Think of the Consequences

NHSCA EDITORIAL September 2014 Think of the consequences This July, a passenger aircraft was shot down such clinics are usually staffed by GPs with a over Ukraine by a ground–to–air missile which, Special Interest (GPSIs), many of whom do not it seems likely, was provided to one of the fulfil the supposedly mandatory experience armed groups in the area by a third party. This and training criteria for such posts. David Eedy appalling event raises many issues, including points out that the use of these ‘community’ the immorality of the arms trade and the results clinics has never been shown to reduce hospital of interference in a neighbouring country’s waiting lists, they threaten to destabilise the territory and politics, and beyond this there are hospital service and they cost a lot more than the issues of unforeseen consequences. Those hospital clinics. The service thus provided is operating this complex modern equipment not acting as a useful filter to reduce hospital almost certainly had no intention of annihilating referrals and causes only delay in reaching a true 298 innocent travellers, neither, presumably, specialist service. Further, we cannot ignore the did the providers think they might. It seems inevitable impact of this continued outsourcing likely that inadequate training, against a on education of students and trainees as the background of inexperience of such dangerous service is fragmented. At a recent public equipment, resulted in this disaster. Unforeseen, meeting a woman who had attended a local but not unforeseeable. private sector dermatology clinic told us that she could not fault the service - everyone was very Nearer to home, we are increasingly aware of professional and the surroundings pleasant - decisions about clinical services made by those except that they could not deal with her problem who know little about them, do not wish to look and she had to be referred on to the hospital. at the evidence and ignore all expert advice on the Not a good use of public money and all this was grounds of vested interests. Have they thought eminently predictable. through the consequences? The Coalition seems to be rushing headlong and deliberately towards Outsourcing usually does result in patients a US-style insurance model, but have they really being seen by less well trained and less considered all aspects of what it will mean if this experienced staff as well as much performance is the outcome? management. A local private-sector talking therapies service which has taken over NHS Across England, most CCGs have adopted the staff expects them to be present at work but frequently promoted mantra of ‘Care Closer to does not pay them if the patient fails to attend Home’. It may seem like a good idea initially and –(is this a zero hours contract?) - while some may win a few votes. 70% of contracts for clinical outsourced community carers have been forced services have now gone to the private sector but to make shorter visits to patients’ homes and Contents: Editorial Andrea Franks, pg 1; David Eedy on Dermatology In Crisis, pg 3; Malcolm Bateson on Rescuing Out Of Hours Care, pg 6; Linda de Cossart and Della Fish on Education Matters, pg 8; David Wrigley on the NHS General Practice Crisis, pg 11; Eric Watts on Attacks On The NHS, pg 12; Mark Aitken on Racing To The Bottom, pg 17; Anna Athow on Keeping District General Hospitals Open, pg 18; Peter Fisher on Meeting Andy Burnham, pg 21; Arun Baksi on the Exclusion Of Doctors From Work In The NHS, pg 22; are no longer paid for travelling time. and a constant ‘cost improvement programme’, while the Health Service Journal describes chaos In the Netherlands similar pressures on district in specialised commissioning. Bringing down nursing and home care had been occurring, flight MH17 cost 298 innocent lives and was with great reductions in trained staff. In the last probably a dreadful mistake, but these NHS few years, an interesting ‘Buurtzog’ initiative in policies, if continued, will cost a great many more community nursing, mentioned by Roy Lilley in lives than that and result in far more suffering, his ‘NHS managers net’ blog, has shown that use physically and financially, in years to come. This of relatively well paid and experienced nurses can be predicted by looking across the Atlantic with a high degree of autonomy has resulted in where the US system is the least cost-effective more effective care with patients needing fewer and most expensive in the world, where at visits. An additional bonus has been a reduction least 26,000 Americans – up to 48,000 in some in sick leave and a much lower turnover of estimates - die each year from lack of medical nurses, a predictable outcome as a degree of care and where health costs are the commonest autonomy has long been shown to increase cause of bankruptcy. job satisfaction. Is there hope of a change? A recent Yougov poll Nationally, in the English NHS the Health and shows massive support for public funding and Social Care Act, combined with austerity and provision of public services, particularly the a massive squeeze on NHS budgets, is having NHS (84%) but also others such as railways, a very serious impact. Linda de Cossart and water and electricity. A ComRes poll in July 2014 Della Fish mention concerns over the morale showed that, although tax rises are generally of young doctors and their enjoyment of their unpopular, 57% would support a tax increase professional work; in an MPS survey last year to maintain current care and services in the 1/3 were apparently reconsidering their career NHS. Probably even more would do so if the choice. Constant media scare stories (eg, in the predictably wasteful market could be dropped. Mirror: ‘GPs failing THOUSANDS of cancer Can we follow Scotland and Wales and go patients by failing to spot early warning signs’), back to public provision? Andy Burnham has combined with ever-increasing workloads, are made some encouraging statements about his demoralising and frustrating for the senior staff proposals if Labour wins the next election, but who should be their mentors and role models. Ed Miliband’s intentions are not altogether clear. The ‘Sun’ recently urged its (literally) misguided Or will we (I write this as Liverpool has again readers to phone in with their NHS horror stories, hosted a ‘Giant Spectacular’ street performance so more will doubtless follow. Management with huge and wonderfully expressive puppet manuals suggest that constant reorganisations, figures) see even more of the NHS taken over by an environment of uncertainty, stressful Virgin, Serco and other international ‘giants’? competition between people and departments and a feeling of being unappreciated are very For most of us, failure to recognise foreseeable common reasons that people are unhappy in consequences, or foreseeing them but ignoring their work and wish to leave. Does this sound them, constitutes negligence, about which the rather familiar? GMC has views. Understaffed A&E units are unable to appoint Public awareness is slowly rising, though new consultants as so many have emigrated in relatively few people seem to realise the search of a better working environment. There enormity of the damage being caused to the appears to be a crisis of GP recruitment too, both NHS or the ultimate aims of the policies. Can to practices and to out of hours services, where the new Jarrow march, soon to set off as I write, we are told that 60% of providers have gaps in possibly be the trigger to alert the public to the their rotas. Privately run GP services can be, and dangers, and induce our politicians to look at the have been, abruptly terminated, presumably evidence, not the ideology? because they are insufficiently profitable. Could all this have been predicted? Of course it could. GP funding is in crisis, hospital funding is ever ANDREA FRANKS more precarious because of reductions of tariffs Guest Editor 2 Dermatology in Crisis: the new NHS Dermatology today faces a number of challenges, disease is life shattering with severe cosmetic and some of which will be familiar to many other disease psychological consequences. Skin disorders are more specialties, while others are largely unique to than just an annoyance. Skin cancer is now the UK’s dermatology. With Simon Stevens, the new CEO of commonest cancer, and its incidence is rising with NHS England stating that three quarters of the NHS no sign of slowing down2. Chronic sun damage and should be handed to private companies in the next multiple skin cancers make this the most significant decade to encourage “disruptive innovation”, the dermatological long-term condition. Skin disorders, problems may well get worse.1 including skin cancer, also arise in patients with other medical problems (e.g. HIV, diabetes, organ A major issue is the lack of political will. The transplantation, immunosuppression) and from the government still does not see skin disease as a priority side effects of drugs for other diseases. area. Whilst dermatologists are doing what they can to highlight their patients’ needs, for example by Yet despite the pervasiveness of these diseases and influencing the commissioning process, it requires the huge impact they have physically, cosmetically, other stakeholders to recognise the risks to patients emotionally and financially on people’s lives, and services and to militate for changes that will dermatology has suffered from the negative impact alleviate the burden of skin disease in the UK. of non-evidence-based health service reforms, with patients consequently suffering. There are few What are the fundamentals? Demand for dermatology true alternative providers for skin disease patients, services is at an all-time high, with more than half because dermatological teaching in medical schools the population every year suffering from a skin is sub-optimal and specialist numbers insufficient, condition.

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