Chapter 7 - The Future of NHS

This is a summary of chapter 7, written by Dr Mayur Lakani, Chairman of the Royal College of General Practitioners, Visiting Professor in the Department of Health Sciences, University of Leicester School of Medicine.

In this chapter he discusses primary care, and mainly concentrates on the role of GPs. He explains how primary care is expanding and is imperative to the running of the NHS. He tackles some common concerns, such as the inability to book GP appointments in advance, not being able to access GPs out of hours, and the new GP contract.

He also explains the significance of the Government White Paper on 'Care in the Community', which is aimed at reshaping the NHS, by transferring services from hospitals, into the community. He sums up by considering some suggestions for the future development of primary care:
· Longer and flexible consultation times with patients (say 15 minutes)
· Focusing more on prevention and well being, including mental health
· Focusing on earlier diagnosis
· Making patients the key holders for deciding on their treatment
· Integrating primary health care teams
· Improving communication between hospitals and GP practices
· Providing more tests and procedures, and services in primary care
· Improving primary care access, particularly for urgent problems
· Developing stronger GP services in deprived areas
· Increase the sexual health services in primary care settings
· Offer patients a choice of seeing a named GP and the choice to register with their preferred practice.
· Let the GP be the navigator rather than the gatekeeper

· Improve management of co-morbidity which is found more in deprived communities.

To offer comments on his chapter please feel free to comment on this blog, or add to the forum debate on www.thefutureofthenhs.com/forum

Chapter 6 - The Future of the NHS

This is a summary of chapter 6 - The Future of Surgery. It was written by Professor Peter J Friend, Professor of Transplantation at the University of Oxford, Director of the Oxford Transplant Centre and a Consultant Surgeon specialising in Transplant and Hepatobiliary surgery at the Oxford Radcliffe NHS Trust.

Professor Peter Friend describes that the medical world is on the cusp of radical change and if properly implemented, will provide a better, safer service for patients and a more cost-effective service for the provider. He considers several possible areas of change for the surgical specialties, and a few of those are mentioned below.

1) The changing face of surgery
The surgeon, used to direct the progress of a patient often single-handedly, but notes the surgeon is now part of a ‘committee’ that determines how the patient should be treated. However, the multi-disciplinary team will now be the key to the way the health service of tomorrow will look.

2) Surgery as a technology-driven specialty
He believes the future of minimally invasive surgery will involve robotic procedures under video-imaging, carrying out the entire operation using robotic arms controlled remotely by the surgeon. He notes that this technology is hugely expensive to buy and operate. Therefore, it will be a challenge to deliver new technology and cost-effectiveness.

3) Surgery and training
He explains how the traditional system of apprenticeship surgical training is becoming replaced with a more active training process to enable a surgeon to achieve competence with less than half the clinical contact time of his/her predecessor. [There is nothing more important than investing in the future of training.]

4) Surgery and regulation
He describes how a surgeon's future will include a closely scrutinised performance record. In fact hospitals are subjected to ‘league table’ comparisons. He argues that although transparency is clearly a good principle, the use of such simplistic measure of outcome, such as crude death rates, could be extremely misleading. One surgeon may be the best in the country but if the most difficult and highest risk cases are referred, then the mortality may still be high. If crude mortality becomes the marker by which surgeons are judged, then there will be a natural tendency to refuse to take on high-risk or complex cases and warns this would be very much to the disadvantage of patients. He highlights the need for this to be considered.

To comment on this please post a comment, e mail me direct at mail@drmichelletempest.com or join in the discussion forum on www.thefutureofthenhs.com

Chapter 5 - The Future of the NHS

This is a summary of Chapter 5 - The Future of Medicine. It was written by Dr Robert Winter, a consultant physician and Medical Director, Cambridge University Hospitals NHS Foundation Trust.

He explains the Paradox that although the scope of modern medicine is immeasurably greater than it was, the optimism generated by its advances seems to have evaporated. In short, ‘medicine is doing better, but feeling worse’. The future of the NHS is a scenario where the elderly are living longer yet in less good health towards the end of life, the young with more ill-health related to lifestyle all demand access to high cost, high technology drugs and resources. This scenario is undesirable and unsustainable.

Perhaps the challenge for the future NHS will be to develop a more holistic, integrated approach with an emphasis on keeping people well and a service that better reflects high, but reframed, consumer expectations. He believes this will provide a more balanced and therefore a more hopeful future – the basis of a new kind of modern NHS. If this can be achieved then he thinks this would be the cusp of a new enlightenment.

To comment on this chapter please feel free to leave a comment here, or on the discussion forum www.thefutureofthenhs.com

Chapter 4 - The Future of the NHS

This is a summary of chapter 4, written by Professor Steve Webb MP, Shadow Secretary of State for Health (Lib Dem)

Professor Webb argues that the debate surrounding the NHS is unhelpfully polarised, and that an observer would be forgiven for concluding that there are only two possible positions.

Pole One: The market-driven approach:
This has merit of simplicity and argues that competitive markets usually deliver lower prices, higher quality and greater. If this works for supermarkets, the argument runs, it should also work in public services. [But is the NHS like a supermarket?]

Pole Two: The “do nothing” approach:

This is believing there is nothing much wrong with the NHS that can’t be solved by pouring in yet more money.

He believes the reality is that neither of these extreme positions stand up to rigorous scrutiny.
He discusses there must a third way. He goes onto discuss accountability, decentralisation, creating a pattern of local health services, determined locally and accountable locally. Finally, he suggests that prevention is better than cure and we need more emphasis on public health and encourages people to live healthier lives.

He also offers the metaphor that watching the current state of the NHS is like watching the NHS is being subjected to amputation with a rusty hacksaw.

To comment on this chapter please don't hesitate to contact me direct, or post comments on the discussion forum www.thefutureofthenhs.com

Chapter 3 - The Future of the NHS

This is a summary of chapter 3 written by Andrew Lansley CBE MP, Shadow Secretary of State for Health (Conservative)

In this chapter Andrew Lansley raises the concerns that the NHS has all the complexities and bureaucracy of a huge organisation, yet lacks any of benefits of scale and consistency being delivered in practice. He discusses :

1) Public Health

He believes there is a distinction between the NHS and the health of the public at large; the NHS should treat the patient, whilst the government should treat society. Therefore, the first element in his future NHS, is to deliver improved public health.

2) Return the NHS service to its staff
He believes that in an NHS which is professionally-led and patient-centred. The professionals (doctors, nurses and managers) should be trusted to deliver the NHS service, free from day-to-day political interference.

3) Increase plurality – using competition to increase efficiency.
He believes that by using a plurality of providers, this would increase competition (a tide that can lift every boat) and in turn greater efficiency would ensue.

4) Finite resources versus insatiable demand
He believes that commissioning bodies will have to reconcile the tough decisions involved in finite resources with insatiable demand.

He believes the future of the NHS must be secured by a clear consistent strategic approach. This can not be achieved without the skill, care and leadership given by the staff of the NHS- managers free to manage; doctors able to offer clinical and professional leadership; nurses able to focus on the needs and care of patients; and all the staff of the NHS able to realise the potential of their service. He looks forward to an NHS in which patients put themselves in the hands of empowered professionals.

To read this chapter in full, please buy the book 'The Future of the NHS' - which is available from amazon, good bookshops or buy on-line www.thefutureofthenhs.com

Chapter 2 - The Future of the NHS

This is a summary of Chapter 2, written by the Rt. Hon. Patricia Hewitt MP, Secretary of State for Health.

Ask people what makes them proud to be British and most will name the NHS. In this chapter Patricia Hewitt explains the nature of necessary change and describes what a reformed NHS will look like. She first tackles why we need more change and then explains the four strands of reform:

1) More choice and a stronger voice for patients
She wanta to create a self-improving health service that designs its services around patients, rather than making patients fit in around the service.

2) Money following patient.
She beleives as patients exercise more choice, as different hospitals challenge each other to provide the best quality, as payment by results exposes differences in practice and therefore in cost, every clinician, every manager and every organisation will have an inbuilt incentive to compare themselves with the best, to innovate and improve, to give patients the best possible care – and taxpayers the best possible value for money.

3) Create more diverse providers
In her new NHS, there will be an element of competition. As that drives the less good hospitals to improve – or sees their services replaced by better providers.

4) A new framework of regulation and decision-making that guarantees quality, fairness, equity and value for money
She believes this will ensure proper stewardship of public funds.

She concludes that now is the only opportunity we will have in our lifetime to secure a health service that is true to its founding values, but fit for modern demands.

If people want to comment on this chapter, then please log onto www.thefutureofthenhs.com or send me a comment direct.

The Start of the Book Summary

Introduction - Chapter 1 The Future of the NHS, written by Dr Michelle Tempest.

The book aims to assist the reader, to penetrate the fog of confusion, about how to make future plans for the NHS. It brings eminent experts together from centrally relevant disciplines with a wide range of perspectives, to set out views clearly and readably; to enable the general reader (whether professional or lay person) to better understand the cardinal questions involved in this NHS debate. Early chapters express views from main political parties, Labour, Conservative and Liberal Democrats. Then chapters continue from top NHS professionals, experts at the forefront of their specialty, who collectively bring Centuries of experience. Their wealth of knowledge is unrivalled, admired and invaluable; they are the leading authorities across a broad range of specialties. The discussion continues about how the NHS is managed, trained, regulated and funded, and considers alternative and innovative methods of tackling complex financial issues.

It is imperative for every person to be involved in the debate, as it is not just for the ‘experts’ in the disciplines concerned, but for everyone - doctors, nurses and patients, lawyers and clients, legislators and voters, young and old, - because the debate crosses every age group and every social divide. Each one of us has a right to contribute to the debate, not least because, how we as a society answer the questions raised about the NHS, will ineluctably have a profound effect on the very nature of society as we know it. This book allows views regarding the NHS debate, to be informed rather than ignorant, rational rather than emotional, and to evaluate competing arguments and various ideas. ‘The Future of the NHS’ book enables the reader to take the first step into the most exciting debate of our times.

2006 is an important year for the NHS marking 60 years since the implementation of the National Health Service Act 1946. Therefore, it is an ideal time to start planning for the future of the service and to ensure '60th birthday celebrations' are not a sign of retirement. It is hoped that by gathering together some of the most eminent and respected health care professionals, policy makers and opinion formers, this book could go some way to pooling their collective wisdom into one volume and help start what might be the great health debate in this country.

So, where do we start with this process, to acquire long-term strategies for successful rehabilitation? In medicine, when a patient presents, the doctor starts by taking a history and then examining the systems. This book also takes this approach by asking the most involved and knowledgeable people from many walks of the NHS for their thoughts and ideas.

Each day for the next 34 days will include a very brief chapter summary of all the 35 book chapters.

An NHS Independent Board

Our health service has been founded on the principle that healthcare should be freely available to all from cradle to grave, and that provision should be based on need rather than ability to pay. These noble aims and ideals have been translated within the NHS to create what is frequently described as a ‘beacon to the rest of the world’.

This weekend Gordon Brown released his plan for the NHS: to devolve power away from politicians and create an NHS independent board. Basically, repeating his trick with the Bank of England by taking decisions away from ministers. This seems to be in tune with a recent YouGov poll carried out following the book ‘The Future of the NHS’ which found a two-to-one majority favouring the government withdrawing from day-to-day running of the NHS.

To give any possible future NHS independence board some idea of the mammoth task ahead, it’s worth noting that the NHS is the fifth largest employer in the world with 1.33 million people, behind only the Chinese army, the Indian Railways, Wal-Mart and the US department of defence. At any one time the total NHS population equals around the size of a small African country, such as Botswana. Thinking of the NHS as a country, and of this magnitude, really brings home some of the difficulties faced in how to manage an organisation with a vast number of patients, an unstable economy, an ageing infrastructure and an organisation that does not produce saleable goods.

On the face of it, an independent NHS board may look like a welcome reform, removing the temptation of politicians to meddle for short-term political gain. So why has the British Medical Association warned that the new proposals do not help address NHS problems? Perhaps, the reality is that by creating an independent board, it hands over an important part of our political system to an unelected group, and takes the decision-making process yet one step further away from the people it directly affects. After all, we already live in a society with 882 such quango bodies costing a total of £124 billion.

Next year sees the end of the increased level of spending pledged to the NHS and what will remains are some extremely difficult policy decisions to be made. The question then seems to become, is this new level of bureaucracy a method of passing the buck on political decisions?

Stick-thin obsession must end

This was published in The London Paper, 18/9/06

To celebrate London Fashion Week, try the following exercise. Count the number of times your brain registers an image of a thin woman between getting up and going to work.

Check your cereal box, your newspaper, your morning TV, posters on the Tube. When I did this recently, I was staggered to count 63 models who appeared underweight in less than an hour. Almost every minute, my brain was being subjected to an unhealthy image. Society now seems to accept that junk food is an unhealthy input into our mouths, yet it still seems unconcerned that junk information is unhealthy food for the brain. We get a choice of different foods on offer, so why don’t we have a choice of what stimuli our brains are bombarded with?

Eating disorders including anorexia nervosa, bulimia nervosa and binge-eating disorder, affect a staggering 12 per cent of the population with milder forms being more prevalent. The common factor among all eating disorders is dissatisfaction with body shape and consequent dietary restrictions. Although these disorders are multifactorial, few would dispute the social pressure to be thin, especially for women.

The sad fact for anorexia nervosa sufferers is that as many as 20 per cent may die – some during their quest to imitate underweight role models. What must be done?

Few people would argue with the general proposition that weight in itself is a matter of personal choice. Further, that press freedom is crucial to a democratic society. However, with freedom comes responsibility and this is where the problem lies. By turning a blind eye to the effects it is having on society, the media is simply abusing its freedom at the expense of us all.

One solution may be to add provisions into the constitutions of the media’s regulatory bodies, such as the Press Complaints Commission, to try to avoid portraying the symptoms of eating disorders as glamorous. Or, as we celebrate the start of London Fashion Week, a lead might be taken from a recent show in Madrid to ban models with a Body Mass Index below 18 and urge them to go see a doctor rather than go down a catwalk.

Why Society is Part of a Big Family

Tory leader David Cameron said his party must do more to keep families together, after a report suggested that parental splits are creating an underclass.

Indeed, it is known that behaviour is learnt after spending years imitating parents, siblings, friends and society. Many people like to blame their parents for their maladaptive coping strategies, and this may, in part, be true. However, this also leads onto the good news – if behaviour is plastic then it can also be modelled, so new behaviours can be learnt changed and modified. After accepting that behaviours can be learnt from others at any age, the door is opened to breaking the cycle of maladaptive coping mechanisms, by modelling new behaviour on different adaptive coping mechanisms.

Whilst the report highlights the role of parents, we forget at our peril, the societal social responsibilty.