2 Mar 2011

NHS surgeon: the reality of ‘choice’ could hit healthcare

NHS frontline blog: rather than improvement, “choice” in the NHS could lead to a two tier system, with the poor and sick at the bottom, writes trauma surgeon Catherine Blake for Channel 4 News.

NHS reforms could see UK lose one of the best and cheapest healthcare systems in the world (Getty)

The Spectator reported, in 1712, on the business model of Thomas Hobson, owner of a livery stables in Cambridge. To rotate the use of his horses, he offered the local scholars the choice of hiring the horse in the stall nearest the door, or none – take it or leave it. This is derivation of Hobson’s choice, or no choice at all.

More choice in the health service is this Government’s prescription for patients. It sounds good, giving the impression that the patient will have more control over their care. But like David Cameron‘s electioneering promise to “cut the deficit, not the NHS“, the reality may be very different from the sound-bite. A close reading of the Health and Social Care Bill reveals that “choice” is the lever with which the government propose to prize open the coffers of the tax money we spend on each other when we are ill, to profit making corporations.

No public mandate, no evidence, and no medical justification: where is the demand for the Government’s plans?

Everyone wants to have to feel they have options, particularly when the stakes are high. They also want quality, unbiased, expert advice to make key decisions, particularly when it comes to their health. Choice is a very positive word. And a slippery one. It is a New Labour-y, touchy feely, ad-man’s word: a euphemism for privatisation used liberally by a political class who imagine that the electorate are too feeble to grasp any model of interaction more complex that the shop.

Patients in England already have a free choice of which hospital to go to, and, except in emergencies, they make informed decisions about their treatment when they get there. How will “choice” operate in the free market? How will you choose which treatment, which surgeon, which hospital? Perhaps you will research the internet and look at adverts. Perhaps you will seek advice.

Read more in the Channel 4 News Special Report on the NHS reforms

But what if your family doctor had a financial interest in your decision? Perhaps owns the company he is recommending? There is nothing in this bill that precludes a financial conflict of interests. It is a matter of public record that the Health Secretary, Andrew Lansley, himself has received funds from the very health companies which stand to benefit from his legislation. Publicly funded healthcare will now be delivered by any company or organisation, not just the NHS. Any willing provider is the buzz-word. As a surgeon who has been in intensive medical training for fourteen years (and counting), any willing and able provider might have sounded more reassuring. But maybe that’s just my self-interest talking.

A YouGov poll in January confirmed yet again that the public are not in favour of an increased role for the private sector in the NHS. Only 27 per cent of people supported it this time, and less than half of conservative voters. The British Medical Association opposes market reform of the health service. Although Lansley repeatedly refers to the “evidence” necessitating his reforms, Ben Goldacre and others have comprehensively debunked his claims in the broadsheet press – there is no evidence in support of them. No public mandate, no evidence, and no medical justification: where is the demand for the Government’s plans?

The proposed Government shake up of health in England amounts to a charter for corruption at every level of the health service.

There is lots of waffle in the bill about charities and social enterprises, but the international legal framework underpinning these reforms – called the General Agreement on Trade in Services or GATs – is the result of protracted negotiations of corporate interests at successive World Trade Organisation meetings dating back to 1986. The proposed Government shake up of health in England amount to a bill of rights for transnational health companies, and a charter for corruption at every level of the health service.

Far from increasing meaningful patient empowerment, the legislation prioritises competition law over clinical concerns. GPs may be compelled to refer to the most competitive – ie cheapest unit cost – provider. That sounds superficially like a good idea, doesn’t it? But what if cheaper meant not as good? Price is easy to measure, but quality is difficult, and the quality of a heath intervention – a new medicine say, or an operation – only becomes apparent after the fact.

NHS reform (Getty)

Just as importantly, our hospitals currently use the income generated by relatively simple procedures, such as healthy people having joint replacements for arthritis, to subsidise the care of more complex, unwell and expensive patients. Sticking with examples from my specialist area of Trauma and Orthopaedics, a contract to perform joint replacements on otherwise healthy people would be attractive to a private company: it is easy money, things only rarely go wrong, and if the patient did become critically unwell after the operation they could be transferred out the local A&E. The company could employ temporary staff with no rights or pensions, and set up in a glorified operating shed. It would be easy to undercut a hospital on cost for this group of patients.

But other patients – elderly diabetics, for example – would be too high risk for an operation outside of an NHS hospital with full intensive care facilities. Their care is unpredictable, complicated and costly. Similarly, it is difficult to see how a young man who gets knocked off his bike by a bus, breaking both his legs, bursting a lung and suffering a massive brain injury, who then requires a month in intensive care, multiple teams of specialist surgeons, and may still die, could be turned into a profit, financially speaking.

It is companies, not patients who will get the choice: taking the easy work whilst leaving the difficult and loss making treatments and patients in the public sector.

Taking this into consideration, it is easier to see how hospitals will lose revenue, but still have to foot the bill for the most expensive and most critical care. It is companies, not patients, who will get the choice: taking the easy work and easy money whilst leaving the difficult and loss making treatments and patients in the public sector – the industry term is cherry-picking. In this context, the Government’s statement that there will be “no bail-out” for hospitals or organizations in the red, sounds very ominous indeed. This is a prospectus for a two-tier national health system, with the poor and the sick on the bottom.

This new Government promised to cut red tape, put the patient at the centre of the health service, and free doctors and nurses to get on with treating and caring for them. But the camouflage is already beginning to slip. At my hospital, the mood is very grim indeed: 100 beds and 250 nurses are to be cut, just for starters.

The NHS is part of our social contract; a very British covenant between young and old, rich and poor, healthy and sick. It is a safety net, a promise we underwrite for each other: when the time comes, each of us will have the treatment we need, regardless of personal circumstances, wealth, where we live, the illnesses we get or the accidents that befall us. It is not perfect at all, but it numbers among a few things—the right to a fair trial, the right to an education—which allow us to call ourselves civilized.

More “choice” is on its way, in the sense that there will be more companies pocketing the taxpayers shilling. We haven’t asked for it, but they have. Over this, then, the most important decision facing our country in several generations, whether to keep the world’s cheapest and best universal health insurance scheme, or lose it, we are offered Hobson’s choice: no choice at all.

Catherine Blake is a pseudonym.