Every experienced doctor will have their own story of a case which went badly wrong for all the wrong reasons. In the 70s, when I was in my second week as a surgical houseman, I was cross-covering the urology team.
The professor contacted me in the evening concerning a private patient to be admitted, Mrs B. She had had an appendicectomy that afternoon, but the appendix was normal. The surgeon thought he could feel a dilated right kidney (this was before the advent of US and CT). The patient was shocked, septic and the presumptive diagnosis was a pyonephrosis. I was given explicit instructions as to her management, including fluids and antibiotics. I was the only doctor to see her on admission.
Examining her at midnight I experienced that deep sense of unease we all recognise, and sure enough she arrested and died just before dawn. The post mortem revealed a normal kidney and an underlying undiagnosed cardiac anomaly. She died of crashing heart failure. It was the tragic combination of the wrong diagnosis, the wrong treatment and an inexperienced junior doctor who dared not question his seniors.
From this I learned one of the fundamental lessons of my career which is that it doesn’t matter how important or prestigious another doctor might be, you must not assume that they are right. Being an expert allows you to be wrong with authority! You need to step back and make your own judgements in every case.
This brings me to the Health and Social Care Bill. I acknowledge that there are very strong feelings against Lansley’s proposals and I do not wish to minimise the concerns of many. The debate has made me careful to reflect on my own views on this issue. However I get the feeling that there is a bit of a bandwagon rolling on (argumentum ad numerum, “if many believe so, it is so”).
The recent Ipsos MORI on-line poll commissioned by the BMA implies overwhelming opposition to the bill, but I note that there was only a 9% response rate from the 18,456 doctors surveyed. I therefore think it is rather disingenuous to extrapolate from this to the rest of the profession. I listened to some of the Lib Dem conference last weekend and was dismayed at the low level of the debate. It seems that our NHS is so wonderful that nothing must ever be reviewed or changed. I also get very frustrated at the repeated use of the word “privatisation” by the Bill’s opponents. To Joe Public this word means that our healthcare will no longer be funded by the tax payer, and we will have to pay up front like the US system. This is rubbish, and is a political scare tactic used merely to garner uninformed opposition.
During the time of the last government I spoke and wrote vociferously against the top-down, command and control, target-driven, name-blame-and-shame management style of the NHS which I believed stifled innovation and motivation. The result was that many doctors simply disengaged, feeling powerless and de-professionalised.
I stated this to Andrew Lansley when I met him with several others about a year before the election. So what has he done? Well he has taken us (and many others) at our word, inverted the pyramid, and is putting clinicians back in the driving seat and aims to reduce the power of the government to interfere. Now I know he is a politician and therefore, by definition, not to be trusted! But I have been impressed over the last few months at the care he has taken to answer in detail the questions put to him, even responding to the letters written by individual doctors. He has also demonstrated a willingness to listen and modify his proposals appropriately.
The concept of ‘any willing provider’ linked with competition also causes apoplexy among many. It seems that the idea of companies ‘profiting’ from the tax payer by providing healthcare services is anathema, on a par with sacrificing babies to Beelzebub. But excuse me; there are thousands of companies which make a profit from the tax payer by contracting to provide all manner of infrastructure of our society. That is how a liberal democracy functions. Do we expect Balfour Beatty to build our roads for no profit? Why is the NHS so sacrosanct?
The attempts of the last government to introduce the independent sector to the NHS largely failed because the contracts awarded were unfairly financially weighted to bribe the companies. The drive to make them succeed also blinded managers to clinical quality issues. But, given a level playing field, there is no reason why a health company or a not-for profit organisation should not provide some aspects of healthcare, as long as they can deliver on quality and are subject to exactly the same monitoring as the NHS. I personally have never been against this. Let’s be honest some of the current NHS services are very poor, and there is little or no motivation to improve under the current system.
Even as I write the BMA are debating the issue and no doubt, because I take a different view, I will be branded as an agent of destruction. But I am passionate about the NHS and have served it loyally, at some considerable personal cost, for many years. It is just that I don’t think it is untouchable. What was right 60 years ago is not necessarily what is right today and there are other, and possibly better, ways of delivering healthcare.
I want a sensible diagnosis and the correct treatment. Remember Mrs B.