Written evidence from Dr Jonathon Tomlinson
(COM 128)
I welcome the intention to increase the role
of clinicians in management decisions.
Nevertheless
The aim of any system of universal healthcare
is to distribute healthcare according to need, hence avoiding
the `inverse care law' which states: "The availability of
good medical care tends to vary inversely with the need for it
in the population served. This | operates more completely where
medical care is most exposed to market forces, and less so where
such exposure is reduced." (Hart, 1971)
Evidence about health inequalities shows that
the inverse care law still holds true today, and yet the aim of
distributing care according to need has been replaced with the
aim of distribution according to market forces. Economists as
diverse as Freidrich Hayek, Adam Smith and Amartya Sen, all recognised
that markets are blind to need. Whereas healthcare distributed
according to need may be efficient, the converse is not true;
for example refusing to treat someone may be cheaper than treating
them and screening low risk populations can be highly profitable.
Commissioning increases the role and effect
of markets in the NHS and will therefore exacerbate health inequalities.
As GPs our primary duty as codified by the General Medical Council
is to our patients. Monitor, the body set to oversee commissioning
will add the conflicting duty to behave competitively and efficiently.
Well educated, motivated patients with uncomplicated needs that
are amenable to medical solutions can be looked after efficiently
and will therefore attract more resources. Complicated patients
with high levels of socially determined health needs, complex
medical problems, low literacy and chaotic lifestyles cannot be
looked after as efficiently and we will lose resources even though
their needs are greatest. It is important to note that the very
best quality care may not be efficient. Patients in primary care
very often need a doctor who listens, who is considerate, understanding,
sympathetic and who gives a clear explanation and reassurance.
It is hard to see how, if at all, visiting a bereaved patient
or taking time to discuss a serious diagnosis can be deemed efficient.
Up to 30% of patients in primary care and 50% in secondary care
consult with medically unexplained symptoms. The evidence is that
these patients benefit from continuity of care and are harmed
by excessive investigations. British general practice has a universally
admired tradition of continuity of care but this will be undermined
by a plurality of providers and payment by results rewards excessive
investigations.
The serious choices patients have to make, such
as when to stop chemotherapy, whether to die at home or in hospital,
whether to continue with an unwanted pregnancy depend on continuity
because they are best made with a doctor they know and trust.
These choices are far more important to patients than the choice
of hospital.
GPs in affluent areas with low levels of need
are already supplementing their income by offering cosmetic treatments,
whilst in deprived areas GPs still lack the resources to manage
serious physical conditions, psychological problems and drug or
alcohol addiction.
Forcing providers of health within the NHS family
to compete with one another instead of collaborating is a great
threat to the provision of integrated care. My patients with serious
long term conditions depend on close collaboration between primary,
secondary and community care. The purchaser provider split and
payment by results are already damaging the relationship between
GPs and their hospital colleagues; GPs are suspicious that their
hospital colleagues see patients in order to earn money even when
they could be managed in primary care and hospitals worry that
GPs are working beyond their expertise by holding onto patients
in an attempt to make savings.
The abandonment of practice boundaries risks
young, mobile patients with few health needs joining practices
designed for them, leaving other practices to look after greater
concentrations of complex, elderly patients. Historically, GPs
have been able to afford to manage their complex patients because
they have a balanced population, including an income from young
people who only consult occasionally.
The conversion of the National Health Service
into a fragmented system of competing providers based on profitability
marks the end of universal health care planned and distributed
according to need.
November 2010
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