Dr Teck Khong: The flaws in the NHS must be addressed by rebuilding it from its very core

Dr Teck Khong, a Leicester GP and a forensic physician for Northamptonshire Police, is on the Conservative Party's approved list of parliamentary candidates. Here he reiterates the key elements of a new health system which he first proposed at the 2003 Policy Forum on Health.

The debate about NHS funding does not really concern the average citizen when he or she is in good health and needs no medical attention. Funding constraints only come a real problem to the patient who desperately needs treatment that makes a difference to whether he or she can walk again, maintain or return to employment, do all the normal things that are taken for granted by a healthy person, or avoid premature death and enjoy life with loved ones. It is also a conundrum when a doctor is compromised in what he or she knows by professional instinct should be done in the best interests of the patient. For the doctor, anything less is an assault on his or her conscience and a subversion of integrity.

Devolution notwithstanding, it is important to ensure uniformity of access to medical services and compassionate care for all UK citizens. To maintain such equitable standards, there has to be deep and fundamental changes, some of which have not been properly addressed.

In the process of acting as the procurement agency for treatment primarily through the engagement of professional services, the government has progressively increased and vastly distorted this remit. It has created immense administrative structures that lack coherence and efficient management with the twin consequences of massive waste and poor results. How could a Strategic Health Authority justify the metamorphosis of one Family Practitioner into six Primary Care Trusts over a 20-year period when it would not invest in a neurosurgical unit for the same region?

The main role of the NHS should be treatment and management of medical conditions. However, all other ‘healthcare’ activities have been stuffed under an over-stretched umbrella called the NHS. For example, it is unacceptable that a PCT employs 13 officers just for cigarette cessation alone for a population of 350,000. That is in addition to all the associated support costs and incentive payments to doctors and pharmacists, costs of nicotine substitutes, withdrawal therapies, publicity and literature. Such expenditure in health education has grown out of all proportion and impacts on medical services.

To address such basic flaws, the NHS must be rebuilt from its very core – the public-profession interface – focusing at all times on medical services and keeping intrusions out so that delivery and accountability are undiluted.

The demarcation between primary care and secondary care with enforced antagonistic funding is an anachronism. Amongst other things, it leaves the hapless patient as a financial burden avoided by both. The flawed policy is further compounded by the fragmentation of medical services based on the premise that the only solution for a mismanaged service is to break it up and privatise the pieces. For greater patient satisfaction and genuinely holistic care, there is no substitute for tightly run units that absorb all elements of primary, secondary and tertiary care. Funding must therefore be integrated.

With smaller and well-integrated units, the costs of administration would be lower. The entire stock of hospitals should be reviewed from local, regional and national perspectives with respect to needs of the population, facilities offered and service reach. Super-sized hospitals are unwieldy and difficult to run well despite the potential to realise the economies of scale. In Sheffield, the Royal Hospital was a small hospital near to the city centre with a tiny A&E department; it even undertook arterial surgery and housed a professorial medical unit. It had one administrator and a matron and a retinue of staff you could count on both hands. Infection rate was low. Morale was high and standard of care was exemplary. There was effective communication between GPs and hospital doctors; multi-billion pound computer systems were unheard of yet patient care was maintained.

With changing management of primary care, GPs now have an incongruous mix of responsibilities while their business priorities rival clinical ones. Moreover, paying GPs for administrative and clerical targets is both costly and distracting. Doctors are for treating patients, not collecting and collating statistics. These activities and therefore their budget should not come from funds designated for medical services.
Clinical targets, which form a significant part of a GP’s pay, are rooted in an obsession that all aspects of quality can be wholly measured. Such an approach is convenient for managers but has the undesirable effect of removing sound clinical judgement and compassionate behaviour. The pay structures for all doctors should therefore be revised into a much simpler model.

Regulation and quality assurance of all aspects of medical care require the stewardship of the government but not its direct and total involvement or even domination in many instances. There are now far too many organisations with overlapping and conflicting functions. EU directives also have an undermining influence over our health considerations. Particular attention must be given to the intake and training of medical professionals, resource allocation and the length, duration and supervision of apprenticeships, including provisions for career progression and retention. The diminished role of the medical professions in these matters and the inordinate dictation from the government has uncoupled real patient needs from the functions of the nurses, dentists and doctors. Such anomalies require decisive corrective action.

In the midst of the entire calamity, dentistry has become inordinately expensive and inaccessible for the majority of people, so it must be a priority to reclaim for the public an essential service that has been neglected by the government.

Priority setting of medical services is therefore a vital consideration for the reconfiguration of our health system. Although this principle is generally applied to surgical operations, it should be extended to include a restricted drugs formular, comprising all the essential medicines with a mechanism that admits top-up by patients expressing their own preferences.

A health system that is far superior and which costs less than the one we have today can be a reality.