The Rt. Hon. Andrew Lansley CBE, MP
Secretary of State for Health
Department of Health
2nd June 2011.
Dear Mr Lansley,
I hope I am not too late to comment on the proposed reforms to the NHS. I am afraid that I have been rather ill of late and this is my earliest opportunity. However, I am conscious that the service that I worked for for 40 years is in great danger from the demographic drift and greater than the average health-specific inflation and I would feel that I was lacking in my duty were I not to give you the benefit of my acquired knowledge. There are many vested interests in the NHS and I am conscious that many of my profession want to retain the status quo.
1. Justification for my giving advice.
1.1 I worked in the NHS from 1967 to 2003. I was consultant haematologist in a DGH from 1974 to 2003 and involved in hospital management for 11 of those years, four of which were spent as medical director. During this time I managed an acute services review which involved dividing services between two DGHs to the satisfaction of both and quelling a local newspaper campaign of dissatisfaction. I was also involved in commissioning a new hospital and gaining Foundation Trust status. The Hospital Trust that I worked for has been one of the best performing in England.
1.2 I worked in Academic Medicine from 1974 to 2008 rising to full professor in 1987 at the University of Southampton. I raised several million pounds worth of research grants, published over 300 medical and scientific research papers and was recognized by my peers as the first British winner of the International Binet-Rai silver medal for outstanding research in chronic lymphocytic leukemia. I have also edited an international specialist medical journal for 25 years.
1.3 I have been a cancer patient for the past two and a half years. As such I have experienced first hand both in-patient and day-case care from surgeons, physicians, junior doctors, nurses, health-care assistants, cleaners, physios, radiographers, phlebotomists, O.T.s, receptionists, caterers and social workers. In that time I have come across a couple of incidents of poor administration and one (agency) nurse with a bad attitude, but overwhelmingly I have been impressed by the dedication and competence of NHS staff. Happily, I am enjoying a remission at present.
1.4 I have always been involved in medical charities. During my career, through Tenovus and other cancer charities I raised over £3 million for cancer research. Since retirement I have been heavily involved in disease-specific charities. I founded the UKCLL Forum and the UK MDS Forum and helped to found the UK Myeloma Forum. All three are dedicated to democratizing how these three chronic leukemias of the elderly are managed by involving a much greater variety of doctors and scientists together with representatives from industry and especially patients. For the past five years I have been advising the Association of Cancer Online Resources (ACOR) for patients with chronic lymphocytic leukemia as well as some other internet advice sites. It is extremely important that such internet sites have the help of a qualified professional. This is a voluntary activity.
1.5 I am kept up to date on NHS matters by family members. My older son is Director of Intelligence at the Care Quality Commission and my younger daughter is a registrar in Haematology on the Oxford rotation having just completed a PhD in oncology.
2 My advice
2.1 GP purchasing: I have endured several NHS reorganizations and can hark back to the days when we went to local councilors for improvements to the service. I’m sorry to be cynical but in my experience one ends up dealing with the same people as before with different job titles. Although I can see the justification for GP commissioning, along with many of my consultant colleagues I have many doubts as to whether it is a wise move. Most doctors are more concerned with their individual patients than with the structure of the NHS. For many years general practice attracted in large degree those doctors who could not make it in hospital practice, though recent uprating in GP incomes has reversed that trend. There were always those GPs who were dedicated to the concept of the NHS, of course, but are there enough of them to go around? GPs will also be conflicted since they would be providers as well as commissioners of the service. Whether adding other providers (nurses and hospital doctors) to the commissioning teams is helpful or harmful is moot.
2.2 Competition: In general I have no problem with the introduction of competition to the NHS. It is important that quality is maintained, however. I have experience of inspecting pathology laboratories with Clinical Pathology Accreditation UK. I inspected the haematology laboratory of the largest private laboratory in London. I am afraid that although they competed on price, they could not compete on quality. They had chosen the cheapest options and were not fit for purpose to service a modern haematology department. I also had the opportunity to inspect several the laboratories of London teaching hospitals and these also fell short of the quality required, often because of the idiosyncrasies of famous leaders. So, my recommendation is that quality standards have to be agreed and adhered to (if it is not a forbidden word) religiously.
2.3 Efficiency savings: Much of the efficiency savings that were possible in the NHS have already been made, being chiefly the switch from in-patient to day-patient elective surgery. To save 5% per year for four years cannot be achieved by reduction of bureaucracy. There are some obvious options such a bulk purchasing, forbidding the changing of logos, pressure on pharmaceutical companies by multi-unit negotiation of contracts, and facilitating the participation in clinical trials so as to obtain free drugs from the manufacturers (clinical trials have moved to Eastern Europe, but from my contacts with Big Pharma I know that there is great dissatisfaction with the quality).
2.4 Doing less: The NHS should consider doing less than it does. This is not a new idea; Nye Bevan’s NHS used to prescribe free hot water bottles! While NICE tried to restrict expensive treatments, these are the very things that the NHS ought to provide; it is the trivial things that patients ought to provide for themselves. A few years ago the NHS was paying over £2 billion for the treatment of indigestion but only £167 million for all cancer chemotherapy. This was because the best treatment for heartburn was the PPI class of drugs which had been newly introduced and were expensive. On the other hand most people’s indigestion can be satisfactorily treated with over-the-counter (OTC) drugs which the local pharmacist can advise on. There are many other conditions where OTC drugs are the most sensible option. Many patients demand antibiotics for colds and flu. They don’t work, of course, but GPs are often browbeaten into prescribing them. Why not make the most commonly prescribed, Amoxil, available OTC? Resistance to it is already widely developed among bacteria, so making it more widely available would not affect that. It is already available OTC in many European countries and this measure would reduce the NHS bill at a stroke. Similarly, back pain can usually only be treated by pain killers which are already available OTC. There is a silly limit on the amount of paracetamol that can be purchased, as if those who wanted to kill themselves with it didn’t have the wit to visit several different chemists. So my fourth recommendation is to free up the OTC market and ‘nudge’ patients to the pharmacist rather than the GP for trivial illness.
2.5 Private practice: The Conservative party should not have Labour’s horror of private practice. It is a little known fact that the American government spends a greater proportion of its GDP on what some critics call ‘socialized medicine’ than the British government does (the CDC, VA, Medicare and Medicaid, tax subsidies and yet others). The big difference in America is that it also has a thriving private practice market. There are elements of the American (and indeed most European) health care systems that it would be difficult to reproduce in the free-at-the point-of-consumption system that we have here. Examples would be single rooms in hospital for all, elective surgery at the patient’s convenience, some cosmetic surgery, and costly treatment that has been approved by EMA but not by NICE. In America and most of continental Europe this is funded by the private sector. Measures to encourage private medical insurance should be introduced.
2.6 Social care: The really big extra cost of the NHS is in the area of social care. The government really has to grasp the nettle of how this is to be provided in the future. Best of all is for old people to stay in their own homes with the state and charities funding the supplementary requirements to make this possible. Churches and other charities are already providing enormous resources – shopping, transport, entertainment, cleaning, laundry, cooked meals, even furniture and clothing – at no cost to the recipient. This is David Cameron’s Big Society in action. With the number of unemployed on benefits, it should be possible to use some of them as an untapped labour source and if the worst comes to the worst the state could oil the wheels of these endeavours with the sparing use of cash. But we come up against the barrier of dementia. This has largely been the province of private care homes which in Bournemouth have worked fairly well. Although not concerned with the elderly demented, the recent disaster in Bristol, featured on Panorama, puts the situation of all private care homes in jeopardy. The problems associated with private care homes have been several. The change to unitary authorities has meant that because they now work for smaller units, specialism among social workers has diminished and they can no longer form one-to one relationships with consultant geriatricians in hospitals. The vagaries of the housing rental market has altered the balance between using large houses as care homes, apartments or buy-to let investments. Staffing has largely been by Eastern European immigrants working for minimum wage. This makes language a problem. Funding is still dependent on the children of the elderly being willing to forgo their expected inheritance. I am not sure why this social problem should have a medical solution and therefore impact on health service funding.
2.7 My big idea: The management of chronic disease should be controlled by those who know most about it. This is not GPs or hospital consultants, but the patients themselves. For conditions like arthritis, diabetes, heart disease, MS, and even cancer there are expert patients. The big charities like ARC, CRUK, BHF, Diabetes UK, MS Society and MacMillan have unrivalled expertise in the management of these chronic conditions and should be asked to take the lead in their management. MacMillan does palliative care far better than DGHs or GPs. They even employ their own staff. Given a block grant these charities would raise charitable money in excess of this and provide a superlative service to the NHS. Being national bodies, everyone would have access to the very best. After all they have a vested interest not in making a profit, nor in providing employment for professional staff, but in giving patients the best possible management.
Professor Terry Hamblin DM, FRCP, FRCPath FMedSci