Why healthcare is a responsibility, not a right... by MITCHELL BROOKS

Why healthcare is a responsibility, not a right

by MITCHELL BROOKS, MD | in POLICY | 




There is no “right” answer to the healthcare reform issue. There are facts, opinions, myths, politics and reality, all in no particular order of magnitude. Unfortunately, thus far and likely in the future, the reform will be political and thus costly and painful and will not address the core issues involved in fixing the inherent systemic problems.

There have been many things written with regard to this topic and I suppose one chooses to read that which comports with one’s leanings on the subject. In my case, I have tried to access diverse opinion sources from Brookings and Rand to Cato, National Center for Policy Analysis, The Hudson Institute and everything in between. 

I have taken the best thoughts from individuals with whom I have corresponded and have incorporated those thoughts as well as my own. If some of these words are similar to others you have heard or read, it is not because I choose to plagiarize them, it is because they have become part of the lexicon of my thinking.

My thinking and these principles are also offered as a consequence of extensive American, Canadian, and, to a lesser degree, British experiences as a physician, surgeon, instructor, and cardiac transplant patient (in the former of the three healthcare systems). They are meant to provoke thought and discussion, and are not offered as sole solutions, though they may have some individual merit by virtue of their common sense. I offer ten principles for healthcare reform and they are of comparatively little cost to the taxpayer when compared to the current Act.

• Healthcare is not a right, but a responsibility.
• We do not require a single payer, but, rather, a single payment system.
• Changes should be made in small increments, easily understood by the People.
• Rationing is a logical outcome in any system with limited resources and high demand.
• Efficient, effective healthcare must be provided to the truly needy
• Medicine must be practiced in a manner and place that is economically efficient, evidence based, specific to local community needs.
• All members of Congress, their dependents and all federal employees must live under the same healthcare rules that they themselves create for those that pay their salaries and provide their pensions--We the People. No waivers can be given to any company or entity.
• American pharmaceutical companies must decide at what end of the drug development / delivery-to-patient pipeline they wish the American taxpayer to subsidize. They can no longer take from both ends.
• Healthcare reform cannot occur without tort reform.
• We must create a national healthcare database so that best practices may be established
• Healthcare is not a right but a responsibility

If one does not accept responsibility for his or her actions, there are no consequences for a particular behavior and when translated into the delivery of medical care, that only means increased expenditure. 

“Rights” are either things you, as a free citizen, may do either without interference (with the implicit caveat that you do no harm to others during the conducting of the specific activity deemed a right) or may not be done to you without permission (such as search and seizure).

What is implicit in a right is a protection but not a gift of goods and services created because of the work, sweat, time and capital investment of others. If healthcare is indeed a right, then these healthcare goods must then be seized forcibly, by law or by theft, from others who have provided them in what is a frank violation of their right not to be robbed of their property. 

This then begs the question of whether the absolute right to healthcare also involves the right to steal from those who produce the goods and services necessary for that care. In a broader sense one must also ask where do one’s rights end? Do they extend to food, or housing or a job?

Mitchell Brooks, MD is an orthopedic surgeon and the host of Health of the Nation on Talk Radio 570 KLIF in Dallas, Texas. He blogs at Health of the Nation.

We need a single payment system instead of single payer... by MITCHELL BROOKS

We need a single payment system instead of single payer

by MITCHELL BROOKS, MD | in POLICY | 

One of the great myths of healthcare is that there is an actual “system” in the United States. If such a system exists, I have yet to become familiarized with it. What we have are mountains of paper that slavishly tie the patient, doctor, hospital and insurance carrier alike to a system of coding interpreted by individuals with no sense of what the codes mean or the labor and risk involved in their accomplishment. This inertia is inclusive of purposeless and an infinity of idiotic government regulations that create more dead forest. For the patient, this system is akin to entering The Twilight Zone; actually, it is The Twilight Zone.

As a result, the consumer doesn’t know what they are paying for and the doctor and the hospital spend endless hours trying to explain exactly what was done to an insurance company employee who is not a medical professional. This is akin to the proverbial mouse asking the snake for safe passage across a river.

Administrative costs as a percentage of healthcare expenditure in America comprise anywhere between 18-31 cents out of every healthcare dollar. This figure varies because so many different things can be considered “administrative,” because there are differences in small and large health insurance plans, and because there are differences in excessive spending between private and public sectors. 

Generally speaking, Medicare/Medicaid administrative costs are between 5-6 cents out of every healthcare dollar percent. According to a CBO report, administrative costs account for approximately 12 cents out of every dollar spent, depending upon the size of the plan.

The McKinsey Global Institute published a study in December 2008 accounting for the costs of U.S. healthcare. They estimated that excessive spending for “health administration and insurance” accounted for as much as 21 percent of excess spending. Translated into current dollars, that’s $525,000,000,000.00. 

This report suggested that 85 percent of this spending was attached to the “system” described above (that amounts to almost $450 Billion in a $2.5 Trillion spending spree). The remaining 15 percent is attributed to public plans.

Last, consider this well publicized study that included the administrative costs of all parties feeding at the healthcare troth, but not the productive time wasted by patients in receiving care. In 2003, Woolhander and Campbell published a study in The New England Journal of Medicine in which they concluded that when comparing purchasing parity dollars, in 1999 the United States spent $1,059 per capita on administrative costs while the Canadians spent only $307. Imagine the cost today? Imagine the waste that could be reinvested in delivering real healthcare?

So what is the conclusion we can draw from all of this? It is not that we need a single payer. What we need is a single payment system applicable to all that receive healthcare in the United States by whatever means. It means only one system of paperwork and system process, one system reproducible throughout. This true “system” would be online and easily accessible. 

Furthermore, if we take all these complex codes and bundle them to be inclusive of many things for the more predictable and common surgical and medical procedures and their attendant CPT codes, the estimated savings per year could be substantial. If we can reduce our administrative costs by say, one third, that would translate to $150 Billion in the private sector or a 6 percent savings. If we can cut the administrative costs in half by shamelessly stealing from the Canadians, we would save what amounts to approximately $262 Billion. Soon we will be talking about real dollars.

We don’t need a single payer to control our healthcare freedom; what we really need is a single payment system, a true system, and the freedom to choose our own healthcare.

Mitchell Brooks, MD is an orthopedic surgeon and the host of Health of the Nation on Talk Radio 570 KLIF in Dallas, Texas. He blogs at Health of the Nation.

Rationing is a logical outcome, and any changes must be incremental.... by MITCHELL BROOKS

Rationing is a logical outcome, and any changes must be incremental

by MITCHELL BROOKS, MD | in POLICY |

http://www.kevinmd.com/blog/2011/08/rationing-logical-outcome-incremental.html

This post continues my Ten Principles of Affordable Healthcare Reform.

Health care changes should be made in small increments, easily understood by the People.

Any changes that are made should be made in small increments and they should be cost effective and easily accepted by the public. It is clear at this juncture that we cannot afford the breadth and the scope of “reform” that is being currently proposed; to do so would constitute nothing less than fiscal nymphomania leading to financial suicide. We would not be pushing grandma over the cliff; we would be pushing ourselves along with her.

If I have learned anything in the last 35 years addressing these questions, it is that any change must be gradual and universally acceptable by the constituency most affected by it. What I cited above is an example. Such small steps that would be universally accepted would include the elimination of geographic boundaries with respect to the provision of healthcare insurance claims and ratings. 

The elimination of the “preexisting” clause is yet an example of another small step that could be accomplished. The issue of insurance portability from job to job, and state to state is another that could be readily accepted. Biting off more than one can politically chew not only leads to constituency indigestion, but can, in a further political sense lead to choking to death, particularly in severe economic times when the populace has little if any trust in their elected representation. The problem is it would be We the People doing the choking, and not those who we elected.

Rationing is a logical outcome in any system with limited resources and high demand.

We must accept that rationing is a logical outcome of any system with limited resources and high demand. To grandstand this issue is not only an insult to your intelligence, it is out and out balderdash, pure rubbish!

Any scarce resource that must be used over an extended period by a large number of people logically must be rationed. The terms, definitions and nature of the rationing of public money should be determined by those charged by that same public to ascertain, adapt and legislate outcomes that are in the best overall interests of those they serve and whose money they distribute. 

These decisions should not be in the hands of political appointees, hand picked by the Administration as is the case in the current Law (Independent Payment Advisory Board or IPAB). To whom would we appeal? Will the bureaucrat on the other end of the line really care? What further cuts will this arbitrary board make in the future as our abilities to fuel this monster diminish over time?

At this time, The PPACA aka Obamacare, which is now the law, calls for all healthcare expenditures to be monitored by the IPAB, including those of commercial carriers. That said, let’s turn to Medicare and talk about rationing and Death Committees.

Right now, Medicare turns down 6.85% of all its claims, more than double that of Cigna and Humana (but interestingly, almost the same as Aetna). Is this not rationing? In the last years of life, how many of you have a Do Not Resuscitate or DNR in your Living Will? How many of you want to pass peacefully, and not squander what you have saved to pass on to your grandchildren and children? 

So, if you think it not prudent to spend your own money, where is the prudence in spending the public’s money? We need to understand that death is a part of life and accept that, and like anything else, it is something for which we must plan. When I hear the gibberish about Death Committees all I want to do is just say Put a sock in it!

Clearly, difficult choices will have to be made in the future. Our choice right now is whether healthcare should be rationed by free people making their own economic decisions and calculations or by a bureaucracy run by a non-elected, not Congressionally approved IPAB with no Congressional oversight who can run amuck any time they choose. If I am making my own decisions, as any free individual should, then I am likely to utilize only what I value above price, using funds I have earned, or in the case of charity, have given voluntarily. 

This self-imposed rationing is done freely and of my own will with my own property and my own discretion and not at the political whims of others for whatever reasons they choose. Simply stated, I believe that the individual at the end stages of life and his/her family, and not the government must do the rationing, for it is in the last two years of life that Medicare spends 27.4% of all its outlays for the elderly. 

I also believe that sometimes the physician must just say “No!” What a street-smart colleague of mine has said is that we must no longer be presented with a smorgasbord of care. The price is too high and the value of becoming overstuffed is no longer fiscally healthy or sustainable.


Mitchell Brooks, MD is an orthopedic surgeon and the host of Health of the Nation on Talk Radio 570 KLIF in Dallas, Texas. He blogs at Health of the Nation.

The NHS reform & shake-up

Bbc News, 14 June 2011 Last updated at 13:57 GMT

The government wants to overhaul the way the NHS in England works.

Under the plans, GPs and other clinicians will be given much more responsibility for spending the budget in England, while greater competition with the private sector will be encouraged.

It has been dubbed one of the most radical plans in the history of the health service - and has certainly proved controversial.

Ministers even had to take the unprecedented step of putting the plans on hold after criticisms from MPs and health unions.

The government has now agreed to make changes after an independent review called for parts of the plans to be re-written.

Why does the government want to make changes?

Despite the NHS budget being protected, it is not immune from the need to make savings.

In fact, financially many believe the next few years will be the most challenging in its history.

Costs in the NHS are rising at a much higher rate than inflation.

This is because of factors like the ageing population, costs of new drugs and treatments and lifestyle factors, such as obesity.

To cope, the NHS has been asked to make savings of up to £20bn by 2015.

To put that in context, it would require the NHS to become 4% more productive each year. And that is for a service that has become gradually less productive over the past decade.

If it does not meet the challenge services will undoubtedly suffer. There could be more rationing longer and waiting lists and so ministers believe overhauling the way the system works could help the NHS meet this challenge.

Who is responsible for the budget now and how is that changing?

Local health managers working for primary care trusts currently control much of the spending. They use the funds to plan and buy services for patients including community clinics, mental health units and hospital care.

The changes will transfer much of that responsibility to clinical commissioning groups.

Although it is likely responsibility for services such as dentistry and specialist care like neurosurgery will end up with the national board that is being set up to oversee the new system.

Originally, the commissioning groups were to be led by GPs, but other professionals including hospital doctors and nurses will now be involved too.

As the changes happen, both PCTs and regional bodies known as strategic health authorities are to be phased out.

What about competition?

The reforms are partly designed to encourage greater involvement from the private sector and charities.

In many ways, this is nothing new for the NHS. Under Labour, they were encouraged to get involved, especially in elective operations such as hip and knee replacements.

However to date, just 3.5% of these operations are done by the private sector.

In other areas of health care, especially mental health, the role of other providers is much more pronounced.

In total, £1 of every £20 spent in the NHS goes to a non-NHS provider.

The reforms will probably expand this - something that has proved extremely controversial and opened up the government to claims it is going to privatise the health service.

Ministers have responded by agreeing to introduce competition in a more managed and balanced way.

How much will the changes cost?

The cost of the programme is £1.4bn.

Most of that will come in the next two years as more than 20,000 management and administration staff are made redundant from health authorities, PCTs and the Department of Health.

It could cost as much as £1bn to make redundancies. Another £400m will be spent on things such as IT and property in setting up the new consortia.

But the government claims the cost will be more than off-set by savings.

The reduction in staff alone will save £5bn by 2015, according to the government's own costings.

What changes will patients see?

Visually, very few. Patients will still walk through the doors of their local GP surgery and talk to the same staff they always do.

However, if the government achieves its aim they may find themselves with more control over their care.

The government has said patients will be handed more choice over how and where they are treated.

They can already choose which hospital they want to go to for non-emergency operations, such as knee and hip operations.

In the future, this choice could be extended to GPs. Practice boundaries may be scrapped, enabling a patient to register with any family doctor they wish to.

Patients have been promised more and clearer information. Central to this will be HealthWatch, a patient body which will collate information on performance and feedback from patients themselves.

What happens next?

The pause that was put in place while the listening exercise was carried has now been lifted. In many ways, it is all systems go.

The government will spend the next few weeks making amendments to the bill so its passage through parliament can be started again before the summer recess.

If everything now goes to plan, the new clinical commissioning groups will take responsibility for the budget in April 2013.

However, those areas that are not ready to take charge will not have to. Instead, the national board will be in charge of the purse strings until they can get their arrangements fit for purpose.

Health Reform: Why We Need Caution & More Meaningful Dialogue (Part 1)... President's Message, Berita MMA, Feb 2011 Dr David KL Quek

Health Reform: Why We Need Caution & More Meaningful Dialogue

(Part 1) 
This has now been published in The Malaysian Insider, 8 Feb 2011 
This is also published in Malaysiakini, 9 Feb 2011

President's Message, Berita MMA, Feb 2011

Dr David KL Quek, drquek@gmail.com

“The Government's response to its consultation on the White Paper, ‘Liberating the NHS’, was a missed opportunity to demonstrate to the profession, and others, that it genuinely was listening to the concerns that many had put forward. We are not opposed to reasoned and evidence-based change, and accept that there needs to be some improvement to the way services in England are planned and run, but it is our duty to speak out when we can see the NHS we care about and work in being put at risk.

“Whilst we support proposals to increase clinical involvement in the design and delivery of healthcare, enable greater public and patient involvement and put the focus on quality and outcomes, rather than crude targets, we have real concerns about other aspects of the planned reforms. In particular, the lack of detail in many areas, the increasing emphasis on competition and the market, and the significant risks created by the process of rushed and unnecessarily risky transition…” ~ Dr Hamish Meldrum, BMA Council Chairman on the NHS Reform[1]

‘Health For All’ 11 years on…

In 1999, The MMA published a monograph on ‘Health For All’, a document, which was intended to promote and urge for a more systematic approach to our healthcare.[2] The MMA leadership then and even now, felt that Malaysia could do better by enhancing our healthcare system so that health equity can be assured for everyone residing in Malaysia—a single payer model was proposed as a possible approach towards ensuring this objective.

In that document, we discussed the dichotomous public-private divide, which was seen as wasteful and occasionally leading to lack of access or affordability for some of the less endowed, the marginalized and those encountering catastrophic ailments.

We lament the fact that up until now, Malaysia still does not have a declared policy of equitable healthcare for all (although in reality the huge healthcare subsidies are considered by many to approach such a system). Ideally healthcare should be freely accessible for all, regardless of ability to pay, and should be based entirely on the basis of need.

Although the social aspects and ideals were widely discussed in this monograph, there was a distinct slant towards social equity taken in the context of the prevailing socioeconomic circumstances then. There was and still is that great need for courageous and prudent leadership in addressing structural as well as financial reform when it comes to healthcare.

Health Systems Malfunction—a Global phenomenon

Simply put, the past 2 decades have seen the unraveling of many health systems even among the richer first world economies globally. Healthcare costs have simply outstripped all economic projections and segued onto exponential trajectories, causing severe strains on national budgets.

Healthcare issues continue to arouse deep-seated partisan passions and disagreements that have become so central as to even destabilize and/or derail governments and leaders! This global phenomenon is now a core sociopolitical issue debated in every nation, rich or poor.

The USA has been struggling with the more inclusive but mandated aspects of Obamacare vs. the Republican Tea-Party push for autonomous patient choice (with zero or as little government intervention as possible) with no regard for the huge 49.6 million uninsured.[3] And the new conservative UK government is trying to dismantle the 62-year old NHS by offering a radical GP commissioning restructuring programme in the vain hope of reducing healthcare costs by some £15 to 20 billion over the next 5 years; this is pitting primary care GPs against tertiary and hospital care.[4]

Surprised? The USA health system is about the most market-driven ever, consuming some US$2.57 trillion (17.3% of GDP!), with arguably the most superlative state-of-the-art care, but with huge problems of inequity: neglected uninsured poor and staggeringly high costs; whereas, the UK system has been a socialized state-organised single-payer system for decades, but with increasingly unmanageable delays and queues angering even the most patient of stiff upper lip Brits!

So what is happening? Such fraying of these entrenched systems is not entirely new. The troubles within the various if disparate health systems have been brewing for some time. The costs and structural tensions have been straining about its seams for decades, and are now finally close to bursting…

So it is questionable who has got its health system right, and it now begs the urgent question that “if it ain’t broke, why change or mend it”? Because, there is no system the world over, which is of one size or one standard that fits all!

Knowledge Economy empowers greater personal choice and demand

Stupendous technological advances, diagnostics and therapeutics, have been so well-publicised that these are creating extraordinary demands for these scarce if initially exclusive and expensive technologies, surgeries and medicines. The result: more and more ordinary people are coveting these life prolonging or health enhancing treatments, all of which are simply overshooting most conceivable health budgets!

Compounding the problem is knowledge explosion and enablement for ordinary people. The Internet and WWW has empowered huge swathes of people with information, and created even more personal demands and wants!

More often than not such ‘k’ empowerment enhances more individualistic tendencies and self-focused behaviour.

That is a given. Knowledge begets personal power. Everyone has become more self-centred and more consumerist. Many are exposed to being more concerned as to individual rights, health and medical possibilities and ‘cures’ for themselves and their loved ones. Many would seek Medicine’s best and especially last gasp therapeutic measures, regardless of costs or actual longer-term benefits.

So, how do we tell different groups of people that not everyone can have everything that he or she desires, especially in the current pervasive free market consumer-driven economy? Open society means non-filtering of data, which in turn means unfettered diffusion of knowledge to all who wish to access such information.

How do we explain self-restraint and eschew selfish demands to instantaneous gratification for quick diagnosis, testing and treatment? Who is to say which patient deserves to be seen first or cared for sooner? Who would have to wait and possibly suffer more pain and/or delayed complications, etc.?

How do we balance such growing demands for better, more select, more costly healthcare for a few, against the greater need for wider lower level primary care for more? How do we damp down these rising costs without appearing to curtail the free-spirited advances of medicine, of science, or the freedom to choose by patients?

Rationalising the need for Reform is not universally an accepted given[5]

How do we persuade medical professionals and patients alike, that perhaps primary care gate-keeping is the way of the future? Would top-down edicts or dictates work? Would our society tacitly allow such a prescription of radical change without adequate consultative debate or choice?

In this day and age, it would be foolhardy to expect that such changes can be brought about without adequate buy in by most if not the majority of the people. This is especially so, when more uncertainties than benefits appear in the preliminary pronouncements of the government, regarding the healthcare reform plans. Slogans such as 1Care remain nebulous and unclear, and are not convincing enough to encourage acceptance by our citizens, and certainly in the current form, not by the medical profession.

Many have asked why reform now? These reforms have been proposed due to concerns that healthcare costs have been escalating, particularly private spending, that there have been too much out-of-pocket (OOP) payments, that there have been possible duplication and wastage of utility of resources, and that the divide between public and private healthcare services have widened to worrying levels.

The MOH believe that the private sector is not sufficiently disciplined or robust in addressing the growth of chronic ailments, and are not promoting primary care and health maintenance enough. The private sector is thought to be too disjointed and have not been providing holistic or family care for patients. The MOH appears unduly concerned that there have been too much doctor-hopping/shopping and thus resulting in poor continuity of care in the private sector. We have asked for specific data to prove this arguable presumption.

Indeed, we have argued that the converse is true in practice. In the private sector, although the cost is higher, more patients and their families follow up with a specific doctor or group of linked doctors, than is the case in the public sector. Most private patients have family doctors who know them and their families intimately. We agree that for the more itinerant patients who doctor-hop around, or those who do not subscribe to seeking healthcare on a regular basis, this might occasionally be a problem.

But for these groups of sporadic and difficult patients, this would almost certainly also be the case within the public sector! We know for fact, that patients following up with outpatient clinics or klinik kesihatan’s encounter a different doctor (MO) almost every time, or a medical assistant, and a different one at best! Most clinical notes and prescriptions are often hurriedly transcribed as harried doctors ‘rush’ to see through the long lines of patients! Otherwise, why should patients pay more to see private physicians, if not for greater personal and more attentive care? Also if patients were really poorly taken care of, surely market forces would dictate a discontinuation of such a failed relationship!

Notwithstanding such a preconception, the MOH understandably believes that its public sector functions more efficiently at offering this modicum of services, touting their capacity at addressing these healthcare concerns from ‘womb to tomb’. We argue that because of debatable accounting methods (which do not take into consideration, infrastructure cost or manpower support staff and wages), the public sector healthcare is more costly per patient seen than that in the private GP sector.

Proposed Gate-keeping role of Primary Care Physicians feared…

One way to reduce healthcare cost is to restrict free access to doctors by any one citizen, especially to reduce self-referral behaviour to specialists and hospital. These have been shown to have an economic conflict of interest, which leads to possible over-use of already available resources and amenities.

So if every citizen can be registered, then this would perforce discipline everyone better to follow a prescribed path of healthcare access, through a primary care physician: whether a GP or a family medicine specialist. More importantly these primary care physicians would be the de facto entry point or access person, from which to approach further secondary or tertiary care, i.e. they function as gate-keepers.

With such a system, it is hoped that healthcare costs can be better streamlined and kept under control. Direct referral to specialists or unnecessary testing or investigations would hopefully be discouraged and reduced, especially if reimbursement disincentives are inbuilt into the system.

Bypass the gate-keeping function of the primary care doctor and such medical bills will not be covered, i.e. this will have to be reimbursed personally, via costly OOP means. Government-assisted payment is only assured when the prescribed pathway is followed. Thus, the plan is to integrate the public-private sector at least at the level of primary care for a start, to create a seamless approach for all citizens.

But can such a system work, especially with our people being so used to the current ‘free access’ mechanism when seeking medical help? Do people want such a change when there would be a drastic restriction of access and care to one doctor? Do our citizens wish to be confined to one GP or FMS for all time? If not, how can anyone change doctors, and how easily can this be done? Would such GPs or designated doctors be forced down on the patients, as already happening with the issue of foreign worker medical examinations? What about free choice, second opinions, etc?

Also how much would this cost the citizen? How much would this restructuring exercise costs? How much would everyone have to contribute to the planned social health insurance (SHI)? Or would such changes only lead to additional costs and additional taxes, without enough tangible benefits or coverage, or possibly with even less access?!

These are the pressing questions and concerns, which have arisen during our dialogue with doctors and citizen groups. Many are extremely worried that leakages (already legend with many government and government-linked entities) and inefficiencies would waste even more money and shrink their already meagre benefits with the current system.

No one is willing to pay more (through the SHI), when they are not reassured that the system would truly benefit them more and reduce OOP and costs! Why change if it benefits only a few concessionaires etc.? We have to address these perceptions, these questions, before we can get support from our increasingly skeptical and knowledgeable citizens.

Practical Concerns remain unanswered

Other more practical questions also come to fore. Can we exert control efficiently enough so that duplication and overutilization of tests and services be truly truncated; that hospitals and tertiary care be services of last and evidence-based needed resort, without aggravating patient safety, endangering lives, even causing delayed therapies, precipitating or provoking complications or deaths?

Who would pay or be responsible for higher chances of medical misdiagnoses, delayed diagnoses, errors and mishaps possibly associated with such rational ‘rationing’ of healthcare?

How do we change physician behaviour that perhaps fee-for-service mechanisms may not be the best approach to rational healthcare cost reform? How do we convince professionals that they would have to accept a new reality and a possible modifying cut in fair wages for fair work based on a new paradigm? Would we be ready for case-mix DRG forms of reimbursements for health professionals as well as for corporate owners of for-profit private medical establishments?

What about the planned commissioning of healthcare services to selected consortia or regional trusts? Would these be carried out without the much-feared corruption or leakages crippling the process? Would private care survive such a change? Or would this go the way of secretive and preferential government-linked concessionaires so much a curse and exemplar of profligate waste and hiked-up costs in recent Malaysian sociopolitical discourses?

How indeed do we revolutionise an entrenched system such as ours, which can lead to probable disruption in healthcare, in reduction of choice for patients, in possible lowered and constrained professional autonomy and remuneration, as well as possible redistribution of resources and re-delineation of authority?

Clearly there is currently neither any simple solution, nor can there ever be.

Let us take the example of the current malaise in the UK’s NHS reform. Health secretary Andrew Lansley has bulldozed his way towards extremely aggressive reform plans, which are now threatening to disrupt the much vaunted if flawed NHS.

Lessons from the current NHS stalemate¹

In the wake of the financial meltdown of September 2008, The Cameron-Clegg administration seems bent on restructuring the NHS to reduce costs. This was unveiled in July 2010. Despite its purported public consultations, its rushed implementation has left much to be desired. But like most authorities, health secretary Andrew Lansley had not waited for much feedback before he unleashed the timelines or the details for the restructuring.

Sadly, this has cast a strong confrontation with the British Medical Association, which represents some 144,000 doctors in the UK. BMA, a doctors' union, argues that the NHS reform plans are potentially damaging. The rushed approach risks pitting groups of clinicians against each other, appearing to encourage competition in saving costs, which might actually be detrimental to patients’ safety. Furthermore, it is not at all assured that this will bring about more prudent use of public money to enable the NHS to save a predicted £15bn-£20bn by 2015.

The BMA warns that there are many aspects of the reform proposals which could undermine the stability and long-term future of the NHS," [6] Other critics of Lansley's strategy, such as the Royal Colleges of Physicians and Surgeons, have also warned that these measures would spell the end of the NHS in its present form.

BMA warns that changing the status of existing NHS providers to foundation trust status has threatened the character and ethos of NHS provision… Deploying more corporate entities could also destabilise the NHS, the security of its employees and their terms and conditions of service, it says.

BMA had also cast serious doubts on many of the policies, which are thought to be vital to improve NHS performance, reduce bureaucracy and improve the outcomes of treatment for patients.

In a robust message to Lansley, the BMA adds: "We urge the government and NHS organisations to focus on those areas where they can truly eliminate waste and achieve genuine efficiency savings rather than adopt a slash-and-burn approach to health care, with arbitrary cuts and poorly considered policies."

The BMA's stance questions the rationale of empowering family doctors fully with unprecedented autonomy, almost total influence over their patients' treatment, and control of the £80bn NHS budget through a switch to GP-led commissioning of healthcare, while leaving out hospitalists and specialist groups, thus leading to possible conflict and disagreements. Such a ‘divide and rule’ approach cannot hope to offer a better, more seamless health service for Britons.

Dr Hamish Meldrum, the BMA chairman, argues that doctors approve of some measures, such as patients having more say and a greater focus on outcomes. "But there is also much that would be potentially damaging. The BMA has consistently argued that clinicians should have more autonomy to shape services for their patients, but pitting them against each other in a market-based system creates waste, bureaucracy and inefficiency."

It appears that governments around the world are not dissimilar… Its pronouncements often have grave and momentous bearings on its citizens and for healthcare and medical professionals as well as for the patients and citizens!

We wait with bated breaths as disruptions and stalemate shake the very foundations in the touted NHS, which model, our very own MOH is trying to emulate!

Let’s hope common sense and a greater consultative approach emerge, with most of the grievances and misgivings given a chance to be resolved for the ultimate good of the public!

---

[1] Hamish Meldrum. New Year message from the BMA's Chairman of Council. 31 Dec 2010. http://www.bma.org.uk/representation/newyearmessagehamish.jsp (Accessed 26 Jan 2011)

[2] MMA. Health for All. 1999, Kuala Lumpur

[3] By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens, Andrew J. Madison. National Health Spending

Projections: The Estimated Impact Of Reform Through 2019. HEALTH AFFAIRS 29, NO. 10 (2010). doi: 10.1377/hlthaff.2010.0788

[4] Department of Health. Equity and excellence: Liberating the NHS. The Stationery Office Limited, London, July 2010.

[5] David KL Quek. Health Reform in Malaysia: What should MMA’s Response be? MMA News, August 2010.

http://myhealth-matters.blogspot.com/2010/08/mma-news-august-2010-health-reform-in.html (Accessed 26 Jan 2011)

[6] British Medical Association. NHS reform consultations, responses and briefings. 19 January 2011 http://www.bma.org.uk/healthcare_policy/nhs_white_paper/consultationpaperswp.jsp (Accessed 26 Jan 2011)

NHS Reform: New Year message from the BMA's Chairman of Council, Dr Hamish Meldrum

New Year message from the BMA's Chairman of Council

Dr Hamish Meldrum, 31 December 2010

There is no doubt that 2011 will be an exceptionally testing time for the NHS, patients and the profession. Set against a backdrop of an unprecedented financial challenge, with efficiency savings of at least £20 billion being sought in England alone, the Government's is pushing ahead, at break-neck speed, with an unnecessarily ambitious programme of reform in England. The NHS is facing similar financial challenges in the devolved nations and it is only of little comfort that this is not combined with the additional burden of organisational upheaval.

As doctors and clinical leaders, your role in dealing with the current demands, protecting the quality of patient care and helping to ensure the future viability of NHS services, will be crucial. I am confident that the profession will rise to the challenge and will do its part to minimise any adverse impact on patients. However, the profession can't do it alone.

The Government's response to its consultation on the White Paper (for England), "Liberating the NHS", was a missed opportunity to demonstrate to the profession, and others, that it genuinely was listening to the concerns that many had put forward. We are not opposed to reasoned and evidence-based change, and accept that there needs to be some improvement to the way services in England are planned and run, but it is our duty to speak out when we can see the NHS we care about and work in being put at risk.

Whilst we support proposals to increase clinical involvement in the design and delivery of healthcare, enable greater public and patient involvement and put the focus on quality and outcomes, rather than crude targets, we have real concerns about other aspects of the planned reforms. In particular, the lack of detail in many areas, the increasing emphasis on competition and the market, and the significant risks created by the process of rushed and unnecessarily risky transition, particularly at a time of such financial stringency.

Despite some of our scepticism, and, more so, because of our concerns, I believe there is a continuing need for the profession to remain closely involved in how the NHS develops in putting our evidence for change forward, and in reflecting how the NHS is delivered differently across the UK.

Over recent years, we have had major concerns about the erosion of professionalism and professional values. Doctors have the skills and experience to balance clinical evidence, the views of patients and the public, and the needs and constraints of the service itself to make the best possible decisions, often in very difficult circumstances. And not just at an individual patient level but, increasingly, at an organisational and whole health system level too.

If we are to create and maintain a sustainable health service it is vital that we encourage professional values to flourish and help to break down barriers between primary and secondary care, between health and social care, between clinicians and managers and between the health service and the public. It is only by working together that we will be able to make the difficult decisions and achieve the most effective outcomes with finite resources.

Strengthening professionalism and professional values will be an important ingredient in ensuring future sustainability of the NHS.

We also need to point out, both locally and nationally, what the efficiency savings actually mean in practical terms for services, patients and their staff. This is not, as some have accused us of in the past, shroud waving; it is being open and honest with patients and helping them to share the difficult choices that will have to be made. The Government may shy away from this but we have a duty of trust to our patients to spell out the reality of their actions.

While doctors will do their bit to identify waste and lead improvements in efficiency, we expect the government to spread the responsibility fairly – which means looking again at the very high rates of PFI equity returns, the generous allowances for return on capital for pharmaceutical companies and the financial consequences of fragmentation, excessive bureaucracy and unnecessary duplication caused by unfettered markets. Simply attacking hard-working staff by limiting their pay even further, will risk undermining those professional values and alienating those who make the real difference to patients in the care they provide, day-to-day.

Instead we must be encouraged to drive innovation, building on and promoting the world-class achievements of our medical academic community, embedding evidence-based change, backed by a robust national framework for training the next generation of doctors. The NHS must have a medical workforce that can meet the challenges of the future. The

BMA will keep on demanding a more sustainable UK solution as it responds to the Government's consultation on plans for education and training.

2011 will be a defining year – one in which the NHS will be tested to the limit. The BMA will continue fighting to improve the quality of care for patients, protect the values that ensure the NHS thrives, enhance the working lives of those who work within it, and guard against the threats facing the profession at large to ensure a better future for all.

I wish you all a very happy New Year in these uncertain times.

We are continuing to seek members' views on the proposed NHS reforms in England to help us lobby on your behalf, especially as more details emerge. If you would like to have your say, please complete the feedback form