Tory MP Jesse Norman today proposes that we should send everyone who uses the NHS an Annual Healthcare Statement. The statement would show them how much they have cost the NHS and 'by implication the value of NHS services'. It is designed, it says, to dissuade people from presenting to hospital or GP surgeries unnecessarily. The report also suggests 'more incentives' could be added in the future.
Fear that a free NHS would result in overwhelming demand has been around since the very idea of an NHS arose. It’s an idea that has been superbly deconstructed by Julian Tudor Hart. Politicians and economists couldn't believe that free healthcare wouldn't result in unsustainable demand. In a panic they introduced prescription charges, which led to Nye Bevan's resignation. But in fact:
“In 1951 the first postwar Conservative government set up a Royal Commission to measure abuse and extravagance. After painstaking studies the Guillebaud Commission found no evidence of either, only hard-working staff and stoical patients, underfunded and lacking investment.
Study of a poor inner city area in the early 1970s showed that for each person who consulted with a minor problem, more than two others failed to consult at all, despite recent severe or worrying symptoms. Contrary to subjective impressions of overworked doctors, fear and denial of illness were more powerful than avidity for free consultations. Despite free universal access to the NHS, for most important chronic conditions less than half are medically recognised, of which roughly half are treated, and roughly half of these are controlled. Far from expecting infinitely, NHS patients expect too little.”
The most vulnerable patients already fear that they are a burden on the NHS. As a result they attend too little. Or they fail to attend because they are feeling ashamed, or even when they are feeling too unwell. Parents of young children struggle too, feeling “strongly influenced by a sense of responsibility to act as competent parents and the fear of overwhelming guilt should they fail to do so”.
I have had a patient present with a breast cancer that had almost completely destroyed one breast, another that had a stroke but waited 3 days until they could see me, instead of going to A&E, another who ended up on a ventilator because she thought she was wasting NHS resources because her asthma is so difficult to control.
For the last two years GPs have been required to review all their patients who attend out of hours, A&E and the GP surgery frequently in order to try to identify whether they can be better cared for. The majority of patients who attend frequently are very sick, with, for example, severe heart, lung or neurological diseases, often requiring admission for intensive care.
Others have serious mental illnesses, sometimes compounded by illicit drug or alcohol use.
Under Jesse Norman's proposal those who require the most intensive care would be presented with by far the highest bills. I can think of one patient who spent 6 months in hospitals with recurrent perforations of his intestine due to his Crohn's disease.
There are certain groups of patients who attend frequently, who on superficial analysis might be assumed to be attending inappropriately. Some of them are suffering from 'medically unexplained symptoms'. These are physical symptoms like chest and abdominal pain, headaches, blurred vision, numbness and tingling, weakness and so on. In some cases they represent serious, difficult to diagnose disease, and in other cases the symptoms are a manifestation of unresolved and often unresolvable psychological pain.
Other groups that frequently attend are patients who are extremely anxious, those that are suffering domestic violence, those that have been abused and the very lonely. Experienced GP John Launer has asked, 'What is an emergency?' He recalls diagnosing a child with meningitis who appeared, at the time they came into his surgery, entirely well. He continues,
“I will happily accept having seen tens of thousands of mildly snotty toddlers over the years, giving their anxious parents a bit of friendly advice and education, and seeing them on their way in less than 5 min. We cannot, in other words, preach the importance of our own expertise and at the same time berate people for making use of it."
Jesse Norman said to me this morning that it was “easy to see a GP reviewing a statement with a very vulnerable patient and encouraging better use with better outcomes”. He said that it would be “especially valuable to the most vulnerable patients”.
When we meet with our most vulnerable patients, we spend the time trying to work out how best to help them. Usually we know them very well, because they come to their GP a lot as well. I have a pretty good idea about the impact of an Annual Statement. It will almost certainly add to their sense of being a burden on society and the NHS, something that they already feel. It will add to the anxiety parents of young children feel when they try to identify the goldilocks zone where their child is sick enough to warrant medical advice, but not so sick that they've left it too late.
It will encourage a superficial view of healthcare as a commodity, rather than care as something complex that happens between people. Something recorded as a minor illness on a hospital letter happens to someone with a history and a home-life, hopes and fears.
Once you start to understand these, you might come to the conclusion that there's no such thing as a trivial consultation.
Which incidentally was the first blog I ever wrote.
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