13 Nov, 08 | by Deborah Kirklin
This week a leading national paper in the UK broke news of what has been rightly called a medical scandal. They revealed the existence of a report into the systemic inadequacies of management systems at Birmingham Children’s Hospital. The impact of these failings on the standard of care provided by the hospital are now the subject of a further report, deemed necessary once the contents of the first report were made public.
The report was commissioned by the local Primary Care Trust (PCT) for whose patients the hospital provides care. Rather than being commissioned because of identified negative impacts in terms of increased patient morbidity and mortality, the report is, instead, the result of the PCT’s response to a collective and anguished cry for help from the world class doctors at Birmingham Children’s Hospital and other local hospitals. No longer able or willing to stand by whilst their reasoned arguments about patient safety, duty of care, and the ethical imperatives inherent in their role as both care givers and patient advocates fell on deaf and ignorant ears, they looked elsewhere in the hope that reason and integrity would prevail. News of this situation has been met with widespread public declarations of shock. And so I am aware that it may appear perverse to admit that my heart leapt on reading this story. Although I was certainly distressed by what I read, I was not in the least surprised by the dysfunctional relationship between management and clinicians described in the report. The experience of these doctors is far from unique but rather constitutes a demoralising daily reality for both hospital and community -based doctors. So I wasn’t shocked, or at least not in the sense of being surprised that the concerns of medical experts about patient safety, duty of care, and clinical priorities should be so routinely ignored. But I was pleasantly surprised- and hence the small leap in my heart- to hear that somewhere, within the Orwellian world within which clinicians in the NHS are now forced to operate, the silent scream so painfully audible within the medical profession for a number of years had finally found a way to be heard.
Describing the way the NHS is currently managed as Orwellian has become commonplace, at least amongst those I work with. Fiction was of course just one of the many genre’s in which Orwell excelled, nevertheless he is perhaps best known for two of his novel’s, Animal Farm (1945) and Nineteen Eighty-Four (1949). It is arguably the latter that bears the greatest responsibility for inspiring the term Orwellian, referring to certain ways in which the State and The Party behave, especially when the Party is the State. Sadly, and contrary to the interest of the citizens of this country, the State now is the Party (for which in this case read NHS) with the parallels between how they are choosing to control the NHS all too easy to recognise in the meaning of the adjective Orwellian.
Perhaps most pertinent amongst the behaviours associated with the term Orwellian is the political manipulation of language, whereby language is used to obfuscate meaning or to reduce and eliminate ideas and their meanings that are deemed dangerous to its authority. Prize-winning in this category in today’s NHS must be Commissioning = Choice. The government’s choice agenda has been much trumpeted, with the IT intensive and very expensive “Choose and Book” the jewel in its choice-crown. Heralded as a way to enable patients to choose where to go for treatment, and to allow rapid access to appointments, the idea sounded reasonable enough. Equally central to the government’s strategy for the NHS is the idea that local GPs along with PCTs commission services to suit the needs of their local population.
Except that therein lies a conundrum, because the reality of allowing patients to choose whom they see inevitably entails costs, costs that can be directly at odds with attempts by a PCT to provide the services it deems a population needs/can be afforded as economically as possible. In the end of course the only way to allow those commissioning services on behalf of populations of patients to make their choices is to restrict the choices available to individual patients.
Just one small example might help explain what I mean. A few years ago if I thought a patient needed to see a particular consultant for say a musculo-skeletal problem I would address my letter of referral to that particular specialist. On recommending the consultant I would mention their expertise in their condition and that, in my judgement, this individual was the best person to see them. Then as now the patient’s priority was to be seen by someone able to help them and within a reasonable timeframe. Not so much a choice as a rational and reasonable desire. The choice, such as it was, was mine to make and was based on my knowledge of the patient, their condition and the appropriate specialist services available. I did not make the choice because of a desire to control but because it was exactly for this local and specialist knowledge that I had been consulted.
Which brings us back to the Orwellian world currently inhabited by both patients and doctors where, apparently, patient choice is King. Except that if that same patient comes to see me today I am now required to refer them to an assessment service run in a nearby hospital where a doubtless highly competent physiotherapist will decide by whom, if anyone (other than themselves) the patient needs to be seen. It may well be that I think they need to see a rheumatologist and not just any rheumatologist but a very particular rheumatologist, working in a hospital that may or may not be within the PCT’s commissioning circle. The patient, having done her own investigation and having asked me my opinion may well agree. The patient has no choice but, no matter, they’ve got Patient Choice, just read the government literature, visit the website, it’ll all make sense. Or it will after you’ve re-read your Orwell.