Double dichotomy on the rocks

There are obvious dichotomies in the coalition health policy. While health secretary Andrew Lansley promised ‘no major top down reorganization of the NHS’, his chief executive David Nicholson has been busy telling anyone who’ll listen that ‘the reorganization of the NHS will be so huge you can see it from space.’ Lansley has now admitted that his changes amount to ‘a significant reorganisation of the management of the NHS’, and Nicholson has been rewarded for his impertinence by becoming surprise chief executive of the new NHS Commissioning Board. He will now take the rap if the NHS doesn’t come up with £20 billion of productivity savings by March 2015, an impossible task the Tories have labelled ‘the Nicholson challenge’ to ensure the buck knows where to stop.

GPs were supposed to hold the purse strings in Lansley’s NHS, but the government’s response to its White Paper consultation – helpfully released just before Christmas – has deemed that the ‘accountable officer’ in the new GP consortia doesn’t have to be a GP. This is good news for GPs, many of who were wary of taking on the top jobs knowing they could well be sacked in a few years when the debts mount up and Nicholson looks for someone to pass his buck on to. Some Primary Care Trust chief executives are now moving back into their old PCT buildings as the new chief executives of the GP Pathfinder Consortia, and Nicholson will still be pulling their strings. It’s a change so small you couldn’t spot it from the other side of the desk.

Lansley is hoping to distance himself from the front-line carnage of a cash-starved NHS by becoming the Secretary of State for Public Health. This at least recognises that no health service can cope with the current levels of alcohol abuse, smoking and obesity. Labour’s biggest health improvement was to ban smoking in public places, but only after sustained lobbying defeated John Reid’s ludicrous compromise of allowing smoking pubs in poor areas where people had nothing better to do than die prematurely.

Lansley’s Public Health White Paper couldn’t fail to recognise the impact of alcohol misuse. It costs the economy over £25 billion a year, the NHS almost £3 billion and is a major cause of violence, family breakdown and premature death. There is strong evidence that a minimum price of 40-50p for a unit of alcohol would significantly reduce future harm all round, but the Treasury review of alcohol taxation has come up with another toxic fudge by merely recommended a higher tax on high strength beer and lager. This leaves strong cider taxed at only 7p a unit and 9% wine attracting the same tax as a 14% wine. Alcohol is alcohol, and there are still far too many cheap routes to liver failure.

The UK is the European leader for alcohol-related disease and while the treatment and life expectancy for just about every other chronic disease and cancer has improved markedly over the last forty years, premature death from alcoholic liver disease has increased nearly six fold. For the millions already affected, the NHS offers a very disjointed service, with no quality standards, precious few dedicated alcohol care teams in district general hospitals and very little co-operation and co-ordination between hospitals, GPs, social and public health services. Too many staff are disinterested and judgmental, perhaps unsurprisingly given the widespread denial of alcohol problems amongst NHS workers. For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower risk levels. This alone could have a huge impact if more staff saw it as their responsibility.

The British Society of Gastroenterology has already produced an excellent action plan to help the NHS sort out its alcohol problem, if only it could stop obsessing about reorganizing itself. If Lansley does nothing else in his five years but reduce the availability of cheap alcohol and increase the availability of a joined-up service for those with alcohol problems, he will do more for the NHS, and the health of the nation, than any amount of vainglorious structural reform. Happy New Year.

Christmas Massage

We all know what’s wrong with the NHS. There are too many hospitals swallowing too much money, and too many patients swallowing too many calories. Labour got NHS funding above £100 billion a year, cut waiting times and improved patient care and satisfaction overall. But they failed to get healthcare closer to home, failed to get people to take more responsibility for their health, failed to spot and stop appalling health scandals and failed to narrow the gap between rich and poor. So now it’s the Coalition’s turn to fail.

There are some good ideas in the White Paper, most notably that clinical staff should have more responsibility for planning services and rationing healthcare, but it’s being done at ridiculous speed. The perceived wisdom of NHS reform is that you spend the first year blowing everything out of the water and then next four picking up the pieces. Abolishing strategic health authorities and primary care trusts may be the right thing to do, but doing it all at once sends NHS management into free-fall just at a time that it’s supposed to be making huge savings.

The NHS budget has increased year on year for decades, allowing it pay off its debts with next year’s increase. Now the budget is flat-lining, debt will rise sharply unless unprecedented £20 billion ‘efficiency savings’ can be made, something the Coalition has cleverly branded ‘the Nicholson challenge’ to ensure the NHS chief executive takes the blame when it all goes tits up. PCTs are already feverishly rationing care to balance the books this year, and patients are either being denied treatment or having to wait more than the NHS constitution’s meaningless pledge of 18 weeks. The financial squeeze will kick in over the Autumn, and the cuts in social care will inevitably hit the NHS as the desperate pitch up to GPs and casualty. Next winter could be a bad time to get sick.

Whether GP consortia will have made an impact by then is anybody’s guess, and an anxious Treasury has stopped the Health Bill appearing before Christmas. GP commissioning can only work if the consortia have the money to develop community services, the balls to stand up to hospitals and the openness to involve the public in any changes. The premise is that it takes a thief to catch a thief. Doctors are the best people to find other doctors who’ll do it better for less.

Dr Kosta Manis, a South London GP, has designed a rapid access chest pain clinic in the community at a cost of £800 a patient compared to £1,500 charged by local hospitals. In the first seven months of the year he saved £300,000 by forming partnerships between GPs and specialist centres. Consultants from Guys and St Thomas’ run clinics in four local surgeries and, if needed, the patients get door to door transport to the European Scanning Centre on Harley Street for a state of the art scan that uses only a fifth of the radiation of conventional scanners. It’s faster, safer, cheaper and more convenient than going to the local DGH, and all on the NHS.

Bexley Clinical Cabinet (sic) is one of 54 ‘pathfinder’ consortia that health secretary Andrew Lansley has given the go ahead to prove his point that GPs can be trusted to manage £80 billion of the NHS budget. But who will be holding them to account? A colleague who asked to read the board minutes of Stockport Managed Care was told they were ‘for board members only’. Secrecy in the NHS is strangling trust. All GP consortia need to publish the minutes of their meetings in full, without patients and the press having to issue tedious FOI requests. Accounts of how every penny is spent need to be published. First class rail trips to London and fact finder missions to America must feel the force of public scrutiny. NHS Hospitals still buy the silence of whistleblowers to bury bad news. If GP consortia continue this secrecy, they are doomed to fail. When you wish your GP Merry Christmas, ask him how much he or she earns. It’s your money, after all. (MD is on £50 an hour, no holiday pay or sick leave.)

Quote of the Year
‘This Inquiry was only established because of the articles in Private Eye and, had it not been for them, the issues would have continued to be ineffectively addressed.’

Bristol Pathology Inquiry Report (The full report, comments and a list of GP Pathfinder Consortia are at www.drphilhammond.com