NHSCA Editorial March 2011 Interdependence and Autonomy in the NHS - A Market Conundrum This issue of the NHSCA Newsletter has been Classical public health, having largely themed on the general concept of how a variety conquered the contagions, was finding common of specialist/consultant medical practitioners ground with the relatively new discipline of see their specialism taking its place in a well clinical epidemiology which was increasingly integrated health care system. The general concerning itself with the non-communicable principle of integration of health and social diseases. This set the scene for important new care services extends into the very many life concepts relating the health of individuals to and work customs and activities which bear the health of the societies in which they lived. on human health and disease. Each of the In his momentous paper “Sick Individuals and contributions to the Newsletter is necessarily Sick Populations” Geoffrey Rose demonstrated brief and constitutes the personal reflections of clearly that the largest numbers of disease the contributor. They cover only a small part of victims – numerically the major social burden of the great number of specialised activities which the disease – arose from people with only minor now go to make up a comprehensive medical elevations of risk factors, at low individual risk service. They have been written by individuals but of whom there were great numbers. Medicine who are very aware of the opportunities and traditionally concerned itself with patients with limitations of the current structure of the health major risk factors for the disease, at very high individual risk but contributing little to the total care and social services and with some regard population toll. to the new pressures applied to them by past and portending market reforms. It would be of Integrating the New: Public Health interest to seek the response of the patient-public to the thoughts and ideas expressed. The consequence of these observations was that while identification and treatment of those at high Broadening Frontiers of Medicine risk, i.e. the high risk strategy and the business of clinical medicine, was of great importance for The dream in 1948 was of a fully integrated this small number, it did relatively little to lessen National Health Service, aiming for healthy the total social burden of disease. A substantial individuals within healthy populations in which reduction of this burden required a strategy care in the community, eventually to be delivered which called for significant modifications of through a network of Health Centres, was linked habit and way of life throughout the population. in a continuum of care with specialised services This recognition introduced new dimension into provided largely in refashioned hospitals. The the interaction between medicine and society. long period of public discussion and debate The application of these principles in prevention which preceded the landmark 1946 National and treatment of coronary heart disease was Health Service Act broadened the concept of demonstrated by Pekka Puska in the North health care from the paradigm of the hospital Karelia province of Finland. A determined ward, filled with patients with advanced intervention into the nutritional, physical disease, into the large communities of working activity and tobacco smoking behaviour of the people and their families where so many of these population was rewarded by an 80% fall in the devastating clinical disorders were incubated. rates of coronary heart disease, dramatically greater than the fall in the rest of the country. It that consultants might just have some say in the is highly likely that the greatly improved outlook disposition of these resources. It is difficult to for coronary heart risk, particularly in younger escape the conclusion that this is an example of a people in many westernised countries has been ‘divide and conquer’ strategy of a manipulative effected by such well coordinated, population government. based measures. It is reassuring that, in an attempt to forestall the Primary and Hospital Care; the GP and the increasing separation of primary and secondary Consultant. care by the Lansley Act, the Royal College The sharp divide between the general of Physicians has recommended hospital practitioner and the hospital consultant has consultants to meet with the GP colleagues historical origins, now almost irrelevant, but who will, nominally, be commissioning them. still influencing the relationship and inflicting a Together, on a colleague to colleague basis they damaging division upon the profession. In the could try to work out the most clinically and 19th and much of the 20th century, the consultant professionally desirable ways of remodelling was seen as the aristocrat of the profession who their relationships and hopefully frustrating regarded his GP brethren as the lower orders, a the transactional Chinese Wall which currently contempt which he kept carefully cloaked since separates them and which renders both sides consultant practice depended on referrals from more manipulable by market management. below. The workplace of the GP was often a How secure these meetings between consultants converted drawing room in a respectable house and GPs will be from accusations to the but sometimes, in the city centre, a lock-up shop- Cooperation and Competition Committee that front in a down at heel street. The consultant they unfairly favour the NHS as against the lorded it often as an unpaid honorary, in some private provider remains to be seen. Doctors in noble old Victorian pile or among the soot- a Lansley future may have to tread much more stained stones of the great teaching hospital but carefully in professional relationships which turn with consulting rooms in some select quarter out to be malpractices that they never imagined of town. Their reward, apart from the glory might breach competition law. It may not only reflected from the brand of the famous teaching be the entrepreneurial private commissioning hospital, was the privilege of instructing medical companies that are readying themselves for students who would ultimately be the source of action but a whole new set of opportunities may paying referrals. be opening up for enterprising law firms. GP Purchasers (Commissioners) and Teaching, Training and Research - Consultant Providers – the Transactional Orphans of the Market Divide Proposed legislation from the impatient Lansley These old roles and attitudes which conditioned reformers shows a lack of real concern for the generations of professionals have largely vitally important areas of medical education, dissipated but the division remains. Even a professional training and clinical research. The new and advanced generation of GPs took (as dissolution of the long-established and fruitful some probably still do) a grim pleasure in the cohabitation of clinical and academic medicine ‘dethronement’ of the hospital consultants and within the NHS operating successfully, on the a certain reversal of roles which followed the basis of an informal ‘knock-for-knock’ formula establishment of the market NHS more than 20 was an early casualty of the financial stringencies years ago. Division still scars the relationship of the internal market. Subsequent reluctance of between primary care and hospital practice and management to allocate more time and resource has lent itself to skilful political exploitation. outside income-generating items of clinical Consultants and GPs have been deliberately service has not fully succeeded in re-establishing separated into a transactional posture across a the lively academic life of heretofore. pseudo-market gulf between ‘purchaser’ and ‘provider’. The most recent act of placing 80% Continued Professional Development – or so of the NHS spend in the hands of the GPs postgraduate education and the like – depends carries little more than an airy acknowledgement upon the collaborative working of a variety 2 of locality clinical units and the Postgraduate Health and Social Care Coordination Medical Deaneries of their areas. The abolition A well coordinated working relationship of the Postgraduate Deaneries as proposed in a between health care and social care has been the recent White Paper ‘Developing the Healthcare subject of discussion and dissension probably Workforce’, linked to the Lansley NHS market since the dissolution of the monasteries (which reforms and this has raised concerns with the in their own unquestioning way looked after General Medical Council which has argued that both the sick and the poor). Despite the clearest local spokespersons with special concern for of links between social conditions and the medical education should be appointed to ensure genesis, treatment and outcomes of ill health that market-driven changes are not allowed to and disability, the problems of the division of override the needs for education and training. resources between them remain contentious; Also on the agenda is a potential new demand should they draw on a single funding source, for remediation resulting from revalidation basing allocation on a flexible local appraisal of failures. It is difficult to predict how large a new priorities or should each be provided with its requirement this will be but it will need to be own ring-fenced resource allocation with a hard, accommodated and coordinated with academic agreed and inescapably arbitrary line drawn and training activity which will themselves be bedding