Not in my name

The government is very keen on using people with long term conditions as an excuse for their changes to the NHS. They say that without the changes we will use so much healthcare that we will bankrupt the NHS. I am not against change, but I am against blaming people for unpopular change.

On the 18 January 1976, at the age of 11, I was diagnosed with type 1 diabetes. I remember, during one of the appointments I had with the diabetes specialist, I was told that in later life I would have kidney problems; there was no "if", it was a definite statement based on the middle aged diabetics that he was treating at that time. I distinctly remember the specialist telling me that by the time I am 50 I will need a new kidney.

A lot has changed since then. I am three years off the half century and my kidneys are still working. Part of the reason for this is because of the preventative medication I have been taking for the last 15 years or so (ACE inhibitors and calcium channel blockers for hypertension). Part of this is because of better management of my condition through purer insulin and through finger prick blood tests. None of this costs much, in fact through new processes of making insulin the price of insulin has dropped over the last 30 years. It is cheap to keep me alive!

Dialysis, organ transplant and the long term follow up care for a patient with a transplanted organ is expensive. In 1976 a health economist could have looked at me and visualised a deep pit being dug to consume future piles of NHS money. The health economist would have been wrong. I am sure that I have cost the NHS a lot less than could have been predicted 35 years ago.

I am going to be uncharacteristically optimistic here: I do not think I will be a big drain on NHS finances in the future either. This is why I wish the government will stop using me as their reason for breaking apart the NHS.

What's happening in the Lords

Yesterday I attended Labour's West Midlands Regional Conference. The day was dominated by a debate on the economy and workshops on developing policy. Notably absent was any session on the NHS: Labour are very quiet about what their policy will be, whether this is embarrassment because they handed the Tories a legislative framework that would enable them to marketise the NHS is unclear.

Anyway, in the final Q&A session, in response to a question on the NHS (just one!) Lord Hunt mentioned the changed voting habits of the upper house. Michael White mentions this too, in the Guardian:

"When Labour was in power, the party's chief whip Lord Bassam could expect to lose one in three divisions if the Lib Dem, Tory and crossbench peers decided to strike down an offending clause in legislation. On issues like 42-day detention of terror suspects, defeated by the Lords in 2008, the unelected house spoke for public opinion. David Cameron's rose garden pact with Nick Clegg has changed the maths. With 170 Tory and 88 Lib Dem peers (the 153 crossbenchers often split 50/50) the coalition partners usually have a de facto majority over Labour's 238. No one party was supposed to have one in the half-reformed system bequeathed by Tony Blair, but no one planned for coalition. Government defeats are down to around 15%."

Yet again, the Lib Dems are allowing this damaging Bill to be passed. The Lords exist to amend legislation, and they have experts who can see the important nuances of the laws and suggest ways to improve bills. The 30% of votes that Labour lost means amendments to make the bill in question better. The 15% figure now means that the government is imposing its view and forcing its peers to vote en bloc. This is political and reduces the effectiveness of the chamber and allows bad bills to be passed.

The Bill sailed through the Commons Committee stage precisely because the Lib Dem members voted en bloc with the Tories. Not one single Labour amendment was passed by the Commons Committee. In fact not one single non-Government amendment was passed, because the Tory whips threatened Tory and Lib Dem MPs telling them that the only amendments that would be allowed to pass the Commons Committee would be those proposed by the government. This is the behaviour of a authoritarian government that believes that it is always right (a very frightening concept). We are finding the same behaviour in the Lords Committee.

If the Tories had not been handed a Coalition, and were now ruling by supply and confidence, the Lib Dem peers would be free to make amendments and make this bill better. Even if the Tories had scraped through the 2010 with a narrow majority, the Lib Dem peers would more often than not be changing this bill. Now they are sitting on their hands. It is very clear: Coalition is bad, and allows bad laws to pass.

Choice

I attended a patient forum meeting last night at my local hospital. During his talk the Medical Director told us a joke that he said was prevalent in the NHS of the 80s:

Receptionist: We can give you a date for your hip replacement: it will be 10:30am on June 22nd, 2015
Patient: Sorry, but I cannot make that appointment. The Gas Board is coming to install my cooker at 11 on that day.

Well, I guess the humour is all in the delivery. The point was to illustrate the "Soviet-style" of public services in the 80s: we were just too amenable to waiting long times.

Things have changed now, of course. The NHS constitution says that we have to be treated within 18 weeks and as David Cameron has found, there is a political cost to allowing waiting times to go up.

The 18 week RTT target was politically concocted, there is no special meaning to 4.5 months. (In Denmark, for example, the waiting time has to be less than 1 month.) Anyone who has been on a waiting list will tell you that it is not necessarily the amount of time that is the issue, it is the uncertainty of not knowing when you'll get the treatment. The uncertainty is especially acute if the patient is worried about the treatment.

Cutting waiting lists is expensive, so it is unlikely that any political party will promise to cut the (arbitrary) 18 week target. However, there is another policy that could be offered. Patients could be given one of two choices: treatment within 18 weeks, but the date is determined by the provider (the situation at the moment); or treatment on a date of the patient's choosing as long as it is outside the 18 week window (the actual limit may be different to 18 weeks). The idea would be to guarantee (as much it is possible to guarantee) that a patient will get the treatment on the day that is specified by the patient. This means that the patient will know that their cataracts will be replaced before they go on their birdwatching holiday, or their hip will be replaced before their child's wedding. There will be still work for NHS providers to so: they will have to have the capacity so that patients on the 18 week guarantee will fill the "gaps" between the patients who have booked.

So the joke would be partially true, patients may recieve treatment many months in the future, but the difference would be that they choose to have their treatment on that date. I think that this could be a popular policy at the next election.

Dithering

During the second reading of the Health and Social Care Bill Lord Owen suggested that clause 1, the clause that determines the Secretary of State's responsibility, should be considered by a Select Committee of legal and health policy experts rather than the full Committee of the House. The Government claimed that this was an act to wreck the Bill and Lord Owen stressed that this was not the case, even offering to put a time limit on the Select Committee:

"My noble friend and I said we thought it was absolutely reasonable that to protect the business of the House they wanted this Bill before the new Session. We had already made it clear that this would have to be reported out from Select Committee by 19 December, and that was acceptable. The clerks tell me they have to report it out. They may say they want more time but there has to be a report. So I think we have dealt with one of the problems."

This explicitly says that the Select Committee will report before the 19th of December.

Lord Howe, the Government minister rejected this amendment:

"The provisions that the noble Lord, Lord Owen, asks us to send to a special Select Committee affect the entire Bill. The twin-track approach that he advocates carries a major risk: the potential disconnect between the special Select Committee and the Committee of the whole House. The Select Committee might recommend amendments to parts of the Bill that have already been debated by the Committee of the whole House. The result could be that, notwithstanding the offer made in good faith by the noble Baroness, Lady Royall, we could see a slippage of the timetable of the Bill that would be most unwelcome."

This basically says that Lord Howe rejected the idea of having a Select Committee because it may discuss amendments already discussed by the entire House (sitting as a Committee on the Bill) and this would delay the Bill further. The Government is desperate to ram the Bill through Parliament because if the Bill is not passed before April 2012 the timetable for major changes like abolishing PCTs and SHAs will have to be changed.

Then yesterday the Government had a re-think. Commenting on the group of amendments to clause 1 being debated, Lord Howe said:

"having spoken to a number of noble Lords during the past few days, including my noble and learned friend, it is my view that the best course for this Committee would be for none of the amendments in this group to be moved today, and instead for us to use the time between now and Report to reflect further on these matters in a spirit of co-operation."

Now Lord Howe is saying that he does not want the full Committee of the House to discuss the clause, and instead he wants to submit an amendment during the Report stage of the Bill (in January). Later in the debate he added:

"I have said that I believe the balance of advantage for this Committee lies in our agreeing collectively not to amend the Bill at this stage and I am pleased that there seems to be consensus around that view. I believe instead that it would be profitable for me to engage with noble Lords in all parts of the House, both personally and with the help of my officials, between now and Report to try to reach consensus on these important matters."

During the Second Reading Lord Howe said that the clause must be debated by the whole House Committee, rejecting the proposal to ask a Select Committee of experts; yet yesterday Lord Howe  says that he wants informal talks with Lords rather than to allow debate in the full Committee.

The result of this dithering means that there is now a real danger of delay in the passage of the Bill, something that Lord Owen had tried to avoid with his original amendment. There is also real danger that there will not be sufficient time to debate whatever amendments that are made to clause 1. If Howe had allowed the clause to be examined by a Select Committee there would have been an opportunity for a full debate.

Lord Howe has handled this very badly, but it is symptomatic of the entire Bill: extremely badly drafted and badly managed.

GP Market

There was a short piece on the Today programme yesterday (here at 52m52s, also on the BBC website here) where journalist Jane Dreaper interviewed Sir David Nicholson. There wasn't much discussed, but the following was interesting.

Sir David said that under the Health Bill data will be provided about what services your GP provides compared to other GPs in the area and nationally:

"this is a powerful mechanism for patients to make choices about which GP they use - if you have a long term condition you might want to think in the future about different GPs and whether they are providing a full range of services"

There are a couple of issues that Sir David is ignoring here. First - it should not be necessary to say this, but clearly Sir David seems to have forgotten - a long term condition (LTC) is 24x7 and it is usually for life. A patient will die with the LTC and most likely will die of the LTC. This makes continuity of care vitally important. The best control of their condition comes when patients with LTCs have a good and continuing relationship with their care team. The idea that patients can simply "shop around" for services means that such relationships will be difficult to form and maintain and this threatens continuity of care. Jonathon Tomlinson has written extensively about the relationship between GPs and their patients and Sir David could do no better than to read his latest blog.

Then there is the issue of how will patients know what services could be available? Occasionally I attend diabetic support group meetings and it is clear that there are some people who have had diabetes for decades and are still treating it like they were first taught to. Their blood tests show that their control is adequate so there is no need to tell them to do things differently. If a patient is treating their diabetes like it is 1980, they will not know if their GP is not providing all the diabetic services they should. It should not be the responsibility of the patient to move to a GP with the best services, it should be the responsibility of all GP practices to provide all the necessary services.

The final issue with Sir David's comment is that it appears to ignore the structures that he is putting in place. Every GP has to be part of a Clinical Commissioning Group (CCG). The Health Bill says that CCGs have the responsibility to ensure that healthcare services are provided for the patients in the area that the CCG covers. This is important: it is a responsibility of the CCG that the GP practices in the group provide the services that are required for their patients. So if a GP does not provide a service that will be as much the responsibility of the CCG as the GP. To get the service the patient needs, s/he will have to move to a GP practice in another CCG that supports the service. There are some large CCGs (for example the Manchester CCG has 107 GP practices, Liverpool has 91, County Durham has 88) so moving to another GP in another CCG will mean having to change to a GP in another city. That is simply not possible for most patients and certainly not possible for patients with long term conditions who need a continuity of care.

Sir David was suggesting a market of GP, but he has structured the NHS so that this is not possible.