The prime reason that this legislation will prove a disaster for patients is obvious. If you are relying on the NHS for care it is your GP who will be the sole arbiter of the care you receive, and most importantly will control the funding for any referral to secondary care. GPs will not be obliged to accept any guidance from secondary care specialists. The funding that GPs will receive will be inadequate for the tasks in hand when economic conditions are difficult. Therefore it will fall to GPs to be very circumspect about which patients actually get referred to secondary care. A friend of mine rang me recently and told me that she had type 2 diabetes, uncontrolled hypertension, and hypercholesterolaemia. She had requested referral to a diabetes specialist, but this had been refused several times. This was before the bill became law. If this lady could afford to pay for private care directly or by insurance, she would be referred without question. She cannot afford to do either. She is doomed to receive second rate healthcare, and this will be enshrined in the debacle of which Andrew Lansley is the architect. If you can pay you will get the care you require, when you need it and where you need it.
We have already moved to a system where the best medical care is not available at the point of need under the NHS. The Blair/Brown government took us down this road, initiated in the Thatcher/Major years, and it has now been confirmed by the Coalition government, so all three main political parties have the blood of the NHS on their hands. On 7 March NHS Diabetes reported that there is a huge variation in the amputation of legs among diabetic patients across the country. It is likely that this problem is directly related to a variation in referral rates for certain diabetic patients to specialists in secondary care. These amputations will cost the patients and the nation dearly. It is highly unlikely these patients will return to work. By the time they need an amputation they usually have widespread macro and microvascular disease leading to heart attacks, strokes, renal failure, and serious eye disease. With appropriate care supervised by secondary care diabetes specialists, whose experience cannot be matched by primary care specialists, many of these problems could be avoided, or at least considerably delayed. Patients with complex diabetes need the input of the doctors with the greatest expertise to supervise their care. Expertise arises from vast personal experience that develops innate judgement on management, be it medical or surgical. Secondary care specialists have this in abundance.
There is something perverse about what the Health and Social Care Bill enshrined into law. GPs will decide who gets referred where and to whom. With any chronic condition, if the GP can claim that their practice can provide the care, then they will be able to claim the funding, which provides a real incentive for them to do so. This nicely achieves what is perceived to be the cheaper option, although in the long run it may not be, and it takes the heat off the politicians.
Another colleague rang me to tell me about problems he was having getting appropriate orthopaedic care for his 90 year old mother. She is a feisty lady with a hip completely wrecked by osteoarthritis. It is so bad that the bones can be heard grating together as she moves. My colleague accompanied his mother to see her truly excellent GP. They were told that the practice had been forced to make no orthopaedic referrals for three months because the Shadow Clinical Commissioning Group (CCG) were trying to keep referrals down. This caring GP was more than prepared to stick his neck out and incur the wrath of the number crunchers to help, but goodness knows how long it would all have taken because my colleagues’s choice of orthopaedic surgeon did not conform with what the primary care trust or shadow commissioners thought appropriate. Whatever happened to patient choice? It is a nonsense, and yet our political masters tell us that their cunning plan will give us more choice. So my colleague organised an operation privately with the surgeon that the family and the GP considered would do the best job. As he and his family were caring for their mother in their home they were concerned about problems with stairs after the operation. They enquired of social services if there could be an assessment for a stair lift. A lovely letter came back from the Directorate of Adult, Community, and Housing Services that read as follows. “Unfortunately at the time of writing due to the huge demand for assessments, there is currently a delay of approximately three months before we will be able to allocate your case a worker.” In order to get his 90 year old Mother out of hospital my friend has invested in a stair lift which will mean a very speedy discharge from hospital, all being well. My friend’s Mother is lucky that she has a family that can afford to do the needful. What about the majority who cannot?
Secondary care doctors have not been involved in the decision making concerning the organisation of NHS healthcare. They are becoming a demoralised, dispirited, and completely disempowered group of people. The consequences will be a second or third rate NHS for those too poor to afford anything else. The private health industry will thrive. Teaching the next generation of doctors and clinical research will suffer as it has been doing. The doctors of the future will have borrowed £9000+ a year for five years and they will face longer working lives, with smaller pensions that require higher contributions, and will believe money not patients is what really matters. The coffin to bury the NHS has been 25 years in the building. Andrew Lansley ably assisted by the rest of the Conservative and Liberal Democrat cabinet have put the last nails into it. Do they fully understand what they are doing? They have been persuaded that this bill will save some money by right wing dogmatists and silver tongued lobbyists with vested interests. The one thing our politicians have not done is ask the people who really understand these issues. It is not just the GPs in the frontline. In fact they are not in the frontline out of hours. Where are the secondary care advisers, the specialists who know all about the frontline 24/7, the nurses, the professionals allied to medicine?
Apparently the government thinks that CCGs will be incentivised to compete for patients. Quality of service will be an aspect of that competition, including referral rates. Only those without any practical knowledge could suggest such a thing. Patients want to see their friendly local GP who will refer them appropriately. CCGs will, like Primary Care Trusts, their predecessors, look after distinct geographical areas, and I cannot see them fighting for patients. It is funding that will be the constraining factor. This unrealistic expectation that competition will improve quality and keep costs down is difficult to understand. The rail service was privatised and it is now the most expensive in Europe with very indifferent quality. The gas and electricity supply industries were privatised resulting in variable quality of service, opaque billing, and ever increasing bills pushing more people into fuel poverty. The privatised water companies provide the most expensive water in Europe.
This bill will receive Royal Assent by Easter. It is being implemented before it has become law which must be unconstitutional. It is not in the interests of patients or the ideals of the NHS. It will hasten the further decline of the NHS and ensure a greater role for the private health industry.
Ken Taylor is a consultant physician, Birmingham.