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Leader: Care before budgets

Leader: Care before budgets
19 October 2015

The chair of The Commissioning Review editorial board wants caring for patients to come before NHS budgets

The chair of The Commissioning Review editorial board wants caring for patients to come before NHS budgets

Having been brought up overseas, my first experience of the NHS was as a 17-year-old medical student. I was reading about lymphoma when I felt a lump under my chin, then another in my neck. After a sleepless week I plucked up the courage to see the university health centre GP. I was prepared for bad news but not for the way I was treated. After the most cursory of examinations he incinerated my idea, crushed my concerns and exploded my expectations! He told me I was wasting his time and should think twice about darkening his doorstep again. I left none the wiser about my lumps. But I vowed I would never allow any of my future patients to experience that.

I treated a 95-year-old man recently with metastatic prostate cancer who had fought in the war. He sees me because I put a little local anaesthetic in before his implant so it does not hurt so much. He told me he knew it was one appointment one problem, but would I mind checking his ischaemic foot brought on from years of smoking during and after the war when people were encouraged to smoke. I duly reassured him and then he asked the thing that worried him most. After more than 70 years of marriage his wife had developed dementia and he wanted reassurance that she would be cared for if anything happened to him. There are no Qof points, read code or enhanced service for that and no money could buy the look on his face when I said I would do all I could for her.

I asked Professor Sir Malcolm Grant CBE, non-executive director, NHS England, in April 2013 as he was the only new face at NHS England what would be different? I asked the same question of Simon Stevens, chief executive of NHS England, in April 2014. The changing of the name from failure to success regime, without changing the tools and personalities, means for those going through it, there is little difference. The bullying culture around the finances and meeting targets is as bad as ever where fear is the fixed emotion. Fear paralyses progress. It is perceived that taking a risk and investing when the books are not balanced is a step too far. I have never understood the concept of having to do more for less when any pilot always seems to have some extra funds behind it. Once the pilot is over and the money has run out, it is back to business as usual, before the behavioural change is embedded. Results in healthcare can take many years to realise but with the annual cycle nothing is allowed to continue unless it is delivering in year. I was very surprised that there is going to be another winter this year having had one last year and every year as far back as I remember. The planning has already started with the baton of blame relay warming up. What is different is an acceptance that the whole system, primary care, community, ambulance as well as A&E and secondary care struggle. The targets must be hit but we miss the point. There are very few people working in the NHS who wake up and think I must achieve financial balance. They wake up to care for the people entrusted to them. What is missing is the time to care.

The website gives the public a chance to give feedback on how they are being cared for by the whole of the NHS. The overwhelming thing looking at the results is that the vast majority of the feedback is extremely positive for all aspects of the NHS. People are more likely to go to the effort to complain when they have bad service but what is amazing is how many are so positive. Reading through some of the comments, the very negative ones are about not caring and feeling rushed, the positive are mainly about the feeling of being cared for and being given enough time.

What I think is the most positive change is that organisations will be judged by the Care Quality Commission and finally the clue is in the name we will focus on care and quality! The vanguards must be allowed time to be properly tested and that there needs to be an acceptance that what may work in Tower Hamlets may not work in Devon and vice versa. Devolution is coming for health and care and there will be much greater focus on value for money rather than organisational stability. The Atlas of Variation will drive much of the thinking. Difficult decisions are already being made and there will be rationalisation of the service based on quality of care.

What the public needs to decide is as quoted by my patient: “McDonalds medicine or Michelin star?” Do they want to see anyone, anytime or see the clinician of choice. The true cost of the health and care system must be made available to the public so they can decide how much they are willing to pay to get the care they want. It cannot be left to formulas. l


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