Politicians of all colours are now very keen to offer us increased choice in healthcare. There is an assumption that if you can choose to ‘buy’ your healthcare from anywhere you like then this will lead to the best becoming better and if a provider is not good enough then they will see that they need to improve or else suffer the consequences.
Choice, or perceptions of the ability to choose have been evident in education for some years. The schools that have been perceived to be ‘good’ are over subscribed, they are staffed by excellent teachers and people move house to be able to send their children to them. In some areas, where people are particularly mobile and affluent this may be the case. In healthcare choice in relation to maternity has been a particularly popular phenomenon with some people. Choice of the place you have your baby, whether this is home, a midwife led unit or obstetrics unit, or whether it is about choosing one hospital provider over another is very important to some people. Exercising choice can be a tricky thing. For one thing you have to know what choices are available, and in maternity you have to understand something of your own level of risk in exercising that choice. Perhaps your pregnancy is medically or socially risky when it comes to making some of those choices, perhaps you don’t have the means to travel 30 miles to a chosen different hospital. Perhaps also the services in your area struggle to attract the right mix of skilled staff, not because they are providing a poor service but because they are geographically situated close to an area where staff can attract higher pay.
If you are pregnant, then one thing is sure you will need some kind of maternity service, and it will be the duty of your local healthcare commissioners to make sure you can access it safely. Those commissioner will be required to make sure that the maternity services offered are safe, adequately staffed and that those staff are appropriately qualified to fulfill their role. Maternity Matters gave us a role in promoting choice and in making sure that those choices were available and that people were assisted in making those choices. When though does choice become a want or a demand? When does choice and the way it is exercised by the few mean that those who are more able to move, more affluent, more able to make choices have a detrimental impact on the many?
As a nurse working in a PCT I am obliged to take part in one of the much maligned prior approval schemes that are popping up all over the place to manage the demand for healthcare. ‘Low priority’ treatments such as removal of non cancerous skin lesions and varicose vein surgery are judged against a set of criteria set by a panel of doctors and approval is given or not for surgery to take place. What strikes me most about the way in which cases are presented is the extent to which GPs and surgeons struggle to tell patients that their problems don’t quite meet the criteria. Often they will write that the patients ‘wants this surgery performed’, and I am left wondering; yes, but do you think it needs to be performed.
I had the pleasure of setting up a new nurse led service a few years ago for people with rheumatoid arthritis. My job was to manage the day-to-day issues that arose for patients coping with a long-term illness, while taking potentially lethal drugs and still needing to deal with normal life. We set up a great service with a help line, monitoring clinics, home visits etc. What it taught me though was that where you create choice and opportunity you will also create demand and to a certain extent want. The people who shout loudest will often if you are not careful get the biggest share of what is on offer and that may be to the detriment of those who cannot shout and indeed may not even know what to say.
Whoever is in charge, whoever does the work of commissioning or buying healthcare, whoever provides it, there will never be enough of it to go around if someone doesn’t take the responsibility for making sure that decisions aren’t only made because of what is wanted, where it is wanted and whom it is wanted from. That of course is what makes my job interesting if not tricky!
Comments on: "Increased choice? Unsustainable demand?" (6)
Hi Julie
Yes that is always going to be the problem – increased demand. There was, I think, a belief that as society got better welfare treatment – in this case open access to health care facilities – then less people would need it as the populace became more healthy.
The need versus wants is a tricky one. Wants became criteria based, as it should do in any state provided scheme, not so in a pay up front scheme of course. Then some ‘needs’ are shuffled over to the ‘wants’ section because people see the doctor more and ask for tests and are more prone to obesity, smoking and drinking related health conditions and diseases; responsibility for your life style becomes a state problem, which can in turn lead from a ‘want’ to a ‘need’.
The word ‘choice’ has become a health related question unheard of in 1948 and for several decades or more after that. There was no choice. Choice was not expected. That was the preamble of the welfare health care provision. Only private monies got choice – more fool them if they paid over the top for a ‘routine’ operation or spent their money on superficial things.
That is why, as you said, “there will never be enough of it [health care] to go around if someone doesn’t take the responsibility for making sure that decisions aren’t only made because of what is wanted, where it is wanted and whom it is wanted from”. Indeed not. That is one of the reasons the NHS has had such a difficult time cost effecting. Society does not get better, it finds new things that needs treating, or new technology allows old things to be ‘healed’. That is the nature of life.
Do we say only certain things are available on the NHS full stop, and all non life threatening wants or even needs are to be funded by external payments? It looks that will come about in the future. Then your job will be a telling task, as there will be a need for someone somewhere to say no, not unless you pay for it – as in private, not through taxes – the truly two tier health service provision.
I found this:http://torylies.blogspot.com/2011/04/are-uk-private-hospitals-capable.html
Have to say very interesting. Free markets and private rules – not quite.
It’s hard to know how to start this comment as there is so much to say. So let’s start with basics.
Nothing is perfect, however that doesn’t mean imperfection should be simply accepted. For any state funded health care system the issue of affordability by the economy (and that means the taxes raised from the private sector – public sector employees pay tax but that is simply the left hand of government taking back some of what the right hand has given). The UK economy is a poor thing.
Wealth creation is the production of goods and services the market values. For the private sector that valuation is easy – someone puts their hand in their pocket. The public sector is more of a challenge especially as much of the ‘valuation’ is done by politicians to satisfy what is often a short-term political need. That is, to influence a woefully ignorant electorate. The formula used to calculate GDP is fundamentally wrong. It consists of four terms – business investment, retail consumption, government spending and the difference between exports and imports. Only the last term reflects wealth creation, the ability of the domestic economy to create sufficient wealth for the domestic market and then some more for export. Since the UK has had a balance of trade deficit for nearly all of the last 20 years, with it becoming increasingly worse since 1998, it is evident that it is poor at wealth creation.
In 2007 the other three terms (business investment in the form of financial services, retail and government spending) accounted for 70% of the GDP figures. Since bank loans are assets that produce an income stream (interest payments) and much of the retail activity and government spending was debt fuelled, it is obvious that the bulk of GDP in 2007 arose from a debt-fuelled economy. Not wealth creation.
Having removed the façade of debt with the eventual realisation that the mathematics used by banks to manage risk were fundamentally flawed, what is left is the growth (more or less) that is currently being experienced. As unpalatable to many as it may seem, the City of London is the only real economic advantage the UK has over other economies. It has neither the cost competitiveness of China, although wages are falling to these levels as Chinese wages rise – so narrowing the gap, nor the managerial skill of Germany, for example.
Across the western world, from China to the USA, the public sector burden on the private has reached its limit. In the UK that limit has long been passed.
So, it now becomes a matter of managing reducing resources better.
The basic failing of the NHS stems from its very foundations. It is organised as the Soviet Union where the great and the good determine what is needed and a self-serving elite decide how that can be delivered to suit their own interests, naturally – what else would they do?
In 1947 this would make sense. The Soviet Union having defeated the finest army in the world (the Wehrmacht) such centralised control would seem only reasonable. However, Nye Bevan’s own observation – that he ‘had to stuff their (doctors’) mouths with gold’ should have given a clue. In 2011 this is so out-dated it is barely believable.
The British are generally poor at management and organisation, the demise of the British car and domestic electronics industry bears witness to that. The effects of foreign competition in the 1970s and 1980s sorted the wheat from the chaff. Since the public sector is isolated from these competitive pressures its management is dire and in the case of the NHS frequently deadly.
Five inquiries were held into deaths of the elderly at Gosport Memorial Hospital. One of which concluded there was a culture of ‘involuntary euthanasia’ . No one stood trial for this Shipmanesque state of affairs.
At Mid-Staffs anything up to 400 people may have died unnecessarily despite there being 30 bodies charged with ‘quality’ control. Getting an inquiry proved a massive task and the history of inquires in the UK from Bloody Sunday to Iraq does not bode well for any sort of meaningful outcome. Certainly no on will face retribution much less trial for manslaughter.
The Tory proposals are evidently ill-conceived. My experience of GPs is that they are fundamentally over-paid clerks with no problem solving skills whatsoever. Reflecting over my 59 years I can only think of one who was skilled out of 6 or 7 I have experienced.
So why anyone would consider them to have managerial skills is beyond me.
There is excellent competition available from European providers. The previous Labour government worked hard to protect NHS employees from the rights offered to the British as EU citizens to use European health care systems. Indeed the opposition to the plans voiced by Shirley Williams, representing LibDem opposition, stems from the fact that competition would expose the NHS to EU competition laws. Since European health care providers are some of the best in the world this opposition is not meant to benefit patients but those who currently benefit from NHS budgets.
In conclusion, you have an economy that is not going to provide the sort of funds the NHS has become accustomed to and the chance that what is available will be managed well is inconceivable. Such situations usually lead to collapse.
410,969 nurses need to know truth on NHS the privatisation is real of nhs…..already they are farming out services like surgery,urology,and all other hospitals specialisms into private hospitals with the sole aim i think of closing nhs hospitals for good!!!!!!!!!!!!!!!many will lose JOBS…AS 20/20 HEALTH CARE SAID..A THINK TANK…the government won’t win this as the people that work in nhs will not except privatisation on behalf of patients..legally professionals know better for whats there patients than ideaologies of agenda’s.
what can be done sign emails or sign and scan a copy of your signature onto email and say no to privatisation………….400,969 sound off for NHS SERVICE AND SAVE IT!
send to and keep a copy yourself,send to ministers………the nhs belongs to you who work there and people not CORRUPTED government for a few like kpmg consulting..,GOVERNMENT have.. no legal right to step into hospitals fact,or there evil lawyers,…..CONTACT ALL NURSES SPREAD CHANGE OR LET NHS DIE OFF,YOUR CHOICE?