Primary care duped: the government’s bill will wreck the NHSBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e998 (Published 14 February 2012) Cite this as: BMJ 2012;344:e998
All rapid responses
Accounts and accountability.
An interesting debate is emerging in parallel to that surround the Health and Social Care Bill. It has to do with accountability and transparency, and could pave the way to NHS reform (for better or worse).
Yesterday (22/2/12) in the House of Commons, a bill was proposed by Dr. Phillip Lee (Conservative MP and General Practitioner) that would instruct GPs to issue each of their patients with an annual statement on their healthcare costs (1). This would be personalised, itemised and include all treatments, medication, investigations etc. attached to their NHS number.
The arguments for this bill are that this information would empower patients to take responsibility for their lifestyle (smoking, obesity, alcohol etc.), it would clarify the true cost of hospital interventions, and ultimately make the British public more receptive to changes to the NHS in the future.
This Ten Minute Rule Motion was quickly opposed by a fellow conservative MP, Mrs Anne Main, who highlighted the effect this could have on the old, those with chronic conditions, and those who already felt like a burden to their carers. She argued that it could lead to viewing people in terms of how costly they were to society and whether it was worth to “keep them going”. The bill was put to a vote and rejected (Ayes 81, Noes 176).
Conveying the cost of healthcare to patients is increasingly being talked about, and is a topic I’ve often debated with my colleagues (usually at the end of a busy shift in the emergency department). Would it lead to more responsible lifestyles, better adherence to medication regimens, fewer missed outpatient appointments and ultimately better appreciation for our role as healthcare providers? After all, it’s our NHS, shouldn’t when know what we’re paying for?
Most of this information is already available and is becoming increasingly accurate and real-time with the use of electronic patient record systems. Indeed, it is currently private patients who are confronted with the cost of CT scans, antibiotics and surgical treatments (maybe even iv cannulas…). Would more financial information change patients’ expectations? Would it change our expectations? Should cost play any part in the decision making process when it comes to healthcare?
The truth of the matter is, as I’m sure we would all agree, it does. Whether it comes in the form of NICE, healthcare commissions or the private sector, my generation will be faced with balancing the books of an increasingly ageing population. And if we as doctors aren’t part of the discussion then it will be our patients who end up paying for it. But how do you inform without it sounding like an accusation.
I propose a variation of this bill, and I welcome your thoughts and comments. All prescriptions should indicate the cost of the items. No doubt this would upset patients whose medication is under the current prescription charge (£7.40) but I argue it would lead to better compliance.
(1) http://www.publications.parliament.uk/pa/cm201212/cmhansrd/cm120222/debt... (last accessed 23/2/12)
Competing interests: No competing interests
Could Prof Madhok please list, briefly, what exactly HE finds wrong with the NHS. Then we can discuss and decide how to put it right?
Competing interests: Old man, NHS patient
Drop the bill – and then what?
There is a scene in the film Charlie Wilson’s War where the Senator asks for a million dollars to start a school education programme following the successful campaign by Afghans (supported by the Americans, largely due to the Senator and his Stinger missiles programme) to beat back the Russian invaders, and is laughed off. The current debate about getting rid of the bill (1) reminds me of this because it is easier to wage (and win) wars but very hard to reconstruct afterwards.
I am afraid I neither understand the Government’s proposals now and nor do I know what the opponents want. Do we have a vision for what the 21st century NHS will look like? Imagine that the Government gives in (sic) and asks us to design the new NHS. Defining ourselves by what we do not want is not the same as what is needed. I am not talking about just the involvement of private sector, important though that is. I am interested in some of the fundamental issues facing us, such as the primary-secondary care (and some would argue health and social care) divide, where rather than find ways of bridging it the consistent policy direction with emphasis on purchasing/commissioning has reinforced it. Or, the denial by politicians that the NHS is not affordable and has to set some limits. We can not provide world class, state of the art, health care to everyone. Rationing has become a taboo word despite evidence, and lately increasing evidence, that some sort of rationing is already happening. Or, our inability to capitalise on the work of the NICE, NPSA, the National Institute for Innovation and Improvement and National Service Frameworks, which have generated unprecedented, and unparalleled elsewhere, intellectual capital. We have been good at discoveries and inventions as a nation, but have not always reaped the benefits; and certainly in the NHS we as clinicians have not always managed to spread innovation and adopt best practice systemically or rapidly.
So, by all means resist the Bill but equally be clear that hard decisions will still have to be made – ‘The system does not need mending’ is not true (2). Standing still is not an option. Structurally there is nothing to go back to- the old institutions and the people are gone, morale is rock bottom, financial pressure remains relentless, quality and safety have become rhetoric, and the less said about public health the better. The challenge to deliver ‘More with less and faster’- the necessary requirement for the NHS – will not go away.
The one good that has come out of this crisis is that the professional organisations (with occasional exception) are united, and this provides a unique platform and the opportunity to reframe and reposition the NHS. But let us not underestimate the difficulties ahead. I had a heart sink moment this morning when I read on the teletext that Ed Miliband wants to make the NHS the ‘defining issue’ at the next election. So, the misery is set to continue for a long time, unless we ‘depoliticise’ the NHS, hold a united front, and come up with alternatives that reflect the reality in 2012, and not the distant 1948.
1. Bailey P. Primary care was duped: the bill will wreck the NHS. BMJ 2012; 344:e998
2. Spence D. The NHS bill puts profit before patients. BMJ 2012; 344:e1082
Competing interests: The views here are personal. I am a very early signatory to Dr Kailash Chand’s e-petition. My observations on the recent changes, and NHS management generally, are available on http://theclnnetwork.blogspot.com/2011/11/dr-rajan-madhok-discuss.html I believe that there are alternative ways of organising the NHS and which have not been explored because of obsession with the narrow commissioning/providing paradigm.