Monday, January 31, 2011

NHS reforms

The NHS is undergoing yet another reorganization. The split between purchaser and provider is being maintained, but rather than the purchaser being a medical manager led Primary Care Trust, in future Consortia of General Practitioners will determine which services are purchased and there will be more open competition among providers. The role of NICE will be diminished to merely offering advice.

There is a good deal of trepidation about the changes. Hospital doctors fear that GPs will not understand what secondary care providers might be offering; that they might go for a cheaper option without understanding why it is so cheap (ie it doesn't work); that they might repatriate services to GP practices inappropriately (eg near patient blood testing which is much more expensive than testing in laboratories with large machines and it is poorly quality controled, though superficially it does offer some attractive qualities like instant access, it is like comparing a Polaroid picture with a professional photographer).

I came across a good example of how things can go wrong. A Primary Care Trust decided to purchase GP blood tests from a different hospital from the one that patients were likely to be referred to for treatment. One result was that patients arrived for treatment with no blood test results on the hospital computer so that everything had to be repeated, but worse than this, the GPs would ring up the lab where the patient was registered to ask for advice on the recent blood test. Of course the hematologist had not seen the recent blood test an could not give an opinion. On the other hand, the haematologist at the hospital where the blood test was performed, could not help; he did not know the patient and in any case the contract was for blood tests, not their interpretation - that's why they were cheaper.

GP's are worried that they have no management training and may not be up to the job, but undoubtedly they will employ some of the displaced managers from the PCTs. Patients are worried that we will be back to post code prescribing. am worried that GPs will purchase complimentary medicine rather than cancer chemotherapy.

In the BMJ of January 29th, Des Spence, a left wing GP and regular columnist, voices his opinion on the changes. He admits that the previous government pushed up labor costs and reduced productivity, but he fears that the private sector will find this an easy way in to the NHS. The private sector, he says is not based on competition, but greed. He is scathing about the effect of competition in the USA. Healthcare costs are twice as expensive as in the UK and 50 million citizens have restricted access to care. Medicare and Medicaid together spend almost as great a proportion of a much larger GDP as the whole of the NHS does of the smaller British GDP, and when you add in the VA and CDC the proportion is greater. He also claims that the US system is more bureaucratic and that 'competition' has produced the world's most expensive drugs. He says that the US system is defined by overinvestigation, overdiagnosis and overtreatment. Mere activity is no measure of quality.


Anonymous said...

Of course, the US system is the best in the world.

Did NICE ever approve rituximab for CLL, or any of the newer renal cancer drugs?

If so, nice, but how many people have died in the interim?

Terry Hamblin said...

Well I disagree that the US system is the best in the world. How many have died because they have no insurance? NICE has approved FCR and CHOP-R and CVP-R and most of the effective newer cancer drugs but not all of them. If you were paying personally for someone else's treatment what would you approve?