March 2011 – Plus ca change…

This was something I originally posted on March 21 2011 on another blog which has since morphed into something else… but I think it still outlines what I think is important to salvage from the NHS Reforms (if they go ahead) or indeed whatever happens in their stead.

Recently the BMA representatives had a knees up in London where they debated long and hard about the NHS Proposed Reforms.  I was following on  Twitter

As I was following the (often predictable) passing of motions (no pun intended) on the live feeds, I was left with the feeling that perhaps this is too little too late – if the medical profession truly wanted to oppose these reforms outright, this should have been done well in advance of the first reading of the Bill in Parliament (see here for the Bill’s progress to date)  I honestly feel that the PCTs and SHAs have had so many of their staff leave that they are unlikely to be able to function as effectively as they had done up until the time that the reforms were  first publicized.

So what to do now?  I am not a politician, but passionately believe that politics matters to me and my patients – the current reforms show that more clearly than ever.  I don’t think that the BMA passing comment is going to radically alter the reforms, and if it does – how much real good can it do now – the horse seems to have bolted.

I feel that the way forwards now is to ensure that, whatever proportion of the reforms makes it through parliament, we as the medical profession sort out three things no matter what:

1.     Secondary care doctors must look to their local community.  It is naïve to think that a hospital only serves those patients that happen to be in the clinic, or on the wards.  Hospitals, if they wish to truly serve the public, which funds them, must look outside their walls, to the community.  We cannot sit on the inside of ivory towers complaining about the standard of care given in the community for patients with our particular illness, and do little or nothing to change that care.  This is “population medicine” – concern for the wider population, not just the referred population.  With limited resources, we need to be sure that specialists are seeing specialist cases, not just whoever happens to turn up.  Only through collaboration in networks or systems of care will we achieve this.

2.  Primary care physicians need to look to each other.  The unwarranted variation in the standard of care between primary care practices is no longer acceptable.  GPs, acting in networks across a community, and in collaboration with specialists should strive to bring up the standards of care across their patch.  Under-performance should not be tolerated, and clinical leadership, with solid clinical support, is essential to provide the credibility to enforce high clinical standards within a local health community. (This applies to the secondary care community too by the way)

3. Primary care physicians need to look to their patients.  When patients come into the surgery looking for treatments that are of no benefit, or are not likely to lead to resolution of an illness or symptoms, GPs must be able to have rational discussions about the risks and benefits of treatment.  Shared decision making processes can help with this (Implementing shared decision making in the NHS — Elwyn et al. 341 …) and result in better-informed patients making better informed choices.  PROMS are an excellent way to make a start on this, and bring home the realities of life and illness to patients.  We have an NHS, we are very lucky – it can’t and won’t be able to provide everything, and you may not need a treatment, just because there was a report once saying it might help you.  Primary care physicians and teams really are the gatekeepers; we should not use a rationing mindset when discussing treatment with patients, but be highlighting the true intangible costs (physical and emotional) associated with some treatments where the benefits are marginal.

Something of the Spainish Inquisition came over me whilst writing – sorry…

4. We all need to look to what patients want.  When it comes to service re-design, we often look for examples of what works in one area, and think – this is what I must do for my clinics.  Involving patients in the work of service design can achieve surprising results.  I have mentioned examples in previous blogs where patient involvement blew apart assumptions of physicians, and service providers about what patients really wanted from a service.    Only by understanding what patients truly want to see in a system, and then making strides towards that, will we start to see “appropriate” use of services.

So, what should we do in light of the SRM outcomes.  Yes, we should push to amend the parts of the bill which threaten the ability of doctors to serve their patients well, but in accepting that we may not get our way (Mr Lansley is not known for giving in lightly) we must start to take a different, pro-active attitude to getting the NHS, our NHS, our patients NHS back on track.  I believe that if we can concentrate on some of the steps above, we have a chance to make the best of a bad job.

So that was what I thought then – and it seems that so much has changes, but also so little has that I can re-post this without any significant editing.

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