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NEWS: Lisa Hitchen Feeling the squeeze BMJ 2006; 333: 1142 [Full text]

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Feeling the squeeze: a patient's view

Peter M Lapsley   (4 December 2006)

Dawdling politicians and NHS decadence

Valentina Lefemine, Stuart Enoch   (27 January 2007)

Rationing or efficiency?

stephen black   (31 January 2007)

Money saving that could save jobs

Samantha A Harding   (7 August 2007)

Feeling the squeeze: a patient's view 4 December 2006
Peter M Lapsley, Patient and lay observer of NHS 27 Lillian Avenue, London W3 9AN Send response to journal: Re: Feeling the squeeze: a patient's view	Editor Lisa Hitchen’s article is an excellent exposé of the woes facing the UK National Health Service (NHS) at present but does not identify their underlying cause. As a lay observer of the NHS and as a patient, it seems to me that many of the difficulties can be traced back to the decision taken almost ten years ago, soon after the government came into office, to devolve most NHS spending ‘to the front line’. That decision was based on the questionable pretext of enabling ‘local services to be tailored to local needs’. It had a number of unwelcome effects. It formalised and facilitated the continuation of what is known as ‘postcode health care’ because, with Primary Care Organisations (PCOs) free to decide how they would configure their services, there was no likelihood that any two of them would take identical decisions. It introduced an expensive new tier of very variably competent management into primary care. And, it guaranteed disinvestment in secondary care services as PCOs, which purchase those services, struggled increasingly to balance their books. The only good thing it did, from the Department of Health’s point of view, was to enable successive Secretaries of State to shrug off responsibility for the Health Service, laying the blame for all deficiencies at the doors of the NHS Trusts – which may account for Patricia Hewitt’s smug smile in the photograph accompanying Lisa Hitchen’s article. The difficulties caused for the NHS by the devolution decision have been greatly exacerbated by a number of factors. The imposition of a succession of poorly thought-through targets, rapidly changing and driven chiefly by political expediency rather than clinical need, and with draconian penalties for failure, have been destabilizing. It has distorted service provision and tempted staff and managers to indulge in slight of hand. Constant reorganisation has added greatly to the confusion. It is some two thousand years since the Roman satirist, Petronius Arbiter, observed that, “…I was to learn…that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization.” Never can the truth of that have been more evident than it has in the NHS in recent years. The negotiation of new contracts which require doctors to be paid more for doing less has placed a huge additional burden on their NHS paymasters and, incidentally, done nothing for public confidence in the Department of Health’s stewardship of taxpayers’ money. The Department’s inept forecasting of the ability of GPs to achieve the targets set in the Quality and Outcomes Frameworks (QOF - performance indictors for a range of activities, each attracting additional payment) has placed a huge and unforeseen additional cost burden on the NHS. The Department anticipated that GPs would achieve sixty percent of the QOF targets; they actually achieved ninety two percent in the first year, and that figure is rising. Finally, the Department’s determination to remove a substantial range of hospital-based services into the community is undermining the essential specialist expertise that is available only in secondary care. It is also creating a very real risk that the quality of care will be compromised, giving us a service with is neither safe nor effective, and which represents poor value for money. The solution to all this is elusive. It brings to mind the well known adage that, “If I was going there, I wouldn’t start from here.” But a solution must be found, and it must be found without further degradation of services, demoralisation of staff or waste of taxpayers’ money. Competing interests: None declared
Dawdling politicians and NHS decadence 27 January 2007
Valentina Lefemine, SHO General Surgery Royal Gwent Hospital, Cardiff Road, Newport , NP20 2UB, UK, Stuart Enoch Send response to journal: Re: Dawdling politicians and NHS decadence	Various reports, as in the article by Lisa Hitchen (1), have unequivocally concluded that the National Health Service (NHS) in the UK is facing major financial hurdles, impending on the disaster. This coupled with the predicted increase in ageing population and ongoing scientific advances leading to novel (and expensive) treatments (e.g., gene or stem cell therapy) will undoubtedly add further strain to the finite NHS resources. However, there is no decisive planning or strategy by the politicians or the policy makers to address this issue. The allegation by Patricia Hewitt, the current Health Secretary, that the NHS deficits have risen because trusts have recruited too many doctors(2) is not just preposterous and misleading but shying from the real issue. Likewise, the Government's "quick fix" penny saving measures such as closing down wards/departments or compulsory staff redundancies are bound to become counterproductive in the long-term. For the NHS to adhere to its basic core principles but to deliver high quality patient care, radical ideas are essential. Hard times demand hard decisions! The private healthcare system seen in emerging economies such as India, in addition to being poorly regulated, unfortunately places the patient's ability to pay (irrespective of patient's age or income) before clinical need. The health insurance system of the United States of America also deprives the poor and the vulnerable. Thus if total privatisation or health insurance are not appropriate for British social justice or values, other options have to be explored. In Italy, as in the UK, the Healthcare System is "free at the point of need". However, the Italian NHS, when faced with financial problems, introduced a "Ticket" system(3) in 1989 which has been implemented since then throughout the country. These "Tickets" are essentially nominal "fees" charged for certain drugs, diagnostic tests and specialist consultations. Patients with non-essential emergencies (decided by the assessing doctor) attending the Accident and Emergency department will also be charged a fee. Fee is exempt for children and those with an exemption certificate (e.g., extremes of age, disabled or the low income group). Behind closed doors, politicians and policy makers in the UK have been "dilly-dallying" on the issue of charging a nominal fee for using certain consultations or specialised services within the NHS. However, they lack the conviction or the authority to implement it. Critics may argue such fees are a form of stealth taxation, but, in addition to addressing the internal NHS issues, this is the only viable option of maintaining high quality patient care. Charging a nominal fee will also deter inappropriate "emergencies" presenting to the Accident and Emergency department, discourage people "not turning up" for appointments, dissuade the demand for cosmetic surgery in the NHS and also encourage people to take responsibility for their health. Perhaps, the time has come for the society to accept the fact that all the health needs cannot be totally free of cost. Isn't this proposal a better option than a poor quality NHS or a privatised health service? References: (1) Lisa Hitchen. News-Feeling the squeeze. BMJ 2006; 333:1142, 2 Dec (2) Lynn Eaton. News-NHS employs too many hospital doctors, minister says. BMJ 2006; 333:1086, 25 Nov (3) Legislative Decree - 23/03/89 Ms Valentina Lefemine, MRCS (Eng) Department of General Surgery Royal Gwent Hospital, Newport, UK Mr Stuart Enoch, PhD, MRCS (Edin & Eng) Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK Competing interests: Competing interests: VL, an Italian citizen and SE, an Indian citizen, are currently residing and working in the UK National Health Service.
Rationing or efficiency? 31 January 2007
stephen black, management consultant london sw1w 9sr Send response to journal: Re: Rationing or efficiency?	The argument that the NHS is in crisis and that we should consider some radical action such as rationing care is based on two false assumptions (though both are almost universally held beliefs): 1) demand is growing insatiably; 2) healthcare is currently delivered efficiently. There is emerging evidence in the UK that demand is not as unlimited as has always been assumed (waiting lists are "good" as they force prioritisation and rationing on the "unlimited" demand). Those specialties where waiting for a long time is now rare have not seen big leaps in demand. Facilities built on the assumption of perpetual, heady growth are starting to be underutilised (and worrying about their financial viability). There is also plenty of room for improved eficiency in the way we organise care for patients in the UK. If health were anything like any other realm of human activity, it would be possible to greatly improve the efficiency year on year (why not use operating theatres on friday afternoons? as Gerry Robinson pointed out). Today's car manufacturers produce products that are faster, safer, more reliable, higher quality and substantially cheaper than they were 25 years ago. I'm not suggesting that hospitals are like car factories, but the core insights that delivered better cars were that different ways of organising people could deliver substantially better and cheaper outputs at the same time. Better organised hospitals could deliver improvements that would way outstrip any foreseeable demographic pressures. Squeezing health providers or rationing access to health, should be last resorts. There is plenty of scope to deliver more healthcare and better healthcare at the same time if we recognise the value of better ways to organise its delivery. Competing interests: None declared
Money saving that could save jobs 7 August 2007
Samantha A Harding, SHO in ophthalmology Royal Free Hospital Rotation Send response to journal: Re: Money saving that could save jobs	LISA Hitchen’s report highlights UK trusts’ failure to balance their books because they recruit “too many” staff (1). However I recently undertook an interesting calculation based on the many hospital identity cards I have accrued since graduating in 2001. Having been fortunate enough to secure a rotation in my chosen specialty after house jobs and A and E experience, I have collected nine such cards to date. If all 39,000 junior doctors in the UK duplicated my experience, which cannot be uncommon with six-monthly job changes, and assuming a price of around £1.00 a card (judging by the advertised prices on various websites 2) a total of £351,000 has been spent on the production of multiple ID cards for UK juniors. Associated hardware (at an additional estimated £1000.00 for every UK NHS hospital trust) has cost a further £200,000, assuming it is a one off cost. I look forward to the day a generic card can be taken from job to job, just as my debit card can dispense cash from a variety of banks. If such a card existed now [in January 2007], 11 more of us could secure run-through posts under MMC in August 2007, bringing the English total of posts in ophthalmology to 305 (3). This would still leave approximately 100 current SHOs in my discipline jobless. Perhaps there are other areas of ‘professional repetition’ in which savings could be envisaged. Miss Samantha Harding MRCOphth Senior House Officer, London 1. Hitchen, Lisa. Feeling the squeeze. BMJ 2006:333:1142 (2 December) 2. Website: http://www.primemark.com 3. MMC transitional spreadsheets (PDF) at www.mtas.nhs.uk. 21 December 2006 Competing interests: None declared