Supplementary written evidence from Dr
Peter Davies (COM 127A)
I have now had a chance to reflect on what was
said last Tuesday 2 November 2010 at the Health Select Committee.
Please may I add three points to my previous written testimony?
As far as I can tell these points have not been made before amongst
the medical witnesses or through the MP's questioning.
1. Is the commissioning being done at the
right level of the NHS?
At present the plan seems to be that primary
care must commission secondary care. This is fair enough, and
an opportunity for me as a primary care clinician. But it can
be argued strongly that primary and secondary care are both medical
service providers. Perhaps commissioning should be at the level
of the overall service or overall patient pathway rather than
of one part of the system by another. Setting one part against
another may result in disjointed services. Perhaps the answer
to smooth patient pathways lies in integrated care organisations
that make the move between primary and secondary care as smooth
as possible, rather than in organisations such as commissioning
consortia that will debate every referral decision in terms of
cost and utility?
2. NHS as a monolithic monopoly
As I said at http://www.civitas.org.uk/nhs/refusingtreatment_commentary.php#davies
"No non-market, planned economy has ever succeeded in matching
supply with demand. You can have as many intermediate process
measures and lengthy reports as you like, but the outcome of centralised
processes such as Ukrainian Tractor Production or the NHS's MTAS
scheme tend to be disastrous."
I think monopolies are intrinsically inefficient,
and tend to generate internal rules, restrictions and hindrances
rather than smooth running systems of care. In terms of John Seddon's
book "Systems Thinking in the Public Sector"
(Triarchy Press) monopolies usually increase failure demand and
resource wastage rather than deliver to value demand more efficiently.
Although you can argue in terms such as "The NHS family"
and "universal and comprehensive" in fact the NHS as
experienced by particular patients in particular places is often
local, disjointed, variable and parochial. Examples of failure
demand and system failures (eg notes going astray, letters not
written or delivered, apparently random clinic appointment rearrangements)
are common throughout the NHS. If alternative willing providers
can provide a better service in an innovative way then from a
patient service viewpoint I cannot see why they should be prevented
from doing so. Perhaps the reason many in the NHS fear the arrival
of the private sector is that the private sector may have the
ability to do things better than the NHS does.
3. Health Inequalities—the middle class
have health needs too
In the oral evidence from Dr Jonathon Tomlinson
the case was made about health inequalities and about moving the
resources to meet the greater health needs of disadvantaged people.
This is true, and fair up to a point. However the NHS is a national
institution that intends to provide care to all the people of
Britain, on the basis of the people's pooled contributions and
for their medical needs as they arise, and regardless of their
social standing. On this basis it needs to provide a good service
to all UK citizens, and this includes upper and middle class patients
as much as the poorer classes. Sometimes I hear advocates against
health inequalities and feel that they only see complexity and
co-morbidity in poorer patients in poor areas of towns. This is
a partial perspective, and middle and upper class patients can
be just as demanding for doctors to deal with, and their health
needs are equally legitimate.
Thank you for allowing me the opportunity to
contribute to this ongoing and fascinating debate.
November 2010
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