United Kingdom

01/02/2016 2021 Views
United Kingdom

The National Health Service United Kingdom

The National Health Service has been described as the pride of the UK and akin to a religion in being a standard that all the population believe in and take comfort from. It, and the concept of a Welfare State, a safety net of benefits for children, the disabled and the out-of work, were introduced to post-war Britain in July 1948, at a time of austerity, and of social and economic problems, and was designed to cover all health care, “free at the point of use – from cradle to grave”. It is funded through general taxation and depends on the contributions of all tax payers to support the needs of those with Acute and Chronic Disease, both physical and mental. Those ideals continue to dominate the ethos of all who work in it, giving rise to extraordinary generosity of time and resources on the part of its staff, who feel they are working for the common good and are ready to stay, far beyond the end of their shift, if they feel it is needed. The public recognise this commitment and recurrent patient surveys have consistently shown satisfaction figures of above 84{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} for General Practice services and around 80{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} for hospital services.

The basis is the system of GP registration where every person in the country is registered with a General Practice (single or group of Family Physicians) who is responsible for all their care – “for everyone who is, or who believes themselves to be, ill”.

The GP therefore knows their patient and their family well, has often treated three generations of the same family and acts as the gatekeeper to further investigations and for referral to secondary or specialist care. The GP holds all the medical records and patient notes along with letters from secondary care consultants and the results of all previous investigations. This creates a costeffective health service that avoids unnecessary referrals and duplication of investigations. GP computer systems also alert users to the cost of drugs and will suggest a replacement if appropriate. It also means than money or income is never a factor in accessing health care and the patient does not have to worry about the financial implications of a diagnosis of a Chronic Disease.

In survey after survey, particularly in The Commonwealth Fund Report, The UK emerges as having one of the most cost-effective Health Care Economies.

www.commonwealthfund.org/

Initially all prescriptions (medications) were free but this has gradually been replaced by a basic charge for prescription drugs of £8.05 (9.79 Euro) in England though prescriptions remain free in Wales,Scotland and Northern Ireland. This will cover up to a six months supply of medication but children under 18, those on social benefits, those over 60 years, pregnant women for up to a year after birth and those with exemptions due to Chronic Disease such as epilepsy, thyroid dysfunction, diabetes Type 1+2(and other replacement therapies) do not pay for medication, nor do patients needing therapies for cancer.

The removal of money from the doctor/patient relationship has a liberating effect for both the patient and the doctor, and drug costs are kept low by medicine management agreements so that >70{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of drugs are generically prescribed.

The overwhelming majority of family doctor practices are group practices with from 3-10 doctors (or sometimes more) working together with Practice Nurses, Health Care Assistants, Receptionists, Secretaries, Counsellors and other Health Professionals in a team centred round. Some Practices will offer space to other disciplines such as Physiotherapists, Podiatrists, Benefit Advisors etc. Community Trusts employ District Nurses (for care of housebound patients) and Health Visitors (care of new mothers and babies as well as children under 5 years old) who can support the practice team.

Access to a general practitioner is straightforward with most practices offering appointments throughout the day. Practices have to be open 8.00 -18.30 but will offer “Extended Hours” appointments either earlier or later than these hours or alternatively on Saturday or Sunday.. Emergency appointments (with any doctor) are available on a same-day basis, routine appointments, for instance for Chronic Disease management, for which the patient may wish to be seen by their regular doctor, are arranged at a suitable time for doctor and patient.

Out of Hours Care is varied. Since devolution, the Celtic nations (Northern Ireland, Scotland and Wales) have not been affected by political changes as much as England has, but have had different challenges. The Health and Social Care Act 2012 has largely applied to England only. In England and Wales, the government brought in NHS111, a phone number which would access OOHs Care. The phone system was inadequately planned and inadequately resourced with non-clinical call-handlers working their way through a set of questions to determine clinical need. Previously OOHs systems had developed from GP-led co-operatives which relied on heavy Doctor input and experienced doctor and nurse clinical triage. It was fronted by NHSDirect, a single phone number. It is being recognised that experienced clinician triage is the safest method of delivering emergency care and results in far less hospital admissions. Ambulance disposal rates (to Emergency Room or for admission as in-patient) are 3{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} with experienced clinical triage as opposed to 10-14{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} with non-clinical call-handlers.

There has been a perceived strain on Accident and Emergency Centres though in part this is due to different methods of collecting data and the inclusion of data from Walk-In Centres which are not accident and emergency but deal largely with minor medical problems. Accident and Emergency departments see 21 million consultations a year; GPs see 370 million consultations a year – an increase of 70 million from 5 years ago.

There is also an increasing emphasis on targets; targets in the hospital system (not more than 4 hours wait in Emergency Room, referrals for suspected cancers must be seen in under two weeks) and more targets in primary care (Cholesterol <5mmol/l for patients with cardiovascular risk, HbA1c <7.5{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} for Diabetics, BP, renal function and dementia monitoring, Learning Disability health checks and many more).

The Quality and Outcome Framework, which incentivised good clinical management, was introduced in 2004 and has had a profound effect in standardising and raising the targets for managing Chronic Disease: for instance before 2004, 30{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of diabetic patients achieved a HbA1c <7.5{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}; by 2009 70{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of diabetic patients reached this target: before 2004 the numbers having an annual record of a check for microalbuminuria were negligible; by 2009 90{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} had a regular check with ACE1 prescription if appropriate. There is no doubt that cardiovascular risk has been substantially reduced in the hypertensive population and statin use in those at risk has significantly lowered the rate of strokes and heart attacks. However reliance on protocols and pathways, while laudable in intent, may shift the focus from the patient themselves and an holistic assessment to an concentration on biomedical markers. For instance, data on renal function (eGFR) in those over 80 years may reflect ageing kidneys rather than a disease process and lipid targets may lead to inappropriate prescribing in the very elderly. Political interference, micromanagement, a target culture and repeated changes have led to low staff morale.

Over recent years, the reduction in the benefit system has had an impact on the poorer section of society with a rise in the numbers of children living in poverty and the increasing use of “Food Banks” by families who may be in work but whose pay is too low to constitute a living wage. It is recognised that deprived communities have poorer health outcomes as described in Sir Michael Marmot’s Review of Health Inequalities “Fair Society, Healthy Lives” .

www.ucl.ac.uk/whitehallll/pdf/FairSocietyHealthyLives.pdf

The whole of the NHS, GPs and hospitals, is under severe financial strain. Despite promises before the last but one election that the NHS would be left alone, the Health and Social Care Act 2012 has caused disruption and reorganisation which, along with the burden of having to save £20 billion this year, is causing huge strain to the system, The UK has one of the lowest hospital bed numbers in Europe with just over 300 beds/100,000 population and one of the lowest numbers of physicians per population and this is against a demographic of an ageing population with more complex and chronic disease.

To save money, care and management of Chronic and Complex Disease is increasingly being shifted out of secondary care and into primary care without the appropriate resources necessarily following. The funding also militates against co-ordinated care: hospitals are paid on activity, so busier is better; GPs are paid on a block contract which works out at roughly £12/patient/month no matter how much resource the patient takes up. The government favours funding hospitals above funding primary care which has suffered from increasing disinvestment over the years. It now is allocated 7.4{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of the total NHS budget where five years ago it received 11{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of NHS Budget (which may still have been too low). A robust primary care is the basis of a cost-effective health system and it is enlightening to compare EU health systems. The NHS suffers from lack of stability due to government measures, from recurrent financial cuts which have caused loss or down-grading of staff and from micro-management with the recently reorganised Care Quality Commission undertaking an inspection of every health provider.

The CQC has the authority to inspect every Medical Practice, Health Centre, Dental Service, Walk-in Clinic, Hospital and Care Home concentrating on staffing (up-to-date training, appraisal, CardioPulmonary Resuscitation, safeguarding of children and vulnerable adults), safety (infection control measures, storage of vaccines and drugs), providing access for patients ( entrances and toilets for the disabled), and Management. This is as well as NHSEngland inspection of GP practices and Health and Safety Inspections. For doctors, annual appraisal has been in place for 8 years and revalidation was introduced in April 2013. This will occur every five years and requires 5 valid appraisals, a patient survey, a colleague 360 degree survey, a significant event audit, evidence of other audits, evidence of continuing education (250 hours over 5 years) evidence of reflective learning, evidence of updated skills (CPR, Child Safeguarding) and declarations of health and probity. This degree of surveillance of performance, of hospitals and of practices may have a tendency to promote what some have called “a culture of fear” as practices and their staff endeavour to make sure they have complied with every regulation.

Morale among General Practitioners/Family Physicians is low, due to increased work load, reduced funding (and changes to the NHS Pension System), and the continuing rise of patient expectations, fuelled by the media and the government. The media, in particular, seem to blame GPs for whatever goes wrong in the health system, partly because generalists are involved in some aspect of every patients care but also because if hospitals are blamed the staff are more anonymous where attacks on GPs seem personal and the constant barrage of articles castigating lazy GPs, for not having surgeries open on Sundays for routine appointments or not doing Outof-Hours work (despite the fact that GPs staff the OOHs rotas) leads to low morale since most GPs are working harder than ever, due to increased bureaucracy, monitoring of biomedical targets and data collecting. GPs in an average practice (7000 patients, 3-4 doctors) now arrive at their place of work before 8.00 and, though average workload is difficult to determine, a GP, having seen 30 -45+ for face-to-face consultations during a morning and an afternoon surgery, made 4-5 home visits, finally checked all pathology results, completed all phone calls to patients, reviewed and acted on all hospital correspondence and dictated all referral letters, may not leave until 19.00- 20.00. This is leading to a recruitment and retention problem with older doctors considering early retirement (often when they are in the mid-fifties – that is with 10 years or more before they might otherwise have retired) and younger doctors not taking up training posts in family medicine, or not contemplating partnership in a practice, or emigrating to other Englishspeaking countries such as Australia, Canada or New Zealand. These problems in General Practice are causing such concern that a Special Conference was called in January 2016 to discuss the reasons for and possible solutions to the Crisis in General Practice Despite all this, NHS Staff remain loyal to the organisation. They have endured years of pay cuts and changes to the pension plans which induce stress fatigue, and staffs cuts which may impinge on patient care.

I have talked to many people within and outside the NHS during the writing of this report. The one fact that they always mention is that the NHS does not cost the patient anything to access and those who had worked abroad commented that medical care costs did not factor in peoples lives. This, they feel, is the best aspect of this Health Economy. They also commentated that the financial constraints were making it increasingly difficult to maintain the standard of care needed.

For those who work in it, their pride in the NHS, as an ethos and a philosophy, is unshakeable.

Dr Mary McCarthy FRCGP

Head of UK Delegation to UEMO

February 2016

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