I recently went through what I presumed would be the pedestrian task of changing my internet provider to Sky. It involved much more frustrating, mundane drudgery than I expected. Forget 'Believe in better' - I was left not even believing in mediocre. The catalogue of errors included Love Digital, who signed me up, neglecting to inform me that there would be a six-week delay in my phone-line being connected. But why let such minutiae get in the way of a sale? When I finally did manage to agree a date (after several phone calls to people whose enthusiasm outweighed their English, Sky customer service operators), I took the day off work, ready to be connected.
At the last minute Openreach, texted me the "good news" that an engineer was not needed, and I should be up and running in a few days. I wasn't. After a plethora of irritating phone calls, an engineer did come round, and I was finally connected. I'm not just ostensibly bitching about my bad experience here. Bear with me - I'm making a (somewhat convoluted) point ...
Earlier this year, in January, our coalition government introduced the Health and Social Care Bill to Parliament. It was passed through the House of Commons and is currently being considered by the House of Lords. There was an uproar from the medical profession for many reasons, and a tirade of negativity was thrown at Andrew Lansley (including, bizarrely a 'diss-rap' - see YouTube).
Although some doctors agreed with the principles of the Bill, the consensus was that it was bulldozing through Parliament far too quickly and with an inconsiderate temerity, ignoring public and professional opinion - especially as it had not even been mentioned in any election manifestoes in 2010. This chorus of complaints was appeased to a certain degree when David Cameron put the plans on hold for a "listening exercise" in April (though allegedly some actions had already been irreversibly implemented at this point).
I can only blog from the point of view of a psychiatrist, though of course all the specialties of medicine are affected, not least GPs, who through the abolition of Primary Care Trusts have to carry the financial burden of commissioning. This of course is closely accompanied by the burden of blame, if it does fail. A slippery way, cynics may say, for the government to relinquish responsibility.
Like my peers, I have many concerns about the proposals. Here are some of them:
Say we have an imaginary person, Stephen, with very real mental health problems. Stephen develops schizophrenia in his early 20s. His insidious negative symptoms (withdrawal, inertia) are followed months later by positive symptoms (paranoia, hearing voices). Eventually, his family become so worried they seek professional help. His GP start him on an antipsychotic medication, and introduces him to the Early Intervention Service (a specialist psychiatric team that proactively treats and monitor initial presentations of psychosis, as this improves prognosis). He gets better initially, but has a relapse due to the stress of falling behind at college.
His local Crisis Resolution Team (psychiatric team dealing with mental health sufferers in crisis) see him daily and give him support, but unfortunately one night he is particularly unwell and distressed. The voices torture him to the point that he needs admission. He is taken to Accident and Emergency, where the doctor refers him to a Liaison Psychiatrist, who recommends voluntary admission to a psychiatric ward.
With a stronger dose of medication, supplied by hospital pharmacist, and several weeks of structured activity, support and encouragement from nurses, he improves. Whilst on the in-patient ward, he sees an Occupational Therapist who helps assess his skills and engages him in various groups, assisted by a Social Therapist. A Social Worker helps him sort out his income support, and arranges accommodation after discharge, in a specialist psychiatric hostel with round-the-clock supervision and staff support. A Psychologist administers talking therapy, and as well as a Psychiatric Consultant, there's also a junior doctor on the team who monitors his progress every few days. He is given increasing periods of leave, and feedback from the hostel workers is positive. On discharge, Stephen is reviewed regularly by a Community Mental Health Team, which is made up of a different Psychiatrist, Social Worker and Community Psychiatric Nurse.
This is a typical journey through the mental health services. I count around 17 health-care workers, belonging to 12 different specialities, in a variety of settings. Currently, they all work together as a well oiled machine. They all work for the NHS (except maybe the hostel worker), which ensures that there are regular communications. Clearly, efficient interface is needed.
According to the new Bill's proposals, funding and commissioning will no longer be handled by Primary Care Trusts (local healthcare organisations who have an elected board of directors, and hold open, accountable public meetings) but by GP consortiums (made up of probably well-meaning, but economically naive GPs), who are encouraged to outsource services to "any willing provider".
The problem is, this opens the doors to private companies, many of whom are big and powerful enough to undercut current NHS services, and bully them into bankruptcy. The GP consortiums themselves could crumble under their financial inexperience, and inefficient budgeting can culminate in their own bankruptcy. Unfairly pessimistic? Perhaps not - there are numerous similar examples in the US for the past couple of decades.
Even if economically viable services are set up, they might all be from different companies, with different structures, styles of working, priorities and codes of ethics. Hell, who's to say they even have a code of ethics? They are ultimately private companies, striving for profits, in contrast to the ethos of the NHS. Saving money is in their interests of survival, as competing contract-seekers could be nipping at their proverbial heels. They might not agree that Stephen needs follow up quite so regularly, or could provide a watered-down service, or employ cheaper, less experienced clinicians.
Let's say Stephen's psychologist is concerned about another resident in a hostel intimidating him and using peer pressure to bully him into taking drugs. She may want to address this problem with his social worker and hostel manager. Currently, the social worker might be in the office next door, and even if he is busy this morning, our heroic psychologist can catch him at the end of the day at the Team Meeting, during which every patient problem is discussed. If there is a failure of care, or any concerns, they can be raised then and dealt with. But if these professionals all worked for different companies, in different buildings, how can we be sure that smooth communication is possible? If the problem is too complex, it's easy for people to shrug off responsibility, and pass the buck - especially if your boss is talking to you about profits, rather than quality of care.
What if I'm wrong? What if the company that is commissioned to provide follow-up actually does so to a decent standard, by not cutting corners? Without a minimum contract, they could be undercut and replaced at any moment by a competitor, leaving Stephen with the uncomfortable process of having to trawl through his history, problems and issues again. With strangers.
Don't get me wrong, in theory I can see how competition promotes quality and efficiency, and of course I acknowledge that the NHS has finite resources that must be distributed fairly. But are GPs prepared and able to handle such responsibility? I would not expect them to have in-depth knowledge of all the specialist treatments needed in psychiatry. Why would they? They spend little or no time in their careers working on psychiatric wards or for Community Mental Health Teams. Just as I have limited understanding of medicine outside mental health.
Other specialists such as surgeons shared this concern about the expectations put on GPs making commissioning decisions without experienced and knowledgeable input from specialists. Additionally, many GPs that I personally know don't want to be pressurised into this position. The original Health and Social Care Bill proposals overlooked this issue, though apparently it'll now be taken into consideration.
If the aforementioned well-oiled machine is disintegrated into several individual, privately-funded, cogs, what happens if some of the components don't pull their weight? Psychiatric services contain some of the most vulnerable patients. Would somebody with severe depression, or negative symptoms of schizophrenia necessarily realise if they are being short-changed, or have the motivation to speak up and proactively resolve the situation?
Stephen's case is fairly typical. But what if it was more complex? What if he had comorbid substance abuse issues, or learning disabilities? This would fragment his care even further, amongst more profit-driven companies. If he drained too many resources, he could be passed around services just like the proverbial buck. The danger is that companies might even see him as a financial liability, and not treat him at all.
What of patients with other complex psychiatric disorders, that are challenging to treat? Like Borderline Personality Disorder or anorexia. Might private services find them economically unviable, and so few in number, that they may simply feel they are not worth spending money on?
Whilst all these issues hang in the balance, another important question is: "Who is in charge?" More importantly: "Who is accountable?" Instead of one organisation like the NHS, there will be several - Department of Health, National Institution of Health and Clinical Excellence, the Care Quality Commission and Monitor (who will oversee finances), to name a few.
When I complained to Sky about shoddy service, they replied with an apology, but explained they could not be responsible for the actions and failures of Love Digital or Openreach. I really hope this marriage of inconvenience doesn't occur within the management of the future NHS. (See, I told you earlier that there was a point in my moaning).
Like many other doctors, I am not against the principles of the Health and Social Care Bill or against the theoretical restructuring of the NHS. What worries me is the potentially misguided and hasty way it is being proposed. One only has to look at the outcome of the privatisation of rail services - dire quality and ever inflating fares. Whilst fat cats at the top get fatter.
"Quality care makes the world go round" - I'm pretty sure they don't teach that at business school.
In a perfect world, companies might prioritise patient welfare over money. In a perfect world, competition might inspire service providers to work and budget more efficiently.
The problem is, I don't live in a perfect world.
Do you?