Saturday, March 10, 2012

Power to exclude people from the health service?

The title of this post is taken from this BMJ article by Allyson Pollock, David Price and Peter Roderick. These are not sellers of the socialist worker on street corners. Allyson Pollock is a respected health services academic. These words are some of the scariest I've read - and there is no shortage of very frightening predictions about the likely consequences of the NHS reforms in the UK.

There is no question in my mind - the NHS bill should be stopped. And it's not just me who says this. My College, the RCGP, has been at the forefront of health service workers who are against these plans, and that's because its members are against the reforms. The government somehow claims that doctors support the bill, but they've mistaken carrying on doing their best or their patients as support. I have never known such unified support against a health reform.

Why should I care? I work in Australia. There are a few reasons why I care.

1. All my family live in England. They range in age from well into their 90s down to very early childhood. They'll probably be OK because they are all bright eloquent people. They are not on the poverty line, but don't have enough cash around to visit us in Australia. So I want them to have a good health service.

2. I trained in the NHS. The values I have as a GP I got from working in an area of Sheffield which had been devastated or decades by the closure of mining and steel works in the area. The doctors, practice staff and hospital staff who trained me worked hard to provide the best possible care to people who were not sought out by commercial firms. There's a lot of thought put into improving this sort of service - for example see the GPs at the Deep End project.

3. I now see the effects in Australia of people being excluded from the health service - not deliberately, usually just thoughtlessly - and I am astonished that a service that is the envy of the world would seek to deliberately make themselves more like the worst services.

What does that mean in practice?

Just this week, I spent half an hour on the phone trying to find an ENT surgeon who would see someone without charging extra money. This was not for something minor, either, but a condition that needs surgery to be treated if it is not to eat away the bones in your head. Seriously. Clinical need wasn't the deciding factor, income was.

Someone once came to me in tears because the specialist had said to her "You must have $2000 tucked away somewhere" about her operation. She was upset and incredibly embarrassed.

Anecdotes, yes, but most GPs practicing in underserved parts of Australia will recognise these stories as being very common. (And the difficulty of getting GPs to work in underserved parts of Australia is another part of this story, of course). Just about none of my patients have private health insurance because they can't afford it - we regularly run out of food vouchers for people where I work. Paying for medical appointments and medications comes a long way behind paying for food and rent.

Australia has a "Universal" health care system, called Medicare. Medicare statistics show (p6) that Medicare expenditure for Aboriginal and Torres Strait Islander people is just over half that for other Australians. As you may know, Aboriginal and Torres Strait Islander people have the worse helath outcomes in Australia. There is a lot of work currently to "Close the Gap," and a lot of this is around improving access. It is incredible that a service like the NHS that get's this so much more right is moving in the exact opposit direction. An NHS bill that even allows the possibility of excluding people from the health service needs stopping. Having a service in the world that prides itself on excellent access for all is an inspriation to those of us elsewhere in the world. Yes, it's not perfect. But it does a lot better than anywhere else. Until the bill gets passed of course.