Austerity and rationing: two words which are strongly reminiscent of Second World War years. However, add to them the phrases postcode lotteries, cut-backs, and year-on-year savings and one is rapidly brought into the modern day. A further phrase, the ‘Nicholson Challenge’, is one more familiar to those working within the National Health Service; nonetheless, it has the power to impact upon us all. For the NHS, the Nicholson Challenge is a descriptive phrase that sums up the biggest ‘efficiency drive’ in its entire history.
By the year 2015, the NHS is expected to have found at least £20 billion in savings. At present, that means reducing budgets by 4% per year. In an organisation that is already struggling to meet demands for health care for an increasingly aged population, incorporate the latest treatments, allow access to new drugs, and extend provision of trained staff (e.g. consultant cover at weekends), the savings are not easy to come by. To a great extent, that has been a driving force behind the new Health and Social Care Act; the remorseless reduction in administrative personnel (by closing Primary Care Trusts) and the drive to increase the managerial input from GPs.
‘Putting GPs in the driving seat’ may seem like a catchy, vote-winning strap-line to the latest reforms; in reality, it is ‘GPs in the firing line’. Those difficult decisions about whether a new drug or service can be offered to patients will now need to be taken by your GP through an organisation called the Clinical Commissioning Group (CCG). Many patients will understandably think that is good on the grounds that doctors are supposed to act in the best interests of the patients. The problem for GPs is that, in today’s austere financial climate, restrictions on prescribing have probably never been so great, and they are going to get worse. As a professor of public health research and policy recently told a conference of doctors, ‘you haven’t got any idea what is coming your way; it’s goodbye to professional autonomy’.
The latest news from the Department of Health is that the 4% efficiency drive will need to continue beyond 2015, which means a downward pressure on GP drug budgets for a decade. It is therefore understandable that CCGs greet the arrival of new drugs with dismay rather than clinical excitement. The situation is not helped by the NHS Constitution stating that ‘patients have the right to drugs recommended by NICE for use on the NHS, if your doctor says they are clinically appropriate’. Unfortunately for GPs, NICE (the National Institute for Clinical Excellence) makes its decisions on the grounds of drug effectiveness, not whether the NHS budget can afford it.
One recent example has been paraded widely in the national press. Dabigatran is a new drug that may offer an alternative to warfarin therapy for conditions such as deep vein thrombosis. In many ways, this would offer several advantages to patients and doctors. However, the price tag is steep. It has been estimated that its use will force drug costs up by 20% (£10 million pounds per year in some areas of the country). Set against the need for 4% savings, such a threat to the drug budget is causing widespread alarm, and CCGs are desperately looking at local prescribing policies in order to restrict the use of dabigatran.
The Health and Social Care Act may be here and GPs may well be in the driving seat, but the NHS is on a one-way track; attempts to turn it are equally likely to derail it and now that will be the doctors’ fault, not the politicians’ doing. The danger of failure is the imposition of large corporations in providing commissioning support, with private control of prescribing and referrals; welcome to US-style medical care.
There can be little doubt left that, as GPs, we are now firmly placed between that proverbial ‘rock and a hard place’.
(First published in the Scunthorpe Telegraph, Thursday, 12th April 2012)