The NHS

[Murph7355]

Berw said:

...
The thing is the NHS need to decide what it dosn't treat, the principle is established it dosn't do optical or dentist, it should not do, minor cosmetic, IVF or other non life threating conditions than it would be affordable....

This is key IMO. Though I'm not 100% sure it would be affordable even if only covering life threatening condition.

I think a central body needs to draw up a list of what conditions will be covered (limited to life threatening conditions and also with a view to what the country can afford) and it gets applied evenly across the country. If people want more, they pay (health insurance). New treatments only get added as old ones pop off or more money becomes available.

Do this and it then also becomes easier to remove a lot of the bureaucratic crap that goes on.

Ref fast food outlets etc, the problem with this sort of thing (which in principle I tend to agree with) is where do you stop? Should you tax people who play sports where injuries are common? Or posh restaurants as their food is no doubt as unhealthy as McDs (if eaten in volume)? Or certain types of foodstuff in supermarkets? The admin burden would get worse than it already is, and it needs making simpler not more complex.

[AJS-]

Berw said:

The thing is the NHS need to decide what it dosn't treat, the principle is established it dosn't do optical or dentist, it should not do, minor cosmetic, IVF or other non life threating conditions than it would be affordable....

Doesn't this defeat the principle of the NHS though? And what principles are applied or is it simply arbitrary?

I.e. why should money be a determining factor in someone's ability to have IVF treatment for infertility, but not in someone's ability to have say physiotherapy after a stroke? Minor cosmetic surgery because Kylie wants a smaller nose is an easy one, but what if it's a young lady disfigured in a car crash and doesn't have the means to afford a minor surgery that would restore her life to normality? Why should someone in their 60s get an expensive cancer treatment to allow them another 6 months of life, while someone in their teens is denied minor dentistry that would give them a better quality of life for decades to come?

As I see it, the principle of the NHS is cradle to grave healthcare that is free at the point of delivery regardless of means ensuring, health equality for all income levels. And that principle has been proven to be far too expensive to apply to reality.

[dcb]

thinfourth2 said:

The biggest problem with the NHS is it is used as a political football

Remove it from the hands of politicians and it would probably work fine

Maybe, but if it's doing so well why not give folks a choice
of health provider ?

Allow the private sector to compete for health care services with the NHS
and allow economic reality to impinge on the NHS.

Allow the great British public to opt out of the NHS, not get billed for
it. and let them spent it elsewhere on a private healthcare provider.

There are plenty of countries around the world which have a better
health care model than the UK and no, we don't have to copy the USA.

[Murph7355]

AJS- said:

...
As I see it, the principle of the NHS is cradle to grave healthcare that is free at the point of delivery regardless of means ensuring, ...

Define "healthcare".

And what "at the point of delivery" means.

I suspect that when the NHS was created there was a much, much more limited scope of what it covered. Even accounting for advances in technology.

Scope creep and a population that is living longer (and hence the "cradle to grave" window is somewhat wider) means that a service that may have been affordable at one point, isn't now. Tough choices need to be made. Benefits (across the board) need to be stripped back to the absolute minimum level possible. People needing critical assistance should receive it, beyond that no.

Once our debt is paid back and the country is once again on a stable footing, then we can possibly look at re-introducing increased levels of benefit. But not until then.

The emotional side needs removing from NHS cover while we're in the state we are in financially. It's unfortunate and sad that the disfigured lady has had an accident. But it's not life threatening so unless her insurances cover it (either her car insurance or medical insurances), then there should be no cover. Focussing on individual examples leads to a slippery slope of trying to provide for everything, as every case needing medical attention is unfortunate and sad in someone's eyes.

[AJS-]

Murph7355 said:

AJS- said:

...
As I see it, the principle of the NHS is cradle to grave healthcare that is free at the point of delivery regardless of means ensuring, ...

Define "healthcare".

I suspect that when the NHS was created there was a much, much more limited scope of what it covered. Even accounting for advances in technology.

Scope creep and a population that is living longer (and hence the "cradle to grave" window is somewhat wider) means that a service that may have been affordable at one point, isn't now. Tough choices need to be made. Benefits (across the board) need to be stripped back to the absolute minimum level possible. People needing critical assistance should receive it, beyond that no.

It wasn't affordable then though. Initially it included all prescriptions and dental care too. These were later scrapped. Prescriptions in only a couple of years I believe.

Murph7355 said:

Once our debt is paid back and the country is once again on a stable footing, then we can possibly look at re-introducing increased levels of benefit. But not until then.

The emotional side needs removing from NHS cover while we're in the state we are in financially. It's unfortunate and sad that the disfigured lady has had an accident. But it's not life threatening so unless her insurances cover it (either her car insurance or medical insurances), then there should be no cover. Focussing on individual examples leads to a slippery slope of trying to provide for everything, as every case needing medical attention is unfortunate and sad in someone's eyes.

But ignoring individual examples and only talking in the abstract leads to these absurd discrepancies whereby a lifelong taxpayer is left waiting for vital cancer treatment while a perfectly healthy attention we is given a new set of boobs on demand.

Your first point was the crux of it as far as the NHS goes - what is healthcare? Again though, if you define it as only life saving then amputation is probably cheaper than saving a limb in an alarming amount of cases. If you bring quality of life into the equation then you are open to the raft of psychological conditions and avoidable problems that we complain about. If you try to limit quality of life to certain criteria then you are subject to the capricious nature of our changing values over the course of time.

The reality we seem to have settled for is that it does include an element of quality of life, and yet doesn't go as far as removing the element of ability to pay from the ability to have the best healthcare available. This is a necessary compromise in any healthcare system, but the NHS allows no element of consumer choice in the matter, except through the ballot box, ensuring it is always a political football.

[dbdb]

hedgefinder said:

the problem with the nhs is not the service provided nor the doctors or nurses.
Its the unnecessary paper pushing middle managers in charge of authorities making ridiculous decisions and wasting large sums of tax payers money ( substantial ammounts on their own salaries!)

Sadly this was not my family's experience. The problem is the service provided by the doctors and nurses in some hospitals. 'Paper pushing' is concomitant however.

[Deva Link]

dbdb said:

Sadly this was not my family's experience. The problem is the service provided by the doctors and nurses in some hospitals.

Same in my experience - missed colonic cancer until far too late in MIL, refused to operate on my mother's spinal problem until she was more or less paralysed, my Dad and Godfather both had very poor care in hospital (Godfather, dependant on carers, was sent home and no-one was told).

I would say my FIL has been fairly well treated in the more minor issues he's had but he's a more forceful character so perhaps that's the answer. Most people are lost in a "our NHS in wonderful" world and just accept what they're told. I had to intervene to get my adult daughter's foot operated on - the hospital was just fobbing her off.

[dandarez]

'AJS has deposed CMD as leader of the Conservatives and is heading into the next election proposing to abolish the NHS, sell off the hospitals to charities, companies or whoever else wants them.'

Well, you've answered your own question... you'd be annihilated!
Even the PH poll is voting in favour of keeping the NHS by a sizeable majority. That should tell you/me everything.

As for what to do with the NHS, I have no idea. Politicians and the rest mess it up constantly.
You don't even know which way to turn now. Free at the point of entry has been a joke for years.

You don't even see a doc or nurse now, you see your 'Health Care Professional'...
How long before they wear baseball caps?

[turbobloke]

The extremist, nanny state NHS?

These letters sent to parents of young children are highly questionable at best.

http://www.dailymail.co.uk/news/article-2133428/Mo...

The financial cost and emotional cost of body shape fascism arising from bending the knee to over-zealous BMI freakery are unacceptable.

http://www.sciencedaily.com/releases/2007/03/07030...

[stichill99]

My new girlfriend is a physio who used to work in nhs and now works for a private practice. I happened to ask her her views from the frontline. nhs was a skive compared how she has to work now.There was always meetings to be had and patients to discuss,cancelled apointments so more meetings could be arranged,training days and on and on. Private clinic.Half hour appointments and work all day,all week,no time to get paperwork up to date. Oh and clients tend not to miss apointments when they are paying for them!

[hedgefinder]

Deva Link said:

Same in my experience - missed colonic cancer until far too late in MIL, refused to operate on my mother's spinal problem until she was more or less paralysed, my Dad and Godfather both had very poor care in hospital (Godfather, dependant on carers, was sent home and no-one was told).

I would say my FIL has been fairly well treated in the more minor issues he's had but he's a more forceful character so perhaps that's the answer. Most people are lost in a "our NHS in wonderful" world and just accept what they're told. I had to intervene to get my adult daughter's foot operated on - the hospital was just fobbing her off.

Obviously there will be exceptions to the rule but,
generally you will find that these problems in the majority can be traced back to red tape - form filling - alledged cost cutting and regulations all brought in by bureacrats putting front line staff under pressure to make poor decisions to fall in line with trust policies.

[Mojooo]

turbobloke said:

The extremist, nanny state NHS?

These letters sent to parents of young children are highly questionable at best.

http://www.dailymail.co.uk/news/article-2133428/Mo...

The financial cost and emotional cost of body shape fascism arising from bending the knee to over-zealous BMI freakery are unacceptable.

http://www.sciencedaily.com/releases/2007/03/07030...

BMI is a poor indicator I agree but I think the girl might be a tad overweight.

I spose it is about trying to take preventative action to save having to deal with ill obese people later (of which there are currently no doubt many). Mnay parents are probably too thick to know if/when their child is a tad too heavy. A letter might make them think - but probably won't.

[turbobloke]

To my mind it's way OTT at that age with that body shape (pic in link).

A waste of time and postage but if it's going to happen at all there should be a far higher cut-off targeting those children who are not 'a tad overwwight' meaning hardly anything, but the total lard buckets who happen not to have visited their GP or hospital since ballooning...if that's possible.

Or just stop.

[jimnicebutdim]

I have a question for the 'opt-out' folks.
Who would provide your Pre-hospital emergency care (ambulances)?

[ninja-lewis]

dandarez said:

As for what to do with the NHS, I have no idea. Politicians and the rest mess it up constantly.

The biggest problem in the NHS is the District General Hospital.

These will built all over the country from the 1960s onwards, with the intention of offering most, if not all treatments, that were available at the time. The NHS started to revolve around these hospitals and their model of local secondary care intervention at the crisis stage - the sort of experience a few posters have mentioned already.

The trouble is this model is not fit for the 21st Century. It costs too much and more importantly it does too much harm. We have lots and lots of hospitals trying to heart surgery but relatively few patients who need it. Around the country, there a couple of hospitals that are centres of excellence for heart surgery - mainly because they have the resources, and crucially the patient throughput, to be safe. They have enough experienced consultants and registrars for 24/7 cover and each of them sees enough cases (coming from all over the country and indeed the world) to keep their skills honed.

Contrast that with the smaller DGHs. They might only have 1 cardiac consultant and they certainly don't have the staff to provide specialised care around the clock in case of complications. And because the staff might only see 4 or 5 complicated cases a year (as opposed to say in a week for the centres of excellence) their expertise is much lower.

The problem becomes all the more acute as treatments become more specialised. Hence the NHS has a number of reviews ongoing to reduce the number of departments around the country carrying out certain specialised treatments - children's heart surgery being one of the main cases at the moment. By closing the smaller inadequate departments and centralising their resources and patients in a limited number of specialised centres, the number of lives saved is significant while the cost per patient is lower.

Another example is A&Es. Normally if you need trauma care, the ambulance takes you to the nearest A&E, regardless of whether they have all the expertise you might need. If, however, you're in certain parts of London, the ambulance crews are trained (with the support of London Air Ambulance) to bypass local A&E departments and take you straight to the Royal London Hospital, which is a Major Trauma Centre. That means they have medics experienced in trauma medicine (rather than just general medicine), they have all the specialties you might need on hand (surgery, burns, intensive care, etc) and because they see many of London's victims of serious car accidents, knife wounds and gun shot wounds, they're extremely experienced compared to the average A&E department.

It's estimated that if that model was rolled out across England, 3,000 lives might be saved each year. Hence why London is already developing 3 other Major Trauma Centres and regional ones are in development around England.

The same is true of heart attack and stroke care - you're almost always better off with a slightly longer journey to a specialised Chest, Heart and Stroke centre (bypassing A&E in the process) as opposed to being taken to your local A&E department, stablised and then undergoing a risky transfer to another hospital.

However in order for these models of specialised care to work properly, you have to downgrade the other local A&E departments to minor injuries only or close them altogether. And that's where the trouble starts. Because nobody likes to hear that their local hospital is being closed. One Government minister once told the Health Minister that while he completely understood and agreed with the arguments for closing the hospital in his constituency, he had to oppose the closure and be SEEN to be opposing the closure if he wanted any chance of reelection!

Secondary care is not just under attack from tertiary care either. As many patients will have experienced over the past decades, the NHS is focused on reactively treating patients at the crisis stage in a hospital. It is not really set up to act any other way - hence many elderly patients being kept in hospital when they really shouldn't. This is pretty much the most expensive way you could treat patients.

Preventative treatments that stop people becoming ill in the first place are cheaper. As is community-based care that allows people to be looked after in their own homes rather than on a ward. In other words, funding Weightwatchers now is better than dealing with the complications of obesity in the future. The main reason the NHS hasn't done this in the past is the fear of failure: if the preventative treatment fails, you have to fork out for the crisis stage treatment anyway. But as techniques and understanding improve, success rates are improving. Quite simply, if the NHS is to remain viable in the future, it has to move to a model keeping people healthy in the first place rather than trying to make them healthy again. It's why there is also a big focus on holistic health and social care. The NHS and local authorities will have to work together to enable vulnerable patients to stay out of hospital.

If this succeeds then all those District General Hospitals lose even more patients. But still people are rarely keen to see a local hospital shut and politicians are all too often unwilling to take the difficult decisions. To a degree, the focus on "Competiton and Choice" is intended to help this along by encouraging more people to choose to go to a good hospital slightly further away rather than their less good local hospital.

A couple of other changes the NHS needs to make is to continuing building on the various computer system projects (more focus on standards rather than actual systems though). They simply cannot go on with paper records, letters and snail mail forever more. Those letters are one of biggest causes of delay in treatments (as you wait for the consultant to write to your GP and then your GP to you...). Indeed whole clinical pathways (how you get from raising a concern to diagnosis to treatment to recovery) need to be rewritten. If you have a suspected heart problem it can take ways to get a diagnosis: first you need a referral to a specialist then scans and tests then wait for the results to be analysed then deciding on a course of treatment.

But one group of GPs in London turned the system on its head. Instead of sending patients to the hospital for referal, they got the cardiac consultant to come and hold weekly clinics in the community. When scans were needed, they sent patients the same day to a private Harley Street clinic rather than the local hospital. The private clinic had a state of the art CT scanner that carried next to no risk and gave better information than the angiographs carried out by the local NHS hospital. Better yet, the private clinic was half the price of the NHS hospital, even once door-to-door travel was included. Altogether they got the time down to a matter of days, not weeks - which can make a big difference in treatment.

Ultimately there are parts of the NHS that perform excellently but equally there are parts who fail to follow best practice - using treatments that cause more harm than good, prescribing too much, to name a few. Simply bringing the worst performers up to the average would save huge amounts of both money and lives.

[The Black Flash]

ninja-lewis said:

The biggest problem in the NHS is the District General Hospital.

<snip>

Excellent and informative post Sir

[jimnicebutdim]

ninja-lewis said:

Another example is A&Es. Normally if you need trauma care, the ambulance takes you to the nearest A&E, regardless of whether they have all the expertise you might need. If, however, you're in certain parts of London, the ambulance crews are trained (with the support of London Air Ambulance) to bypass local A&E departments and take you straight to the Royal London Hospital, which is a Major Trauma Centre. That means they have medics experienced in trauma medicine (rather than just general medicine), they have all the specialties you might need on hand (surgery, burns, intensive care, etc) and because they see many of London's victims of serious car accidents, knife wounds and gun shot wounds, they're extremely experienced compared to the average A&E department.

It's estimated that if that model was rolled out across England, 3,000 lives might be saved each year. Hence why London is already developing 3 other Major Trauma Centres and regional ones are in development around England.

The same is true of heart attack and stroke care - you're almost always better off with a slightly longer journey to a specialised Chest, Heart and Stroke centre (bypassing A&E in the process) as opposed to being taken to your local A&E department, stablised and then undergoing a risky transfer to another hospital.

MTCs have already started rolling out. The protocols are in place for these. However, there are still needs for DGH A&Es. If a pt is unstable then they will go to a DGH to stabilise prior to transferring. Also, if the MTC if further than 45minutes blue light drive, then again it's off to the local DGH.

As for 'heart attack' victims, define a heart attack. If you are referring to Cardiac Arrest, then you go to the nearest A&E. If you mean Myocardial Infarction then most people will travel to a specialised cardiac unit (known as a cath lab). The problem arises when you have cardiac chest pain that is not an MI (angina, Left Bundle Branch Block, Pericarditus). These patients are not suitable for Cath Lab, and can usually be treated and referred in a normal A&E.
When you remove the local option for people and centralise the facilities.
Same as Stroke vs TIA (mini stroke)

I agree with the idea of centralisation of major units such as MTC's and Cath Labs, but flexibility is still a key consideration.

[Deva Link]

stichill99 said:

My new girlfriend is a physio who used to work in nhs and now works for a private practice. I happened to ask her her views from the frontline. nhs was a skive compared how she has to work now.There was always meetings to be had and patients to discuss,cancelled apointments so more meetings could be arranged,training days and on and on. Private clinic.Half hour appointments and work all day,all week,no time to get paperwork up to date. Oh and clients tend not to miss apointments when they are paying for them!

My niece is a physio and I was astonished how many there are in the pretty small Trust that covers our area - I have no idea about these things but in my head was thinking she'd say 20 or so. The actual number is over 400. Further, just 3 yrs after coming out of uni, she doesn't actually treat any patients, she's in 'management'. She does private work just to keep her hand in.

[968]

ninja-lewis said:

The biggest problem in the NHS is the District General Hospital.

These will built all over the country from the 1960s onwards, with the intention of offering most, if not all treatments, that were available at the time. The NHS started to revolve around these hospitals and their model of local secondary care intervention at the crisis stage - the sort of experience a few posters have mentioned already.

The trouble is this model is not fit for the 21st Century. It costs too much and more importantly it does too much harm. We have lots and lots of hospitals trying to heart surgery but relatively few patients who need it. Around the country, there a couple of hospitals that are centres of excellence for heart surgery - mainly because they have the resources, and crucially the patient throughput, to be safe. They have enough experienced consultants and registrars for 24/7 cover and each of them sees enough cases (coming from all over the country and indeed the world) to keep their skills honed.

Contrast that with the smaller DGHs. They might only have 1 cardiac consultant and they certainly don't have the staff to provide specialised care around the clock in case of complications. And because the staff might only see 4 or 5 complicated cases a year (as opposed to say in a week for the centres of excellence) their expertise is much lower.

The problem becomes all the more acute as treatments become more specialised. Hence the NHS has a number of reviews ongoing to reduce the number of departments around the country carrying out certain specialised treatments - children's heart surgery being one of the main cases at the moment. By closing the smaller inadequate departments and centralising their resources and patients in a limited number of specialised centres, the number of lives saved is significant while the cost per patient is lower.

I completely disagree. Having worked in both teaching hospital 'centres of excellence' and DGHs, it is not true that services offered by DGHs are inferior to those by teaching hospitals. Yes, it is true that the super specialised cases are not dealt with, but they are RARE. The majority of work in the NHS (secondary care) is done by the DGH setting, the majority of cases are dealt with by Consultants who are highly trained and experienced and often have been the main innovators in clinical medicine, as they aren't in a lab, but on the shop floor. The fact that more specialised treatments need specialised services has resulted in the centralisation or regionalisation of services. That has happened already. However it is still the case that a vast amount of work needs to be delivered and the teaching hospitals are wholly inadequate at providing this and are often highly inefficient.

I think you vastly underestimate the quantity of work done in the DGHs you deride and also the quality. I've been involved in lots of work about quality standards and I know first hand that the teaching hospitals fail massively in various regards, and yet some DGHs demonstrate high quality care. You've raised some interesting points but have rather generalised about the standards of care offered.

[0000]

Deva Link said:

The actual number is over 400. Further, just 3 yrs after coming out of uni, she doesn't actually treat any patients, she's in 'management'. She does private work just to keep her hand in.

That sounds quite unusual to me.

I believe physios are normally bands 5-7. Management starting at band 8, although bands 6 and 7 would take on more responsibilities I wouldn't class it as management and they'd still take on patients.

Band 6 is normally reached after 2-3 years, band 7 a much bigger leap (another 5-10 years?) and 8 then even further beyond.

That said, my sister's not a physio, she left uni and went straight into a band 8 role so I'm sure there are many other career paths than the usual.