n the morning after the budget I awoke in a small ward in
Whipps Cross Hospital, an undistinguished general hospital
serving the whole of north-east London. I took one look at
the headline in The Independent, read about a paragraph and
had to put it down; I couldn't bear to read any more.
What The Independent picked up on, to its credit, that none
of the other papers gave anything like the same prominence
(so busy were they lauding the money that is coming to the
health service at least five years too late) was that the
government's "reforms" in return for which the chancellor
was prepared to bestow such largesse was to make patient choice
the keystone of the NHS. Patients are to be allowed to go
to whatever consultant or hospital they wish.
To illustrate just how infantile and ill thought through
that principle is, consider my own situation that week. That
Sunday I had to be taken, much to my embarrassment, to my
local A & E department (nobody there calls it Casualty)
and had ended up spending a pleasant few days on a drip while
my insides untied themselves from the knot into which they
had managed to get themselves.
It had been clear from the start that the problem would right
itself, but if it had not I would have had to make a decision
whether I stayed put at Whipps, and with the surgeon I had
met on Monday morning, or whether to ask to be transferred
to the Middlesex, my more usual haunt.
I have a degree in medicine and 25 years experience managing
four (or five depending how you count them) complex and specialist
conditions. If any patient was qualified to make that kind
of decision, it was I. But I came to the conclusion that I
was in absolutely no position to make an informed decision.
A nursing friend pointed out that someone might have had
a bad experience with a particular hospital or consultant
and want to go somewhere else. That is something a decent
GP could sort out, if GPs weren't so overworked and underfunded.
We would do better making sure primary care is funded at a
level that allows GPs to do their job properly (and not have
to cope with problems that are more social than medical).
The signs had been there for some time: foundation hospitals
had been floated some time previously. NHS Lift is a PPP bringing
in private money to rebuild GP practices which is supposed
to be "the only way forward to get the levels of capital
investment we need" (Guardian Society 27.2.02) in which
GPs can "take or earn an equity stake in the company".
Charles Webster, an historian of the NHS, in a recent book
pointed out that government policy has amounted to more privatization
than even the Tories dared. The NHS Alliance has been critical
of league tables, suggesting that meeting local need should
be the criterion of success.
But on budget day there it was: all the paraphernalia of
opting out, foundation hospitals, allowing those that succeed
to prosper and failing hospitals to close. The Guardian did
pick up the following day on the fact that most of it was
little different from the Tories failed internal market, but
the government essentially got away with it. All we heard
about was the £61 billion and not the fundamental erosion
of a national service. Even Frank Dobson, not exactly the
most obvious new Labour opponent, has worked out that this
will bring in a two tier health service, just as the same
deification of choice has brought in a three or four tier
It is not simply that neither patients, nor necessarily GPs,
have the information to make clinically informed decisions,
but that they will, being human beings, tend to make their
decisions on quite spurious grounds. I read that depressing
abandonment of a unified health service in a fairly run down,
run-of-the-mill local general hospital serving a not particularly
affluent part of East London. I was struck forcibly by the
difference between the social background of patients here,
and, say, the National Hospital, or Great Ormond Street. Whipps
does not have particularly high scoring health outcomes, it
has just dropped from two stars to one on the Department of
Health's ratings. It is not very high status: it isn't the
sort of place whose inclusion in your CV confers an automatic
caché. But there is twenty years of hard research evidence
that says the primary factor in health outcomes is one's place
on the income ladder. Whipps has poorer health outcomes because
its patients are poorer.
But the result of this lack of status, and an undeservedly
lowly image, is that "the better class of person"
tends to go elsewhere, to St. Margaret's Epping, to Harlow,
and, of course, privately. So, when people are given a choice
as to where they should go, how many will accept a referral
to their run down, slightly grotty, local hospital, or want
to have 'the best'? And of course, as even Frank Dobson has
now worked out, if the patients follow the 'successful' hospitals,
they will become more successful: they will attract the best
qualified staff, they will get to do the high status work,
and a spiral of decline will set in for the less fortunate
As for strategic planning it is ludicrous. This is a system
absolutely guaranteed to generate perverse outcomes that will
make the postcode lottery look sane by comparison. You cannot
have a system organized on the larger scale if the bulk of
the decisions are made by a series of independent units.
The same problem will occur with Primary Care Trusts (PCTs)
if all strategic organization is left to them: indeed it is
already happening. Last year I spoke to the chairman of a
PCT who said that if PFI got him the money his patients needed,
then PFI it was. The problem is that each individual trust
taking that view has resulted in a situation in which PFI
has become established and entrenched, a situation virtually
nobody wanted. Indeed one could be forgiven for suggesting
that the breakup of the system into autonomous units is actually
designed to achieve this outcome: none of the decision making
units will be large enough to stand up to central government
And it will be a lot harder to fight the inclusion of private
providers if individual patients are making rational individual
decisions for themselves, some of which decisions will include
using private facilities: once enough people are using the
private providers it will be a lot harder to argue and organize
against their exclusion from health services.
Too many people will already have said an effective yes.
Smaller decision making units will also find it harder to
stand up to the (GATS allowed) corporations that are eyeing
our health services as a potential market. The neo-liberals
must be regarding the chancellors efforts with approval.
There is, however, some hope that it won't quite work out
as the government wishes and which can show us a way to work:
an awful lot of people have a deep-rooted loyalty to the institution
that looked after them when they were ill. For every critical
letter in my local newspaper there are two or three supporting
the diligence and damn hard work of Whipps staff.
Patients may also subvert the government's intentions for
another reason: the one thing that patients really want, and
the one thing that is most emphatically not on the menu for
them, is a local hospital. They would prefer a small, friendly,
local hospital where they stand a chance of getting to know
the staff and having a relationship over their lives with
the people who will treat them.
And that is one thing the government has absolutely no intention
of offering, what with walk-in clinics, NHS direct, and atomized
individual choice. They don't want cohesive local communities
who will stand up to them, they want individuals who are much
more likely to accept outcomes they do not like because, standing
alone, they see no alternative.
But second to that, many people will prefer to go to their
local hospital, good, bad or something in between, because
that's where they've always gone, because they know it already,
because other people swear by it, and because that is where
people from round here go. From now on, I shall be supporting
my local hospital.