Reading the Bible

 

 Rescuging the NHS

In February some friends and colleagues, and their friends and colleagues, signed a letter to the then Opposition leaders pointing out that saving the NHS was not jsut a matter of pouring more money in. It needed a change of culture. An edited version of this letter was published in the British Journal of General Practice last month. For those who may not be able to access this that text is pasted below.

Since then Lord Darzi has published his report on the state of the NHS.Fortunately for those who lack the stamina to read 163 pages stuffed with figures and graphs, he has also prepared a letter summarising his findings. Although phrased differently many of his findings, particularly his call for greater engagement of patients and NHS staff and the reduction in ineffective and excessive regulation, reflect our concerns.

The Government has promised to develop a ten year plan to address his findings over the next six months. It is the nature of the BJGP that it is read by GP’s, so I thought I would repost our text with links to the Darzi Report here to encourage a wider discussion of what ought to happen to rescue the NHS. Whether you are a professional, a patient, a relative, carer or a combination of all of these please contribute to this discussion by posting your thoughts below, and also if you can sending them to your MP.

Peter D Toon

Here is the text of our open letter:

Dear Sir Keir and Mr Streeting,

We were very pleased to hear that the Secretary of State for Health and Social

Care has commissioned an immediate and independent investigation of the NHS with

a particular focus on assessing patient access to health care, the quality of health care

being provided, and the overall performance of the health system.

Addressing the chronic underfunding of the NHS in recent years is crucial, but in

order to make the best use of additional money we must also review the way in

which the NHS is managed. No doubt OVID-19 placed an enormous strain on

the NHS. However, much of the current low morale, high levels of burnout, and

consequent difficulties in recruitment and retention in primary care are the result of a

neoliberal market paradigm that promotes a ‘factory model’ of health care. This

industrial model of care is predicated on increasing control, micro-management,

and targets as the solutions to failure to meet demand. As a paradigm, it devalues

the importance of personal relationships, continuity of care, and of seeing disease

within the broader context of people’s lives.

A recent article in the BJGP compared this efficiency drive with 19th century measures

to improve drainage by straightening rivers.At first this seemed beneficial, improving

fertility and productivity, but more recently, adverse effects, increasing flood

risk and washing sediments downstream, have become clear and the changes are

being reversed. Similarly, measures to improve ‘efficiency’ in primary care that

superficially look reasonable can in fact just wash problems ‘downstream’ and result

in ‘flooding’ of community and hospital services alike. Community, hospital, and

emergency services are drowning, and the most experienced and compassionate staff

are leaving or reducing their hours, and even taking their own lives.

As the Royal College of General Practitioners (RCGP) emphasised in a recent

joint letter from the membership to the new Secretary of State for Health and Social

Care, there is a need for adequate funding of primary health care to make the NHS

work. However, ‘re-wilding’ and ‘re-wiggling’ of primary care, valuing and strengthening

patient–professional partnerships, and collegiality between clinicians is also

needed. This requires measures that support continuing relationships, so that trust

develops between patient and professional, and also between clinicians. We were

therefore pleased to hear before the election that Labour plan to reward general

practices for providing continuity of care, but a change of philosophy is also needed.

Self-efficacy rather than dependency should be promoted in an environment where

patients can be confident that support from familiar and trusted clinicians is accessible

when needed. Conversely, systems that encourage a customer/provider model of

health care must be discouraged, as these reward activity and short-term metrics of

success rather than good, long-term care. This holds true both for industrial and

consumerist approaches to health care. Humane health care also requires

subsidiarity; organising healthcare systems at the level of the smallest unit practicable

— the practice, hospital department, or hospital, instead of monolithic systems that

do not account for local variation in need or recognise the shared and diverse values of

our fellow citizens.

This includes enhancing accountable professionalism. Professionals

need to feel trusted but also responsible for the standard of care they and their

colleagues offer, rather than be treated as cogs in a machine.

This requires an end to toxicmanagerialism. We recognise that the NHS

needs good managers; in both primary and secondary care, they are essential members

of the team. But their focus should be on building morale and commitment, and

on the practicalities of cost-effectiveness, rather than implementing systems of

targets and protocols without regard for the people who deliver the service and the

experiences of service users.

While implementing these values requires changing attitudes, and in some cases,

particularly at senior levels, perhaps changes in personnel, structural re-organisation

should be discouraged since it is an expensive distraction and often further

damages morale. Measures to improve professional morale

and promote continuity of relationships are not just a matter of making professionals or

even patients feel better (although that is no bad thing), it has financial benefits. Good

morale helps retention and recruitment, and continuity of care improves efficiency (for

example, by avoiding unnecessary tests and referrals) and outcomes, including mortality.

When the Labour Government took over in the 1960s, their ‘Family Doctor

Charter’ reforms laid the foundations for the transformation of general practice

from a cottage industry into a system of primary care that for more than 20 years

was admired as the best in the world. We hope and trust that this government will do

something similar to revive general practice and primary health care more widely.