Politicians, not GPs should be held to account

While the country decides whether to side with striking doctors or the government which has provoked today’s protest, some medics are pointing to the background to the strike – the fundamental reform of the NHS earlier this year through the Health and Social Care Act – which they say forms the true background to the industrial action, not just a pension dispute.

Claire Gerada, GP, RCGP chair, pictured on <em>Under the Scope</em>

Clare Gerada: Bear with us

But for patients caught in the middle, perhaps at home today instead of being treated, why are doctors so fed up with the Government’s health reforms? Will they really be so disastrous for medicine as so many medics claim (every major professional body including all Royal Colleges, bar that representing surgeons, protested before the Bill became law that they would worsen patient care)?

Particularly vocal in her fears, Dr Clare Gerada, London-based GP is Chair of Council of the Royal College of General Practitioners; when she talks about the risks of widening health inequalities, she speaks with authority. Since 1992, she has been a GP (now a partner) at the Hurley Clinic inSouth London– a 40-year-old practice on the ground floor of a 19-storey housing estate in Lambeth. No middle class health dilemmas here. This is belt-and-braces care of a shifting population with complex needs.

How the conclusions of the new Health and Social Care Act play out here will show quite vividly whether the modern reformed NHS will still offer the cradle-to-grave, comprehensive and free medical care which most of us cherish so much.

When the Bill was passing through Parliament, Gerada was outspoken in her fears of how the dismantling of Strategic Health Authorities and the creation of GP-led clinical commissioning groups might lead to privatisation by front and back door. Once the Act became law, she was equally clear that GPs now had to make these changes work.

But no one should confuse that ‘roll up your sleeves’ attitude with hearty approval. Gerada is still deeply concerned about the changes to our system – and has a few suggestions about the future too.

It’s worth getting her to explain the background to the changes to our NHS as they will affect the public; after all, plenty of experts have struggled to get through the detail. And it does put the doctors’ collective fury (even amongst those not out on strike today, there is fierce resentment at the government’s treatment of the entire profession) into some perspective.

‘Put, simply,’ she explains, ‘the Act shifted responsibility to determining what can and cannot be funded from politicians to GPs, grouped in clinical commissioning groups or consortia (CCGs or CCCs).

‘Most of the familiar structures of the NHS are still there – the hospitals and clinics patients use. But the decision making process has changed, so that GPs will effectively ration care.’

She adds: ‘You could say GPs have always prioritised care – according to need – so patients go on waiting lists in order that urgent cases can be seen quickly. That’s fair.  And of course it is important GPs are involved in clinical and financial decision-making in their regions.

‘But the big decisions about what we can and cannot afford – as a nation – should be made by politicians. Then if you don’t agree, you can hold them to account at the next election.’

She points specifically to the part of the Act (clause one) which controversially stated that the Secretary of State for Health’s duties – fixed since 1948 – were changed from a duty to provide , to one to promote.

‘How this will pan out – who knows? Those who are cynical say the NHS will become the healthcare system of last resort – eg working in areas of prevention, immunisation, sexual health, drugs – the parts that private companies are not interested in as they offer little chance for profit. And how would you feel if you were also now asked to co-pay or even entirely pay for something like minor skin surgery or painful varicose veins?’

If the public was angry before at postcode lotteries, they will have to calm down now – or explode.  Every region will define its healthcare needs differently.  The Sussex coastline will have to prioritise its large elderly population – so younger tax payers may feel hard done by.  Northern inner cities will not be able to provide for students, single mums with large families, and still meet the high cancer drug bills required to cover environmentally stimulated lung cancers. There will be scores of winners and losers, but with the latter paying a much higher price than hard cash.

And all the time, the public will now blame the GP sitting in front of them – when they might be better aiming their fire at Westminster, where responsibility has been neatly abrogated.

‘In a public funded system, you can’t provide everything – so decisions must be accountable to the electorate – and made by them. There have to be some safety nets.

‘And one is that if you aren’t provided a treatment which NICE says you could have, but your CCG says no, too expensive, you can sue. But only the middle classes will afford to sue, so that will widen health inequality whilst making NHS costs shoot up as their liability increases and they have to buy more insurance.’

Meanwhile, patients who are prescribed treatment will find their pathways less smooth than before due to the increasing dominance  of referral management centres. These will lengthen waiting times (unofficially of course) and may even grind the process to a halt.

‘In the old days, ‘ explains Gerada, ‘if say I thought a patient needed a hysterectomy, after investigation and discussion, I’d write a letter to the hospital consultant and the operation would be scheduled within 18 weeks.

‘Now my letter will be intercepted by managers, not clinicians, who may well write back to you to say you haven’t try cheaper alternatives – such as drug therapies – enough. You may kick up a fuss. It may not be in your best interests. But this ‘hidden stranger’ in the consulting room is becoming more common as practices look to reduce costs.’

On a wider scale, the move towards CCGs threatens something more basic – the notion of universal cover. Primary Care Trusts are responsible for everyone in their geographical area. But CCGs are memberships – lists of patients – which you can fall off – perhaps because you move a lot.

Or worse, because you have an expensive pre-existing condition – cancer, thrombosis, even diabetes. Only  last month, a GP practice run by a doctor who has been of one of the most prominent supporters of  the health reforms de-registered 48 elderly and disabled care home patients from Churchill medical practice in Kingston last year to save money, an NHS investigation found.

Will GPs carry on with this increased workload – especially in the light of so much criticism over today’s strike?

‘My predictions are that most GPs will want to concentrate on being providers of care, not on commissioning itself.’

And they are clearly fed up with the exhaustive work of saving the Treasury money which has been twinned with the NHS changes. ‘The sheer scale of the health service reorganisation has been monumental,’ says Gerada. ‘We’re now conflating systemic changes demanded by the Act with efficiency issues demanded by the Treasury. We shouldn’t be doing the two at the same time.’

She points to cost-cutting already underway all over theUK- staff redundancies, clampdown on referrals, ‘re-badging’ waiting lists (changing the terms so that patients wait longer without  the PCT being fined by central government for not hitting targets). ‘We are squeezing the budgets but you can only clamp down so long.’

Her worst fears are seeing in the next two-three years the emergence of a two-tier health care system, like education, with private and public operations side by side.

She says: ‘Those who can’t pay, will have to queue, those who can, will top up their NHS care as and when they choose.’

This trend will be exacerbated by another NHS Act change: the decision to allow hospitals to make 49 per cent of their income privately.

‘Hospitals are looking to maximise revenue now so they become centres of excellence, they advertise themselves, and they pay big salaries for chief execs.’

What should the public do if they don’t like what is happening? Is it too late to do anything other than roll over?

‘We should all – doctors and the public – use our voices, express concerns, tell our MPs we are not happy to have unelected GPs ration care.’

But she asks, especially in the light of a medics’ strike which is not fully supported by the public, ‘please bear with GPs – we are heaving with patients, and a new workload, and cost cutting, and we are trying our best.’

And she points out that – contrary to all the hype – our NHS remains good value for money. ‘We spend 10 per cent of GDP on healthcare – we are still way down the list. Even theUSspends more than us.

‘The NHS is cheap. But we’ve sold a dream of instant access by both recent governments – but not told of what that would cost us.

‘If we still want a public funded NHS for everything, we need to start a proper debate now.’

STRIKE POLL

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About the Author

Victoria Lambert has been a journalist for more than 20 years, and specialises in health and medical matters. She writes for the Telegraph, the Times, the Sunday Times, the Guardian, the Mail and the Mail on Sunday. She contributes to Saga, Geographical and First Eleven magazines – where she is the agony aunt.

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