DEMAND SIDE MANAGEMENT FOR A VIABLE NHS

 

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1.1 Introduction
This submission to the 1997 NHS Review is from Dr Richard Lawson MB BS MRCPsych, qualified London 1969, a GP for 18 years, lead GP for the Weston Locality Commissioning group 1994-97, and Health Speaker for the Green Party of England and Wales.


Health is a state of positive well being of body, mind, society and environment. The discussion of health in the present review should go beyond the usual discussion about NHS finances, although there is no doubt that the NHS is underfunded on international comparisons.


1.2 NHS Funding
The NHS lies at or near the bottom of international league tables for per capita funding on most counts. This gives substance to the grumble of health care workers that the NHS is underfunded. Against this, it has become commonplace for conservative health funding experts to speak of the "insatiable demand for healthcare". It is argued that the more care is given, the greater the demand. Health care, they argue, is a bottomless pit: the demand can never be satisfied. There is a grain of truth in this, but only a grain. NHS funding is supposed to rise by half a percentage point each year, but it is commonly recognised that the increased demands of an ageing population and advances in medical technology easily wipe out this increase. Add to this the increased demands due to:
- the burden of bureaucracy imposed by the 1992 (and subsequent) reforms,
- increased patient demands stimulated by the Patients Charter,
- the tendency for doctors to practice defensive medicine, that is to perform unnecessary investigation and treatments in order to avoid being sued, a danger that has increased since the 1992 "reforms".
- ill-health due to ecological conditions - unemployment, poor housing, poverty and the breakdown in social cohesion.


The NHS certainly is underfunded, and the Government should aim to bring NHS funding up to the average for comparable countries, but its problems cannot be cured simply by throwing money at the problem.


· First, the social and ecological causes of ill health must be cured through real health promotion.
· Secondly, the whole system must work more efficiently. This does not mean the forced efficiency savings that the Government seeks, currently set at an utterly unrealistic 3% per annum, but rather through "Downshifting". We must look at the scope for education and empowerment of NHS "consumers" (to use the dismal in-word) in creating a more efficient service overall.

1.3 Real Health Promotion
Like motherhood and apple pie, everyone believes that prevention is better than cure. Unfortunately, few understand what preventive health really means. The 1992 reforms aimed at individualised health promotion, with doctors and nurses, who can ill afford the time, urging people to eat more fibre and take up jogging. Unfortunately, the professionals are not persuaded that their time is well spent in this exercise, because
- It is usually only the "worried well" attend these sessions, rather than the fat smokers who should change their habits
- the Government before May 1997 failed to play its part; in particular, it failed to ban tobacco advertisements, which is the simplest first step in improving public health.
-Even the good health advice that gets across is limited by the general state of the world, caused by Government policies that are beyond the control of the individual, as exemplified in the next section.


1.4 The limits to "lifestyle" mediated health promotion
- Healthy eating is a important part of the health promotion message - but healthy food is expensive, and poor people have no choice but to fill up on cheap carbohydrates and fats. Health policies should be designed to break people out of the poverty trap and make healthy food cheaper.
- Healthy lifestyles mean taking more exercise - but at the same time we are all pressed to buy labour saving machines and cars. People who would not dream of walking two miles into work are happy to take themselves off to the gym to walk three miles on electrically driven mats. Those who jog or cycle on poor air quality days, may do themselves more harm than good due to the increased throughput of polluted air. It is to be hoped that new transport policies will make it easier to walk, cycle and use public transport, but more difficult to drive, especially if there is only one person in the car.
- Healthy living means taking a relaxed approach to life, but workers are stressed by overwork, while unemployed are stressed by their unemployment. This is clearly irrational. Government policies should aim to increase the size of the workforce by extending the scope of Earnings Disregards for those on benefit. The unemployment trap is a product of 100% marginal taxation on benefit at the point when the claimant enters work. This point needs radical re-examination and reform, as it is the administrative contribution to the unemployment equation. (See Bills of Health, Ch.3)


It is clear therefore that the previous Government's individualistic approach to health promotion was inadequate. If there is to be any significant improvement in the health of the nation, Government must play its part by bringing in healthy social policies.

1.5 Community (Public) Health can deliver real health gains
The question of community health is basic to the health case. It can be argued that people living and working in decent communities with pollution-free physical conditions would be happier and healthier. It has been calculated that one fifth of the NHS clinical effort is wasted in treating illness caused by


1.5.1 Unemployment
Illnesses caused by unemployment absorb about 3.2% of the NHS budget. It can be solved by the Wage Subsidy proposal outlined in "Bills of Health" which allows people to break out of the unemployment trap. It has been calculated that 1-2 million jobs in the green sector of the economy could be created by this means. (Bills of Health p 58).
1.5.2 Poverty
About 2.4% of the NHS budget is spent on trying to cure illnesses brought on by poverty. The Basic Income/Wage Subsidy proposal helps people to break out the poverty trap.
1.5.3 Housing
Bad living conditions are known to make people ill. Illness created by poor housing accounts for about 6% of the NHS budget. It is clearly irrational that 145,000 empty properties coexist in the UK with about 60,000 homeless families, and 120,000 unemployed building workers - especially when councils have £5 billion in their treasuries from the sale of council houses. It is ten times more cost effective to build a house than to keep people in temporary accommodation (Bills of Health, Ch.5). All in all, the problem of poor housing is not just a human tragedy, it is also downright economic foolishness. The housing problem can be solved by the use of the policy of Empty Property Use Orders, low cost self build housing, and low impact developments. The Treasury convention that 100% of the cost of building a new house must appear in the PSBR for the year that the house is built must be changed. Treasury thinking must be updated to include the concept of the mortgage through a Housing Finance Act (BoH p 254).
1.5.4 Environmental conditions
; 5-10% of the NHS budget is estimated to be spent in an attempt to cure illness caused by pollution. The forms of environmental problems are many and various, but most of them can be addressed by the institution of an Unwanted Effects Restitution Levy.


1.5.4.1 Unwanted Effects Restitution Levy
There are some 70,000 man-made chemicals in our environment, and every year, about 2,000 more are added. Many of these have adverse effects on our health, so the burden of demand on the NHS rises in proportion to the number of chemicals produced. With every passing year the gap between illness caused and health services bought grows greater. It is difficult to pay for the scientific work to establish the truth of these effects, bearing in mind that it took 20,000 scientific papers to establish the simple fact that smoking causes cancer. Natural justice suggests that the solution is to put a levy on any suspect product sufficient to pay for the work to study its effects. If evidence for a causal link is found, but the harm is not sufficient to ban a product outright, a further levy should be applied and earmarked for the NHS efforts to repair the health damage caused (BoH p 255).


1.5.5 Social breakdown.
Several conditions have come together to cause the breakdown of social conditions:
Individualism: Mrs Thatcher showed a certain detachment from reality when she claimed "There is no such thing as society". Like wolves and baboons, and unlike bears and hunting wasps, we are social animals.


The perceived threat of crime, which keeps people in a state of fear and mistrust, although in fact people's estimate of the risk far exceed the real risk .
-Television, which downgrades all forms of social interaction, and breeds the cult of passive mental stimulation.
- Geographical mobility, which scatters family members far and wide across the country.
- Road Traffic, which divides once close knit communities.

These have all contributed to the break up social cohesion. This must have cost implications to the NHS, but the effect cannot be counted. Social cohesion can be promoted by a new emphasis on the local economy and community, and by the introduction of community workers and community centres in needy areas.


By tackling these problems we could create a healthier, happier nation. Under these circumstances, the NHS could function much more adequately, with 20% of the workload removed.


In the meantime, we are still faced with the problem of how to help the NHS which is struggling to cope with the demands placed upon it.


2. TAKING THE PRESSURE OFF THE NHS BY "DOWNSHIFTING"

Working in the NHS is like going up a hill in an overloaded vintage Austin Seven car in top gear at half throttle. There is a sense of shakiness and loss of headway. There is a need for a combination of more power, less load, and a lower gear ("Downshifting").
We must curb inappropriate demand. The NHS is failing because the demand exceeds the supply of professional help. Increasing the supply of the professionals is not the sole answer. Demand management is also needed.
There are a variety of means for achieving this, of which a few are outlined below.


2.1 Patient education
The first step in demand management is a need for a educational programme for NHS users. During the 1992 NHS reforms, a Patient's Charter booklet was pushed through every letterbox in the land, which proclaimed patients' rights. This needs to be counterbalanced with another booklet explaining patients' responsibilities. As well as explaining how the NHS works, it would teach self reliance in coping with minor illnesses like coughs, colds, sore throats, and gastroenteritis In the Netherlands, where such a booklet has been in use, it has been shown that GP consultations fell by 20% in some social groups.
2.2 Health wardens
One of the reasons for excessive demand on the health services is the break-up of the community and the extended family. When a young mother is faced with a minor health problem in her child, instead of calling upon the wisdom of older female relatives or neighbours, she takes the child to the doctor. It would be possible to begin to reinstate the old system (and foster the sense of community at the same time) by helping to set up a system of health wardens, one in each street, responsible for, say, five or ten households apiece. People with minor health queries could approach the warden, who would be trained to advise on simple, common illnesses. If they do not know the answer, they can take it to a meeting of other health wardens, attended by a health professional who can share best practice and current knowledge with the group. In this way, there would be a general raising of consciousness of health matters throughout the locality, and messages could pass from the centre to the periphery and vice versa more efficiently than the individualistic, one-to-one method that is currently used. Naturally, the street warden system would complement, not replace, the individual consultation with a GP. Access would improve as inappropriate demand fell, bringing waiting times down with it.
2.3 Using the Broadcasters
Waves of minor viral infection regularly sweep across the population especially in the winter months. Each virus has a distinctive clinical pattern (e.g. occipital headache, sore throat, weakness), and each wave produces a spate of unnecessary visits to GP surgeries. If newspapers, radio and television stations could be persuaded to co-operate with health authorities to inform the public of these patterns, and educate them in the appropriate self-management of them, the burden on the health service could be diminished. The resistance to this idea comes from the overweening emphasis of the broadcasters to "entertain" and to have "an angle" on any item they put out. On the other hand they could be reminded of their Reithian mission to "educate, inform and entertain".
2.4 Stay home when you are ill
At present, people are expected to go to work even when they have a cold, cough or sore throat. The consequence of this policy is that the infection spreads around the workplace (especially in offices with recycled air systems), that the sufferer cannot work efficiently, and the infection lasts longer, possibly leading to secondary bacterial infection and even Chronic Fatigue Syndrome. It would be better if the presumption was that a viral infection should be treated at home. The Civil service would be an ideal place to pilot and monitor such a policy.
2.5 "The Computer Will See You Now"
While health wardens call upon traditional ideas of community, at the other end of the scale it is possible to use computers to relieve the pressure that is suffocating the NHS.
There are three steps in diagnosis: history taking, examination, and investigation. Of these, history taking is the hardest and most time consuming. This is because people are so eager to give us all the facts that they run out of time, and doctors are so overloaded with useless information that they may miss out on important information. Computers, however, have infinite patience, and can order the data that pours haphazardly from even the most circumstantial historian. It is possible to use computers for taking histories. It would be possible to have a computer in the waiting room, with several dumb terminals, so that those who wish to may enter all their medical data together with all their symptoms. Internet access would also be possible. The programme will be able to order the data into a format that the GP can work with. It will also be able to suggest diagnoses, and in some cases to supply full diagnoses.
The doctor, having scanned the computerised history, can then verify it, and proceed straight to a thorough examination, tests, and explanation.
A prototype of this is here.


Not everyone would want to go down this path, and those who do not want to deal with the computer, need not do so, but many will appreciate the convenience and infinite patience of the computer.


2.6 Going to see Dr Nurse
Nurse practitioners and extended practice nurses can take much of the routine, low level consultations off the shoulders of the GP, acting like the highly successful "barefoot doctors" in the Third World. This is already happening in some practices.
2.7 Quality Medicine
The point of all this is not simply to allow the GPs to put in more time on the golf course, but to allow them to practice quality medicine: to listen and question in more depth, to examine more thoroughly, and to order more accurate investigations. In other words, to practice what we were trained to do, instead of the frantic, rushed form of triage that GPs currently practise: diagnosing minor viral illness after minor viral illness, and sending anything that seems remotely more complicated off to the hospital waiting list, because we don't have time to deal with it themselves. Time - the time to listen to the patient - is arguably a healing process in itself. People who visit healers and complementary practitioners often comment on how helpful they find the process of talking about themselves for an hour or more.
As well as going into physical diagnosis in more depth, GPs can use their newly found extra time to go into the psychological processes that so often underlie physical symptoms. Although few GPs have formal training in psychotherapy, they do have a wealth of experience of people to call on, and the very act of being listened to and acknowledged by a doctor can be therapeutic. More training, both of medical students and postgraduate training, should be made available.
2.8 Complementary Therapies
This term covers a wide spectrum of activities from techniques that are accepted in most areas such as psychotherapy, to processes which are relatively untested. Over and above the time element, complementary medicine itself has a big role to play. Acupuncture, chiropractic, homoeopathy and environmental medicine - that is, the study of the impact of diet and chemicals on health - have already demonstrated their effectiveness in respectable studies. Environmental medicine in particular is remarkably cost effective .
The problem lies in carrying out the scientific work necessary to validate complementary therapies. Current research is heavily biased towards drug therapy, because the result of such research is a product that can be patented and sold at a profit. No company stands to benefit from research that shows, for instance, that arthritis can be effectively curbed by following certain exclusion diets customised to individual patients. Only society stands to gain, and therefore society, through central funding, should pay for the research into this form of non-drug therapy. An added bonus is the fact that non-drug therapies are often cheaper to carry out than drug therapies.


Richard Lawson MB BS, MRCPsych.
Green Party Health Speaker

 
© 2001 R. Lawson This page was last updated on 13.11.04