The Glade 4.0

LONDON — Perhaps the only consistent thing about Britain’s socialized health care system is that it is in a perpetual state of flux, its structure constantly changing as governments search for the elusive formula that will deliver the best care for the cheapest price while costs and demand escalate.
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Andrew Testa for The New York Times

The new British government’s plan to drastically reshape the socialized health care system would put local physicians like Dr. Marita Koumettou in north London in control of much of the national health budget.

Even as the new coalition government said it would make enormous cuts in the public sector, it initially promised to leave health care alone. But in one of its most surprising moves so far, it has done the opposite, proposing what would be the most radical reorganization of the National Health Service, as the system is called, since its inception in 1948.

Practical details of the plan are still sketchy. But its aim is clear: to shift control of England’s $160 billion annual health budget from a centralized bureaucracy to doctors at the local level. Under the plan, $100 billion to $125 billion a year would be meted out to general practitioners, who would use the money to buy services from hospitals and other health care providers.

The plan would also shrink the bureaucratic apparatus, in keeping with the government’s goal to effect $30 billion in “efficiency savings” in the health budget by 2014 and to reduce administrative costs by 45 percent. Tens of thousands of jobs would be lost because layers of bureaucracy would be abolished.

In a document, or white paper, outlining the plan, the government admitted that the changes would “cause significant disruption and loss of jobs.” But it said: “The current architecture of the health system has developed piecemeal, involves duplication and is unwieldy. Liberating the N.H.S., and putting power in the hands of patients and clinicians, means we will be able to effect a radical simplification, and remove layers of management.”

The health secretary, Andrew Lansley, also promised to put more power in the hands of patients. Currently, how and where patients are treated, and by whom, is largely determined by decisions made by 150 entities known as primary care trusts — all of which would be abolished under the plan, with some of those choices going to patients. It would also abolish many current government-set targets, like limits on how long patients have to wait for treatment. The government has promised that the new plan will not affect patient care and that the health care budget will not be cut. But some experts say those assertions are misleading. The previous government, controlled by the Labour Party, poured money into the health service — the budget is now about three times what it was when Labour took over, in 1997 — but the increases have stopped. The government has said the budget will continue to rise in real terms for the next five years, but it is unlikely that the increases will keep up with the rising costs of care and the demands of an aging population.

“The real mistake that is being made by the health secretary is to drive through an ideologically determined program of reorganization which is motivated by the principle of efficiency savings,” said Robin Durie, a senior lecturer in politics at the University of Exeter. “History shows clearly that quality will suffer as a consequence.”

Dr. Durie added, “The gulf between the rhetoric of the white paper and the technicalities of what is involved in the various elements of the overall reorganization being proposed is just extraordinary.”

For example, he asked, how will the government make good on its promise to give patients more choice — a promise that seems to require a degree of administrative oversight — while cutting so many managers from the system?

“How will the delivery of all this choice be funded?” Dr. Durie asked. “And how will the management of the delivery of choice be funded?”

Dr. Vautrey said the country needed to have a “mature debate about what the N.H.S. can and cannot afford.”

He said: “It is a sign of the mixed messages that government sends out. They talk about choice and competition and increased patient expectations at the same time as they tell the service they need to cut costs and refer less and prescribe less. People need to understand that while the needs of everyone may be met, their wants will be limited.”

As they prepare for the change, many doctors are wondering whether it will be permanent this time around.

“Many of our colleagues have seen this cycle of change repeatedly,” Dr. Vautrey said. “Many would look at previous reorganizations and compare it to this one and wonder how long the current change will last before the next one comes along.”

Axe falls on NHS services
NHS bosses have drawn up secret plans for sweeping cuts to services, with restrictions on the most basic treatments for the sick and injured.

By Laura Donnelly, Health Correspondent

Some of the most common operations — including hip replacements and cataract surgery — will be rationed as part of attempts to save billions of pounds, despite government promises that front-line services would be protected.

Patients’ groups have described the measures as “astonishingly brutal”.

An investigation by The Sunday Telegraph has uncovered widespread cuts planned across the NHS, many of which have already been agreed by senior health service officials. They include:

* Restrictions on some of the most basic and common operations, including hip and knee replacements, cataract surgery and orthodontic procedures.

* Plans to cut hundreds of thousands of pounds from budgets for the terminally ill, with dying cancer patients to be told to manage their own symptoms if their condition worsens at evenings or weekends.

* The closure of nursing homes for the elderly.

* A reduction in acute hospital beds, including those for the mentally ill, with targets to discourage GPs from sending patients to hospitals and reduce the number of people using accident and emergency departments.

* Tighter rationing of NHS funding for IVF treatment, and for surgery for obesity.

* Thousands of job losses at NHS hospitals, including 500 staff to go at a trust where cancer patients recently suffered delays in diagnosis and treatment because of staff shortages.

* Cost-cutting programmes in paediatric and maternity services, care of the elderly and services that provide respite breaks to long-term carers.

The Sunday Telegraph found the details of hundreds of cuts buried in obscure appendices to lengthy policy and strategy documents published by trusts. In most cases, local communities appear to be unaware of the plans.

Dr Peter Carter, the head of the Royal College of Nursing, said he was “incredibly worried” about the disclosures.

He urged Andrew Lansley, the Health Secretary, to “get a grip” on the reality of what was going on in the NHS.

The Government has promised to protect the overall budget of the NHS, which will continue to receive above-inflation increases, but said the service must make “efficiency savings” of up to £20 billion by 2014, which would be diverted back to the front line.

Mr Lansley said last month: “This protection for the NHS is protection for patients – to ensure that the sick do not pay for the debt crisis.”

Dr Carter said: “Andrew Lansley keeps saying that the Government will protect the front line from cuts – but the reality appears to be quite the opposite. We are seeing trusts making job cuts even when they have already admitted to being short staffed.

‘‘The statements he makes may be well intentioned – but we would implore him to get a grip on the reality, because these kinds of cuts are incredibly worrying.”

Katherine Murphy, of the Patients Association, said the cuts were “astonishingly brutal” and expressed particular concern at moves to ration operations such as hip and knee operations.

“These are not unusual procedures, this is a really blatant attempt to save money by leaving people in pain,” she said.

“Looking at these kinds of cuts, which trusts have drawn up in such secrecy, it particularly worries me how far they disadvantage the elderly and the vulnerable.

‘‘We cannot return to the days of people waiting in pain for years for a hip operation or having to pay for operations privately.”

She added that it was “incredibly cruel” to draw up savings plans based on denying care to the dying.

On Thursday, the board of Sutton and Merton primary care trust (PCT) in London agreed more than £50 million of savings in two years. The plan included more than £400,000 to be saved by “reducing length of stay” in hospital for the terminally ill.

As well as sending more patients home to die, the paper said the savings would be made by admitting fewer terminally ill cancer patients to hospital because they were struggling to cope with symptoms such as pain. Instead, more patients would be given advice on “self management” of their condition.

Bill Gillespie, the trust’s chief executive, said patients would stay at home, or be discharged from hospital only if that was their choice, and would be given support in their homes.

This week, Hertfordshire PCT plans to discuss attempts to reduce spending by rationing more than 50 common procedures, including hip and knee replacements, cataract surgery and orthodontic treatment.

Doctors across the county have already been told that their patients can have the operations only if they are given “prior approval” by the PCT, with each authorisation made on a “case by case” basis.

Elsewhere, new restrictions have been introduced to limit funding of IVF.

While many infertile couples living in Yorkshire had previously been allowed two cycles of treatment — still short of national guidance to fund three cycles — all the primary care trusts in the county are now restricting treatment to one cycle per couple.

A “turnaround” plan drawn up by Peterborough PCT intends to make almost £100 million of savings by 2013.

Its cuts include closing nursing and residential homes and services for the mentally ill, sending 500 fewer patients to hospital each month, and cutting £17 million from acute and accident and emergency services.

Two weeks ago, Mid Yorkshire Hospitals trust agreed plans to save £55 million in two years, with £20 million coming from about 500 job losses.

Yet, a month before the decision was taken, senior managers at a board meeting described how staff shortages were already causing delays for patients being diagnosed and treated for breast cancer.

Mr Lansley said any trusts that interpreted the Government’s demands for efficiency savings as budget or service cuts were wrong to do so, and were “living in the past”.

19 Yet she became more and more promiscuous as she recalled the days of her youth, when she was a prostitute in Egypt. 20 There she lusted after her lovers, whose genitals were like those of donkeys and whose emission was like that of horses.

What cracks me up is we watched a documentary called "Sick Around the World' last week in my Medical Ethics class. The guy interviewing people could only seem to ask people if they ever had to pay medical bills in England. Actually looking for problems with their system was apparently beyond him.

In comic strips the person on the left always speaks first. - George Carlin

What does Keynes have to do with public health care?

The English are silly and they gave us Keynes who is English and silly.

Facism is not a school of thought, it is a racial slur.

You don't know enough Keynes to call him silly, Elmo.