Dr Macgregor’s Diagnosis

Aneurin Bevan argued like someone willing to go to the wall for what he was saying. He spoke belligerently. He spoke as though to oppose what he was saying would be to offend against common decency. British politicians don’t talk that way any more, even when it matters. Take Andrew Lansley, the secretary of state for health and once the principal private secretary to Norman Tebbit. Like so many of his cabinet colleagues, and so many of those student politicians in the shadow cabinet, he appears to grasp the bullet points of an argument without ever grasping the argument. There’s a little moral seasoning to his dinner party rhetoric, a little dead-eyed flutter of words like ‘innovation’ and ‘commitment’, but Lansley has no feeling for the needs and fears of people who go to the doctor. He has no idea, but plenty to say.

Lansley’s Health and Social Care Bill will summarily abolish 152 primary care trusts in England, and GPs themselves will have to choose where to buy services from. The NHS thereby becomes a stimulus to energetic competition in the private sector, and the notion of universality goes out the window. Even GPs, who are not known for hating power, don’t want power this way: turning them into commissioners is a category error. Lansley’s proposals borrow the sound of freedom in order to usher them into a financial prison. It won’t work, and GPs know it. Yet Lansley’s department continues to show a peaky disregard for sound paragraphs. ‘Liberating the NHS’ – see what I mean? – is said to be the result of the consultation process. Here’s a typical block of text:

To further incentivise improved outcomes and financial performance, consortia will receive a ‘quality premium’ based on the outcomes achieved for patients and their financial performance. Some of the outcomes from the Commissioning Outcomes Framework will inform the premium – but not necessarily all, since some may not be suitable for translation into financial incentives. The Bill introduces the powers necessary for the quality premium, and we will discuss further with the British Medical Association and the wider profession on how to shape it.

By way of contrast, let’s look at Bevan’s speech to the House of Commons on 30 April 1946, on the occasion of the second reading of the National Health Service Bill. ‘In the last two years,’ he said,

there has been such a clamour from sectional interests in the field of national health that we are in danger of forgetting why these proposals are brought forward at all … Many of those who have drawn up paper plans for the health services appear to have followed the dictates of abstract principles, and not the concrete requirements of the actual situation as it exists.

So far, so clear. Today’s conjurors with ‘paper plans’ might hang their heads. Then, this:

It is cardinal to a proper health organisation that a person ought not to be financially deterred from seeking medical assistance at the earliest possible stage … The first evil that we must deal with is that which exists as a consequence of the fact that the whole thing is the wrong way round. A person ought to be able to receive medical and hospital help without being involved in financial anxiety … If it be our contract with the British people, if it be our intention that we should universalise the best, that we shall promise every citizen in this country the same standard of service … the nation itself will have to carry the expenditure, and cannot put it upon the shoulders of any other authority.

You can hear the putter of hope and the crank of disgust in that very plain speech. Orwell would have liked it – its lilt, its flow and its moral transparency. But it is the quantity of solid civic ambition that resounds now.

People who cry out for change in the NHS always cry out against the past. They see only ugliness and failure, never success, and, like Simon Jenkins writing in the Guardian last month, they seem content to throw out the baby, the bathwater, the taps, along with the reservoir supplying the taps. Jenkins is right when he says there are too many back-office staff in the NHS, but this isn’t his real complaint: he is a Bevan-basher, not really liking the ‘national’ or the ‘service’ ideals embedded in the National Health Service. Herbert Morrison ‘was right’, he wrote, ‘in wanting a new health service based on charitable and municipal hospitals, as almost everywhere else in the world’. But it might be argued that ‘everywhere else in the world’ offers no lovely example to Britain. Defeatism about Britain’s health service is hard to defeat, and it’s there in the new language of hopelessness. But in his 1946 speech, Bevan spoke for many of us, alive, dying or yet to be born.

I believe it is repugnant to a civilised community for hospitals to have to rely upon private charity. I believe we ought to have left hospital flag days behind. I have always felt a shudder of repulsion when I have seen nurses and sisters who ought to be at their work, and students who ought to be at their work, going about the streets collecting money for the hospitals. I do not believe there is an Honourable Member of this House who approves that system. It is repugnant, and we must leave it behind – entirely.

The new healthcare reforms would bring flag days back into our lives. Which is a shame, because, despite all the talk of ‘gigantism’, and the attempts to reduce it, lessons have been learned in the NHS and excellence is showing its face.

Recently I began to wonder what Britain now would seem like to Lloyd George and Churchill, Beveridge and Bevan, the not-always-eye-to-eye-seeing visionaries of the Welfare State. And it occurred to me that when some of them sat down to dream about an ideal future, the things that floated into their mind must have looked – surprisingly, perhaps – a great deal like the present health centre in Kentish Town. So I went to visit it. When you walk in, you wonder if you’ve somehow wandered into a North London satellite of Tate Modern. Unlike most receptions, Reception here appears eager to offer you a decent reception, and the building is full of colour, light, optimism and efficiency. People smile. It’s a palace, actually, or a modern church of the common man, and I fancy that half the ailments in existence might be alleviated or cured just by sitting here waiting your turn.

The NHS is, and will always be, an idea. It is an idea that requires constant renewal in the face of depreciation, and some of that renewal has clearly happened here. For those of us who remember some of those scrofulous surgeries of old, those rooms filled with paperwork, cotton swabs, cigarette smoke and resentment, the health centre in Kentish Town will come as a complete surprise. Beside a meeting area is a bank of fold-up bikes for the GPs to use on home visits. Upstairs there is a room where acupuncture can be administered to three patients at a time. There is a gym, a library, several patios with chairs, and soon, they hope, a café. Before the angina, aslant the catarrh, I’m thinking of moving in.

Dr Roy Macgregor describes the building as his baby. He spent a dozen or more years arguing for the new health centre and everybody acknowledges that his pride in it contributes to the general atmosphere. The building alone represents a small aesthetic triumph at the top of several streets of grey English houses. Built by Paul Monaghan of Allford Hall Monaghan Morris, it is green-panelled, transparent, a bright uplifting sentence in the worn story of the street. Inside, a group of GPs were discussing preventative measures against heart disease. Other doctors and support staff were moving from room to room, desk to desk, fulfilling an almost Japanese-seeming mission of ‘zero waste’. I sat down with Dr Macgregor and asked him about Andrew Lansley’s way of talking. Is it treatable?

‘My biggest puzzle about these reforms is I don’t understand why we’re doing them,’ he said. ‘The GP community hasn’t been balloted, they haven’t been asked, they haven’t been consulted. They’ve been landed with this role of suddenly holding the purse strings. I have dreaded the day when a patient walks into my room and there’s a pound sign in front of them. And if someone comes to see me, in the new world, and they need an endoscopy to see if they’ve got a gastric ulcer or cancer, instead of meeting that patient’s needs immediately, I’ll be thinking, hold on, in this practice we’ve sent 22 people this month for endoscopies, and my consortium is telling me that last month we had too many endoscopies, so I will think twice. I will think twice about giving this man what he needs and that will affect my clinical care. If I fail to send him for an endoscopy and that man gets cancer, I will have been guilty of giving that man bad care.’

There are family pictures on Macgregor’s pinboard. There are journals and a bike helmet on the desk. He speaks about the new proposals as if their framers didn’t understand the principles of general practice. He sees himself as a clinician: he has to make decisions based on clinical need, and the failure of Lansley or the doom-commentators to understand that puzzles him. ‘I have no desire to hold the budget. I feel there’s a perfectly competent organisation doing that. In our patch, Camden was not in debt and was doing the job efficiently. I have two GPs currently forced to work on this commissioning business: taking up time and not able to see patients as a result.’

What’s the government trying to do, one might wonder. Another GP I spoke to put it like this: ‘Everyone wants the service to be better, and to cost less, and not to have queues, and to have fewer managers. But none of these things can happen if they compromise people’s health. That’s the problem. That was always a basic understanding. And I’m afraid these recent proposals are what some of us know to be “Andrew Lansley’s Dinner Party NHS”. They are based on the frankly passé and unthought-out notion that all administration is a waste of time and on the idea – voilà! – that the clinicians should do it themselves. A complete mistake. It is not a job we can do without harming patients. It asks us to make decisions about patient care that are extra-clinical. And that’s just wrong.’

I asked Macgregor about the argument, made by Lansley and others before him, that GPs are best placed to make judgments about how to distribute scarce resources. You are in the room, after all. You can assess the need. ‘The need, yes. But not the cost of the need. If they care about our assessment, why are they getting rid of 150 primary care trusts? Because that is how our “in the room” experience was fed through. So now we’ll have … aha, 150 commissioning groups to replace the 150 PCTs abolished. The new groups will have GPs obligatorily involved in costing, but the whole thing is just a route to something much bigger and more damaging.’

‘What?’

Macgregor shifted in his seat. He looked to the door. ‘Oh, the dismantling of the NHS,’ he said. ‘You will not be able to go on with the NHS if every patient who comes in here is wearing a pound sign. This Lansley plan is the first step to privatising part of the NHS and forcing people to have “top-up” private insurance, so that I’ll be able to say: “Oh, good. Here comes Mr Williams with his private medical insurance. I can get him that Cat scan without worrying about the costs. And, oh dear, here comes Mrs Roper with no insurance. I’m going to have to worry about whether we can afford to get her hip replacement done.”’

It would be hard to argue with him, even if you wanted to. The present proposals are a mess, and there’s no evidence that GPs will be better able to be GPs with Lansley’s plan. ‘It’s craziness,’ Macgregor says. ‘Just think about it. Here we are in Kentish Town. A lady with the backing of the local newspaper wants a cancer drug, which she may need, but which costs £100,000. So we give it and treat her as well as we can. Then a lady in Tower Hamlets is turned down for the drug, because they can’t afford it, because there’s no pressure on them, and the lady says, quite reasonably: “But they gave it to a woman in Camden.” I mean, have they thought about that? Have they thought about the impossible position that puts GPs in? It’s about rationing, plain and simple. It’s about cutting down the service. General practice in this country is one of the most efficient gatekeeping services in the world. And it is being pulled apart by these plans. This government’s commissioning proposals are blind and unthinking. They will destroy, at one fell swoop, the doctor-patient relationship, which has been the most important element in general practice over the last 60 years. It will destroy the confidence you must have that when you come to see me with a problem I will do what is in your best interest. People who don’t have insurance, and who generally won’t make a fuss, i.e. the poor, will suffer immediately from what can only turn out to be a messy and socially divisive set of changes.’

Your health is now about where you live. It’s about the steps you have taken to be middle class. A health system that once acted against inequality is now set to enshrine it. The idea that this is a nation of equal opportunity when it comes to personal health can only be obliterated by forcing doctors to carry out economic rationing. I asked Macgregor to explain how provision works when it comes to one area of the country and another. ‘OK. If you need your cataracts done and you live in, say, Basildon, it may be that the local eye department has set up a day surgery unit on a Saturday morning to get rid of the waiting list. So, as a local GP, I would write to the eye department and say, “This patient’s got cataracts, can you deal with them?” and they’d say: “Yes, we don’t have a long waiting list at the moment so he can have them done quickly.” Meanwhile, in Eastbourne, there are so many elderly people and no big general hospital. I, as a local GP, send my patient there but they cannot be seen for months, because they have no clinic at the weekends and only do a standard operating list and the waiting list is three months or six months. And that’s directly to do with the resources that they have locally. Lansley’s fantasy is that the GPs in Eastbourne would get together and say: “Let’s buy more eye services in here, and improve the cataract waiting lists.” That’s the theory, but in reality, there’s going to be less money than before. They’re giving “buying power” but no money, which makes the whole “commissioning” thing a farce.’

Dr Macgregor had appointments to keep. As we walked down the corridor he showed me work by local artists. I couldn’t get over the fact that there were picture-rails in the corridors. It was cold outside and the winter sunshine fell benignly through the windows. ‘I’m very proud of what we’ve been able to achieve here,’ he said. ‘It’s involved years of work and we have such plans for even better things.’ Before I put my notepad away, the modern doctor looked down and there was a wee Chekhovian pause in his confidence. ‘I wish they would just stop and think. Stop and look,’ he said. ‘If they carry on with this craziness, before long there will be an NHS disaster. I’m frightened of the future. The world they’re forcing on us is not the world I set out to practise in. I don’t want to be an accountant. I don’t want to be checking the bills that come in from the hospital, seeing if I can make a saving. I want to be careful and responsible and efficient, that’s part of my job. But you can’t ask me to ration care. You can’t ask me to ration judgment. This system of ours was always supposed to be about looking after people.’