Colin Appleby
BA(Hons) MA
Industrial Economist
Professor, The Open University
Colin has a strong interest in health issues as a layperson and from a family perspective. Any views expressed are entirely his own and do not in any way represent those of the university
So Wayne Rooney played in this year’s World Cup after all. Football followers might recall the acres of newsprint devoted to the scrutiny of the offending metatarsal with appropriate diagrams of broken bones. The story went through several phases. It was a simple break … it was a double break … it had been pinned … if he broke it again it would be career threatening, etc. His orthopaedic consultant finally informed us that none of this was true. Rooney had in fact damaged the soft tissue in the metatarsal and within three weeks of the injury was feeling no pain. There was never really much doubt that he would play a prominent part in England’s World Cup campaign.
It is significant that experienced, expert medical opinion was pivotal to the Rooney outcome. All the rest was peripheral media-, management- and finance-driven ephemera. This is legitimate if you are trying to manage football clubs, sell newspapers or run TV stations, but what if you are trying to run the NHS?
The NHS – like the football industry – is now subject to unprecedented media coverage. The NHS has millions of pounds of debt. The jobs of nurses, doctors and consultants are threatened. Secretarial work is being outsourced abroad. Pharmaceutical companies are pursuing profit at the expense of cheap and cost-effective solutions for patients. Some hospitals will close. Not a day goes by without some apparent scandal being exposed in the “soon-to-be-privatised” but free-at-the-point-of-delivery NHS.
NHS versus US healthcare system
What should we make of all this, as the government pursues its reforms? Perhaps it is best to reflect on our own experience of this in comparison with other health systems. We are clearly more secure than citizens in the US, 46 million of whom do not have any health cover.(1) The real cost of losing your job in America may be losing health cover with little or no safety net on offer. But who should we believe regarding our own reforms – the politicians (most of whom have no expertise or experience of the sector), the media, management consultants or healthcare professionals?
Touch wood but I am soldiering on past 60 with, as far as I am aware, no serious health problems. I feel fit and well, but of course you never know! My experience has led me to be clear about a number of things. First, I do not feel the imperative to exercise choice within the system. I believe there is an unbridgeable asymmetry of information between the patient and the nurse/doctor/consultant. I studied some biology at school, but that was so long ago I have no useful information on health and bodily functions. The internet is an apparently powerful tool, but I would be suspect of applying such information to the individual case.
What I am therefore looking for from the health system and the professionals I meet is well-founded, ethically respectable, expert, evidence-based and informed advice built from the basis of my own medical history and their vastly superior, practice- based knowledge of possible medical conditions and treatments.
An important precondition for confidence in the system to be maintained is that consultations with health professionals must be based on an unfettered consideration of what is “best” for me as their patient (not their customer). There will be options for treatment, and insofar as I understand them, I believe I would be willing to take professional “best advice” on those options.
The doctor–patient relationship
Central to my confidence in the system is what used to be known as the doctor–patient relationship. There is confidentiality, there is expertise, or referred expertise, and there is the promise of reasonable access to treatment. Several developments or reforms in the system lead me to question the current health and integrity of this central doctor–patient relationship.
GPs are now fundholding partnerships organised on business lines, working to government-generated targets. Patients are “customers”, and routes to fast access often lie in private provision. Older and more experienced GPs are seeking to extract capital from the system through private finance initiative (PFI)-funded, purpose-built facilities leased from the private sector.
In an effort to respond to deficits, hospital managers are moving in directions that seem to be an affront to my beliefs as to how the system should work. A leading Midlands hospital informed its local newspaper that the problem of an £80m deficit at the hospital was being tackled – two consultant orthopaedic surgeons and the chief radiologist were leaving.(2) Ah, so that’s all right then!
At the same time, the hospital has outsourced secretarial work abroad, resulting in the loss of 100 medical secretarial jobs.(2) Typical typing errors allegedly coming back from the outsourcing operation were: “known malignant” instead of “nonmalignant”; “phlebitis” was typed as “flea bites to the leg”; and “hypertension” (high blood pressure) was down as “hypotension” (low blood pressure). It has been argued that such cost-saving measures are putting patients’ lives at risk.
Medics in charge
Another component of my ideal world would be that individual rights are effectively suspended and trust and confidence are placed in the health professional establishment. This vision, of course, lies in stark contrast to the current system, in which the NHS is facing vast compensation claims from dissatisfied patients – sorry, I mean “customers”.
The NHS must represent a social contract between local and national communities and the mass of health professionals. It should not be conceived as a business that can be “managed” like any other business, where cost and efficiency savings are the paramount driver. A peculiar trait in the UK seems to be the belief that “management” is a set of generic skills that can be applied regardless of business or sector. This misplaced view has been damaging in telecommunications (what happened to Marconi?), to the rail system (thank you, Railtrack ex-chief executive Gerald Corbett – once a wine importer and now a manager of Woolworths) and to many other UK sectors.
As you may gather, I tend to the idea that health professionals should be left to manage and run the health service. It is estimated that 7% of current costs go on management and administration,(3) and that current government initiatives, often informed by private sector management consultants, are destabilising the system. My solution as a typical patient would be to learn from the Wayne Rooney case. Doctor – read also nurse and practice manager – usually knows best!
References
- US Census Bureau. Income, poverty, and health insurance coverage in the United States: 2005. Washington: US Government Printing Office; 2006. p. 20.
- From the Wolverhampton Express & Star, June 2006.
- Scottish Parliament written answers to questions. NHS expenditure. 24 July 2006. Available from: http://www.scottish.parliament.uk/business/pqa/wa-06/wa0724.htm
