Thursday, July 5, 2007


Or maybe I should address this post “hello I´m a patient … I don´t know what´s going on …”.

There is a certain amount of commentary at the moment in the U.S. medical (and other) blogosphere about Michael Meacher`s latest film Sicko which examines the U.S. healthcare system compared with “socialised” systems in Canada and Europe.

The general opinion is that the film is strong on its criticism of the U.S. medical system but weak on its arguments in favour of “socialised” systems. I haven`t seen the film.

My U.S. friend and colleague Myron has related to me fights with insurance companies to get payments for his (now deceased) wife`s cancer treatment. With the stress of the cancer, I would not want to be dealing with financial issues with insurance companies as well. It is enough to keep the bread and butter on the table …

Another issue raised by a commentator is that although emergency treatment is guaranteed under the U.S. system, how much emergency treatment could be avoided by cheaper preventative treatment only available in the U.S. through private insurance?

However, this post is not about comparing U.K. “socialised” healthcare with U.S. healthcare …

U.S. Sandy at Junkfood Science provides a useful round-up of recent U.K. news reports, of which some are issues we have discussed here.

She points me to a 1997 article in the Indian Journal of Medical Ethics by an Indian doctor, Satyajit Bhattacharya, working in the U.K., relating the “reforms” instituted by Margaret Thatcher`s government in the 1990s. It is well worth reading, I would like to copy the entire paper but will restrict myself to, albeit extensive, quotes. Bolded text is from the original but highlighted by myself.

“… by 1987 the perception between NHS cash supply and demand had reached crisis proportions (annual government expenditure for 1987-88 was 20 billion pounds) … At the time the management structuture of the NHS .. consisted of the Department of Health (i.e. the central ministry or DOH) at the apex and District Healhth Authorities (DHAs) and Family Health Service Authorities (FHSAs) at the ground level. The DHAs and FHSAs) were responsible for the provision of hospital-based care and primary health care for the residents of that district. To this end, they received an annual sum from the DOH … which was then disbursed among the hospitals, general practitioners (GPs) and other medical care in that district. Salaries of hospital staff (doctors, nurses, paramedics) and GPs were paid by the DHAs from these funds, according to uniform pay scales that applied nation-wide, and to all specialities.”

The changes brought in by Thatcher were as follows:

Regional Health Authorities (RHAs) were created by combining the DHAs and FHSAs.

The RHAs would “purchase” healthcare for the population from the “providers” i.e. the hospitals and GPs.

But there was another twist – those GP practices that were sufficiently large could receive money directly from the DOH direct and “purchase” services from the “providers”.

They would, in other words, fulfil dual roles as purchasers and providers, and Hospital Trusts would have to enter into contracts not only with the RHAs but also with individual fund-holder GPs …”

The effects:

“The effects of the reforms have been too far-reaching to be grasped in their entirety yet, but certain effects are quite apparent from the viewpoint of a hospital doctor”.

Medical infrastructure:Closure of wards and in some instances casualty departments has led to increasing demands on the existing beds and facilities, with longer waiting times for patients. Recent newspaper reports state that over the past 3 years, 28 out of 60 casualty units in London have been closed down …”

Human-power and morale: “Hospitals have also sought to downsize their workforce as a means of economising. This has led to job losses, and those who have retained their jobs are left with increasing workloads, a severe crisis in morale and a growing sense of insecurity … The possibility of pay scales being set locally …(as pposed to national pay scales) has generated fears that already low salaries may be slashed even further. One of the assets of the old NHS was a committed workforce that was willing to accept modest salaries and poor working conditions because of the satisfaction they derived from their jobs. The Trusts have also been recruitingng more managers at the same time that they have been shedding medical and nursing staff …”

Medical Practice: oh fuck, read the article for yourself!

Patients` expectations: “… the Government has also attempted to raise the patients´ awareness of their rights, by ublishing a Patients` Charter … In fact, one of the deplorable consequences (I think) of the prevailing managerial ethos in hospitals has been the tendency to perceive patients as customers and refer to them as such."

Research: “Usually, research funding is one of the first casualties of healthcare penny-pinching. This was predicted, and has already begun to happen …”

Fears of privatisation: … The Government of course denies these accusations of backdoor privatisation vociferously,and as evidence of its commitment to the health sector points to the fact by 1994-95 its annual spending on the NHS has increased to 39 billion pounds. … However, even the Labour Party, which vehemently opposed the reforms when they were introduced, now acknowledges that the changes have been far to extensive for them to consider a total reversal if they come to power.”

The role of the doctors

“… the BMA [British Medical Association] has a poor record when it comes to standing up to a determined Government …when Mrs Thatcher´s ministers opted to bring in such wide-ranging reforms with little prior consultation with the BMA, and with total disregard for pleas that the reforms be initially tested in a pilot area or in pilot institutions, the BMA was unable to defend its position strongly enough or mobilise public opinion effectively in its support … As one who grew up in the strident militancy of junior-doctor politics in India, I have in turn been impressed by how civilised their forms of protest are, and been stunned by how ineffective they were in the long run”.

Roll on the clock to … 2007

Many of our medical staff continue to criticise the reforms initiated under Thatcher and, seemingly, continued under Blair`s Labour government. I will not repeat these criticisms here – go see the blogs of others (NHS Blog Doctor will take you there).

Sandy points me to a BBC graph showing employment rates and categories in the NHS from 1992-2004. Not a surprise with all these contracts to be administrated!

I will summarise a survey, commissioned by the aforementioned British Medical Association before its annual conference last month, of what our Great British Public thinks of NHS reforms.

1. Should the NHS continue to be funded from taxes and be free at the point of use? 93% yes

2. If resources are limited, can a small charge be made for some services? 53% yes.

3. Should the NHS be managed by an independent board of governers answerable to Parliament (rather than to the government)? 60% yes

4. Should decisions about local health services be made by bodies elected by local populations? 69% yes.

5. Should doctors have a major input on how money is spent locally? 82% yes.

6. Should the NHS provide the same set of baseline services throughout the country? 75% yes.

7. Can additional services be provided on a regional basis if funding permits? 79% yes.

8. Is there too much involvement of private organisations in NHS provision? 44% yes (35% don`t know, 21% disagree)

9. Should private organisations be allowed to provide NHS care where there is an identified gap? 66% yes

10. Should private organisations be allowed to provide unlimited NHS care? 34% yes, 48% no.

11. Does the purchaser/provider system improve the quality of healthcare for patients? 40% no, 34% yes.

12. Would hospitals funded and run by the same organisation lead to better collaboration and local health services? 73% yes.

Need I go on …

Is the current NHS “socialised”? Seems to me, it´s a mixed-up sorry bastard. Really Michael Moore you should not have used it as an example.

The Department of Health says the BMA´s survey is a load of hogwash … but the local community of Rochdale would fail to agree.

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