I was thinking of this post being one on general medicine within hospitals, that area of pitched battleground for most...but that will have to wait till the next one. As for this one, I am going to touch upon that most interesting of subjects...patients. We keep on hearing about putting "patients in charge"- I will leave all politicians out of this to avoid an idealogical debate (as most things nowadays descend to) so lets concentrate on the professional leaders who keep saying they mean to. Throw in the mix the conversations from patients as to how they would like to be more involved and you have a heady cocktail. There's always been the assumption that doctors, managers, nurses ergo folks who run or are part of the NHS know best and its always interesting to see whether that is actually true. Indeed there are attempts to involve the patient in pathway developments but lets try and extend that theory. How about we really try and let go? Would it work? Too dangerous? Well, lets theorise and see, shall we?
How many patients actually know what a referral to the hospital costs? How many know how much their follow up costs? Could we open all that up? There has been talk of individualised budget- a minefield to decide how to actually cost it and set it up but even if you give an individual a budget, what happens when that is spent? Can we let the patient decide? Are we bold enough? My type 1 patients could ask why the NHS doesn't fund all to have CGMS (Continuous Glucose Monitoring System)..well I could but it means I will have to stop delivering something else to balance the costs. Who decides that? The patients as a group? What would my pituitary patients then say? What in fact would my Type 2 patients on a dialysis machine say? Lets talk about some numbers. A new patient appointment gets my department £239 while each follow up about £99...an amount which is not constant as that rate is going down year after year- while the staff costs are same if not more. Add in the pressure from Commissioners to reduce costs each year and you have a shrinking pot to play with.
So yes of course I would want to have 7 day service, psychological support for all, CGMS for all...but without any money available to invest, I can deliver those by only one way...drop something else. In the world of diabetes, the other choices are, or at least for my team...pregnancy service, kidney dialysis service, foot diabetes service...what do we do...go Big Brother style..put it up to the public vote and say "You decide"..?
The other question is does each patient approach it from their point of view? When I had the problems with my back, I instantaneously felt that this had to be most important issue that needed to be sorted. I suspect its the same for anyone who has themselves or has relatives with mental health, long term conditions, neuropathic pain or a pituitary tumour...which explains all the patient charities jostling for space and attention. Does he who shout loudest get the biggest slice of the pie or is about which celebrity you have to back your cause? Stephen Fry beats Amelia Lilly hands down any day...does that make mental health more important than Type 1 diabetes..an interesting conundrum indeed.
So how about we actually throw open the gates indeed as regards tariff? Not talk to patients in sanctimonious terms as to how we "all should work together", how "its about the process", how " we all need to come together"..and actually showcase the financial problem we are in? The master plan that we, as doctors, managers can manage finances has clearly not worked, so why not open the books to patients...perhaps they may come up with suggestions we haven't thought about? I certainly have no clues and I can assure you nor does the majority of leaders in the NHS.
The financial grapple is something all Chief Executives and Finance Directors worry about- without any obvious solution in mind..so why not try something different? I for one, would be up for it..invite patients with diabetes and open the departmental budget up- show the challenges, ask for ideas and then perhaps we may have a way ahead. If not, at least we would have stopped fuelling expectations that we can deliver everything. If any patient organisations are up for this...lets try it out...could be an interesting 2 way experience.
But continuing the way we are without actually explaining to patients the financial nitty gritty, simply spouting grey terms that financial problems will be overcome by "tackling inefficiencies" is wrong and will go nowhere to facing up to the challenge this country is about to face. You think you have a problem now? Forget the "spectre" of privatisation...there is a bigger problem at hand...simply put...the money is running dry..so any help from the users of the system should be grasped with two hands, if offered.
The question is...we talk about patient involvement...how much do WE seriously believe in it?