NHS 101 please!

[Sticks]

'Art_of_the_table',

Surely you can't be so stupid as to patronise someone you don't know. Oh, wait... er.. what's that you say?

OK I hear you but you must ensure that you think with your head rather than your heart (and remain critical about what you read in the papers).

Oops, I take that back. But I can assure you that if either my head or heart were damaged in someway, neither would appreciate the massively extended journey to the nearest A&E.

There were two A&Es within a 25 mile radius of each other, so one gets closed and town A thinks 'that's ok, there's another one not far away, we can deal with that'. Then town B's department shuts, and everyone is screwed.

As for 'reading about it in the papers', (I laugh at your random assumption of where I get my information) I was volunteering at the second hospital during the uproar over the A&E department. Some doctors, I assure you, have strong views AGAINST centralisation.


"If you spread services around too much, you limit the availability of skills"

Pfft, you're arguing against yourself with this one. That's a logical fallacy. By the same reasoning, you could evenly distribute all services amongst hospitals, and then direct patients to which ever one suited their need.

Are you in favour of polyclinics too?

[art-of-the-table]

Why do things need to be so black and white. All this negativity is precisely what is plaguing the NHS.

Polyclinics have many advantages for patients. The only ones who really moan about them are GPs who will end up working for them, but then we all know why - they are going to lose all the cash they made on the back of taxpayers in the past 5 years and start working for it!

The only argument they give against polyclinics is that chronic patients will not get continuity of care, which is absolute tosh since many GP surgeries don't provide continuity anyway. In any case chronic patients only represent 20% of patients.

I think it is important to keep things in perspective. The system needs to change, there is no doubt about that if we want to be able to afford more. It needs to be more efficient. Any constructive proposals?

As for doctors being against A&E restructuring, of course they will be against them if you are asking A&E doctors. The fact also remains that many doctors don't understand the changes and react emotionally because, like everyone, they don't like change.

And for the information, I speak as a senior consultant in central London, and one who sits on interview panels. Trust me, it';s best to remain open minded about these things. The reason doctors keep moaning is because they have been so apathetic over the past 20 years that the government has decided to take the initiative instead. Not always pretty, but unfortunately the only way to make things change in such a dinosaur system

Now, with regards to spreading skills. I give you an example. In A&E, it would be very good in there were a few doctors who could do echocardiography as this would save having to involve cardiologist or radiographers every time. Not many A&E doctors can do them. If you have few A&E doctors spread over many hospitals, every hospital will be average. With more doctors in less hospitals, you can have at least one doctor with a give skill or special interest in situ. That is a major advantage.

[ben_]

Yes but by the same logic the places which had doctors before now have none. I don't see how this is an advantage. The logical conclusion of your arguments would be just a few large A&E centres, which for reasons of speed alone does not seem optimal. Besides which you have failed to address my point that medical care is not necessarily related to profit-making. Any serious argument for privatization will have to articulate a reliable way in which the two can be linked - I'm not sure this can be done.

If "negativity" is what is plaguing the NHS, surely you only have yourself and others like you to blame - the one who has been the most negative about the NHS in this thread is you.

On another point, you have both claimed that:

There are always several sides to consider and this is one of the areas where media hype is not helping. As mentioned earlier, most A&E physicians are actually in favour of the move for the above reasons.

and also that

As for doctors being against A&E restructuring, of course they will be against them if you are asking A&E doctors. The fact also remains that many doctors don't understand the changes and react emotionally because, like everyone, they don't like change.

I'm curious as to how you will reconcile these posts. Surely it couldn't be that you are spuriously referring to what 'most A&E physicians' think to make yourself sound more authoritative?

[ben_]

And for the information, I speak as a senior consultant in central London, and one who sits on interview panels. Trust me, it';s best to remain open minded about these things.

I don't know which is worse - either you're lying in the hope of impressing, or telling the truth in the hope of impressing...

[art-of-the-table]

I'm curious as to how you will reconcile these posts. Surely it couldn't be that you are spuriously referring to what 'most A&E physicians' think to make yourself sound more authoritative?

Very easily. Again not everything is black and white. It is true that most A&E doctors are in favour of the changes in the sense that they see how it could benefit patients and see that there are arguments in favour. However, some will inevitably have to relocate and work in different ways. What they are against is not so mcuh the change to the system as the impact it has on them at a personal level.

In the same vein as most GPs recognise that they have taken the government for a ride on the issue of pay but then few would be in favour of a pay cut. What reconciles the two arguments is that one is a rational argument (i.e. most people recognise that the system needs to change) and the other one an emotional argument (i.e. they don't want the changes to affect them personally). And in a way, this is the "Not in my back garden" argument that is causing the problem. Everyone wants change but not for them.

With regards to the issue of privatisation, I agree that privatisation has its risks and that people can take their eyes off the need to focus on quality rather than quantity. But there are other changes which are currently taking place which are precisely designed to address this issue. For example Lord Darzi issued a strategy to deal with the quality issue back in June this year. There are many changes proposed, one of which being that when a patient undergoes a procedure for example, the payment receivd by the trust will be split between a payment for doing the procedure and a payment for the quality of the work done, including the patient's perception of quality of care. So for example, if at the moment a trust (both NHS or private) gets £1000 for a procedure, in future they will only get £750 but will get paid the additional £250 if they can demonstrate the work was of sufficient quality. Since the £250 would effectively be the profit to be made on the £1000, essentially if you don't do a good job you don't make a profit. This obviously has its own problems (e.g. how do you assess quality) but it is one step in the right direction.

I don't know why you think I am the most negative here; on the contrary I feel I have tried to balance the arguments. In fact I have mentioned several times that I agreed with some of the arguments made whilst at the same time trying to paint a slightly different picture of the problems, with the inside story. Others however have only criticised or simply refused to consider the arguments from a more objective point of view. All I am advocating here is a bit of common sense and openness in considering that the issues are not as simple as "it's good" or "it's bad". The reality is that the old system was not financially viable and widely inefficient. So the real question is "how do we become more efficient without spending more money?"

Perhaps you would also like to consider my motives to post on this site. As an established consultant, my sole aim here is to help you understand the issues so that you can present them in a mature debate when you are being quizzed on current issues at an interview. Many medical school applicants, with all the fire of their youth, can sometimes lose sight of the bigger picture and often dig themselves into a hole by not presenting themselves are open-minded enough or, worse, as judgmental. I don't pretend to have the answers, otherwise I'd either be a politician or a very rich man (or both!), but please, look at things from different points of views. It'll only make you a better doctor (and when I say "you" I don't mean you personally, but med school applicants in general)

[ben_]

Fair enough - I can see a case for reform and greater efficiency but only if care does not suffer. I think that this would be incredibly difficult to ensure though and you may well end up eating up your 'savings' in costly bureaucratic oversight to prevent the private organizations from doing what comes naturally; that is, cutting corners to make a profit. However, I do take your point that this issue is an emotive one and can provoke unreasonable reactions. Saying that, I don't think people in this thread have been guilty of that.

[art-of-the-table]

It is indeed possible that some of the savings get swallowed up by the bureaucracy that such move engenders, though, as ever, it cannot be quantified in advance.

THe main problem that politicians face is that if they don't make big changes, they are accused of just tweaking the system or introducing change for the sake of appearing to be doing something. If, however, they introduce greater changes, as is the case at present, they are accused of taking risks and playing with patients lives. The media then just pick on one or two bad cases to generalise the negative side. So either way, whoever makes decisions, and whatever party they are from, they can't win.

At one stage the government was accused of not knowing anything about healthcare and was told that those in charge of the NHS should be doctors. So, they recruited Lord Darzi, an eminent surgeon to look into the NHS problems; he suggested loads of changes and then now people complain that he is wrong too. This just illustrates the complexity of the problem and that people are just fundamentally scared of change. As far as decision makers are concerned, it a no-win situation so you might as well be bold in your decisions. We won't know until in 30 years time what the best solution could have been, with the benefit of hindsight.

The issue of not affecting patient care is also a tricky one. For example, the consolidation of A&E will benefit many patients, but may make things worse for a minority of them. So what do we do? Improve the situation for many, whilst making things worse for a few? Or maintain things at an average level for everyone? Again it is not a case of everything will get worse. The real question is where do we strike the balance.

[NorthernLight]

Personally, I think the problem with recruiting "Lord" Darzi is that he comes across as what some might see as a "typical" hospital doctor, hence his ideas for Primary Care come across as basically turning it into a pale imitation of secondary care (Polyclinics are what you might call mini-hospitals?!) which have some of the advantages of pooling skills and resources but also the disadvantages of putting services further away from more people.
I don't have enough knowledge or experience to propose a better solution, though I know that there is a combination of sincerity as well as vested interest in the status quo which lies behind many complaints against change . . . I do find it amusing, however, that after years of closing smaller community and district hospitals in the cause of "efficiency" we are now seeing such places basically being reinvented as "polyclinics." No doubt in another 10 or 20 years somebody will come along and tell us that polyclinics are an inefficient use of resources and they should be broken up into smaller units much like the GP surgeries we have lots of today.
But hey, if there's still a recognizable NHS in 20 years then personally I won't really mind about politicians tinkering around the structure . . .

[Sticks]

Forget back-door deproffesionalisation, the mere concept of a 'polyclinic' bluntly disregards the doctor-patient relationship as insignificant. Less familiarity; less trust; illness behaviour changes to the advantage of no one exept wikipedia or any other available source of self-diagnosis.
Thinking about this objectively, I see the benefits of economising, but polyclinics are a step too far in what they sacrifice in return for minor financial benefit. Doctors are not JUST a conduit for applied information, which is what polyclinics seem to imply.

[ben_]

I think a major problem with any 'privatize the NHS' gambit is that it is obviously a huge political risk - therefore it has to be seen to work, by fair means or foul. When I was doing some work experience at the radiology department of the local hospital I got talking to some of the staff. They related to me how their patient list was being 'cherry-picked' by a private company (at the invitation of management) who would take on the simplest and quickest cases, leaving the hospital with 'difficult' patients - those with dementia, physical disability etc. These patients took much longer to scan. Obviously, this made these guys look comparatively bad because they were seeing far fewer patients than the private organization per day. These skewed figures were then used as a stick to beat the radiology department with, as though they were doing their jobs badly.

This is clearly anecdotal evidence but I think it results from a political imperative that exists in a general sense.