The radiologist: Interview with Dr Jacqueline Davis
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Dr Jacqueline Davis is a consultant radiologist working in a hospital in London. She is co-chair of the NHS Consultants' Association and a member of the Keep Our NHS Public campaign. In this interview, conducted on 7th March 2011, she talks about the reforms to radiology over the last 10 years and the threats to the NHS contained in the coalition government's Health and Social Care Bill.
How long have you been working in the NHS?
Nearly 40 years.
What does a consultant radiologist do?
A consultant radiologist is responsible for many aspects of imaging patients. So for instance, my special areas of interest are general radiology but also the radiology of children and the radiology of breast disease. We see patients, we report x-rays, we supervise the work of juniors who are training in the department and we are generally available for consultation to the doctors in the hospital who want to come and discuss patients.
The important thing about us, and this may come out in the conversation later on, is that we are on site and available for discussion about those problems all day. Radiology is not, as so many people are starting to categorise it, a back-room function that you can outsource somewhere. It’s very important that we are able to discuss all day long and at night as well, because some people are on call at night.
Before we get on to that, can you explain how the job and how the NHS in general has changed since you started?
Gosh, that’s a huge question. When I began as a radiology consultant in 1981, CT [X-ray computed tomography] had just come in, MR [Magnetic resonance imaging] didn’t exist, and most of the interventional radiology that gets done now didn’t exist either. So it’s become a much more complicated speciality that contributes much more to the work of the hospital.
When I first started as a consultant at my hospital, I think there were four consultants. There are now 11, which just goes to show how the speciality has expanded. Radiologists now do many things that surgeons used to do through interventional radiology. It’s a huge area but, despite the fact that we make a very important contribution to what goes on in the hospital, we now feel under threat, which I’d say we didn’t do 30 years ago when I first became a consultant.
There has been a lot of pressure on us through threats to outsource radiology, and because people view radiology as something that can be labelled a backroom function. Because a lot of it is computerised, it’s viewed like ringing a bank or something like that. There has been a view amongst people who don’t understand what radiology is about that you can send it to Bangalore or Barcelona or somewhere like that. In fact, under Alan Milburn [Secretary of State for Health in the Labour government] they looked around and saw that MR scans were a stumbling block and that patients were waiting in hospitals to have MRIs done. Now what they could have done at that point was to say to the NHS hospitals, “how can we help you do more MRI scans?” And we’d have said, actually our MRI scanner stands idle quite a lot of the time because we haven’t got the people to staff it, we haven’t got the money to run it out of hours. Then they could have funded us to do that.
But they didn’t do that; they just went straight to the private sector and bought in MRI scans [from outside] and that led to huge problems. One of the things that politicians don’t understand about radiology is that it’s a lot about face-to-face discussion about patients, and it’s a lot about having known the doctor you’re talking to, and them having known the radiologist they’re talking to. Now, you do an MRI scan but that’s only part of the examination. The other part of the examination is perhaps the orthopaedic surgeon coming along and saying, “I know you Dr Smith and when you say this, what you mean is I need to operate on this or you’re not worried about it or you are worried about it.”
So here I am, I’ve got this report back from abroad. I don’t know what this person means and I think, to protect themselves in a medico-legal sort of way, they’re over-reporting this case and I’m afraid I’m going to be operating on this patient when it’s not necessary. Now if I had had this report from [the radiologist] who I deal with everyday, we could discuss the best thing for the patient. But I’m getting a report from a doctor who I don’t know, overseas, who possibly doesn’t speak English as a first language, who doesn’t know anything about the patient because they can’t discuss it with me, and so I’m asking to re-report this scan so that I can act on it with confidence. What was happening was not only that where the referring clinicians were getting reports that they couldn’t trust because they didn’t know who they were coming from, they were able to go to the NHS doctors and ask them to have a look at it.
Now you can’t just have a look at an MRI scan. These are dozens and dozens of images. Somebody’s got to sit down and report that. We didn’t get paid for doing that; the private sector got paid for doing that. It took our time and was just a terrible waste of money. And that’s a prime example for me of how the [Labour] government was ideologically prepared to throw money at the private sector when they could have solved the problems in the National Health Service.
Couldn’t that be an argument as well for greater standardisation of communication practices?
Not really, because the more complicated the test is, the more likely the referring clinician is to want the nuances of the debate. So standardisation of communication might go some of the way but it does not help that inter-personal reaction which we have all the time. For instance, we now have a lot of what are called clinico-radiological meetings. And at those meetings we, the radiologists, meet the clinicians to discuss patients.
I was a breast radiologist for 25 years. On a Monday morning, we sat down and discussed all the patients from the week before. That might be something like 50 patients or more. I’m not saying we discussed everyone in detail but, where there was a question, everyone had an input: the surgeon, myself as the radiologist, and the pathologist. Then we would discuss the best outcome. How are you going to get that if your report’s coming from 5,000 miles away? You can try and wriggle as much as you like but the private sector is never going to provide you that, unless they come to your hospital and sit down with your clinicians.
Those meetings don’t happen as much as they did?
Yes, they do, because the outsourcing of the MRI was not a great success. What’s happened to that now I’m not quite sure, but it cost a lot of money and a lot of NHS radiologists ended up re-reporting those films. I’m told that it was done in such a hurry that the private sector [staff] who undertook it were just drowning in scans that they couldn’t deal with. So it wasn’t a great success.
When it was still being outsourced, the meetings happened but people would come along before and ask to discuss these five patients to see whether they needed spinal surgery, for example. But [the scans] had been done outside by some private company that had sent them via broadband. [The doctors] would say, “we don’t trust their reports because we don’t know who these people are and we always work with you, so we’re not going to operate on these people until you’ve looked at these scans.”
The money was coming out of the NHS budget and it could have been much better spent by just saying to hospitals: extend your scanning hours (which is what a lot of us do now), scan on a Saturday, scan on a Sunday, pay the radiographers a relatively small amount of money - compared to what you’d be paying the private sector to do it - to come in and just scan out of hours, and if the radiologist can’t do it during the day, then you can pay them a bit of extra money to do it out of hours as well, but it’s all much less money than setting up the private sector to run it.
What they have done now is that they have beefed up local hospitals through things like the private finance initiative (PFI), which we’ll pay for as taxpayers but means it will stay in the NHS, but we’re still being threatened with outsourcing. In our hospital, our department is now a PFI department. From the point of view of the radiologist, it’s very nice to be sitting in a nice, new department with a lot of new kit. From the point of view of the taxpayer, of course, it’s deeply troubling to think that we’ve got £11 billion worth of new hospitals, which are going to cost the taxpayer something like £60 billion. But as somebody sitting in an office with a nice Pax machine in front of me and new equipment outside, that’s great.
Now they’re saying we can outsource simple things like all the plain films that we do. If you go to your GP and say you’ve got a cough, the GP sends you to the hospital and says, “please can this man have a chest x-ray,” and I’ll report it and say pneumonia or normal, or whatever, and that’s much easier to send down the line. But at the same time, if I’m not reporting those films, how am I going to stay in practice at looking at x-rays and how am I going to train the next generation of radiologists who come to our hospitals to be trained? If that stuff is all being sent abroad, they’ll grow up not knowing how to do it and then it’ll be de facto that it has to be sent abroad because nobody here can do it. So whatever you choose to hive out has an effect. There is a hospital round here which doesn’t have enough kit to do the reporting, which is now looking – very close to signing, I’m told – at a partnership with the private sector. These will come in and supply the kit, but once you start going down that path, it’s a very dangerous path because you don’t know when you’re going to stop.
You can imagine that’s the kind of work that is treated quite dismissively by the government reformers.
Well, because they don’t know what it means. They always think in terms of elective surgery type of stuff. You walk into a room with a technician, have a chest x-ray taken, and then someone sitting somewhere else reads it. That is part of what goes on, of course, but the other part of what goes on - and the part that’s absolutely crucial to any hospital, or anywhere that’s dealing with sick patients - is this interaction that goes on all the time. You know the department has got an open door to every clinician in the hospital and you can walk out at any time into the open reporting area: there will be a clinician who will be discussing a case with somebody. That’s what they don’t factor in. It’s not just chest x-rays taken here, sent by a wire to ‘b’, where there’s somebody sitting reading it. It’s the discussion that they don’t understand.
The other thing they’ve tried to do - and they’ve tried to do this everywhere, because what costs most money in the National Health Service is staff costs - is 'skill mix'. With skill mix you devolve down the work to people who are paid less, basically. And of course, sometimes the people who do the work are completely appropriate to do that work. For instance, much ultrasound scanning and all the obstetrics scanning is now done in our hospital by radiographers. They also do some of the vascular work, for instance, and they do it extremely well. But they do it in the context of their background training, which is not a clinical training. So while there’s this constant pressure to push who does the work down the line, you’ve got to recognise that you lose a little bit every time it goes backwards. I was a breast radiologist; I spent a lot of time reading mammograms. The mammograms are done by the radiographer, who’s a specialised breast radiographer. Many breast radiographers now want to start reading mammograms, and they do in the national screening service. There have been some discussions about that, is it appropriate to do that?
It was very interesting for me when one of the radiographers who’d been involved in this discussion came and complained to me that there were now clinical care helpers who had been trained to do mammograms. In other words, her job was being poached by the next person down. So people were waking up to the fact that it’s not just me that’s getting a step-up, it’s the person below me who might take my job away. And of course, when the private sector comes along and takes anything over, that’s the first thing they do; they try and downgrade everybody.
I think one of the problems is that, as radiologists - in other words, doctors who do radiology - [we] have a clinical background, and so when we look at images, we have five years of medical training plus whatever we’ve done before we went into radiology to set that against. Radiographers aren’t trained clinically. That’s not their job and it is not supposed to be. So when they report things, they have much less of a clinical background than we do. In fact, one of the things they’re not allowed to do, for instance, is to provide a conclusion to their report. So if I look at something and it’s not absolutely clear, I might give a summary saying these are the diseases I’m considering in this situation. The radiographers can’t do that because they don’t have that disease background. So they are very good technicians at doing what they do, but they’re out of the clinical context. So every time you take a step down, you lose that clinical background more.
Could you give an example using a specific problem that someone might have?
For instance, a radiologist might feel more comfortable in saying, “we’ll wait for six months, I don’t think I’m worried about this, I don’t want any tests at the moment.” Whereas somebody who doesn’t have that clinical confidence might say, “this could be something, I don’t really know, so let’s have an MRI scan or let’s have a CT scan.” They’ve put some of the ultrasound scanning out to the private sector and, in my experience, it tends to get over-called. We’ve seen examples in both instances of something simple, like a kidney cyst, being over-called and the patient being made to be very worried, whereas I’d have seen it and said this is nothing to worry about. At the same time, we’ve seen cases where important small things were overlooked. So perhaps it’s just a question of experience, but I do think if radiologists didn’t need clinical experience or a clinical background, we’d be just technicians too. There’s a reason for us being doctors as well: because we need that background in disease management.
And it saves money as well.
Have there been more managers in the last ten years? Have the ratios between staff and management changed?
I can’t quote numbers at you but there do seem to be more managers. Unfortunately they don’t seem to have been allowed to do what I would call useful management. It depends on what you think managers should be doing. For me, I think what managers should be doing is facilitating the work of the hospital, and the work of the hospital is seeing and treating patients. What happened was that managers got side-tracked into meeting targets. Some of that was improving life for patients but, instead of being a means to and end, it became an end in itself. People would be rushing around with clipboards and trying to meet financial targets. When managers are diverted to pursuing financial targets, as they are when a hospital pursues foundation trust status, they tend to take their eye off the clinical ball.
One of the reasons why the managers have also tended to go up in the NHS is because of the purchaser/provider split. [See the accompanying interview with Norma Dudley for further details.] Before the introduction of the purchaser/provider split, management costs were somewhere at 5% to 6%. They’re now up and I’m told the latest is about 15%. So that’s an additional £10 billion a year being spent on management, just in order to administer the marketplace in health which has been introduced in the last ten years.
Your point about the managers and targets has been used to justify the reforms that are being pushed at the moment. David Cameron wrote in the Telegraph that, while he was “always so grateful for the tremendous care my eldest son received, I never understood why local authorities had more control over the budget for his care than Samantha and I did. In the past decade, stories about bureaucracy over-ruling common sense, targets and regulations over-ruling professional discretion, and the producers of public services over-ruling the people who use (and pay for) them – became the norm, not the exception.”
Ai, Ai, Ai! We'll start with the first one. He’s talking about local budgets, I think: Why didn’t we have the budgets for the care of our child? Well, personal budgets are a very difficult path to go down. First of all, if you’re the chattering classes, you’re going to know how to use your personal budget. If you’re not perhaps articulate and not a well person, then who’s going to advise you about how to use your personal budget? Who’s going to monitor what’s happening and what’s going to happen when you spend the money? I can tell you what will happen: The insurance companies will step in and say, “would you like a little bit of a top-up, would you like some insurance?” So that moves us into a two-tier health service straight away.
About the business of bureaucracy over-ruling common sense, no-one ever claimed the NHS was perfect. It has become very bureaucratic, and that was partly because of the introduction of the marketisation of healthcare. I went to the public meetings of our local Primary Care Trust (PCT) on several occasions (and please note that I could go to open meetings of our local PCT, which we won’t be able to do under this bill - so much for public accountability that he talks about!) and I asked at that open meeting, “Who are the clinical representatives on the PCT?” They really couldn’t tell me.
In other words, the PCT, which was designing and buying care locally, didn’t seem to have any clinical representation at all. So had David Cameron wanted to change the NHS, by putting clinicians in the driving seat, he could absolutely have done it with the current structure that we have. He could have taken the doctors from primary care and secondary care who are interested in commissioning - and that’s a small percentage of them - and put them into primary care trusts. He could have taken out the people whose jobs looked highly doubtful and you could have had what everybody wants, and what doctors want: more involvement in the care of patients, without turning everything upside down. They didn’t do that, of course, because this isn’t about giving power to doctors or more say to patients. It’s about the introduction of the private sector and they couldn’t have done that in the current structure, or it would have taken too long in the current structure. So this whole business of giving power to doctors is a fig leaf for what they are really doing.
About “targets and regulations”, I think people would look back now, for example the four-hour wait for accident and emergency (A&E) target, and say they did make people up their game: staff concentrated on getting people through A&E. But the government was completely inflexible about it. A&E doctors went to the government and said, “actually, if you were to reduce this from 98% to 95%, we wouldn’t have to admit drunks who don’t need to be in overnight” and so on, but the government said, “no, it’s 98% or nothing”. So I’m afraid they over-applied the medicine and it harmed some people. The Tories have taken that target away, of course, and they’ve taken the waiting list target away, and I think patients will suffer (the ones who can will turn to the private sector). So there is a place for targets but you have be guided by the profession in how appropriate they are.
Next one, “power will be placed in the people’s hands.” You know, god forgive him for that. Power will not be placed in the people’s hands. Power and money will be placed in the hands of the private sector and people will then do what they’re told. Increasingly professionals will do what they’re told because once the private sector is holding the budget and providing the care, they’re going to be the very uncomfortable sandwich in the middle of that.
And “professionals will see their discretion restored”?
I don’t know what he means by that. What does he mean by “have their discretion restored”? Before all this started, you could go to a GP and be referred to any doctor in the country, and that was professional discretion. We now have United Healthcare, I believe, who have been employed down in Hounslow to handle the referral management of GPs down there. So if you go to see your GP in Hounslow, as I understand it, his or her referral does not get sent straight to me; it gets sent to the referral management centre, managed by United Healthcare, a huge American corporation, who then decide whether that’s an appropriate referral or not. And if [they believe] it isn’t, it gets sent back to the doctor, who knows the patient much better than they do, which is none at all. Or it may be redirected from the hospital to some organisation in which United Healthcare perhaps doesn't have a direct interest, because I’m sure the government will stop that, but is maybe in a sort of 'I’ll scratch your back if you scratch mine' arrangement. So there are huge conflicts of interest which are going to face both doctors and patients. Not for nothing was David Cameron a political spin merchant before he became a politician - it just shrieks out of every sentence he says about the health service.
In terms of the commissioning, the way it’s been advertised is that the GP and the patient will choose a hospital and the patient will say I want to go there.
Nobody actually knows how the patient choice is going to work now. People keep talking about commissioning as if it’s just paying the bills. Commissioning isn’t just paying the bills; it’s the planning of healthcare. PCTs have over 140 statutory functions which include child protection, prison health, vaccination programmes and all the rest of it. So nobody has told me who’s going to do all that stuff. GP commissioning is being offered as the bait in the bear trap of this whole business, against the background of £20 billion “efficiency savings”, which amount to cuts and closures, of course, because they can’t possibly save that amount of money.
The scenario that the government is pretending will happen: I go to my GP, I need something done, I go on to chose and book, I choose anything in the country from a menu of any hospital plus private providers, and then the GP just pays for that. That would be financially ruinous. How can they possibly afford to do that?
No-one has explained this yawning gap between the GP consortium having to save its share of the £20 billion and the patient being told they can have anything they like from anyone. And the consortium will, supposedly, negotiate an individual contract with that place. Are you going to negotiate a contract with everyone around the country for every single procedure you’re going to do? It makes no sense whatsoever. The instruction to the GP is save money and stay financially solvent, otherwise you’ll be taken over by the private sector and the NHS commissioning board will be down on you like a tonne of bricks. To the patient, they put on a completely different hat and say, “sure, patient choice, empowerment, you can have what you like.” It’s schizophrenic; the two don’t meet in the middle.
What they’re doing now is “unbundling” care. So instead of going to the hospital in one go, it may be that the hospital doesn’t have certain services any more, so you’ll have to go out to some private place to have your physio. First of all, what’s that going to look like to the patient? Because you were just used to going to the hospital and everything was done there, but now you’re going to have to start travelling around to all these places. I don’t think that’s patient choice. And secondly, how are all these people going to be communicating with each other? Well, that’s one of the reason why they wanted to set up this NHS IT programme, because if you’re going to have patients travelling around from one organisation to another, of course the information’s got to follow them.
So how far will the unbundling go?
We don’t know. But one of the great threats to hospitals is this business of “any willing provider.” Supposing the GPs want to tender out the local orthopaedic elective surgery, the private sector will come in and say, “we’ll do that for you.” And although they claim there’s going to be no competition on price, although they’ve had to turn back on that, it will happen in future.
So the GPs say they don’t want Monitor [the regulator] coming after them because that would be anti-competitive, so they’ll have to give it to whoever’s cheaper. So the elective surgery goes to Hips and Knees ‘R’ Us or whatever they’re called. But the orthopaedic department in the local hospital can’t survive unless it’s doing the bread-and-butter work as well as the complicate work. So what we’ll find is that, if the profitable work is taken away, they can’t exist, because they won’t be profitable any more and foundation trusts don’t have to do any service that isn’t profitable, so that orthopaedic department will close down. You can’t just mothball it for six months while the GPs are using the private sector. If you haven’t got an orthopaedic department, how can you run an A&E department? In other words, a hospital is an organic whole; you can’t just start pulling bits out of it. It’s like those piles of jenga bricks that children build: if you pull something out, they fall over.
The argument used is that, to some people, hospitals aren’t so much an “organic whole” as opaque institutions in which people get passed from pillar to post.
I think there are a few aspects to that. One is - I think I’ve said it before - that the NHS isn’t perfect and I think there are many ways we can improve it. For instance, putting a lot more clinical input into the PCTs would have helped things.
Governments have never liked hospitals, partly because they consider them places where there are powerful doctors where they don’t have an influence. It’s always been on the agenda to deconstruct hospitals as much as possible. Unfortunately if you walk round a hospital on a Friday afternoon, you will see many sick patients lying around, waiting to be admitted in places where there simply aren’t enough beds any more because of the numbers of beds that we’ve lost. You’re never going to lose a need for hospitals. You can’t take people’s appendix out on the kitchen table. You can’t mend their burst aortic aneurism in the garage, so you’re always going to need hospitals. Now it may be that you need fewer bigger ones, but that has to be done in a much more considered way, not driven by ideology. This is driven by ideology at the moment, because the government wants to get the private sector in.
The big threats to hospitals at the moment are all [centred] around finances. Hospitals need a certain amount of money just to keep the door open, because they have to pay the staff to be standing there for when the emergencies come in. They’re going to lose money in three ways. One is that GPs will be needing to save money and they will save money by not sending patients into hospital. That’s what this whole referral management business is about.
If I see a patient who I think needs to be seen by another consultant in the hospital, I used to be able to send them. I can’t do that now. I have to send them back to the GP who then might have to send that referral to the referral management centre, which will then decide whether it’s appropriate for me to refer a patient to a colleague in a hospital. That’s how bad it is.
That’s happening at the moment?
Yep, these people, United Healthcare, who are managing referral management down in Hounslow, they’re also managing consultant-to-consultant referrals in hospitals. So the private sector will come in and start tendering for the cheap stuff that the hospitals do. And then there will be downward pressure on the tariff, the price that hospitals get paid for each patient. So yes, hospitals are going to get very worried, and one of the perverse incentives of payment by results is that, if the money is attached to a patient, everybody wants the patient, not necessarily for good reasons. So yes, if I’m a hospital, I’ve got to keep my door open, and so I have to look for more patients.
In something like radiology, you are advising on what type of care a patient should have?
Yes, that’s one of our jobs, to say I’m worried about this patient or not and this is what the matter is, or I’m not sure what the matter is and I think they need to go on and have this test. I think there will be much less lee-way about that in the future, as everything has a price attached [to it]. That’s one of the problems: conflict of interests.
There are huge conflicts of interests once you change the relationship between the doctor, the patient and the money. In the old days, of course, money was required but it didn’t enter into the doctor-patient relationship. So if I said, “I think this patient needs a CT scan,” or somebody’s GP says, “I’m not worried about this, I don’t think you need a second opinion,” or “you don’t need that antibiotic,” everybody felt that it was based on our best clinical judgement. Now money’s entered into that equation. The GPs have got the money and they’ve got to save it. The conflict of interest that’s been introduced into what was a very healthy doctor-patient relationship in this country is unforgivable, quite frankly.
Every doctor has to know what the budget is and we have to be aware of that, but I should be thinking about the patient in front of me and it should not be a consideration about the hospital needing the money this week, and that if we don’t get the money we’re going to lose our work to X-rays ‘R’ Us down the road. That shouldn’t come into it. I read somewhere recently that over a quarter of GPs have interests in the private sector. What are the patients going to think?
David Cameron has said that anyone who calls this privatisation needs to grow up. You were talking about the consultant-to-consultant referrals being run by United Health, but how many people know about that?
Not many, because it’s very technical. Why don’t people know about this? There are several reasons. One is that they knew they’d never get away with privatising the health service or using any of those words, so the language has been very clever. ‘Independent sector’, ‘voluntary sector’ and so on. Patient choice has been used a lot. It really means markets and marketisation and commercial interests. Patient choice hasn’t had much to do with it at all.
Then they’ve brought in a lot of people in the Department of Health who come from the commercial sector, who have written these endless papers - you know, the NHS plan and all the rest of it. They’re mental garbage. You can never look at them and say, “okay, this is what these guys mean.” And they’ve had a habit of bringing them out on kill-bad news days.
They killed community health councils, for instance, which had power, and replaced them with patient forums, which are now going to be replaced with something even weaker. While they’ve talked up the patient voice, they’ve legislated against it, so it has almost disappeared. Under foundation trusts and under consortia, there’s no requirement to have open meetings, so the public won’t know what’s going on. And the more you get the private sector involved, the more they can hide behind commercial confidentiality.
They have done what nobody wanted them to do, which is take the NHS down the road to privatisation. And it’s the end game now. If this bill goes through, that’s it. We will have an NHS that is kite-marked out to the private sector and will be dictated by market forces. But it’s not what the people want; it’s not what the profession wants. And yet, 10 or 12 years down the line from the Concordact in 2000, that’s where we’ve got to. You’ve got to take your hat off to them. Labour and Tories between them have done it.
Sorry, that was a little rant!
In the debate in the Second Reading of the Bill in the House of Commons, Andrew Lansley said, “people trust the NHS, and its values are protected and will remain so - paid for from general taxation, available to all, free at the point of delivery and based on need rather than the ability to pay.” That’s important, isn’t it, that it will remain free?
People do trust the NHS and one of the pernicious things that has already happened is that the NHS logo has been put on private companies without any explanation. So people will turn up and be treated by a private company without realising that this isn’t the NHS. What they’ve started talking about is the ‘NHS family’, by which they mean anybody who can satisfy whatever criteria they say can turn up and give NHS service. In the past, the characteristics of the NHS were that it was publicly funded, publicly provided and publicly accountable. We’re losing two of those things. It may still be publicly funded for a while, and we can look at how they can change that, but it’s not going to be publicly provided. It’s going to be provided by competing private sector organisations.
If you look even at foundation trusts, for instance, they are autonomous, competing businesses. So they may look like NHS hospitals, but they behave like private businesses. It’s not going to be publicly accountable because none of these people are going to have to have, as I understand it, open meetings that the public can go to and question what’s going on. So people do trust the NHS but they’ve exploited that trust by taking that logo that everybody loved and sticking it on private companies and pretending it’s not happening.
Regarding this stuff about “available to all, free at the point of delivery”: What will happen, as most people who are critical of this think now, is that because of the cuts, because of the way this is being set up, services will start to deteriorate as they will be delivered by the private sector. That usually means that the quality will go down. The number of things that the NHS can deliver itself – the core services – will reduce. We’ve already seen that. Even hip and knee services are being withdrawn, as being too fancy for the NHS. People will be encouraged to start taking out insurance, to make co-payments, top ups, and so some people will get a little bit more of that treatment than other people can. Previously you could go outside the NHS and buy private care, but within the NHS, equity of access and equity of treatment was pretty much uniform. Of course there were slight variations across the country, but there will be huge variations now. And as services deteriorate and are withdrawn, those who can will pay extra, and those who can’t will be left with this tatty net through which some people will fall and some people will be caught. But it’s not going to be the NHS we knew. They’ll continue to call it the NHS but, unless we wake up, it’s not going to be the NHS that I knew when I started 30 years ago. It’s a Tory version of it.
A lot of your time is spent in education and lectures to students. It’s hardly mentioned in the bill itself but may that go?
One of the really important functions of the NHS that nobody outside really thinks about is its teaching and training. The thing we automatically do is teach and train the next generation. That’s just factored into your day and it’s part of the work you do.
We have four or five junior radiologists in training and they do work on their own. They do supervised work. They get a tutorial every morning. I teach them on a regular basis and that’s just part of what you do. It slows down the work that you do, of course. If I have to spend half an hour giving a tutorial, that’s productive time lost. During that time, I won’t be shown to be doing anything, so if I’m being compared with somebody in the private sector, I’m going to look less profitable. But at the same time, it has to be done. Somebody’s got to train the next generation of healthcare workers.
The private sector doesn’t want to do it because time is money, so if you’re spending time doing that, you’re not earning money. I think they were offered contracts that included teaching but they didn’t want it, because even though there was a bit of extra money, it couldn’t make up for the money that they would lose.
There’s a danger for all junior doctors at the moment. They are the ones who are starting to ask what’s going to happen to them. First of all, from a practical point of view, when everybody works in the NHS, there are national terms and conditions. So when you work in London, you didn’t get paid any more than you did in the Shetlands. Now if you don’t have national terms and conditions, then people are going to waste time on local pay bargaining, and there might be too many people who want to work in north London and nobody elsewhere. And then there’s how they are going to progress their medical career when everything has disintegrated?
But it is argued that people can now go to places where there is more private work?
Yes, and people always came to London because they knew there was more private practice. But it was a fringe activity, outside the NHS.
How have you been campaigning and working against these reforms?
When we saw what Labour was planning to do, we started this [Keep our NHS Public] campaign and we have worked nationally and locally. We didn’t have any funding really, so we knew we were going to have to rely on local organisations. There are a number of local organisations around the country that are mostly based on local changes, because people are more interested in what’s happening to their local NHS than what’s happening on a national level. Ironically, if you ask people what their real “patient choice” is, one of the things that constantly comes out at the top of the list is a good local hospital, and that’s one of the things under threat at the moment.
Every step taken under Labour and the Tories has been another step down the road towards the commercialisation and break-up of healthcare, but it’s difficult to keep up with, or find about, what’s going on. So it’s been difficult to rouse people, really. They kept saying, “but it’s not happening yet,” and we kept saying, “what Labout are doing is that they’re undermining the NHS, and as soon as the Tories come in, they’ll tear the NHS by the roots and that’ll be the end of it.”
But most people have got busy lives and, really, until very recently, it’s been difficult to interest people in it. But people are waking up now.
The press have been very lazy in this. They’ve swallowed the government’s line whole. There’s very often been an anti-doctor agenda and I understand that. In the past, doctors have been powerful and they have not, perhaps, organised things to suit patients as they ought to. At the same time, I’d say doctors really have struggled to do things for the NHS and have constantly been held back by unimaginative management and lack of money. Until Blair came in, we were very under-funded compared to other places. And the first two or three years of Labour, when they were sticking to their financial promises, the NHS didn’t have the money and it still lags behind the continent in the money that we spend per capita on patients. There are some things you can blame doctors for, but I think a lot of the time doctors are held back by poor management and lack of funds.
I would never say the NHS is perfect but I would paraphrase Churchill and say it’s like democracy: it’s the worst way of delivering the system apart from all the others that have been tried. If there were a perfect way of delivering healthcare, where is it? Everybody would be doing it. There is no perfect way. Lots of people have come up with lots of different suggestions, but in terms of value for money and equity of access, which is very important as a social mechanism, the NHS comes out top all the time, so why don’t we try to make it better?
The Tories have lied shamelessly about outcomes. We know that. They keep talking about heart attacks in France and cancer outcomes, but Appleby www.bmj.com/content/342/bmj.d566.full">showed in the BMJ it’s all based on bogus figures They’re using them to scare the public and say we need this reform. They should all be ashamed of themselves.
We’ve got to get people on the streets and we’ve got to get people to understand what’s going on and to see behind the spin. I think people are waking up. A big march in London on the 9th March, a big TUC march on the 26th, though another question for me is: where have the unions been in all this?
Where has Unison been? They have produced good stuff on paper but why haven’t they been out fighting? I don’t understand. John Lister from London Health Emergency said, in four years time, there will be no employees of the NHS. We’ll all be contracted out. I don’t think NHS workers have woken up to that. There are 1.3 million of us and all this cosy talk about social enterprises and all the rest of it is not going to happen because the private sector - with its bags full of lawyers, and with money that can underwrite the bidding process and that can use loss-leaders to win tenders - is going to come in and take over. It’s not going to be cosy little enterprises consisting of local district nurses - forget it. It’s going to be United Healthcare and Virgin.
People talk about the market as if it’s a load of little cosy cottage industries. It may be to begin with but what will happen is, as always happens in the market, is all those people at the beginning, including social enterprises and doctors and nurses trying to set up their own deals locally, will inevitably be taken over by the large multinationals and, instead of an NHS monopoly, we’ll have a virtual monopoly of a few, very big multinationals who come and take over the NHS.
Do you think people are really fooled by the language? People have heard this again and again: you’ll be empowered, flexible, innovative, accountable service etc. People aren’t fooled by that sort of stuff any more, are they? Isn't the problem that people don’t feel they can change what’s going on?
I think most people don’t take much interest in the NHS as long as it’s there when they need it, and that’s a problem. By the time it’s not there when they need it, and they’re being asked to pay more money or travel further, that’s going to be too late. So the important thing is to wake people up about something that’s going to happen.
I don’t think people should ever think it’s too late to do anything about it, and that we can’t do anything about it. Look at Thatcher and the poll tax. Take to the streets and you can change things. Cameron said when the Egyptians took to the streets, ‘look at all the people on the streets, you’ve got to listen to them.’ Well, okay David Cameron, if Mubarak’s got to listen to a quarter of a million people on the streets of Cairo, then I think you should be listening when we hit the streets over this because a government that messes with the NHS against the will of the public, and makes a giant mess of it, is going to fare very badly out of this. And it’s better for him if he woke up to this quickly.
It’s clear what people are fighting against but it’s sometimes not clear what people are fighting for? A lot of stories we hear about the NHS are about the phone not being answered, negligence, dismissive doctors, and all this stuff. Do you think it’s also important to talk about the good things the NHS does and what we should be doing to make it better?
Sure. First of all, one can’t be seen as relentlessly negative in attacking it without putting something in its place. I think we’ve got too used to being told how bad we are, and I think it’s time we stood back and looked at how good we are. In the Commonwealth survey, for instance, we always come near the top for value for money. We deliver good, equitable healthcare to the whole population for less than almost everybody else in the world, except for, I think, New Zealand. So why can’t we continue like this? Sure we’ve got to improve the way we do it, but that doesn’t mean the basic structure is wrong.
The private sector has never done it better and cheaper, so why would we want to go to them? We only have to look at the US and see what goes on over there to see fraud and lobbying against Obama’s healthcare reforms and all the rest. So why do we want that lot over here behaving in the same way - that’s absolutely insane.
There are thousands of transactions every day in the NHS. The satisfaction with the NHS is the highest ever at the moment. Labour put a lot of money into it and a lot of good things happened. Nobody is saying, “actually, 99% of people are happy with the NHS.” You find the 1% of people who aren’t happy, then say you’ve got to reform it - that’s probably the most abused word in the English language. There’s this false connection between the problems in the NHS, so we have to move in this direction. Well, no, because what the Tories are trying to do isn't going to make those problems any better.
So how do we improve it? There are loads of ways. First of all, we could take out the purchaser/provider split. The [parliamentary] health select committee said it was a 20-year failure. Perhaps it’s time we buried it. They don’t have it in Wales or Scotland. Why do we have it here [in England]? It’s been a failure; get rid of it. Look at much better ways of doing it cooperatively and without the split.
Second, don’t appeal to healthcare workers and professionals by constantly talking about what things cost all the time and about the market. Appeal to us through our professional pride in what we do. What Labour should have done when they got in was to start feeding back to everybody working in the profession how they were doing their job. People in the health service have a professional pride in what they do and one of the ways you can reinforce that is by feeding back to people how well they’re doing their job. It’s not about money; it’s about whether I am doing my job as well as I can and how I could do it better, and how I could teach other people to do it better.
Successive governments have missed a huge opportunity to improve the NHS through working with the people who work in it and appealing to their better nature, not by punching them through targets and attacks about how they were doing their job.
But the absolutely critical thing at the moment is to stop this bill because, if we don’t stop this bill, we’re not going to get the opportunity to look at better, collaborative ways of improving the publicly delivered NHS, because it won’t exist any more.
How do you think the radiology service could be improved?
By working with GPs who refer [patients to radiologists], and by providing clinical guidelines to them, for instance. Many people get referred up who probably shouldn’t be there, and we know that if we issue guidelines about who needs an x-ray, and the GPs stick to those guidelines, the number of patients who come in falls, so we save money.
Also by educating patients about how to use the health service. Unfortunately what governments have done is to keep treating patients as clients and customers, almost. It’s not about what patients want; it’s about what patients need, and it is a question of deciding what people need. For instance, should we be funding homeopathy on the health service? I’d say no. It may be what people want, but I don’t believe it’s what patients need. There’s no evidence base for it.
So there are things that we can do but the basic way of running the health service has delivered us a service which is good value for money, is fair, and which has good outcomes. We can improve on that but we do not have to take the whole thing and throw it into the air in the hope that it will fall down in a better pattern than it was before.
Should patients be more involved?
Patients should always be involved to the degree they want to be involved. Why not go back to Community Health Councils? They were very good. They had teeth. They could walk in anywhere, without announcement, and say what’s going on and report straight back to the local politicians. Why did Labour get rid of them? Because they had teeth and because they would never have allowed Labour to do what it did.
The first thing that Labour did while it was talking about patient empowerment was get rid of them.
If there are huge demonstrations and the bill gets stopped, and this government is forced out, what then?
There’s no reason why we can’t have the NHS as it was under Labour. No one wants to see patients harmed and my position has always been that, if the NHS can’t do something then, sure, get the private sector in. But take steps to make sure the NHS can do it in the future because we can do it cheaper. If you need to bring [the private sector] in for a while, then that’s fine.
Right at the end, Andy Burnham, the previous Labour Secretary of State for Health, said the NHS was the preferred provider, which everyone wanted to hear. There’s no reason why we can’t salvage what is left of PCTs, put those doctors who want to be involved in commissioning in there and say, “okay guys, you can have much more clinical input, you go there and sort out commissioning.”
What should people be doing in the next month?
We’ve got to hit the streets. Come on March 26th. Join Keep our NHS Public. Join a local group. Harass your MP, particularly if they’re Lib Dems or Conservatives in marginal seats. But I think it’ll have to be the streets in the end. If we’re going to go down, we’ve got to go down fighting, so when it all goes pear-shaped, everyone can turn round and say, “we told you we didn’t want this.” Because what Cameron’s claimed all along is that, “the public are behind me, the profession are behind me.” We’ve got to expose that [this isn't true].
Do you think that can happen to health by itself, as opposed to public services in general?
I think it has to because health is the first one to go and, once it goes and the contracts are signed, it’s going to be like PFI: those contracts are signed and we’re wasting millions of taxpayers’ money but there’s not much we can do about it. As I understand it, we then fall within European competition law. So health should be out there at the top because it’s the first one under threat. It’s the first one they’ve got organised about and it will be irreversible once it goes through.
May 10, 2011
The community nurse
March 24, 2011
The biomedical scientist
March 24, 2011
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