Paying for Health Care: Will Australia follow the Poms over the cliff?

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1 Paying for Health Care: Will Australia follow the Poms over the cliff? Andrew Bush MD FRCP FRCPCH FERS Imperial College & Royal Brompton Hospital Sir Harry Wyatt Wunderley Nye Bevan Two very great human beings! 1

2 Aim of this Oration To chart the progress of the NHS from bright new dream to the verge of Dante s outermost circle of Hell, after 30 years of institutional vandalism To discuss the key issues which, had they been grasped, could have prevented this To try to suggest a way back from the brink, which may also serve as a way to prevent Australia going the same way 2

3 Your new National Health Service WILL Provide you with all medical, dental and nursing care Everyone - rich or poor man, woman, child No charges except for some special items It is not a charity you are paying for it It will relieve your money worries at time of illness Your new National Health Service WILL NOT Talk about business models and clinical commissioning groups Talk about competition between health service providers Will not employ management consultants Will not talk about Foundation trusts Will not have a colossally bloated managerial structure 3

4 Francis: a catalogue of catastrophe! Contrasts Politics Spin doctors Medical practice Full disclosure of risks News management Burying bad news No straight answer to a straight question, points-scoring Informed consent and discussion of all treatment options Open and nuanced discussion and requirement for comprehensible information 4

5 Components of the Problem The purchaser-provider divide Components of the Problem The purchaser-provider divide Evidence based medicine vs. dogma-based health care strategies 5

6 Components of the Problem The purchaser-provider divide Evidence based medicine vs. dogma-based health care strategies Patients and public side-lined Components of the Problem The purchaser-provider divide Evidence based medicine vs. dogma-based health care strategies Patients and public side-lined Management and management consultants 6

7 2015: where have we got to? Hospitals are run as competing businesses (in the UK) Targets are imposed on Hospitals, who are not given the resources to meet them Anyone who fails to meet these often arbitrary targets is held up to public derision not least in the popular press, who thirst for shock, horror, probe stories on every side Ministers in Parliament want to be told that all is well, because the NHS has become politicised, and they also do not want to be the subject of shock, horror, probe stories Components of the Problem The purchaser-provider divide Evidence based medicine vs. dogma-based health care strategies Patients and public side-lined Management and management consultants The truth must NOT out 7

8 Components of the Problem The purchaser-provider divide Evidence based medicine vs. dogma-based health care strategies Patients and public side-lined Management and management consultants The truth must NOT out Short-term thinking rules What are the solutions? A culture of openness and understanding, where it is acknowledged that even Professors are not perfect, where there is a real duty of candour; and spin doctors and management consultants are banned Patient public involvement real involvement, tackling the REAL problems of the Health service that will not go away Depoliticise the NHS; it is not a political football, and must not be treated as such 8

9 The real problems How do we plan long term to renew our buildings and equipment? What Bevan did not foresee: spiralling costs of medicines and greater ability to intervene in ever older people means the R-word is inevitable Which is currently political suicide in the UK! BUT, must be openly and rationally discussed! Expensive Meds: CF Ivacaftor list price (UK) - 182k / yr for 1 patient G551D n=471 patients (5.6%) total Estimate n=370 eligible or 67m / yr If licensed age>2 yrs, likely n=420 ie 76m / yr Total UK CF budget was 130m / yr (incl. drugs) Other gating mutations? Ivacaftor as an adjunct for all potentiators, gene therapy? 9

10 The case of Mr Soobramoney Plaintiff: Soobramoney 41 year old man with end stage chronic renal failure Unemployed, finances soon exhausted Filed suit to obtain public funding for dialysis Appealed all the way to the SA Constitutional Court Defendant: KZN Dialysis expensive, and not enough facilities to go round Pre-set policy restricted dialysis to those eligible for a kidney transplant This policy excluded Mr Soobramoney who had substantial CVS and other co-morbidity The case of Mr Soobramoney The hard and unpalatable fact (is that, if Mr Soobramoney was wealthy) he would be able to procure such treatment from private sources; he is not and has to look to the state to provide him with the treatment. But the state s resources are limited and the appellant does not meet the criteria for admission to the renal dialysis program 10

11 Soobramoney: Judgement KZN won the case, and Mr Soobramoney died within a few days Chaskalson P. held that resources were limited, and it was not for the courts to intervene provided decisions were based on rational policies Cameron J. writing years later could not see how the Constitutional Court could find otherwise Can you? The Reality the R-word But, while Rome Burns Endless tinkering with managerial structure Pressingly Urgent How do we renew our infrastructure? The public paying the piper do not call the tune How do we prevent research funding squeezes? There is no open debate What should the NHS be paying for? 11

12 Sir Harry Wyatt Wunderley Nye Bevan Let us now praise famous men, and our fathers who begat them! 12

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