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Teck Khong: NHS reform must tackle the fundamental flaws in its management, its funding, and the maintenance of professional standards

Teck Khong Dr Teck Khong is a GP and law graduate who has held various appointments in the NHS since 1982. Concerned by its deepening difficulties, he entered politics with a view to improving it. He contested Bradford North In the 2005 General Election.

A few years ago, a caring GP was driven to suicide through being hounded for over-referral. GPs are told by Primary Care Trusts (PCTs) to cut down on referrals to save money and many comply without compromising safety. However, when a GP exhibits diagnostic skills and manages cases entirely competently, patients with unreasonable expectation complain to the PCT at a drop of a hat! The PCT, with its Customer Complaints Department will indiscriminately approach all complaints on the basis of “guilty until proven otherwise” without even checking their validity or indeed clinical importance. Such an attitude only drives doctors to distraction and wastes time and resources. Under perverse pressure, doctors choose one of several options – they give up on being good doctors and head towards the middle ground of mediocrity that fits all the PCT constraining parameters, or they quit their positions which are either filled with more of the mediocrity, or they simply retire.

Distraction and corruption of professional focus and values come in different guises and they also affect nurses. Tony Blair’s Cabinet Office issued a document in March 2001 entitled “Making a Difference – reducing GP paperwork”. The sad reality is the exact opposite has happened, with great cost to the public in many ways – more managers, more machines, more meetings, etc. Both doctors and nurses have to deal with inordinate amounts of form-filling and the majority are plainly stupid and unnecessary. The lesson is this: the more time a health professional spends on administration, the less time there will be for patients.

Another topical issue that is equally applicable to both primary and secondary care is service during out-of-hours. Although it is not difficult to resolve, there is a dearth of cogent progress. But there is the other side to the coin. At an out-of-hours clinic in a Northamptonshire hospital recently, there were a typically significant number of non-urgent calls – “can I get pregnant with my new boyfriend from unprotected sex even though I had a termination 2 months ago?”; “Can you help me with my weight problem as I get out of breath when I walk?”; “I want a doctor to visit me for my cystitis – can’t come out as I have 2 young children.”

Yet the next day, that same doctor spent 29 minutes with a tearful woman who wanted antidepressants as she could no longer cope with a neighbour threatening violence and neither the housing department nor the police have done anything substantial. Unlike some colleagues, he contacted the police and spoke directly with the duty inspector. That’s 19 minutes more than the NHS target of 10-minute consultation for something that is outside his remit. But he has not scored any target points. In fact, he’ll be lucky to escape censure for breaching the 10-minute or some other silly rule!

For those remaining GPs who have not resigned or prematurely retired and for those new doctors especially inducted from abroad with some well known negative connotations, the media highlights financial gains to be had in General Practice. The truth is that the system of payment is flawed and has over time has moved the ethos of remuneration for professional care and plunged it deep into the realm of business profits. Of course, GP practices require adequate funding to maintain staff and equipment but payments to GPs include a raft of nonsensical ‘financial incentives’ for attending meetings, achieving certain targets such as a whole host of administrative activities and information gathering. Who would have thought that doctors are financially incentivised to enquire about ethnicity, smoking habits, etc., of their patients or even draw up protocols for managing various non-clinical aspects of running a practice, and using the computerised referral system, to name but a few?

Many doctors are unable to reconcile true professionalism with the need to chase targets and there is no convincing correlation between high income practices and standard of care.  Health Secretary Andrew Lansley is right in announcing the removal of some targets, but more needs to be done.

In hospital circles, the service is now so fragmented and compartmentalised that many patients do not receive appropriately seamless and comprehensive care. A patient admitted with a medical problem gets discharged as soon as the condition which is in the clinical remit of that department is judged to have been dealt with. No attention would have been paid to the existence of other or allied conditions. For that, a separate referral has to be made, so it’s little wonder that some hospitals have a high readmission rate.

To save money and to meet time-line targets, some referrals are seen by nurses or physiotherapists supposedly under the supervision of medical specialists. While such delegation might be satisfactory in the majority of cases, it runs unnecessary risks. For those who designed the system, here’s a test – would they be wholly happy for their loved ones to be operated on by a nurse practitioner, or to be diagnosed by a physiotherapist for a joint disorder?

Maintaining an antagonistic system of funding between primary care and secondary care creates such anomalous and undesirable situations. However, over-emphasizing the capabilities of primary care and increasing its scope without first ensuring adequate preparation only amplifies the difficulties regarding quality.

Finally, no one seems to heed the pleas of those needing decent dental care and treatment – pay up or shut up seems to be the rule. Sadly this is one area of healthcare where inequalities are quite marked yet ignored, probably because dental problems are never likely to be life-threatening. And mainstream healthcare must not be allowed to go the way of dentistry.

A renewal of the NHS must not be piecemeal or deal with the symptoms. It must tackle the fundamental flaws – in its management, its funding, and the maintenance of professional standards. And there is a belief that getting all those things right could actually save the Treasury a lot of money while at the same time give the public a superior service.


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