I was asked this week why the NHS doesn't fund all the new technologies available for patients, particularly those with cancer. And when I instantly replied "Because we can't afford to", I surprised myself. Because no-one seems to say that when they talk about the NHS. And the NHS doesn't like to say no.
The vast majority of the general public are grateful for the NHS. They accept its limitations with a wry smile. Most people have a story to tell of when it saved their or a loved ones' life, or how the kindness and care of a single doctor or nurse made a difference. It amazes me that when I have to deal with an emergency, making me late for the rest of my surgery, patients are endlessly understanding. Those who aren't have often been chastised by the rest of the waiting room before I even hear their complaint. Give patients some credit.
They just want there to be enough doctors so they can get an appointment when they need one, and to have a system that works and isn't left to fall into crisis. If we are upfront about what the NHS can and cannot do, apart from a vocal minority, I imagine most people in this country will just be pleased to see an excellent service continuing, and the political arguing and interfering stop. In its constant striving for votes, each government has promised patients the earth from our health service, raising expectations sky-high. They rarely deliver. Not once has any Secretary of State for Health turned around and said "You know what? No. We don't have the money. The NHS cannot be all things to all people."
Perhaps we should be celebrating the free at the point of contact care we have for the populations' basic medical needs, and stop aiming for the stars? The NHS is not private healthcare; it is not a consumer product. We shouldn't compare ourselves to the American market for patients with unlimited insurance. In fact we are actively trying to avoid the American model that those without insurance face dealing with. If you spent the entire GDP of Great Britain on the NHS, I can guarantee we would be back in the red again within a few years.
There is no profit in sick people, as Circle has so deftly demonstrated before leaving the NHS to pick up the pieces in Hinchingbrooke. We have to decide what we want from our National, tax-payer funded, Health service. Despite what the politicians want us all to think, it does not have unlimited resources. We have to get used to the idea that the NHS will say no to certain treatments, to certain demands on it, to patients who don't meet it halfway and try to look after their own health.
So maybe doctors should lead the way, make a stand, and start saying no.
General practice is a profession of Yes men. Not in the traditional sense, but in the sense that we as a profession appear unable to say no. Every day we see the impact that constant reorganisations to healthcare, and the dance of NHS funding and politics has on our patients. It is in our power as doctors to work that bit harder to minimise the effect on them. So for years we have done just that. We have taken on extra work, without extra funding. We have said yes to everything and simply absorbed it into our package of care. With the increasing focus on preventing admissions and moving care out of hospital, conditions that 10 years ago would have been managed by our consultant colleagues, are now managed by us. And we have continued to say "yes".
Yes to monitoring Disease Modifying Anti-rheumatic Drugs for arthritis, yes to organising blood tests for consultant follow up clinics, yes to initiating and stabilising patients on Warfarin, yes to monitoring patients with Chronic Kidney Disease. It makes total sense to provide healthcare locally; it's much easier for patients than having to trek to hospital all the time. But if General Practice is doing this work, then the funding for it needs to follow. If it doesn't, then it has a knock on effect to the routine bread and butter of general practice.
This week's latest example is that GP surgeries in parts of the country have been asked by their Clinical Commissioning Groups (CCGs) to miss vital, compulsory training. Practices have been asked to cancel this because of fears that NHS 111 and the out of hours service won't cope with the demand for urgent problems for a single afternoon.
Just to clarify, that's the out of hours service that the government thought could be run more cheaply and efficiently if it was done by big companies. While there has been muttering about this request, I suspect most surgeries will agree and will forgo the training, which includes child protection in some areas. Why can't we start saying "No" to requests like these? General practice has been represented in negotiations with the government by a monopoly union that only seems able to say "Yes". We have taken on the extra work with only a small amount of very British grumbling, and now end up in a situation where the pressure is so great we cannot provide basic services to our patients.
Perhaps as a profession we need to lead the way, and start showing the NHS that sometimes, you have to draw a line. Sometimes, you have to say no.