick, to roll over and adopt the position of acquiescent or plaintive patient, so too have doctors learned to treat them in ways that remove most of their best opportunities for self-management. Launched in their letter to the Times, the Campaign for Self-Care has to be careful not to make the same mistakes.

If GPs feel compelled to (merely) manage ‘insatiable’ patient behaviours, then surely mitigating those very problems which affect the users of their services will bring them immediate benefits as practitioners? The way that people can be ‘empowered’ to better manage their health conditions, and not just minor ones, can lead directly to relieving the worst aspects of the ‘patient experience’, creating better health outcomes and contributing to the shift in behaviours that could, the Times suggests, lead to £10bn saving over five years. Unfortunately the emphasis in the article is mostly on (negative) patient behaviours: when the question of how doctors behave arises Dr Dixon, a GP from Devon, is quoted as saying: ‘…health awareness [on behalf of the patient]…needs to be balanced with more information on when you need to see someone [or not]. We have become merchants in investigations and referrals and our teaching role is one we need to invest in as well.’

The role of doctors as teachers of self-management skills is welcome. Self-managing health conditions is a very real solution to demand-led dependency. But users of services cannot become wise and responsible users without the tools to do so, and responsibility for their behaviour change cannot be simply expected of them without those tools. The opportunities to acquire them have to be grown rapidly and widely.

Empowering service users is not a question of defeating them in a war of attrition; enabling them to learn the skills to re-orientate their expectations, and to be well-informed about the decisions they do (need to) make, depends on giving them the power to engage in decision-making and act positively based on knowledge. The architect of the NHS, Aneurin Bevan once said ‘The purpose of getting power is to be able to give it away’. Practitioners need to recognise that their part in the dependency culture is not just better management of patient behaviours and expectations, but their own too. Genuine partnership is the key tool to achieve the win-win-win for patient, practitioner and organisation together.

Better outcomes, better use of scarce resources (practitioner time, money etc), depend critically on building a better focus for delivery of healthcare, and enabling all parties to behave differently when appropriate. If 90% of people who turn up in front of their GP with chest pain have no event or disease, then why on earth are we not enabling those people to make better decisions about their situations to everybody’s benefit? This does not preclude calling 999; far from it. But it means doing so when there is good reason, and knowing what a good reason looks like (thus, by contrast, knowing what is insufficient to warrant intervention). It means not heading to the GP with a sniffle, but knowing what to do if that cough begins to create breathing difficulties.

We have been conditioned to ‘play patient’; the NHS makes us ‘sick’. But being sick is not the same as having a disease or health condition. Disease is objective, medically diagnosed pathology; illness, the feelings that are associated with some disease/condition. Sickness however, is a social status granted to the person who is ill. It is a means to getting time off work, benefit support, a cup of tea in bed with some paracetemol, sympathy, help. We still incline people to play the sick role, and reinforce it by constantly refusing and indeed removing opportunities for patients to become informed, decision-making, service users, real partners in their healthcare and condition management.

The doctor’s armoury has relied in the past on their prestige as experts: we generally think of those who get the chance to study medicine as being amongst the brightest. This intelligence puts them in a class of decision-makers that others can feel uncomfortable to challenge. Added to this, their professional expertise, especially because of the inherent nature of healthcare giving, quickly creates a locus for unchallenged opinion based on that expertise. When a doctor says take this pill and you will feel better, have this operation and we can save your life, how can we be surprised that people jump immediately and uncritically to rely on that expertise?

Carry on Doctor, nowdays deeply culturally insensitive, caricatured this model of delivery, but Sir Lancelot Spratt would not have been remotely funny at that time if the parody did not strike at a truth. Some older (no disrespect) consultants will admit they were trained to act like ‘gods’. Sadly, a few, and not just older practitioners, still think they can act this way with impunity and resent any challenge to their power as doctors.

But challenge is not always for its own sake: joint-decision making is nothing to fear or resent.

There have been attempts to enable patients to become managers of their own conditions and sometimes these work well enough. They just don’t travel far enough, and perversely, some patients are reinforced in their roles as ‘sick’. Additionally, programmes to teach patients to become ‘experts’ are flawed. There is a false opposition between the patient’s ‘expertise’, living their condition, and medical training and experience.

Real partnership in healthcare does not dispense with medical expertise. On the contrary, such partnership continues to rely heavily on the professional’s gifts and training: it is the nature of that reliance, away from dependency to condition management, away from the medical model to medically supported decision-making, which is the step-change required now.

‘Incorporating the patient’s viewpoint’, i.e. bringing this into the doctor’s model, not giving it genuinely equal status, nor rearranging the entire relationship between ‘perspectives’, is not a solution. The Calgary-Cambridge guide to medical interviewing (all 71 points of it) still fails to address the key solution, as current condition-management programmes still fail to achieve the desired better health outcomes, better use of GP and other health practitioner time and better organisational returns in terms of the available cost-benefits. ‘Patient-centredness’ is not enough.

I was involved in a trial to support patients admitted with stroke/CVAs through the A&E; of one of the largest acute hospitals in Northern Ireland. A multi-disciplinary team (MDT), physios, OTs, nursing staff, social workers, speech therapists and any other relevant professional, all led by the consultant in charge, set out to improve services to emergency admissions and to create better outcomes for people with strokes. The person missing was the patient (and/or patient representative), but that was in 1978!

To this day, MDTs meet regularly in hospitals and still the person missing is the patient. We want people to stop adopting the sick role, to deal with their illness and disease or condition in a way that can defeat the pressure of insatiable demand for services. But we will not countenance the very thing that will bring this about.

The move to patient-centredness is certainly not new and may be already tired, especially when we have so demonstrably discouraged patients from building any skills that would allow them to self-manage appropriately. Imposing solutions from an organisational point of view won’t do either in a modern age: practitioner and organisational need cannot be served before service user outcomes if the world-class health outcomes are to become real. We cannot be satisfied with patient-centredness, especially in the absence of the person whose life it is.

The NHS has moved from its first days where doctors and opticians were directly engaged through the monies contributed by Tredegar miners and steelworkers, to serve the health needs of the community. In the 21st century we need (again?) a relationship in which the patient is the primary decision-maker, but their informed decision-making is in equal partnership with the expertise around them. We can reduce the dependency relationships patients have with the NHS, but we need do it in an intelligent and sustainable manner.

Written by Dr Kevin Fitzpatrick, WIHSC Associate

1. Waddell, G & Aylward M The scientific and conceptual basis of incapacity benefits TSO 2005 (p7)