Saturday, September 15, 2012

The impossible debate


Its nigh impossible. Actually correct that. Its impossible. Its impossible to anymore have a rational discussion about the NHS. There’s very little room for manouveur..its either, as a tweet from a colleague mentioned, a jewel in the crown, a national heritage, something to be proud of, nothing should be changed..or its absolutely the pits needing a complete overhaul.

The reality,as ever, continues to be somewhere in the middle. It is, have no doubt, a fantastic institution, built on sound principles…but it doesn’t provide high quality care everywhere with the same level. Some of it is down to variation in quality of staff, some of it is down to lack of patient engagement and a lot of is down to finances. A mature adult debate about all those issues seem to be impossible to have and we continue to duck them, continue to be blinded by facts, continue to be sucked into politics with the NHS, as ever, being a lightening rod to attract polarising views and opinions.

A question about variation of quality raises hackles of many…we all feel we work the hardest..but read any patient blog, they are full of as much praise as much as criticism..different staff, different attitudes. But we struggle to raise those issues in public..we struggle to debate them, simply shy away from them, wrapped away in the theme of “we have to work together, we have to go forward together, we must not upset anyone”…to me…that’s a fudge..we “work together” to make patient care better. If there is genuine evidence that someone is not working hard enough, providing poor care consistently, then sweeping them under the carpet is not about “working together”…this isn’t a childrens party where we must get all the kids to play together..this, last time, I checked, was far more serious- and we must be able to debate that.We must be in a position to challenge that and stay true to the core of improving patient care...and if that upsets a few poor performers, so be it. When was the last time you saw Alex Ferguson be afraid of throwing a player out who did not perform well or wasn't part of the team's ambition to be the best?!

What about patient engagement? Now that’s a sacred cow..which we again, struggle to discuss. This is an amazing healthcare system based on a public taxation system and sometimes when you have so much, you tend to forget what benefits they bring. When a patient doesn’t turn up in my clinic and I ask them next time why…a shrug of the shoulder accompanied by " had other things to do, doc" makes me sad. It makes me feel that I could have given that slot to someone who genuinely deserved it and heck there are plenty of them out there. It makes me think of places where I have worked, such as Calcutta, where a patient would sell their belongings to have a chest X ray done, it makes me think of my time in a village in West Bengal where the only drug available for chest pain is paracetamol. We have so much in this country and yet we choose to abuse it, choose to shrug our shoulders. Diabetes UK,the bastion of patient group in diabetes care, has recently shown data mentioning that 60% of patients haven’t hit theor cholesterol targets..accompanied by a statement saying that most GP surgeries though have hit their "targets" which results in payments to surgeries. Sure, thereby opens the debate about the fallacies of performance based payments, sure theres something not right..but what about the patients who don’t take their tablets? What about the group who turn up in clinic and say that “diet isn’t their thing?”. Is it always the healthcare professionals fault..is it always about the right information not being passed on..or is it sometimes about an adult patient making a conscious choice not to follow the advice given..as that the decision they have made? Again, a debate about that is impossible to have..as out of the woodworks steps the evangelical patient groups…I have no problems with them..but come on guys…a sensible debate and a bit of reality check too?

And then finally, the biggest of them all...finances. The fact is that there isn't enough space either in the community or in the hospitals for an ever increasingly ageing population with multiple morbidities, a population whose expectation continues to be fuelled by what they read in the papers and doctors in hospitals heading towards specialism with primary care left holding the baby in most cases. Here's an example, Dan Poulter, a new entrant in the Health Ministry team, a doctor himself, recently said that hospitals weren't on the brink of collapse as most hospitals were running to 85% occupancy..and the NHS had enough beds to cope. Well, Dan..I don't care about politics...but...mate, man to man, doctor to doctor, join me on my daily ward rounds, when I am covering the wards, spread over 11 different wards..and if you find one patient, just one, you can discharge quicker than I can, with existing provisions in the community and most importantly safely, I will work for free in the NHS for the next 3 months. Promise. Scouts honour. I am one of the quickest guns as regards discharges go...and on a daily basis, I take a calculated risk..on a daily basis, I inwardly cringe at the pressure I am putting back on my primary care colleague..and then I hear that it isn't about the resources. Lets stay away from politics on this one, shall we?

Come on fellas..come on you folks who understand issues better than me...why not contemplate that we don't have the resources to offer everything at the same level of quality all around with the same money available? Or at the very least have a sensible adult debate about it? But alas, we can't. I keep on hearing words such as inefficiencies, cost savings, productivity, innovation...which at the end of the day sounds more like doing the same thing, perhaps even better...but with the same finances..or less. 

Of course, the majority of professionals are hard working, of course there are patients who miss their appointment because the letter ended at the wrong address..and of course there is wastage in the NHS which can be minimalised...but at some point..after you iron out all of those..there simply just isn't enough to do everything. Or at least, that's my view. Can we at least raise that issue? Can we at least debate that? Can we at the very least raise those topics...touch upon those sacred cows..or do we wait till it's all reached the point of no return? 

Or more worringly...are we not debating those..because we are already there?

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