Evidence (Personal Narrative): Working together for vulnerable patients

The Health and Social Care Bill converts the NHS, which at present is overwhelmingly a public service into a series of lightly regulated, competitive markets. The basis upon which this is going to built is the ‘purchaser-provider split’. This is an artificial split between GPs as purchasers of patient care and hospitals as providers.  It gives hospitals a financial interest in over-treating in order to make money and GPs a financial interest in restricting or refusing treatment in order to make savings. It works against the efforts of GPs to collaborate effectively with their hospital colleagues, adds complex contracts and billing, and threatens services that are inherently unprofitable. The unprecedented and abrupt freezing of NHS funding, labelled ‘efficiency savings’ but experienced as front-line cuts, combined with the new threat of hospitals going bankrupt is forcing doctors to put financial interests before patient interests. I accept that some doctors do this already, but these reforms, by converting patients and healthcare into commodities, will make the problem much worse than before.

Instead of phoning the local hospital to ask a specialist for advice, we have had to set up a contract with each department for an ‘advice line’ and the calls are logged and we are charged.

Hospital specialists and GPs have been working effectively together to develop management pathways to improve the quality of patient care. Pathways ensure GPs complete appropriate preliminary investigations and trial treatments before referral. The consequence is, in many cases that fewer patients are referred. As GPs we are now beginning to find that hospitals are unwilling to contribute to the kinds of collaborative efforts that will reduce referrals and hence their income.

In order to save money we have to find ways of providing services ourselves that are provided by the hospital or mental health trusts. These may include employing specialist community nurses or consultants. We are very keen for our local hospital to continue to provide the excellent care our patients need, but can make significant savings by providing some services ourselves. Not only are we at risk of conflicts of interest, but in doing so we risk undercutting the hospital, which depends on cross subsidies.

A hospital medical director this week told me he honestly didn’t know how his hospital could continue to provide care for unprofitable patients. The unprofitable services for most hospitals are elderly care, mental health, paediatrics and maternity. Money can be made from services that are easily broken down into commodifiable parts and organised predictably. The lower hospitals put their thresholds for investigations and procedures, the more they over-investigate and treat and the more money they can make. I know of a gastroenterologist who is deeply uncomfortable about performing what she believes to be unnecessary procedures, but her department is generating desperately needed revenue for her hospital. Sadly, personal care for the elderly is not profitable. Hospitals are being put in the appalling position of having to choose between being able to afford to keep patients alive or keep them clean.

Evidence Submission by: Jonathon Tomlinson, GP in east London