Saturday, 17 January 2015

Why Healthcare Insurance to pay for NHS services is probably closer than you think!

Recently, this story featured quite prominently in the UK newsmedia. The response from NHS devotees on social media and blogs was muted. Its significance, in my humble opinion may have escaped obsessees of the UK or English NHS. This is why I think so.
I sit on the cardiac surgery CRG or Clinical reference group.
Please let me explain before you surf away or fall into a deep slumber!!


In England, there is one healthcare service, the National Health Service or NHS . It is exclusively funded through general taxation, universally available and free at the point of delivery.
Despite its universality, the service has a provider/purchaser split, introduced in the 1980s by the Conservative Government of Margaret Thatcher and accepted by governments of all shades since.
Within this bifid service, healthcare is purchased by commissioners. Common types of treatments are purchased locally by Clinical Commissioning Groups or CCGs. Rarer or specialised types of treatment, so called specialist services are commIssioned directly by the centre or NHS England. Healthcare is provided by (you guessed it) healthcare providers. Primary healthcare is provided by General Practitioners (or GPs) and secondary care (which includes specialist services) by NHS Trusts. As a major constituent of CCGs, GPs therfore are paid to buy healthcare from themselves. Incidentally, the organisation and layout of the different commisioning and providing bodies undergoes expensive (and usually pointless) changes every few years (or election cycle), so by the time you get to grips with one system. it all changes again. It reminds me so much of this example of TV gold!




NHS England gets clinical advice on the commissioning of specialist services through bodies called Clinical Reference Groups or CRGs (phew - got there in the end!) There are 72 of these bodies at the last count. Each of these groups has a chairman, and a representative from each Senate Area (I won't go there but a senate area is essentially a geographical area of England and there are 12 of them).
As a heart surgeon in Sheffield, England, I represent the Yorkshire and Humber senate area on the Cardiac Surgery CRG.
When I first joined, I felt that this group of clinicians (and patient representatives) could either a) have a real meaningful influence on how cardiac surgical services develop in England OR b) form part of a cosmetic exercise to justify 'greater clinician involvement', as promised by Andrew Lansley - author of the most recent and most pointless of NHS re-organisations. After 2 and bit years I still am not sure whether a) or b) prevails.

Anyway, as a member of this grouping, I do receive and see a lot of NHS England email traffic and communications relating to specialist services. I am not privy to the secret stuff (so don't bother asking) but one does read between the lines.
There are two unalienable truths in the NHS today, whatever the colour of the leather of the secretary of state's chair.
1. - the NHS is in a financial pickle
2. - Specialist services (see above) cost far too much for the relative number of patients who require them and what they contribute to national or global health. They are a constant headache for those who need to plan the future of the English health service AND balance the books.
Funding of specialist services reminds me of what Kenneth Williams (the granddaddy of British camp comic geniuses) once said (with that very famous nasal drawl of his) on a TV chat show "doctors today are all specialists. They know more and more on less and less. Soon they will know everything on nothing" Apart from the fact that what he said is so true and that rampant specialisation is now seen as inappropriate in a world of ageing (holistically speaking) patients, the allusion to diminishing returns applies to the funding of specialist services as well - paying more and more to acheive less and less.
The deigned future of the NHS is primary care, social care and mental health making specialist care increasingly irrelevant (relatively speaking) and this is where this story comes in.
NHS England has stated that once the numbers of allocated specialist service procedures are completed, the funding will stop. It is grabbing the bull by the horns and will stunt the growth of this troublesome child with partial asphyxiation. The ivoried towers of excellence who provide these services are up in arms.
There is a problem with this approach and it is this -
Although an ageing population does need increased primary and social care, it also needs increased specialist services as well. The "ageing population" affects all of us. Take my specialty, cardiac intervention/surgery, for example - cardiac surgeons and interventional cardiologists are now operating on an exponentially rising number of elderly patients. New catheter based devices, which will make cardiac intervention possible in even older patients are coming on stream. They are hellishly expensive. Interventional Cardiology is one of 72 specialist services and yet consumes a mind boggling 15% of the specialist service budget.
By making this statement, NHS England has alerted us to the fact that they are not prepared to fund the increase in demand for these services. Rationing in this area has already started - just ask the cardiologists in Britain 4th largest city!
Concentrating these services in fewer and fewer centres to acheive economies of scale will only go so far to rectify the situation
There are only 2 ways this circle could be squared - additional funding through top up health care insurance (none of the political parties are suggesting an earth moving rise in tax dollars for the NHS - so far at least) or the acceptance of lengthening waiting lists. Since the conditions requiring many of these services have a poor prognosis long waiting lists will I am sure be accompanied by the sound of patients dropping like flies - surely politically if not ethically, socially or philosophically unpalatable.
The answer to all these questions and more will be answered after May 7th, 2015.