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In an uncertain climate, it’s good to talk

24 March 2011

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Welcome to the spring issue of Management in Practice. It’s good to have a fresh start. At the time of writing I’ve only recently returned to the office, having recovered from a major operation, and I’m pleased to be back.

During the few weeks I was in hospital, the treatment from all the NHS staff was outstanding, and I certainly have no objections to any part of my care. However, I did find one aspect of being an inpatient rather bemusing. Each morning, the doctors and surgeons would gather around my bed to discuss my symptoms and progress. They would talk almost exclusively to one another about ‘the patient’, using medical terminology I didn’t understand. After they held this indepth discussion, I would be spoken to only briefly to ask how I felt.

I don’t wish to overstate my feelings here: the doctors needed to discuss the situation with each other for my benefit, and there’s no way they would have the time to educate me about the jargon they used. Yet at the same time I couldn’t help feeling removed from the process at times, almost as if I were an ailing bodyguard at a presidential meeting that had nothing to do with me.

Into this environment comes the government’s mantra, ‘no decision about me, without me.’ To me, this seems a well intentioned but flawed drive to make patients shared decision-makers where their treatment is concerned. Healthcare is not a shopping centre constructed to satisfy the consumer and, unless they too have spent years studying medicine and the appropriate specialties, patients lack the expertise of their doctors.

In the hospital setting, ‘no decision about me without me’ takes on an even more acute emptiness. How is this supposed to work if an urgent decision needs to be taken when the patient is simply unable to have input; when they are capable of, at best, semi-consciousness, or are drugged to the hilt? The intricacies of the clinical decision are unlikely to be recognised, even if the patient is a medical expert.

Of course, in primary care the patient is more empowered and the government mantra may be more appropriate. But in the modern climate where ‘patient choice’ is the pill proselytised by politicians, I take a view that may seem old-fashioned: that my doctor is the expert and should take the right decision based on the available facts. What is most important is not choice (which in any case remains limited unless you’ve surveyed the competition across the country), but trust. That trust should result from rigorous regulation and a determination to ensure the best standards of medicine across the board.

On the other hand, as my recent experience attests, patients do want – and deserve – to be as informed as possible. Even if the minutiae of the detail isn’t fully understood, open communication of what is happening and why is important.

And so it is with the Health and Social Care Bill, presented to parliament in January. One of the repercussions of the speed of change being introduced to general practice is that many healthcare professionals have been left scratching their heads, confused over aspects of the reforms and awaiting further detail in many areas. And if you’re confused, where does this leave patients?

The government did not argue the case for the reforms before last year’s general election and the whirlpool of recent media coverage has left something of an information void in the public consciousness as to what exactly is happening. As a result, myths have been absorbed by many patients: that all GPs will be commissioners and will be spending half their time running the NHS instead of seeing patients; that consortia will have no accountability; and that the reforms amount to a full-scale privatisation of the NHS.

Practice managers will want to bust any myths – after all, you know all too well the dangers of patients being misinformed. Most recently, negative press followed the winter flu vaccine debacle, as Cathryn Bateman discusses in her column. Before that the public ire was over GPs’ salaries, without the awareness that doctors’ pay increase was negotiated with previous government ministers who underestimated how much GPs actually did, and that the extra income was often reinvested into the practice’s services.

So general practice has much to gain from communicating as much as possible with patients about the Health Bill and its ramifications, in order to separate myth and reality. As Sonia Clark points out in her article on HealthWatch and patient participation elsewhere this issue, the more informed and involved patients are with their local consortia, the less likely it is that practices will be faced with misunderstanding and even hostility over unpopular prescribing decisions or changes to services.

While the coalition’s healthcare reforms have been subject to some disquiet, one of the positive outcomes could be that by giving frontline GPs buying power for services, they could also help to empower patients. After all, doesn’t general practice have a closer understanding of its patients’ needs than centralised primary care trusts?

Family doctors’ knowledge of their patients’ clinical needs was one of the key drivers of the decision to hand £80bn of the NHS budget to GPs. Bold consortia could do well to have patient advisers to their boards, giving them a greater influence on the development of local healthcare services. Such an action could help to alleviate one of the key fears among some critics of the white paper – that, faced with the need to make cost savings, GP consortia will prioritise the funding of profit-making services for the most common conditions, whereas those suffering from rare, difficult-to-treat illnesses are overlooked.

The privatisation of services is likely to be the key debate that government, health ministers and patients will need to have with each other. The idea that GPs’ capacity to commission ‘any willing provider’ will pave the way to the end of the NHS’ founding principles has already taken root, at least in some quarters.

Unison are campaigning hard against the Health Bill, saying the government “wants to break up NHS healthcare services and sell it”. Shadow Health Secretary John Healey has said the changes “are about a far-reaching fundamental shift of ideology which puts a full-blown market at the heart of the NHS.” Since the last government introduced the concept of ‘any willing provider’, PFI deals and independent sector treatment centres, this may again be political rhetoric rather than the complete truth of the proposals.

In such a climate, patients will demand the truth. The difficulty, of course, is that the Health Bill puts forward so many unanswered questions that even those we normally look to for answers 
are uncertain.

However, we must at least credit the health secretary with setting an example of open communication: in this issue, we feature an exclusive interview with Andrew Lansley where he acknowledges the fundamental leadership role practice managers will have in the future of primary care.

In the meantime, those managers who feel unsure of the brave new world of GP commissioning can take one decisive action to prepare for change: strengthen links with their patients and remind them that GP consortia will ultimately be striving to serve them better.