The Point of Departure.

As the Leviathan that is the Health and Social Care Bill, lumbers inexorably to a vote, shrugging off the attacks on its content, like a Tank does small arms fire, I have pondered as to what I would like to see the NHS become. Certainly not that which it is now, so I do not want to 'save it'. And 'curing it' does not appear in any agenda for Health that I can conceive of, because the cancer within has all but consumed the host. Spectacles of a rosy hue, seem to have been donned by the 'liberals', now that their precious NHS is under threat. All the transgressions of the past seem to have been forgotten and it is now to seen  as a beneficent, almost angelic body that we should strive to save from the evil machinations of the Tory's. In reality, nothing could be further from the truth.

At it's inception, the NHS was a construct based upon universal health care for all. Sadly that did not compute with Doctors of the day, so it was 'hijacked' by the Consultants and whilst the 'proles' got their boils lanced and their teeth pulled for free (well almost), there still existed a 'cabal', a 'mafia' of senior Doctors and Surgeons who dispensed their largess very much on a part-time basis, but nonetheless held sway at the BMA and called most of the shots. Several incarnations later (there were many), once a few of the miners son's had made it to Medical School and infiltrated into Hospitals it became it little less elitist, but the 'firms' still held sway, with the 'rugger playing' registrar being more the norm than a lad from the terraces of an Allan Sillitoe novel, even more unlikely a girl! So we move forward through time and seventeen major reports and reorganisations later we arrive to today, or rather the white paper of the Coalition of July 2010 Liberating the NHS (didn't realise it had been imprisoned) from which sprang the Health and Social Care Bill. But, long before then the NHS had lost it's way.

The Thatcher years saw the invention of 'fundholding' and of course the bureaucracy attached to that hugely expensive and pointless accounting system that it was, causing mountains of paper invoices to be generated and mailed to each component of the system. The invention too of the Hospital Trusts, and of course the 'internal market', providing an entry for Private Health care to the NHS, and a proliferation of 'for profit' organisations and Hospitals. Tony Blair, not wishing to be seen in any way as 'socialist' perpetuated and embellished many of these policies including privatising the 'out of hours' provision of Primary Care, Foundation Trusts, incentivisation of GP's and of course the spectacularly useless and costly IT projects, together with the expansion of the Private Finance Initiative. In fact the only good thing he did was to eliminate the internal market, only sadly to decide to reinvent it just before he left office.

In all of this we have seen the 'legacy' of the Thatcher years become the Neo-Thatcherite agenda of today which sprang from the Neo-Liberals of yesterday, all completely oblivious to the vast sums of money they were spending, to achieve little other than the enrichment of an 'elite' cartel of Accountants, Facilities Management Companies, and Consultants, not forgetting 'Big Pharma' of course and to the detriment of the 'end user', the patient, who had no input to all of this, except of course to become a 'victim'. I say victim without any hesitation, because the joint efforts of the politicians, GP's, Consultants, and all the retinue of Nurses, Bureaucrats and hangers on have done virtually nothing to improve the lot of the patient but simply improved their own. I have no desire to save anything for any of them, they are completely undeserving even of the the little patience that I have left.  The GP's are more concerned about their pensions than patients, the Hospitals more interested in the preservation of their empires, even if it's at the expense of patient safety, than adopting better and less invasive protocols, or the concentration of specialist services in regional centres and thus improving mortality (childrens heart surgery?). The health care charities have been 'hi-jacked' by Pharma as patient advocates, to peddle drugs like Avastin which may prolong very slightly, the lives of terminal cancer patients, at enormous expense (and their profit) and with a whole host of side effects that can be terminal in their own right. All in the NHS and those outside it who will be 'willing providers', have an agenda that has nothing to do with patient care and everything to do with profit, with preserving power, extending control and personal gain.

Why for instance do we continue with Angeograms when we can utilise Electron Beam Computerised Tomography which is non-invasive, less dangerous and considerably less unpleasant. Because it's cheap and a lot of people will lose their jobs, power and influence if we 'can' it. Why do we continue with the 'sham' treatment of healthy people for heart disease they haven't actually got, because they have fulfilled some test criteria for a 'surrogate marker' evidenced by one of (several) computer 'risk scores' that are frankly useless and have been proven so. We also 'treat' perfectly healthy pregnant women, simply because 'we can', to ultra-sound scans, hospital births, inductions and other invasive procedures that for most are not needed, when we should be saving them for those that are 'at risk'. Why do we allow 'Pharma' to 'bribe' physicians and Surgeons with nice little 'jamborees' in exotic locations, 'free lunches', financial support for 'pet' projects and studies, all in the interest of promoting their dubious and often dangerous drugs and devices. Of course no Doctor would be influenced by such largess (and Genghis Khan was a really nice guy).

That is where I depart from the 'curers' and the 'savers'. I have seen my best friend die from stupidity and misdiagnosis. My father from neglect of his chronic illness. Almost lost my sight in one eye and watched the woman I love treated with appalling callousness, have her life endangered and her future blighted forever, for the want of diligence in simple protocols that are the foundation of medicine. Many of my friends have lost everything in their lives at the hands of those who swear to 'do no harm' and I have seen them rage at the impotence they have felt in their pursuit of justice and candour.

Denial of their incompetence seems to be the only thing at which Doctors are actually any good. So I want not to save the NHS, I wish it to be demolished like a fire gutted, dangerous building. Let the ConDems do their worst and destroy what is left whilst the Labour dissemblers snipe at the minutiae of the Bill, sure in the knowledge that they would have done little differently. Perhaps then, when we see yet again the differences and inequalities that will have been forged in England's NHS and we look North to Salmond's fiefdom where a new social democratic model is being invented, we can rebuild it as it should have been. I truly hope so, before I'm saddled with the DNAR.

A Pause For Thought?

Cameron, Lansley et al, have announced their intention to have a 'natural pause' in the Bill to reform the NHS. A 'future forum' including that 'porcine' (honorary) Professor, Steve Field is being launched upon the country, to listen to the views of the NHS constituent about the changes that have been proposed (excuse me whilst I choke). Once this period, which coincides of course with the Easter Recess anyway (yes more holidays for the politicos), is over, the Bill will be sent to the Lords for perusal and possible modification.

The problem I have with the current and past reforms, is that they continue to concentrate on structure instead of quality, organisational change rather than the ethos and tenor of what universal health care should be. For far too long the NHS has stood for invasive and pernicious campaigns to to persuade us  (and now nudge us) into a new horizon of well being with moralistic and ill conceived measures about smoking, drinking, sex, and diet, indeed anything enjoyable. With social engineering at its heart, the anxieties of society are constantly addressed by campaigns to reduce cancer, heart disease and diabetes with little result other than a significant  elevation in the Nations blood pressure.

This has in turn led to poor quality health care, dispensed '9 to 5' (weekends and holidays excluded), in Hospitals and Surgeries, to a somewhat hostile patient cohort, who are now being appealed to by the NHS constituent, to 'save the NHS'. Those who have delivered this inferior and authoritarian 'we know best' standard of that which passes for Medicine, cannot really now expect the public to 'go to the barricades' and fight for them to keep their bureaucratic temples intact.

The NHS has presided over ever increasing levels of interventions into our lifestyles and behaviour, very few of which are founded upon any evidence or indeed have had any success. Doctors have become the 'health police' rather than the healer, and as they have distanced themselves from their patients they have prospered enormously in monetary terms, but lost credibility. They are now pawns in the Neo-Thatcherite construct started by Blair and continued by Cameron and his academy of 'toffs'. An NHS that has treated society with such contempt, despite its huge cost to that society deserves to founder.

I do not like the changes proposed very much. They amount to little more than a bureaucratic reshuffle; a movement of the deckchairs, because the fundamentals remain. But the opposition that has formed against it almost worries me more. If Allan Milburn, the BMA and the King's Fund  ( and David Owen for f***s sake) are against something then I'm afraid I will possibly have to review my position. In fact as the number of unprincipled and opportunistic politicians grows, who oppose this Bill, the more I become alarmed that I may have missed something! Hardly surprising in view of the number of pages it runs to (299 clauses!). Perhaps there may be some nugget of redemption in this pointless, needless and irrational Bill after all? Oh yes, the Quango's are going! But no, they are being systematically saved, if not by name then by transfer, such as the Food Standards Agency to the Dept of Health.

Doctors and the BMA never wanted an NHS, of that be certain. They wanted an elitist cohort of Physicians that dispensed wisdom and medicine to the 'proles' at a price that they set, not one set by some 'oik' in a Government Department who went to a ...Grammar School?  They persisted in this view until the Thatcher years, when Maggie offered them more power and control at the expense of a bureaucratic nightmare of invoicing procedures and budget management, when they decided that it was all too much, a bit like the 'poll tax'. Then along came Blair, all fired up to change the mindset and the BMA embraced him. All at once the BMA discovered it's desire to participate in Government sponsored (and guided) health care resulting in massive financial benefits to the membership and less hours! Well that was a surprise then?

Incentivised, at a level they could not have dreamed possible, most Doctors and Hospital Consultants doubled their pay, and reduced their involvement in patient care. 'Out of hours' was handed to private companies and A & E to trainees and locums (60% of all Hospital Doctors are locums).  The patient became the supplicant expecting little and rarely being disappointed. Many died, were maimed or at best received poor care and continue to do so. Yet the gravy train for Doctors, now irretrievably committed to peddling 'Big Pharma's' often substandard or even useless products, rolled on, with further and more intrusive protocols, even for the 'worried well', moving medicine further and further away from diagnosing and treating disease, to fruitless and dogmatic (usually wrong) prevention interventions that were founded in poor or even bad science.

At no point in this train of events was it thought necessary to involve the patient, save for 'patient, public involvement' rhetoric that only sought the views of an unrepresentative minority, of charities and professional middle class campaigners, with the time and money to be involved in the 'tea and biscuit' culture of meta-quango's, discussion forums and pointless conferences. Constantly harangued, largely ignored, the public in general wants little to do with the NHS or even their Doctor, now ensconced in expensive and shiny Health Centres, except when they are sick or fearful. Then they are treated to an endless list of questions, unrelated to the condition they have presented with, to ensure the practise fulfills the QOF protocol and a test regime more interested in their 'lipid profile' than their pain. Is it any wonder that as 'modern medicine' lurches toward wholly preventative measures, instead of treating "the poor and the lame, the sick and the dying" (1), that we are becoming more and more disenchanted with that which we are financing.

There now seems to be a further erosion of NHS principles, driven by privatisation of Primary Care that has more to do with dogma than need, the desire to furnish capitalism with further subsidy, and the utilisation of the latest 'mousetrap' from Pharma, whose greed continues to know no bounds. Older drugs, and medicines that were 'fit for purpose' before, keep falling off the end of the list, for no reason other than a desire to use the new and shiny one approved last week, irrespective of efficacy. Once in fact, all of those in the NHS have had their piece of the cake, there is little left for the actual patient, except indignity, poor care and nonsensical intrusion into their lives. And yet, are not all of these people there for one purpose and that purpose only, to pursue the practise of Medicine?

Change is in fact needed and drastic change at that. Justice for the harmed, together with Candour. Genuine scientific protocols to improve lives, not the treatment of symptoms for the enrichment of a pernicious industry that no longer is fit for purpose; 'Big Pharma'. A cessation of intrusive, patronising and ultimately fruitless endeavours to engineer social change, with fear. Medicine without the boundary of 'out of hours', peopled by real physicians, who actually know what they are doing. Yes let's have a real and vibrant 'Big Society' in the NHS that recognises its goals are set by its patients, not by its political masters and I include in these the BMA, the GMC and the bloody 'think tanks'. In fact I'd rather like to put a tank on their lawn, and see if I could get Niall Dickson, John Appleby and Penny Dash with just the one round. That would be fiscally responsible would it not?

So whilst you politicians are are all pondering, as to what cosmetic changes you can make to a Bill that is widely reviled, and the GP's squeal about how they will be able to cope with all the extra work, without some extra payment (again!), spare a thought for the poor sodding patient, because they're the reason we have an NHS. They aren't the one's that fucked it up, you are!

"Perfection of means and confusion of ends seem to characterize our age." 
(Albert Einstein) 


(1) Quotation courtesy of Morton Thompson - 'Not as a Stranger' C1954.

Mandate, What Mandate?

The current ConDems have launched the Health and Social Care Bill, onto a largely unsuspecting public, who did not vote for them, and did not vote for almost any of the elements of this tawdry piece of 'Privatisation'. During the election, Cameron promised to ring fence the NHS, "I'll cut the deficit, not the NHS", was the clarion cry. He was going to stop "top-down reorganisation". He also promised to not raise VAT, and not to raise tuition fees, but that's another story (lying b*****d), but it displays the treachery, of an unholy alliance, of politicians, without any mandate from the people, to attempt to invoke such policies, completely contrary to their hollow promises.

This Bill takes an axe to the NHS, where a surgeons scalpel was needed. It gives the responsibility for Primary Care into the hands of a somewhat bewildered bunch of Doctors, who have little experience of Commissioning health care, and will be placed in the position of both poacher and gamekeeper. Under the requirement to allow 'any willing provider', to provide services, it will become illegal, not to allow the likes of Tribal, Circle, Virgin, Serco et al, to tender for services, which will be decided on price, at the expense of quality, due to the ability they have, to provide care, at less than 'tariff prices'. They will manage this, by 'dumbing down' the staff cohort with, nurse practitioners, salaried GP's and the Health Services versions, of the 'Polish plumber'.

We do need some perspective on this, I think, because I am not one who holds the NHS in reverence, in fact I have often treated it  with contempt ( which it deserved), and described many aspects of it with unguarded venom. But this was because of the many within it, who have meekly accepted substandard levels of care, turned a blind eye to their colleague's incompetence, and worse lied, to protect them, and thus, deny legitimate complainants, justice and candour. But was it ever the same? Doctors have been hiding behind the protection of the 'Bolam Test' for generations, on the simple principle that they are above the laws, that us mere mortals have to abide by. This is the unacceptable face of health care, both in the past and in the 21st century. As the paymaster of physicians, we deserve better.

But, the concept of 'free' health care for all (which is far from free), remains steadfastly my abiding belief. I spent a good part of my youth, and indeed my life, fighting for this goal, both for myself and for others. I became jaded by the actuality, many years ago (politics that is), after years of smoke filled rooms, far from the public eye, where the real decisions were made. The chamber was just the 'window dressing', for public view. 'Real Politic' was conducted always, behind closed doors. I gave it up, to wield my talents, for what they are worth, as someone in the 'real world', where you are judged by your peers, as competent, or having integrity and is the abiding tenet, I live by.

The NHS is important. But it has been flawed. A concept, conceived in the aftermath, of a war that was to change everything, was taken over by the self aggrandising, elite Doctor cohort, who began to manipulate the 'system' for their own ends. This was a construct, that within a few years, became a self perpetuating 'gravy train' for senior Doctors, Surgeons, and Consultants who had a foot in both the Public and Private camps. Manipulating the system, to enhance their income by 'cherry picking' the patients who could pay. Government stood by without demur, simply to keep them 'on side'. Thatcher ended some of that, probably, with an even worse system, that typified the excesses of the USA, where the concept of 'invoicing' everyone, for well, everything, was born. Another 'top down' re-organisation'  conceived in an era, that was to provide a legacy for the future, we have yet to shed; Neo-Thatcherism.

Blair et al, pursued this ideal, with PFI, PPI, Darzi and all the rest of the 'slieght of hand' that attempted to hoodwink, the populace, that 'World Class Commissioning' was the legacy we were to enjoy, by gist of the huge additional funding deployed, to bring the NHS to a 21st century health care standard. De-regulation, privatisation and draconian social policy, was continued with renewed vigour.  Like many before him, he bought off the GP's with new contracts, that they could only have dreamed of. The private sector boomed and management blossomed, together with the 'new era' of measuring everything, except care. NICE was born, the Quality Outcome Framework, was born, and we became gripped by surrogacy in our designs for measuring outcomes, instead of preventing disease or death. We believed the rhetoric peddled by 'Big Pharma', spurred on by that benign presence, in many of our lives, since childhood, our GP, who also bought into this, or retired (many did).

But what a betrayal! That same GP was being paid, quite considerable sums, to achieve these dubious, and often unrelated goals of lower LDL, increased HDL, lower BP, lower fasting plasma glucose, all founded in a flawed, even 'barmy' concept, with little or no scientific evidence to back it's goals. My masked hero has complained about this himself, here and here.

The public bestow, far too much benevolence, on those employed in Healthcare generally, and 'the hard pressed GP' in particular. Yet we are treated, with these appalling protocols, that are costing the earth, to no real effect, except of course the lovely money that accrues to GP's practise, and 'Big Pharma'. This is where real and meaningful cuts, should be made. And I do believe that QOF,s, ISTC contracts,  and PFI's that are eating up the NHS budgets to a far distant horizon, and 'rubbish', protocols that do nothing to advance the health of the Nation, is a folly we will live to regret, and will bring us closer to the 'NHS' plc of nightmare proportion.