Jeremy Hunt, the Health Secretary, is a decent and well-meaning man. He’s genuinely excited about the new, radical reforms planned for the NHS which he announced last weekend. I have been told that Hunt and his old friend David Cameron see this restructuring of the NHS as the next great step, as significant and successful as Gove’s education reform; something the Prime Minister will be remembered for gratefully in 100 years’ time. I’m afraid they’re wrong. If implemented as announced, these plans will be both expensive and ineffective.
The main trouble is that Hunt’s NHS revamp will rely on a vast, integrated and enormously complicated IT system. The idea is that eventually all patients’ electronic records will be available ‘at a click’. But governments just aren’t competent to deliver or commission this sort of grand IT project —- as we’ve seen time and again. Yes, of course it sounds like a great idea: ‘making the health service paperless by 2018’. But we’ve been here before. NHS Connect cost the taxpayer £13 billion before it was abandoned as unworkable and technically impossible. Long after that scheme was dropped, we are still committed to pay the IT supplier another billion pounds. This is how bad the government is at writing contracts. In a utopian health service, nationwide electronic patient records might be a good idea. In practice, ask yourself why they have never been adopted by any other country with a health service comparable to ours.
The NHS can manage well without them. In the non-emergency situation, the general practitioner referring the patient should give an account of past medical history. In the emergency situation, the patient can almost always provide an adequate amount of medical history. Most know the names and doses of the drugs they are taking. If not, they usually carry a ‘repeat prescription’ list with them.
If Hunt and Cameron are really looking to repeat the success of education reform, perhaps they should consider that one of the first things Michael Gove did was to extract the Department for Education from any complicated, top-down IT schemes on the grounds that Whitehall would be bound to mess it up. Quite apart from that, the NHS just doesn’t have another £13 billion to waste.
Jeremy Hunt’s next big idea is a people-pleaser: bring back the good old traditional family doctor, with GPs once again taking on responsibility for our-of-hours care. Now, everyone is sentimental about old-fashioned GPs, not least the BMA and the Royal College of General Practitioners (without the on-call part). You can just imagine Mr Cameron on holiday, relaxing into a happy reverie about his legacy as the man who brought back ‘Dr Finlay’. But Dr Finlay just doesn’t work in the modern world. Far from bringing him back, we need to retire him and think again.
The trouble with GPs is that they work in group practices, geographically and professionally isolated from the mainstream of hospital medicine. Over the past few decades, modern medicine has been revolutionised by technology, little of which has filtered down into general practice. GPs cannot carry out certain essential tests quickly. Although there are many exceptions, it is very easy for GPs to become ‘de-skilled’, and by mid-career some may not be well enough informed to manage serious acute illnesses. In addition, most GPs fail to provide the services which patients most value — namely, timely and convenient access as well as continuity of care. These deficiencies are most acute in inner cities and deprived areas. There is no incentive in general practice to improve performance or efficiency.
No wonder, then, that patients with acute problems prefer to go to A&E. It’s not that they can’t be bothered to wait for an appointment; it’s because GP services aren’t good enough — which is why A&E units are at breaking point. In A&E a patient will be seen by a junior hospital doctor whose knowledge is contemporary, and who will probably be studying for a postgraduate examination. That A&E doctor will have immediate access to urgent tests and, if necessary, will be able to escalate the problem for more senior and experienced advice. This is how acutely ill patients need and deserve to be treated.
So if GPs aren’t the answer, what is? Well, to cope with the increasing workload in hospitals and to improve services to patients, clinical nurse specialists and advanced nurse practitioners have been appointed and have transformed the scene. They are highly qualified and skilled professionals and would be ideal in general practice to run screening and immunisation programmes, child development, care of the elderly and many other services.
In addition, the role of GPs must change. They must train and work differently. They could adopt a hybrid role working mostly in A&E and benefiting from the nourishing environment of mainstream hospital medicine. This template would prevent de-skilling and would maintain professional and academic acumen. It would transform primary care. It would also solve two of the biggest manpower problems in the NHS.
If, as I hope, Mr Hunt is smart enough to see the errors in his current plans and make some swift changes, then here’s another urgent problem he could solve: we need more British doctors. Most readers will be surprised to learn that every year, we import 40 per cent of our doctors because of insufficient training places in British medical schools. Most applicants to UK medical schools are rejected despite having the required A-level grades. We encourage young people to become doctors, then we slap them back for want of places. Currently, the General Medical Council registers approximately 13,000 new doctors every year; 7,000 come from British medical schools, and the remainder come from other EU countries and from outside the EU. So 40 per cent of doctors starting work in the NHS every year have little or no knowledge and experience of British culture or of our health service — and this in the most -people-centric occupation of all. It really does matter.
You can see why the situation has arisen. The government doesn’t want to pay for thousands more expensive places in British medical schools, and from the foreign doc’s perspective, working for the NHS is a bonanza. As primary medical qualifications are recognised reciprocally across the EU, doctors from every EU country have the automatic right to register with the GMC. European doctors fly in for weekends to cover locum vacancies, especially in general practice.
There is no test of language proficiency before registering. As a result of austerity in southern Europe, there has been a significant increase in GMC registrations of newly qualified doctors from Greece, Spain, Italy, Portugal and especially from eastern Europe.
Importing doctors from abroad on a regular and ongoing basis might not be a bad thing if there were any guarantee that the entry criteria to all foreign medical schools were as rigorous and as discriminating as our own. Also, that the quality of teaching and training was always as comprehensive as ours. But too often, it isn’t. A GMC survey published in the British Medical Journal recently showed that foreign-trained doctors were up to four times more likely to be suspended or struck off than their UK colleagues. Dr Peter Rubin, GMC Chair, launching the second annual report in 2012, said, ‘Most people would prefer a health service run by doctors who have trained in the UK.’ Elsewhere in that report he remarks, ‘The diverse profile of doctors working in the UK brings challenges, not least in making sure that doctors interpret and apply our standards consistently, irrespective of when and where they were trained.’
Defenders of the system say there are filters in place to weed out dodgy doctors. But where was the filter that checked the competence of Dr Daniel Ubani, a Nigerian-born German citizen who on his first GP locum in UK unlawfully killed a 70-year-old man by administering ten times the maximum recommended dose of morphine?
Here’s a thought for Mr Hunt and Mr Cameron: ditch the useless IT scheme and spend the billions you save on training more British doctors. Yes, I know you may not see results before the next general election — or indeed the one after that. But you’re in it for the good of the country, yes? And this is an essential building block of a durable recovery for the NHS.
The reasons I believe in Mr Hunt’s good intentions, and think he still might make the reforms we actually need, is that he is so clearly on the right track in one respect. Last weekend he outlined a plan to ‘create a cadre of senior doctors, similar to school superheads’, trained to take over hospital trusts. This is an excellent suggestion and implies that Mr Hunt accepts the fact that hospital inspections alone will not improve standards.
It also suggests that Hunt understands that the answer to better clinical care is not more management. Clinical standards can only be improved by better training and inspired clinical leadership.
Currently it is rare to find clinicians at the heart of any hospital management structure. Mr Hunt’s intention to recruit more clinicians into management is groundbreaking. Clinicians in management will focus attention on patient care and away from esoteric managerial matters —- and surely that’s something everyone can applaud. Now let’s get on with the rest.
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J. Meirion Thomas is a professor of surgery and a consultant surgeon in the NHS.