How is the National Shared Care Record Project Going?

Today's FT prints a concise summary of the rise and predicted fall of the National Care Record project. You can read it here.

The FT Agrees with Me!!

Some things were ever so. As William Moyes, chairman of the foundation trusts regulator, confirmed this week, reform of the National Health Service has been slower than was hoped. The same can be said of the UK’s other wasteful state services. The Conservative party, which is likely to win the general election due by next summer, has rightly focused itself on public sector reform. But this, sadly, will not help it cope with the UK’s gruesome fiscal position.

The next government will need to close a deficit of about 12 per cent of output. The Treasury’s current plans leave the deficit at a still-cavernous 5.8 per cent in 2013-14, but even reaching that halfway house will require cuts in real terms to departmental budgets of 2.3 per cent each year. This ever-tightening fiscal straitjacket should be the salient feature of British politics. But neither main party has recognised the scale of the task.

The Labour leadership, rather pathetically, has had real trouble simply admitting that spending cuts are a necessity. And, last week, George Osbone, the Tory shadow chancellor, said that, under a Conservative government, “reforms to public services ... mean cuts on the frontline can be avoided ... ” This, sadly, is something of a fantasy.

The Tories are pointing in the right direction on schools, welfare and healthcare: they hope to drive up productivity by introducing competing private providers into these arenas. Such policies would improve public sector value-for-money. In the medium term, they would create room for savings, for example, by helping to contain the medical costs of the greying population.But, in the short term, these reforms would be expensive. During the grim years of restraint, they would be a fresh drain on the exchequer. And, even if they were costless, they could not boost productivity by the amount needed to shelter services from the axe.

Whoever wins the election – and however strong their reforming zeal – the next government will be remembered as a cutter. No reforms can save the British state from its coming resculpting: this is why both parties must unveil coherent political agendas.Labour and the Tories must both explain which functions of government they regard as sacred and which, if forced, they would sacrifice. It is absurd that we do not know what the UK’s national parties would like the British state to be doing in 10 years’ time. One now wonders whether the parties themselves even know.

Reality vs "Real Term"

The forthcoming general election - a maximum of nine months away - will generate a great deal of heat about each party's plans to preserve and improve the NHS. I can't imagine that any of them will admit to any plans to reduce spending so that's alright then ... isn't it?

Well, not exactly.

Given the state of the UK economy and the amount of debt, both government and household, that we have finally started to confront, it is more than liley that the spin will be "spending will be maintained "in real terms".

Things to ponder ...

1. Our population is growing. So maintaining spending means spending less per patient.
2. Our population is ageing and the older you get, the more you cost. So maintaining spending means there isn't enough to look after the additional elderly.
3. New and expensive drugs and treatments are constantly being added to a doctor's armoury. So maintaining the spending means there isn't any money to pay for the new stuff.

Spending in real terms is unchanged. Spending per patient is, in reality, reduced and advanced treatments will be rationed if available at all.

It's an Emergency

I first started working in an NHS GP practice over six years ago. One of the first challenges was to try and get a grip of unscheduled care of our patients; people phoning us or turning up 'at the desk' demanding immediate care usually in the form of "seeing the doctor... now". Being an 'outsider' and a novice, I reached for ... The Contract. This was, and supposedly still is the document that defines what we had to do to fulfil our responsibilities as an NHS general practice. It didn't help.

It told me that we should provide urgent care when it was needed and so I entered the wonderful Heller-esque world of Catch 22. How do I tell which patients need urgent care? I'm not a clinician. Neither are my reception team. The only people who can decide whether something is urgent are doctors or senior nurses and that's precisely what the person at the desk wants. Thus we ended up in the situation that the way to get urgent care was simply to say: "it''s urgent". Actually what they usually say is: "it's an emergency". It rarely is.

During the week, our patients can always get to see a doctor within 24 hours. They may have to wait longer if they wish to see the doctor of their choice but if something is urgent, then that's the maximum wait. It's usually less. Anybody phoning before 11 am and who says "it's urgent" will be seen that morning!! Routine appointments (which last longer) are usually in a couple of days time, and if you want an evening appointment, then it will be anything up to a week (but if you're fit enough to get to work, then maybe that's not as bad as it sounds?

The upshot is that the anxious, the worried well, the over-dramatic, the unscrupulous, and the irresponsible get to the front of the queue; whilst the sensible, the responsible, and the reticent wait until an appointment is available. It didn't seem fair then, and it still seems unfair now.

I have asked "the authorities" to define what constitutes "urgent" but they duck the issue saying it is a clinical judgement. Clearly they can't generate a list of ailments, but they could provide us with something like "an impact scale"; a description of the sort of impacts that are "emergency", "urgent" or "non-urgent". It could be similar to the categories assigned to IT problems where the severity is decided by the effect of the fault (inconvenient, etc) rather than a definition of it. We would probably end up seeing the patient but at least, if they were taking the mickey, we could then caution them about their unacceptable behaviour.

Until that happens, the usual suspects will arrive at the desk, demanding to see the doctor of their choice, because "it's an emergency".

Extra Money? I don't think so!

In 2002, our practice moved over to a different contract under which we supply 'doctoring' to our local population. I won't bore you with the detail but we signed what is, in the jargon, a Primary Medical Services ("PMS") contract. In essence, we are paid an annual sum of money out of which we have to run the practice, rent and maintain the premises, and pay the staff. Whatever is left is the partners' earnings. This is the same contract that the Department of Health propagandists have been denouncing as "too generous".

The first year (2002/03) payment was £1,106k.
This year's payment (2008/09) is £1,128k.

If annual payments had been adjusted by changes in the retail price index (RPI) , this year's payment would have been £1,374k. So inflation has eaten away 22% of our real income. At the same time, our practice list has grown by 7%.

The total amount we have "lost" through inflation is £767k over five years. By end 2010, they will have six years for the price of five.