Address from the President, Sir Brian Jarman
Wednesday 2 July 2003
I have been working at the Institute for Healthcare Improvement (IHI) in Boston, USA for about half my time since I finished as a panel member of the Bristol Royal Infirmary Inquiry two years ago. The CEO of IHI, Don Berwick, and I share an office and many people connected with US healthcare come to the office. This has given me a chance to compare the UK and American health services.
Each has their advantages and disadvantages of course but I have come away with the distinct impression that, on balance, I would rather be a patient in the UK and I would rather be a doctor in the UK. This is despite the fact that the US system is has the highest expenditure on healthcare in the world by virtually any measure (more than twice the per capita the UK expenditure). US healthcare currently costs about $1.5 trillion per year and is said to be the largest industry in the world. I have difficulty with the concept of healthcare being regarded as an industry: I prefer our view that it is a service. The NHS seems to me to be a civilised way of providing health care. It seems to me to be fair and reasonably efficient, but I realise from yesterday's debate on NHS funding that there are a variety of opinions regarding this.
When I was in Boston, at a distance, away from the complaints about how things were going at home, I was able to muse about my experiences as a doctor in the UK during the previous 30 years.
My predominant feeling was of how fortunate I have been to work in a health service where virtually everyone has a doctor free at the point of contact, where payment for the service is born by the whole community whose members contribute roughly according to their ability to pay. My experience has been mainly in general practice and I believe that it is really a wonderful achievement that there is virtually 100% coverage of the whole population, that most people can now get an appointment to see their GP within 2 days, and that overall the standards of practice are high. What an advantage it is for a GP to have a patient's lifetime medical notes which follow them from doctor to doctor as they move around the country. It is amazing that this is all achieved by the general practitioner service at 6% of the cost of the NHS - about £60 ($100) per patient per year.
It is wonderful to be able to prescribe without having to be concerned about the patient's ability to pay, particularly for elderly patients and people with chronic illnesses. When I think of the hospital service and the standards of UK medical research and medical publications I believe that we have a great deal to be proud of despite our relatively lower investment in health care by Western standards.
Working in the NHS there is no perverse incentive regarding quality of care: hospitals do not gain financially by having more defects and thereby keeping patients in hospital longer. At a time when developments in genetic testing are making it possible to predict the risk of illness more accurately I believe that insurance-based healthcare systems, which are used in many countries, will be more likely to discriminate against high risk patients than will be the case with our taxation based system.
We have a service in which politicians, managers, hospital doctors, GPs and nurses could be united to deliver free healthcare by the most effective and efficient means. More than a million NHS staff help to deliver more than: a million GP consultations per day, a million out-patient attendances per week, and a million hospital admissions per month. In population surveys, doctors still come out at the top of a list of people whom the public trust.
By international comparisons of healthcare provision, such as the recent one by the Commonwealth Fund of New York, the NHS does very well. In their survey of sick, non-institutionalised people in several Western countries (including USA, UK and Canada) the NHS scored high on most indices (except waiting times) and was best in the overall assessment.
I believe that the NHS is fundamentally a good health service which has, until now, been under-funded. If the Government's intention to bring our proportion of the GDP spent on healthcare to 9.4% by the year 2007/8 is fulfilled, and if this increased funding is directed to increasing the capacity to serve patients, then we should be doing well by then.
You can see from this preamble that I believe that we are really fortunate, both as patients and as doctors this our country, and anything I say from now on must be understood in that context.
I have said that I believe that the NHS is fundamentally a good health service which has until now been under-funded. One does has to ask, however, whether the fact that patients and clinicians have been pointing this out to the Government for decades to little avail, is not a fundamental weakness of a system that is funded by taxation and therefore very centralised and politicised, and whether a system without these drawbacks would not be preferable.
Although that may theoretically be the case one has to remember that for decades the NHS, and the way it is funded, has had very strong and unwavering support from the public: that does not mean that if there were more funding there would not be even more support. Looking at the OECD data on Western countries' health statistics it is clear that 40 years ago the UK was relatively high in the proportion of GDP spent on health and now is much lower and, in line with this, our position regarding IMR and life expectancy have both deteriorated with respect to other OECD countries and our provision of both doctors and hospital beds per head of population has also remained relatively low. This lack of capacity has real effects on people's well-being: I think for example of the elderly lady whom I know who has been house-bound, living alone, for years waiting for a hip operation; one knows of people who die from IHD while waiting for a heart bypass operation. It is also distressful to see managers, who are well aware of these deficiencies in the service, not being able to admit them openly but having, at the risk of losing their jobs if they don't comply, to manage politically-motivated reductions in, for example, bed capacity in this situation. It doesn't endear the managers to clinicians.
There are some aspects of the US system where I believe that we have a lot to learn. My work with IHI has been concerned with using routinely recorded hospital data to calculate hospital death rates adjusted to take account of the factors such as the patient's age, sex, and severity of illness which influence these death rates, and giving this information to hospitals so that they can try to improve their care in order reduce their death rates. More than 10% of deaths in hospital are thought to be due to avoidable medical accidents in countries where this has been studied (including the UK and USA), so there is certainly scope for improvement. One thing that has impressed me a great deal about the US way of doing things has been the reaction of the hospitals to the information they are given about their death rates (and many ask for the data). If they find that their adjusted death rate is high they first have searching questioning regarding the methodology of the analysis. When they have accepted this (which so far they have done), it is only a short time before they decide that it is important and that it is worth trying change things. The Institute for Healthcare Improvement helps them by getting together experts from around the world and spreading ideas for improvement by conference calls, meetings - there were 1000 people from hospitals all over the country at a meeting in Boston two weeks ago - and developing measurement methods to monitor progress. What is so impressive is, firstly, that they quickly realise the need to take action, and, secondly, that the discussions are with the doctors and managers at the hospitals, not via civil servants, which, amazingly, can be the case in this country. There is a sense that the key people in the hospital are to quite a large extent themselves in control of their working environment and, whilst they accept that they must be independently monitored, they have the freedom to act independently to make the necessary changes - and of course they are the only people who can do that, it cannot be done from the centre.
Thinking of the implications for the UK, I believe that it is important, in a nationally funded system, for independent audit and accountability and also for centralised resource allocation, but there must be as much local autonomy as possible consistent with this, so that healthcare workers do have a sense of being in control of their working environment. We must reduce unnecessary bureaucracy. I am not convinced that we are getting there yet: in the last full year with data available, to September 2002, the number of NHS managers in England increased by 17%, the number of doctors by 5%. We must try to develop an NHS which is not concentrated on wielding authority as an exercise in its own right but which concentrates on improving the quality of the service. To do this, somehow we need to develop a sense of trust between clinicians and government.
At this point I would like to analyse in a bit more depth the relationship between government and the medical profession in a centrally funded healthcare system and how this influences what I believe is the most fundamental criterion by which this should be judged, namely the quality of care for patients. I would like to do this using some of the evidence from the Bristol Royal Infirmary Inquiry. The Inquiry was a public inquiry which took place in a court with a judge (Professor Ian Kennedy who chaired the Inquiry Panel - I was one of the 4 panel members, the only doctor among the 70 strong Inquiry staff). Witness could be subpoenaed and evidence is given on oath. The Inquiry was related to the excess deaths at Bristol from paediatric cardiac surgery in a period of years ending in 1995 - the excess deaths were for open heart surgery in children under 1 year and they had predominantly congenital heart disease.
Sir Graham Hart, who was Permanent Secretary at the Department of Health from 1992 to 1997 stated in court during the Inquiry, in answer to the Inquiry's barrister:
· "The profession had very deep reservations about the Department getting involved [in matters of clinical performance]. Reservations which, to some extent, ... on rational grounds, the Department shared"; and later he stated
· "... if Ministers might be tempted to tread down that path of involvement and intervention [in matters of clinical performance], then they could be pretty sure that there would be a tremendous row about it with the profession, and that is something which you certainly do not want to do without forethought"
What, in effect, he was saying here was that the Department in those days would have been reluctant to challenge doctors in matters of clinical performance.
Dr Armstrong, who as you know was Secretary of the BMA from 1993 to 2000, was involved in the following questioning in court:
· Question from the barrister. "So one had the rather Alice in Wonderland, topsy-turvy position that the doctor who might very well be incompetent in particular areas could not be dealt with for that in any realistic way, ... whereas another doctor complaining about him would, at least until the early 1990s, until the culture began to change, himself be transgressing in a clear and objective way the standards to be expected of him?"
· Answer from Dr Armstrong. "That, sadly, is a very neat encapsulation of the doctor's dilemma."
Here, Mac is admitting, very honestly, was that until the early 1900s, if a doctor complained about another doctor who was incompetent it would be the doctor who was doing the complaining that would be transgressing the standards set for him by his profession.
In a centrally funded health service in which a government body, in the form of the Department of Health, is a major participant in addition to the doctor and the patient, and has a leading role for making sure that there are systems for monitoring the quality of care, it was a most unsatisfactory situation for patients if doctors could not complain about incompetent colleagues and the responsible government department was reluctant to challenge doctors in matters of clinical performance. The situation with regard to the medical profession, I am glad to say, has now completely changed with the introduction of the General Medical Council's document "Good Medical Practice" in 1995 which makes it quite clear that a doctor's duty is to put the wellbeing of the patient first at all times. With regard to the role of the Department of Health matters are, I believe, less clear.
The Inquiry Report stated that "... the Department of Health accepts that it is responsible and is accountable for any failings of the systems that were in place during the period covered by the Inquiry. Ultimate responsibility rests with the Department of Health and the Secretary of State." The Inquiry also concluded that "It would be reassuring to believe that it could not happen again. We cannot give that reassurance. Unless lessons are learned, it certainly could happen again, if not in the area of paediatric cardiac surgery, then in some other area of care." You can see that the Inquiry panel were, even at the time of its Report in 2001, still not convinced that adequate independent systems (and we were insistent that they should be independent of the Department of Health) had been put in place to ensure that another tragedy like Bristol couldn't happen again. I, as a panel member, was certainly in agreement with that conclusion. I believe that we, as doctors, should do our best to co-operate with the Department in a spirit of trust, in attempts to improve this situation.
This is the 171st annual meeting of the British Medical Association, and it is the 100th meeting of its Representative Body. I heard the debate yesterday about the balance between the role of the Council of the BMA, which is to carry out the policies of the Association as efficiently as possible, and that of the Representative Body which is to reflect the will of the members of the Association. These roles may not always coincide. For instance, the Council has to keep the Association financially solvent, but the members may wish to implement policies which, once they are studied in detail, are clearly not affordable. It is not inconceivable that different motions carried by the RB at its annual meeting are mutually contradictory. Council has to sort out these difficulties, but I believe that the power of free and open debate and wide representation of members is a really great strength of the Association which must be preserved at all costs. I feel pretty confident, from past history and the fact that 78% of practising doctors have decided to be members of the Association and pay their dues every year, that the balance between efficiency and democracy will be achieved. As a member of the Association since I was a medical student I believe that we owe an enormous debt to those who run the Association on our behalf. They often give far more of their time far more than they are required to do, or is perhaps than is good for them and their families.
I am not sure what the role of President is meant to be and how much I should say about my own views during the next year, but now that I have you as a captive audience I hope that, at least this once, you don't mind if I mention a few areas where I would like the BMA to change a little. You can treat them as my hobby horses if you like and just ignore them, but as I have to give a speech I might as well go ahead. Firstly, I would like the BMA to be more proactive, rather than reactive, than it is at the moment; I would like it to develop more policies itself, as it has done for instance with the anti-smoking campaign. Secondly, and this is related to the first point, I would like the BMA to be the masters of information and data analysis with a deliberate policy to collect and analyse routinely a broad range of health-related data in order to be able to lead with their own policies, based on hard facts, rather than depend on government analyses. Information is power. The analyses should be broadly directed to informing what I believe are the BMA's main aims - improving services for patients and supporting the medical profession. As an example, I believe that it would have been desirable, in the recent discussions about the GP contract, for the BMA to have been able to suggest its own formula to be used for funding GPs or to commission an academic department to produce one. I am sure that this would have demonstrated, among other things, the importance of basing the formula on the GP practice registered patients list. It seems to me to be fundamental to general practice that named individual patients are the basis on which GPs work: to have a patient in front of you and be told that they really don't count is not very helpful - these supposedly non-existent patients are often the most needy. In the practice that I come from, which has about 8,500 patients, it not very convincing to be told that there are only 6,500 patients. In the electoral ward that has the highest proportion of the practice patients, Church Street ward in Westminster, which is an area of mixed housing, I am told by an expert on the subject that the register of just the council house residents alone exceeds the number of people enumerated in the ward at the 2001 census. I am very pleased that our negotiators have now achieved an agreement that the registered list size will be the basis of funding to GP practices (and hence to Primary Care Trusts, which is very important for commissioning hospital services): it is essential that this starts on day one of the new contract. I believe that it would have been helpful if the BMA had had the ability to challenge the government with hard facts about this at an earlier stage but this would have meant a greater investment in data analysis. Doctors are often not very good at this type of thing; we often find it easier to be led, to just react to things that are put to us. Maybe we need "an evidence based BMA", a term which someone suggested to me yesterday.
The third area is a matter of emphasis rather than change. The BMA is keen to improve the quality of healthcare for patients, which of course depends on the everyday decisions of doctors and other healthcare workers. We recognise that patients, as the experts on their symptoms, want control about the way that they are treated but they want the doctor to act as the expert on the disease in an equal partnership. I sometimes feel that this aspect of our aims and ethos is taken for granted and perhaps is not emphasised enough in policy statements. A BMA patients' committee, if it existed, might help to make this more explicit.
In summary, I feel fortunate to have been able to work in the NHS; I feel it is a fair and reasonably equitable system which doesn't need fundamental reorganisation. I believe that it is doing pretty well at the moment, but needs to improve in several areas such as correcting the shortage of doctors, the unacceptably long waiting times, the problems with targets that distort clinical priorities, and lack of continuity of care. There needs to be trust, not only between doctors and patients but also between doctors and government. If the promised increased resources are put into front line services many of the deficiencies could be corrected. In this development I believe that the BMA will continue to play a very important role.
Click here for Sir Brian Jarman's biography