Blog piece by Dr Emil Shehadeah
“Modernisation: Reform or a Bit of Both? A Question of Courage”.
AT the risk of sounding tautological, modernisation seems to be a modern obsession in the NHS. Politicians seem to think that they can gain popularity by modernising this that or the other service.
Behind this thinking is an assumption that modern is good and old is bad. This is one of the most arrogant assumptions that go unchallenged most of the time. We can all think of many examples where old is much better than new. Generally speaking, old means durable and reliable.
Modernisation means keeping up with fashion. Reform, by contrast means bringing ourselves back in line with original aims and standards. The main difference is that modernisation is driven by changing opinions, whereas reform is driven by timeless principles. Which one takes precedence in the NHS? Well, we have an NHS Modernisation Agency, but no reform agency.
Modernising the NHS means putting demand in the driver’s seat. The NHS provides what politicians believe the voting public wants. The NHS has been modernised many times during my 26 year career as a doctor. Yet all we have achieved is try to keep up with burgeoning demand. “Need” is not a sexy principle, because it involves medical experts having the final word. There is a natural conflict between need and want. Need is based on medical science. Want is based on politics. Need dances to an evidence-based tune. Want dances to a tune of deference by the elected to the electorate.
Let’s assume that by a stroke of luck, our politicians decide to cast away modernisation and go for reform. What would they have to do for the NHS? They would have to ensure:
1. That the standard of care is the same everywhere?
2. All health needs are covered.
3. That it is fee at the point of delivery.
4. That it is equally accessible by all members of the public.
Are standards the same everywhere? No. Start with GP premises. Thurrock has some of the worst premises in the country. Whilst NHS managers sit in plush offices, patients are condemned to visit their GPs in well below standard premises. Contrast that with Cambridgeshire and you will realise that NHS reform is desperately needed. Indeed the NHS fails the modernisation test too, on this front. Why should we, in the 21st century, have to put up with terrible premises?!
Are all health needs covered? It may be the modern thing to prescribe nicotine patches ( which are cheaper than cigarettes), and Viagra for erectile dysfunction, but some of that money comes from prescription charges paid by people with heart disease and high blood pressure, often through no fault of their own. Modernisation has redefined need beyond common sense and affordability.
Is NHS provision free at the point of delivery? Prescriptions in England are not. The Scots pay no prescription charges. Why should the English?! What became of the principle of equality in the NHS? On this point, there is a distinction to be made between “free” and “ free at the point of delivery”. The NHS is not free. Some people pay for it, though some pay a lot more than others. But as long as we have a culture of benefits, the NHS will continue to be deprived and therefore will not be able to maintain that principle. There are many people on benefits who should be in work. They deprive the treasury, and therefore the NHS, of much needed support, which in turn means that free provision cannot be afforded by the NHS. Benefits need to be reformed, and to be fair the coalition government is doing something in this regard.
How about access? The last government, in an attempt to improve access for the more needy, created Darzi centres and called them Equitable Access Centres. In doing so, they were emulating the fashionable polyclinics of Berlin. These are much better financed than the local GP surgeries, and are geographically bound. So the Thurrock centre was placed in Grays. Yet the most deprived parts of Thurrock, such as Tilbury and Purfleet have not seen their access improved. The Darzi centre was a piece of modernisation, but it was the opposite of reform.
It actually exacerbated inequality. The more deprived people of Tilbury are consequently more relatively deprived than the people of Grays. Worse still, when the Darzi centre takes patients away from local GP practices, those practices are deprived of funds and can less afford to maintain their service, let alone improve it. Modernisation, in this respect has done more harm than good and increased the need for reform. Reform would have dictated that the same money, invested in the Darzi centre, be distributed to existing practices so they can improve their opening hours. This would have benefited more patients and ensured equality of access.
So if we have to choose between modernisation and reform, I would always go for reform. However, my preference would be for reform mainly with a touch of modernisation. The only piece of modernisation I would adopt is the change from “free” to “subsidised”. We can no longer offer everything free, at the point of delivery. There is not an endless supply of money at the disposal of the NHS. “Free” encourages abuse, misuse wastage, and a demeaning attitude of entitlement. A lot of GP appointments are wasted, and would not be wasted if people had to pay for failure to attend or if patients had to contribute a small amount towards the cost of a consultation.
The theory of evolution is centred round the principle that to survive, one must adapt. If the NHS is to survive, it has to adapt to the burgeoning public demand. The problem is which politician has the courage to introduce this piece of modernisation, a subsidised NHS?!