Health

Matters of Concern

We would like to contribute suggestions on 6 matters: running the NHS, trends in medicine, accountability, health education, quality of life, and medical liability.

Running the NHS

There is a great temptation to try to solve problems in the public sector through re-organisations. A re-organisation is an obvious sign that "something has been done", and for a while, optimistic claims can be made for what it will achieve. Yet the efficient running of most public sector bodies, especially the NHS, relies heavily on the dedication of their staff, their motivation, and their morale. Frankly, motivated staff will "make the system work" irrespective of the organisational structure. If the NHS is "failing" or "in crisis" we should, unlike the Conservatives, start looking at the underlying causes. We would emphasise 4 things.

1. First, re-organisations that are entered into without care can do more harm than good because they will destroy morale. The demands for locally negotiated pay and short 12 month agreements between purchasers and providers clearly fall into that category.
2. Second, one can not sustain morale when given an impossible job. Both Conservatives and Labour have demanded unrationed health, whilst providing a fixed and insufficient budget and failing to train sufficient doctors and nurses. When faced with irreconcilable problems, they have selected some of the most visible deficiencies (eg waiting lists) and given them absolute priority, often at the expense of more needed cases. In the Mandy Allwood "octoplets" case, the regional office of the Dept of Health overrode the decision of the local HA not to pay for treatment in London, to maintain the fiction that health care was unrationed. In defence it is agreed that the armed forces have only limited objectives. So it should be with the NHS. Politicians have to be honest about the fact of rationing, enter into a contract with the NHS, and take responsibility for any deflation of expectations. They should agree what can be achieved for specific budgets, and what priorities should be pursued. It is politicians who should face up to the cost of beta-interferon for MS or aricept for early Alzheimers, not doctors. If we have honesty, we can have sensible debate, and allow the electorate to influence expenditure.
3. Third, league tables for hospitals, operations and so on should be abandoned. As has been seen with schools statistics rarely tell the full story. They can be manipulated and have adverse effects. Eg measuring death rates for serious operations will cause hospitals to pass by the more difficult cases, just as schools exclude disruptive pupils. Instead there should be "constructive" medical audit, working with doctors to improve medical practices, properly funded.
4. Fourth, the patient's charter should be quietly forgotten, and the monitoring of standards left to CHCs. Doctors and other staff are not Gods and patients can not expect them to be so, especially when they are, as at present, being asked to do an impossible job. Instead more attention should be focussed on individual responsibility. It is appalling that about 25% of patients fail to turn up to consultant appointments; that many attend GP surgery with minor sniffles; and that frequently we, the public, expect the NHS to save us from the consequences of our own unhealthy lifestyles.

Trends in Medicine

Staff in the NHS are rarely given due credit for the advantages in medical treatment and the gains in productivity they have achieved. Transplants, joint replacement, the elimination of smallpox and so on represent a small proportion of the achievements. The trends however are of increasing specialisation and this is affecting the strategic provision of hospital services. On the one hand more treatment can be given locally on a day surgery basis at local hospitals or GP surgeries: on the other complex treatment, and more in-patient treatment, needs to be done at specialist centres. The main impact will be on local general hospitals whose remit will become more mundane and who will probably lose their A+E departments - though they may sometimes be able to offset this by attracting a regional speciality. Indeed "farming out" specialities might be one way to gain political acceptance for change.

Accountability

Party policy is to make the NHS more democratically accountable, and the latest health policy document calls for the NHS to be merged with Social Services under local council control. We are not convinced this will work. Health provision nowadays needs to be considered on a regional basis, and it is almost impossible to see a local council voting to give up "its" local hospital services. Nor are we convinced GPs will welcome oversight by a council. One democratic alternative is for local councils to be formally consulted over annual health plans but, unlike CHCs (whose remit would continue to be to monitor services, pursue complaints by patients, and to consider strategic matters from users' points of view) be given the opportunity to "top up" government funding of the NHS in their area to provide additional services. One of the problems of merging Social Services and local has is that Social Services also covers children where the best partner is not health but education. We could swop one sensitive interface for another.

Health Education + Research

The party has long called for a re-balance of expenditure between primary and secondary treatment, and the proposal for free eye and dental checks represents a real commitment to preventative rather than curative care. However, there are other primary areas needing attention. One is health education. It is true there are active campaigns against smoking and drugs, but whatever one's views on abortion, the fact that a quarter of all pregnancies end this way should be a matter of huge concern. We know of family planning services being cut back, and know of no research being conducted to find the way to reduce unwanted pregnancies.

Similarly the importance of daily exercise is widely ignored, whilst diet is an area of almost total confusion, partly because the triviality of the risk or benefit of a particular food is rarely stated. Health education could be improved in two ways: first by vesting responsibility for health education in an authoritive body charged with giving "balanced" advice, not chasing after every scare. Second by allowing that body sufficient resources to find the most effective way of getting their health messages across. It is obvious that the manner of presentation is at least as important as the message itself.

Lastly drug companies pour billions into research and "fashionable" illnesses like cancer have more money that can be spent. There is a need to look at the less glamorous areas too, such as incontinence. The DoH should ensure all research needs are met.

Quality of Life

100 years ago premature and sickly children died at birth whilst pneumonia (the old man's friend) called the frail elderly home. Medicine has progressed so far that with the right tubes and stimulants patients can be kept alive way beyond the useful point of doing so. Euthanasia was not an issue until 1935 because until then, nature was allowed to take its course.

We believe the notion that patients should be kept alive at all costs is too simple. The pendulum needs to swing back a bit, to the point where doctors and families take a considered view on the probable quality of life likely to follow medical intervention. Doctors should not try to play God. Particular attention needs to be given for example to assisting very premature babies (<25weeks, say) due to the very high risk of severe disability and consequent costs to society; and of maintaining life support systems to coma and PVS victims.

Voluntary euthanasia takes this logic a step further. We believe party policy (to refer to a royal commission) is absolutely correct. The privilege of a dignified death seems one that society should welcome.

There are many legitimate fears expressed over voluntary euthanasia, so if permitted it would be proper to proceed with extreme caution. If only the most compelling cases were allowed initially, the safeguards could be tested, confidence built up, and the boundaries carefully and slowly extended.

Medical Liability

One of the most distressing sights is of a doctor who has genuinely but unsuccessfully sought to do his or her best for a patient, up before a court to answer a case of negligence so the patient can receive compensation.

Like much else we seem to be slipping towards America values, in this case their "blame" culture. If something goes wrong it is said, someone must be to blame. Recently in a particularly difficult case of Ms S, doctors and social workers were found guilty of "forcing" a woman to have a Caesarian against her will. She and her baby survived.

It is all too easy to suspect that if anything had happened to Ms S or her baby, the doctors would also have been found guilty - for not having done enough to make Ms S understand the full implications of failing to give consent.

Currently we understand that due to the risk of litigation doctors are recommending Caesarians in more and more cases, and worse, that there is a shortage of doctors prepared to practice in obstetrics. We have no difficulty with the need to give all possible support to patients or families suffering loss (though sometimes money is not a satisfactory or suitable replacement). Our difficulty is that much litigation is grossly unfair, and that the more it grows, the more defensive medicine will become - to the detriment of health overall.

About 12 months ago 2 nurses were walking to work. A man collapsed in front of them, but they continued walking. They did not help because, had they done so and something had gone wrong, they would not have been insured. The insurance only covered them whilst on hospital premises. That is not a world we should be prepared to accept. We need law to protect the doctor or medical professional "who does his or her best", and a campaign to dissuade the public that "someone is always to blame".

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