"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Friday, 16 September 2011

Corrigan's dumbing down of patients to close hospitals

Paul Corrigan writes today in a pamphlet for the right wing think tank Reform that the hospital is dead. Corrigan is one of the architects of the Blairite NHS Planwith the underlying aim to privatise the NHS and so it is fitting that his pamphlet is published by the pro-market think tank Reform.

Corrigan's thesis is that about 70% of NHS funds are spent on patients with long term conditions and that hospitals are not designed to deal with those conditions. Hospitals fix illnesses and do not manage long term conditions. Or so he thinks. He then gives some free market mumbo jumbo to say that primary care is not good at long term conditions either:
The funding structure of the NHS has been constructed so that the GP practices do not get rewarded for providing efficient, preventative services to the patients. Rather, the payments are received by the hospitals as the patients become sicker. Consequently, in this type of healthcare system, there is a larger incentive to admit patients rather than to avoid admissions.
Corrigan clearly thinks the entire NHS top-to-bottom is not fit for purpose.

If a GP needs to have a financial incentive to treat his/her patients properly then s/he is a poor GP and should not be in the job. The incentive for the GP is to achieve a patient who can manage their condition effectively; just that. The same could be said of hospitals, but remember, the payment by results system that Corrigan criticises was introduced by the team he was a part of. Is he saying that he was wrong? I do not see a mea culpa in the pamphlet.

Corrigan argues that up to 40 hospitals will have to close in the next few years because he says that the care of long term conditions should be moved to "the community". This is the buzzword at the moment, yet no one seems able to say where this "community" is nor where the funding comes from to make the move. While there may be savings in moving care to "the community" (I do not know if this is the case) it certainly involves investment to make the move.

For example, a GP doctorpreneur in my area has decided that his new company is "the community" where treatment must be moved to, and he has decided to set up a primary care clinic. The clinic will replace his own GP clinic (so far, so good) and a community hospital which is run by the local hospital and is out of his control (so is unlikely to close). The new clinic will cost £10m with neither the doctorpreneur nor the local PCT (nor, indeed, anyone else) with any clue where the money will come from. The local hospital has an annual budget of £170m (which includes community health services) with an annual capital budget far smaller than £10m, and a long list of more important things to spend the money on. I will leave it up to the reader to think where the funding will come from and who, in the future, will control healthcare in that community in the future. (Hint: it will not be the NHS, nor anything the community controls.)

Corrigan also puts a lot of confidence in telehealth.

Telehealth ensures remotes delivery of care to patients, usually with long term conditions, in their own homes. The use of telecommunications and other computer-based systems make remote medical care possible. ... Telehealth is primarily used for diagnosis but has also been regularly used in monitoring various conditions related to the conditions of the patients. Recorded data or real-time images are used for clinical inspection which may be required for prevention, diagnosis, or treatment of a disease.
This is all very good as long as the the telehealth makes a difference. I am not sure it will. The problem is that it involves putting expensive kit in people's home, or more likely, expecting them to pay for it. Is this a good use of resources? Will it give better care to the more affluent and better educated and put the less well off and less well educated at a disadvantage and increase health inequalities?

Corrigan uses the example of one long term condition - diabetes - to support his thesis. I have some knowledge in the area since I have had type 1 diabetes for 35 years. Diabetics use blood glucose meters (Corrigan calls them glucometers) that cost about £25 and use test strips that cost about 50p each. The strips are available on prescription but the patient usually buys the meter, or more often, gets the meter free from the manufacturer on the Gillette razor blade theory (they give away the handles because they make a big profit on the blades, you just have to make the customer choose to use the blades). Currently diabetics use the most complex computer in the world to interpret the results from the glucose meter: their own brain. They record these results and then periodically use an equally complex, but slightly more expensive computer: their clinician's (GP or diabetologist) brain. The second computer is actually used for reassurance, and to make periodic changes, there is no need for the clinician to be consulted more often than three or four times a year (if that often) since it is the first computer (them!) that does most of the work.

Both of these computers (the patient and the clinician) needs to be trained and occasionally re-trained. But once a patient understands how to treat their condition, they can - and should - be allowed to manage it themselves. The patient is far better to be able to manage their care, for the simple reason that the patient has all the data at the exact time the blood glucose test is made, and the clinician doesn't. Diabetes is a balance between insulin injections (and or other drugs), carbohydrate and exercise. There are other factors too, like general wellbeing (a cold will raise blood sugar) and other factors which I know affects my blood sugar that no one can explain (the change from spring to summer lowers my blood sugar, and the change from summer to autumn raises it, yet I do not eat differently nor take different amounts of exercise; when my father died, for six months afterwards I needed 25% less insulin, yet I ate and exercised the same).

A patient with a long term condition has expert knowledge, the clinician reinforces, but must not replace this knowledge. Corrigan disagrees:

However, many hospitals and clinicians recognise this and have started to consider care beyond the hospital walls through the effective use of telehealth. At the Ulster Hospital in Dundonald, diabetes management was tackled by Dr Roy Harper in 2009. The aim was to empower patients to become better self-managers of their diabetes through education and self-management and to efficiently titrate patients just starting on insulin to achieve optimal blood sugar control. Patients were trained to use the monitors including their glucometer and all readings are transmitted. Nurses carry out a triaging process and escalate patients according to protocols designed with the specialist nursing team. Virtual clinics are held to review patients who require extra support or a change in medication. The team is able to review real time data without the need for a hospital visit by the patient or a home visit by a community nurse.
What Corrigan is suggesting is dis-empowering patients. Rather than the patient manageing their own condition by using their expert knowledge of how much they have eaten, how much exercise they have taken and how well they feel to interpret their glucose reading and to determine their insulin dose, he is suggesting that the responsibility should go to a remote nurse who only has a fraction of the information: the blood sugar readings. This is day-to-day monitoring that dumbs-down the most important part: the patient.

Corrigan touches on the actual solution to managing long term conditions: "education and self-management".  This is the vital part: diabetics need to have periodic intensive education under clinical supervision so that they can experience getting their management wrong as well as how to get it right. This is something that should be done in a clinical setting - in a hospital - and not at home. Once educated the patient then needs minimal monitoring by a doctor. However, long term checks - like HbA1c, retina monitoring, and checks on the feet - are things that must be carried out and interpreted by a clinician and cannot be done by the patient. I would also say that periodically - perhaps every ten years - a diabetic's computer need a reboot. They should go through the whole process of re-training all over again as if they were newly diagnosed. This is not just to teach them to manage their condition according to the more up to date methods (and get them out of bad habits) but also to ensure that the newer drugs they are using are used effectively and not merely as a replacement for the older drugs they were used to. Again, this has to be done under clinical supervision in a hospital.

Corrigan is not advocating this type of care - a form of co-production with their care team - instead he is advocating that the patient becomes completely subservient and dis-empowered and that the doctorpreneur "in the community" has the control.

Nope, sorry, I do not agree. I far more prefer to see a diabetic consultant to ensure that my computer - my brain -is up to date, and monitoring that I am unable to do, by my GP.

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