Having been essentially ignored by most of the media for the past 18 months, the NHS reforms are all over the news in the last few days. The TV coverage has been mainly awful, chiefly consisting of proponents of the changes popping up to tell us how marvellous it’s all going to be. This reached a nadir for me last night when BBC South’s evening bulletin revealed that they couldn’t find a doctor to talk on camera in opposition to the plans. Now, given that every time doctors have been polled on these changes they have overwhelmingly rejected them, either the government have done an unprecedented job of persuading my famously stubborn profession, or people are too intimidated to speak out. This, at the same time that Jeremy Hunt is talking about absolute protection for whistle-blowers, sent a chill down my spine.
So I thought it might be helpful to describe the possible effect of these reforms on my own, very tiny and insignificant part of this vast healthcare landscape, to illustrate the possible effects on the whole, and why *spoiler* I think they are a terribly bad thing.
I run a small clinic in south London for children with developmental problems. For various reasons, we’ve missed out on a lot of the previous reforms instituted by Labour, so the current wave of upheaval will have an especially big effect on us.
The current situation is this. We are the only publicly-funded service of our type locally. We are funded by a contract based on the approximate needs of our population (not enough, and less every year, we all have to do our bit). Any professional who is concerned about a child can write to us, and we select those most likely to benefit from our assessment to see.
We see the child and family for 90 minutes initially, listening to them, interacting with and assessing the child, and gathering a load of information about the family circumstances and the child’s function within the family. Then we put together a developmental profile of the child, including why some of the problems might have occurred, and, if it’s going to be helpful, suggest some diagnostic labels to investigate
We then produce a comprehensive report, with some suggestions for useful next steps. We link with other publicly-funded local agencies to share knowledge expertise and plan co-ordinated intervention.
None of this is clever, high-tech stuff. It’s just care, thoughtful analysis, and common sense. It seems to work OK
So what will change now that everything’s opened up?
First of all we might not be running the clinic for much longer. The local commissioners are being forced to put almost all services out to competitive tender. This has two effects. Firstly to keep our service going we’ll need to spend money that is needed for front-line care on paying someone to put together a bid for the work, not once, but repeatedly every few years. Secondly, whatever the government’s flimflam, if a private service of ‘apparently equivalent’ quality comes in with a cut-price loss-leading bid for what we do the commissioners will be obliged to award them the contract. Recent legal analysis has confirmed that this is the case despite the cosmetic rewriting of the regulations.
Now obviously if our service were privatised, this would be bad for me, but would it be bad for families? It would if you could construct a service that looks like it will be of equivalent quality to ours, but actually isn’t. Anyone who works in any public service knows how easy this is.
For instance, the current draft NICE quality standards for ADHD specify who does the assessment, but not, bizarrely, what is done. So you could easily save money by cutting down the face-to-face time and instead of finding out about a wide spread of the child’s function and circumstances, just get the family to fill out some questionnaires aimed at specific diagnoses that you are fishing for, for instance ADHD or autism, then wheel in a consultant to deliver the diagnosis and get the prescription pad out.
It seems clear to me that this is inferior care- it’s impersonal, it treats children as points on a graph not people, but also it will both over-diagnose some conditions and miss other important aspects altogether.
So the care itself might go downhill, but be cheaper. You might think that’s a reasonable trade-off so far. But there’s more; under the new system services will be paid per assessment, so it makes no sense to choose those who would benefit most- it makes far more sense to see straightforward cases and find a reason why complex ones should go elsewhere. And believe me, it can be done.
Finally there are no mechanisms in the new system to ensure that different agencies co-operate, so if our service gets taken over by say, Virgin, the joint work we do with educational, mental health and therapy services will instantly disappear, which will lead to fragmentation and duplication of work.
So in my little corner we are likely to see more financially-driven impersonal care directed not to areas of need but to where profits can be made. This will look great to a management consultant looking narrowly at our service’s efficiency, but it won’t look great to patients, and because of the fragmentation and duplication, it will be a less efficient use of public money.
Now think about scaling these changes up through the whole NHS. Depersonalised, financially driven care, fragmented services working against each other? Sound familiar at all? Combine that with unprecedented savings demanded of all NHS services, and I hope you can see why so many of who work in the NHS fear that mid Staffs is only the beginning.
So what can we do? I’m at a low-point in my optimism about stopping this, I’m afraid. I suppose the Lords might vote down the competition regs on the 24th April, but with Labour going so very quiet on the subject in the last few months (no more Andy Burnham ‘i will repeal the bill, full stop’ tweets), I suspect we will need to wait for care to really disintegrate before the country wakes up and demands a sensible, integrated service run around patients, not finance.