Medical matters

The British Medical Journal has a long piece on the current state of the NHS at this election, and what its future might hold. It is a mixed bag, comprised of views from across the profession, although as usual with the BMJ, very few actual working clinicians, which The Knife is privileged to be. The usual suspects are in, such as the nauseating Ian Gilmore, President of the Royal College of Physicians, but there are a few brighter sparks. Here is a selection, with the odd comment:

Ann McPherson, medical director, DIPEx Health Experiences Research Group, University of Oxford:

“…The key election issues for the NHS are funding, funding, and funding. The past 13 years have seen unprecedented investment in the NHS after 20 years of drought by previous Conservative governments…I would also like assisted dying to be legalised. It should become part of palliative care alternatives and should be a respected patient choice available to those who wish or request it…”

Knife View:  lefty ex-GP alarmingly keen on euthanasia and unrestrained spending.

Allyson Pollock, professor of international public health policy, Edinburgh University:

“..planning and resource allocation on the basis of geographical populations, the elimination of transaction costs such as marketing billing and invoicing, and service integration instead of fragmentation and competition, both of which risk either duplication or elimination of unprofitable services. Strong systems are required of public accountability, systems which have been torn down in the past 10 years. There is no evidence to support a market let alone the introduction of commercial providers in health care or welfare; on the contrary, the evidence points the other way. But politicians on all sides have become market fundamentalists mesmerised by short term profit and greed…”

Knife view: generally sensible critic of government interference in healthcare, worth reading

Iona Heath, general practitioner, London:

“..From the beginning, the very best of medical practice has been built on curiosity, imagination, idealism, vocation, and commitment. All of these are now constrained by policy which, by means of reductive measurements and crude incentives, is attempting to micromanage the interactions between patients and clinicians. The destabilisation of general practice, which began under Mrs Thatcher and has been enthusiastically pursued by all subsequent governments, has already proved extremely costly. In times of severe financial shortage, we urgently need to repair general practice on the clear understanding of the cost effectiveness of holding risk and uncertainty at the level of primary care and referring on for investigations and treatment only when there is a clear likelihood of benefit. Gatekeeping is a much maligned and poorly understood function of primary care, but it has been the foundation of the cost effectiveness of the NHS since its inception.

Health care can never be reduced to an industrial process in which patients and doctors are regarded as interchangeable units of need and provision. What is needed is a policy context that maximises the time that clinical professionals have available to spend in direct patient care; provides an environment within which trusting human relationships can develop and flourish; minimises perverse incentives; avoids the wholesale medicalisation of populations by situating preventive interventions at the level of the society rather than the individual; avoids duplication of effort and expenditure; is prepared to scrutinise the potential futility of interventions towards the end of life, especially in extreme old age; enables primary and secondary care professionals to pool their complementary expertise in the care of patients; and, overall, provides a better balance between the transactional and relational aspects of care. If any party is offering this, just let me know and my vote is yours…”

Knife view: quoted in full, as proper clinician who sees big picture well

Ian Gilmore, president, Royal College of Physicians:


Knife view: can’t be arsed quoting him, he was actually semi-sensible for once

Nigel Hawkes, journalist, London:

“..The NHS is like an established church, with rigid doctrines, a well rehearsed liturgy, an army of priests and altar boys and cathedrals in the form of hospitals, paid for under private finance initiatives. It begs for a Martin Luther to nail his 95 theses to the door. It hasn’t found one yet…”

Knife view: far be it from me to agree with a Luther analogy, but he has a point here

Richard Smith, director, UnitedHealth Chronic Disease Initiative:

“..I’d also like to see a very serious commitment to tackling climate change. It and poverty render all other problems secondary, but we seem to be going backwards with both..”

Knife view: “Dick” Smith, the man who, as editor, turned the BMJ into a soppy right-on lefty rag, and abolished authors’ qualifications because they were ‘elitist’. He’s not changed.

Kinesh Patel, junior doctor, London:

“..The big elephant in the room is the demand for health care. What would be truly radical would be to talk about reducing the inexorable demands of health care by introducing a modicum of personal responsibility for health. Let’s see if anyone is brave enough to face up to that challenge…”

Knife view: worth saying, though with views like this he may get banned from even reading the BMJ

Anne Marie Rafferty, head of school, Florence Nightingale School of Nursing and Midwifery, King’s College London:

“..The care continuum is as much about scaling up the capacity of citizens to care for themselves as retooling the healthcare workforce, redeveloping and redeploying it into new roles in integrated care and polysystems…”

Knife view:  eh? See what I have to put up with?

David Taggart, president, Society for Cardiothoracic Surgery of Great Britain and Ireland:

“..surgeons should spend more time in the operating room. It is not cost effective to have highly trained surgeons spending only one or two days a week in the operating room (analogous to British Airways using pilots to staff check-in desks rather than fly)…”

Knife view:  too right. If I don’t push for more I might only get to spend 20% of my taxpayer funded time on operating. This does not make much sense.

Chris Ham, chief executive, King’s Fund:

“..Innovation will be at a premium and the next government will have to be ready to support radical changes in how services are delivered. This includes planning for a future in which less reliance is placed on acute hospitals and more investment is made in primary care and community health services. New models of care will have to be developed by both the independent sector and the NHS to make care closer to home a reality…”

Knife view: the aptly named Ham has made a comfortable living with crap platitudes like this.

Max Pemberton, doctor and Telegraph columnist:

“…For psychiatry in particular, the next government needs to think carefully about the current crisis facing the profession. At present, over 85% of trainees entering the profession are from overseas, and posts are increasingly difficult to fill. Serious questions need to be asked as to why UK medical graduates are turning away from psychiatry. De-professionalisation has resulted in a weakening and destabilising of the role of doctors within mental health and subsequent poor morale..”

Knife view: what do psychiatrists actually do all day? They seem to be all right financially though. Check out the number of ‘Clinical Excellence’ awards at the Maudsley.

Neil Graham, medical student, University College London:

“..The result is that the cost of care can be expected to rise more rapidly than inflation, leaving far behind the sums offered for health by any of the main parties. The discussion on health reform has so far been remarkably limited, given the size of the task ahead. Aspirations like private rooms for patients are laudable but distract from serious discussion of how our new frugal health service will look..”

Knife view:  bright lad.  He spoils it later though.

In all, a good summary of some aspects of the NHS. Some contributors were just too boring to quote from though, and there’s a lot of hogwash in there. As usual, the poor bloody infantry don’t get asked.

Don't worry Sir Lancelot...climate change is all bollocks

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