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Rapid Responses: Rapid Responses published:
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Which came first, the patient or the NHS?
- Oliver H Duncan (11 October 2005)
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Regulating NHS reform: time for Ofhealth
- Ian H Kunkler (13 October 2005)
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European statistics
- John C D Plant (5 December 2005)
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Oliver H Duncan, SHO Paediatrics William Harvey Hospital, Ashford TN24 0LZ
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Editor Ms Dixon (clinician or manager....both or neither?) and Dr's Lane and Paxton ('Bevan betrayed: the demise of the NHS) make valid points. However, in the ongoing argument about reform, one crucial factor is continuously ignored: There is more money then ever being poured into the service, at the same time as there are more managers then ever (largely non-clinical), yet the NHS is facing financial ruin. In spite of evidence pointing to financial mismanagement, it appears in the ensuing cull the only people able to hold their jobs are managers. Wards are closing, doctors and nurses posts are being scaled down, and ever more paperwork is created. Clinical, practical decisions with real effects on patients are taken by managers who, at best, listen to the clincicians, only to ignore their view anyway, but usually do not even seek medics' input. This problem is compounded by ineffective campaigning by the BMA and JDC, and apathy amongst Junior Doctors, with often no support from their seniors: 'You won't change it so why bother trying' as I have been told by a consultant. Sadly, patients' health is not supported by business solutions on a 'no win, no fee' basis. Its high time we take back some control of our own profession, and work with administrators (as managers should be called) in replacing the capatilist, number-massaging aims of Labours' NHS with a service where - and I know this is a novel suggestion - the patient comes first. Competing interests: None declared |
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Ian H Kunkler, Consultant in Clinical Oncology Western General Hospital,Edinburgh,EH9 2JAR
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Many public utilities in the UK have independent regulators to see that commercial interests and unfair pricing do not disadvantage the public. Providers of these public utilities have to submit detailed financial information to the regulator. The regulator may intervene if he/she feels that the proposed pricing of services by the provider is unreasonable. At present there is no independent regulator of health care reform in the UK. Governments may undertake reforms based on market principles which run counter to the widely held principle of collaboration between NHS professionals. Yet the consequences of ill judged reform of the NHS may inflict longterm damage to the delivery of health care to its citizens. The shortcomings of the Private Finance Initiative such as the lack of flexibility in adapting hospital design to changing health care needs [highlighted by Atun and McKee in their editorial (1)], shortage of hospital capacity (2), no independent audit of the reform process and excessive length of PFI contracts to encourage commercial financing are persuasive arguments for an independent regulator of NHS reform. The key tests applied by the regulator might be (i) equity of access to care irrespective of means (ii) collaboration between health care professionals, managers and patients, (iii) financial prudency and transparency (iii) proof of principle from pilot studies and (iv) a clearly defined audit process to assess the clinical and economic impact of reform on health care delivery and outcomes. If these 'golden rules' were met, the UK government would be more likely to carry the support of the public and NHS professionals to meet effectively the health care challenges of the 21st century. 1. Atun RA, McKee M. Editorial. Is the private finance initiative dead? BMJ 2005;331:792-3. 2.Gaffney D,Pollock AM, Price D, Shaoul J.NHS capital expenditure adn the private finance initial: expansion or contraction. BMJ 1999;319: 48-51. Competing interests: None declared |
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John C D Plant, FRCS Beckenham, Kent BR3 5XT
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Jennifer Dixon hopes that the current reforms taking place in the NHS will gradually improve its performance (BMJ 2005. 331.852). Lane and Paton despair that the current government is betraying the fundamental principles of the NHS (BMJ 2005.331.853). Much of what is said is correct but misses the fundamental problem facing the NHS in that the NHS has one of the lowest ratios of Doctors per head of population of any advanced industrial nation. Unless this is addressed it will be hard for the UK to offer its population state of the art 21st century medical care. I say this because I had the rare opportunity to practise in the NHS, also Canada, France and the United States. This gives one an all together different perspective. Let us look at the following statistics; Italy has 570 doctors per 10O,OOO head of population, Germany 464, USA 333, France 330, Japan 177 and the UK only 175 per 100,000 head of population. By chance the UK and France have roughly equal population of about 60 millions, France has 100,000 generalists and 99,000 specialists, the UK has 46,000 generalists and 34,000 consultants (specialists in any other country). Now let me cite some recent examples taken directly from the pages of the BMJ. The UK has 700 cardiologists (BMJ 2005.330.615), France 5000. In a leading article "Reducing the mortality in myocardial infarction" (BMJ 2005.330.856-857) The authors quote guidelines from the European Society of Cardiology - that primary angioplasty is the preferred therapeutic option when it can be performed within ninety minutes after the first medical contact and the authors go on to say, in so many words, that this goal is unlikely to be achieved in the UK where obviously there are not enough cardiologists or facilities available. In practical terms if this goal was achieved it would have the potential to prevent some individuals from having a heart attack, in others it would reduce the size of their infarct, therefore reducing their long term morbidity and it would obviously save many lives. There are 375 neurologists in the UK (BMJ 2005.330.615) The association of neurologists thinks there needs to be at least 950, France has 1400. Obviously, this has major consequences for patients with neurological problems. The same news page of the BMJ quotes that there are only 90 stroke specialists in the UK and that there needs to be a 500% increase to adequately cover the UK hospitals for the 130,000 new cases of stroke per annum. Half the OK trusts have insufficient gastroenterologists to provide out of hours cover for an upper or lower GI bleed (BMJ 2005.330.1000-1). This standard of care would be completely unacceptable in many countries. In large parts of the country, particularly in urban areas, it is very difficult to find a GP if one moves. Had I not been a doctor when I returned to the UK, I would have found it almost impossible to have signed on with a GP in my locality. In summary at all levels of care, there is a real shortage of doctors. Management consultants, productivity targets and internal management expertise are not going to help the NHS: there are simply not enough doctors to provide real choice at a generalist or specialist level. The promised provision of another 7500 generalists and 7500 specialists will hardly replace current attrition due to the fact that large number of doctors are nearing retirement age. Additionally, the European directive upon working hours, should it become law, will have a major effect upon numbers of doctors required. Even the French and the Germans think that they will need more doctors. Politicians of all political parties tend to be advised by public policy experts and medical economists. One really needs a clinician to fundamentally understand the staffing requirements both at a generalist and specialist level. The lack of doctors in the UK has come about gradually over a lengthy period of time. As David Green says (BMJ 2005.330.986) the social insurance system of France, Germany and Switzerland have been more successful than the NHS in giving their population a fairer and more equitable service even to the most deprived individuals in those countries; therefore, should a fundamental change in the structure of the NHS be contemplated. All French statistics come from: La Demographie Medicale Francaise. Situation au 31 decembre 2000. Competing interests: None declared |
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