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As the NHS turns 60, is primary care in good health – or is it getting Sicko?

6 June 2008

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Dr Laurence Buckman

Chairman, British Medical Association’s General Practitioners Committee
GP Principal

If you want to gaze into the future of the NHS in England, then I recommend you to see Michael Moore’s Sicko, a film that contrasts American healthcare with other countries, including England.

As a master polemicist, you would never expect Moore to give an even-handed picture and you would not be disappointed. His rosy view of the English NHS, with happy doctors and patients, is contrasted with the American insurance-based model, where 50 million Americans are uninsured and the rest seem to exist in a state of perpetual anxiety over whether their insurance company will “deny” their insured status on a variety of premises like “undeclared conditions” (however trivial and long ago), pre-existing conditions, the experimental nature of their treatment (even if well established) or even the fact that their emergency ambulance was not authorised before they were put into it.

The insurance companies clearly had plenty to explain, such as why their assessors are told to deny at least 10% of all claims, and several former employees tell us what goes on behind the scenes. There were harrowing tales of withdrawal of medical attention at critical times, as well as scenes with the elderly being thrown out of hospitals when they ran out of money.

I cannot see any way that private and NHS provision can coexist within the NHS without the sick and the poor ending up with a limited core service as the private sector creams off the cheaper quick-hit stuff. Could private providers improve the NHS through competition as the government believes on the basis of no evidence? Not according to the Americans, who are denied healthcare.

Will private and NHS GPs offer the same care? Of course they will – while they are supported by state funds. Once the private sector has milked the NHS dry, as it surely will, and the old GP services and premises are no more, then they will rightly want their investment back and prices will rise. Once the NHS cannot pay, we will see patient copayments and the poor will end up with less and cheaper care.

It is a curious paradox that the Americans (other than a remarkably complacent government and an unpleasantly grasping health insurance market) are trying to change their system while our government is rushing to introduce this model of healthcare without the slightest support from those who work in it.

Roy Lilley

Independent Healthcare Analyst, Writer and Broadcaster

Anyone who says that overseas’ healthcare systems are better than the NHS needs to get out more!

It is true that, at the top end, US healthcare is probably the best in the world, but you need an American Express diamond, platinum and gold card to use it, and it still doesn’t give the copper-bottomed assurance that you get from the NHS – that, when the brown stuff hits the fan or the number 10 bus hits you, it will be there for you.

In France, there are no waiting lists (neither are there going to be here) but you have to pay for your pills and potions. Germany is reigning back on a system that is going bust. Spain is accessible but requires copayments, and Sweden is trying to introduce a UK-style fundholding system. In Italy, they’ve been out on the streets protesting they can’t get access to modern medicines. Most European “insured” systems have problems.

There is a romanticised view of the NHS, exemplified by ITV’s popular drama series Dr Findlay and The Royal. Before the NHS, a visit from a doctor would cost the equivalent of 20% of a working man’s wages. There is a generation that is grateful to the NHS.

The truth is, the NHS is the biggest nationalised industry anywhere in the world and, as such, it is inherently unwieldy, slow to respond and impersonal. But the important things is, it is there. All day, everyday, 24/7.

In the main, it is safe and clean. Generally, its outcomes are first rate, and most of us will have a personal reason to be thankful that in 1948, despite huge opposition from the medics, Bevan had the foresight to make it happen.

However, there’s a problem. No matter how much we cling to the traditional view that our GP is our friend in the business, in some so-called “underdoctored areas” (where it’s hard to get doctors to work), the government’s solution is to bring in the private sector. In effect, these are turnkey operations where practices are built and maintained by the private sector, with salaried GPs working like battery hens in purpose-built surgeries. Well, some might say: “Better some doctor than no doctor.”

The migration of traditional doctor services to the private sector is an inevitability. There are two reasons for this – and they are
GPs’ own fault.

First, general practice is very lucrative. With almost no investment in additional overheads, doctors – because of the soft new General Medical Services (nGMS) contract – have seen their incomes rocket. Put that alongside practice based-commissioning opportunities, and running a practice becomes a very profitable business. Just the job for the private sector to move in on.

Second, the nGMS contract only describes GPs as “preferred suppliers”, not “sole suppliers”, of primary healthcare. This was a major gaffe on behalf of the British Medical Association, who negotiated the contract. In effect, they gave the business away. Doctors, bless ’em, are difficult to manage. Everyone who has ever tried agrees – it’s like herding cats! But it’s much easier to get compliance with best practice and to get changes and variations quickly put in place if you are dealing with salaried GPs on contracts.

Costs can be controlled – what about quality? Easy. What the nGMS contract and its successor agreements don’t cover, ordinary contracts of service will. Employers and purchasers will have a much better handle on performance, fulfilment and outcomes.

And the final change? The one big change ready to come trundling down the road and flatten general practice as we know it? The end of the list system.

In the 1950s, more than half of working men went home for lunch. So a trip to the doctors was easy to fit in. Today, most working men and women don’t get home until long after the surgery is closed. And, indeed, they leave for the office in the morning, long before the surgery is open. To be able to visit a GP close to where they work would be a real improvement in service. Decoupling the patient from a particular GP’s list would achieve this.

It’s on the way. The NHS entitlement card already exists. Couple that with IT developments and it would be possible for a patient to be seen at any surgery – or, indeed at any NHS franchised outlet in Tesco, or on a railway station or shopping centre pretty much anywhere in the country.

Prepare for big changes. The NHS is to become the “MHS”: the “Martini Health Service” – “anytime, anyplace, anywhere”!

Will it be better, will service be poorer, will doctors do the things that make the money and leave the rest? The answer is yes, no and maybe! Yes, it will be better: better access and better and more consistent quality. And haven’t GPs always done what makes them money?

We may love Dr Findlay, but we’re going to have to get used to Dr Who. For most of us, it won’t matter. For people with long-term conditions, and perhaps the elderly, it will. They like to see the same GP, consistently. We have to deal with that.

Tesco, Marks & Spencer, Sainsbury’s and all the others seem to manage it. I use my local branch when it’s convenient, but If I’m away from home and need to buy a new shirt, Marks and Sparks don’t treat me like I’m from Mars. They sell me a shirt and treat me like a valued customer – which is something GPs are going to have to learn to do!

Professor Roger Jones

Wolfson Professor of General Practice, King’s College London School of Medicine

In Sicko, Michael Moore does not discuss the structure of the American healthcare system, so that the almost complete absence of an effective primary care sector goes unremarked.

He does, however, powerfully delineate the brutal entrepreneurism that has run through American healthcare since the days of the Wild West. His condemnation of health insurance companies, illustrated with moving examples of death and bankruptcy among their victims, is made all the more poignant by the contrasts with the medical and social care systems operating in Canada, France, the UK and Cuba.

He accurately diagnoses the absence of a federal, and indeed collective, responsibility for the care of America’s sick and poor. Whether or not his description of primary care in the NHS is a rose-tinted one, it is impossible to watch this film without being reminded of the contrast between the self-serving cynicism of American medical politics and the astonishing altruistic impulses which led to the creation of the NHS out of the ruins of the Second World War.

We should not be seduced, says Moore, and I agree, by the cost-containment promises of health maintenance organisations and health insurance companies, which he depicts as having their origins in a deeply cynical discussion between Richard Nixon and John Ehrlichman in 1971.

Commercial companies’ responsibilities to their shareholders will always trump their responsibilities to patients, and we must scrutinise, with great care, the risk:benefit analysis of the introduction of private providers of primary care within the NHS.

The standards of general practice care may still be uneven, particularly in the inner cities, but even there examples of excellence can readily be found. We should learn from them, and avoid throwing the baby out with the bathwater by seeking to support established patterns of primary care provision, rather than rashly embracing untested models of alternative provision.

Tom Brownlie

AMSPAR Chief Executive

After highlighting failings in the USA healthcare system, Michael Moore selects high points of attainment from other countries – Canada, the UK and France.

In our case, the NHS is condensed into various members of staff laughing at Moore’s questions, such as the cost of a prescription after running through various sizes of requests (no mention of the difference in Wales). While I value our NHS, I really don’t recognise such overflowing laughter and joy among an overworked staff as they try their best under such difficult circumstances.

But the film is not intended for us. This is evidenced by Moore’s voiceover when he asks: “Why do we hate the French and their lifestyle so much?”, however facetiously. Well, I don’t – and I can’t imagine every American does either. And I don’t envy the riots that took place in Villiers-le-Bel and Arnouville last November. This is the difficulty when you try to idealise one system against another – facts distort the entertainment.

Having said the above, Sicko is to be welcomed as a film that can widen the debate on healthcare – something that affects everyone on the planet. If the film can push the USA system towards a universal model then perhaps we won’t stray so far in the opposite direction as we try to emulate them.

Alison Wall

Child Protection Lead and Health Visitor, West Herts PCT

I think we should feel proud of the system we have in the UK, despite its failings. Michael Moore paints a rather idealistic picture of the alternatives to the US system; no system can function perfectly. He makes little of the problem of access and waiting times that a system such as ours struggles to contain. We know that people do attend A&E departments because of the procedural difficulties of seeing their own GP, which results in higher costs being incurred here.

The film serves as a wake-up call to us all – the consequences of allowing privatisation to develop here would be catastrophic indeed. I think the film should be mandatory viewing to help us have a reasoned debate about the values we hold dear.

Companies like UnitedHealthcare and Kaiser Permanente are desperate to break into the UK system and expand their profit margins.

As Moore stresses, their aim is to make the highest profits, and this is achieved by cutting back on medical care.

Nevertheless, we have a responsibility to use primary care resources efficiently, and realise that we are paying for healthcare through our tax system. GP and nurse hours are wasted by inappropriate and missed appointments. Primary care practitioners could become disillusioned with a free-at-the-point-of-use system that is misused, and favour alternatives like private providers.

I hope Lord D’Arzi’s final report, out in June, and policy development around Our Health, Our Care, Our Say will focus on these points.