Douglas Noble on reforming the reforms

douglas nobleThe pause ended in dramatic fashion last week with the publication of the NHS Future Forum’s recommendations

Most interesting was the orthopaedic surgeon at Guys Hospital who confronted the prime minster and deputy prime minister in a rage because the camera crew were not suitably dressed for a hospital. 

It hit home on all sorts of levels. 

Perhaps he’s just an unusual surgeon who wears a bow tie with all its connotations. Or perhaps he represents something deeply troublesome – a fundamental disconnect between profession and politicians. Some may say “of course there is.” Yet, ‘twas not always the way. Despite a rocky start to the NHS in 1948, with doctors being amongst the most vocal opponents, peace was eventually forged between Bevan and the BMA – although in Bevan’s own words, at the cost of: “stuffing their mouths with gold.” It’s also only four years since a surgeon, Lord Darzi, was appointed as under-secretary of state for health, representing a significant connect between frontline and Whitehall. And it is quite an achievement that today the BMA are one of the NHS’s biggest supporters and defenders. 

The government seemed to respond to the Future Forum’s findings quite positively. This included clarifying the role of the NHS commissioning board, making commissioning groups more inclusive than just GPs, and forming clinical senates so that doctors can “march up to the hill” to have their views heard. 

Less clear though is the role of the mysterious Health and Wellbeing Boards. Unfortunately the director of public health seems to be framed as some sort of technical adviser in this new arena.  Sad, given that health and wellbeing in almost every other context is led first and foremost by the director of public health. However, the majority of trainees in public health may never face this difficulty as recent employment statistics indicate public health is dying out.  Sources tell me that only a third of public health registrars in the UK got a substantive consultant post in the financial year 2010-2011.  Given that it costs approximately £250k to train a registrar (in addition to a similar amount to put them through medical school) this represents an astounding waste of time and public money. 

On the reforms overall, the BMA wisely sounded a cautious note, awaiting more detail. But what do the next few months hold in store for English healthcare?  The government has indicated there will need to be some changes to the Health and Social Care Bill. Technically, it is possible that the bill will not survive scrutiny and fail to be passed. Such a fate was almost met by Obama’s health bill in 2010. In the end, for Obama, a watered down bill was passed by both Houses, with much loss of original intentions. In reality, this is the most likely fate of the current coalition bill. What exactly will and won’t survive is less clear, and I must confess I am starting to feel perplexed by all the impending new bureaucracy. Drawing a diagram has stopped being a sensible option; there are just too many boxes and arrows in too many different directions. Am I the only one having this problem?

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO. From 2006 to 2008 he was clinical adviser to the chief medical officer for England. You can follow him on twitter @douglasnobleMD