The UK health care system is about to undergo a major overhaul in how services are funded. Currently, tax funded Primary Care Trusts, based on geographical regions, have contracts with hospitals to provide the services that the NHS delivers. The PCTs decide what types of treatments and services are a priority for funding and negotiates the prices that shall be paid.
All that is about to change.In a move that was not contained in either of the coalition government party’s manifestos, the PCTs will be abolished and the responsibility for commissioning services will be handed over to GPs – the doctors on the front line of patient care. Groups of GPs will form consortia to commission the services they want to deliver using money given to them from government based on the number of patients under their care. The reasons for doing so are undoubtedly a mix of good intentions to save costs by removing a tier of ‘unnecessary’ bureaucracy (and replacing it with a another tier) and dogma based on those perennial Tory favourites of ‘choice’, decentralisation and ‘freedom’ from state authority.
There are those, of course, that fear that this is a right-wing move to allow private companies to get more control over the massive health care budget. And there are those who feel that such a move is good as it has the potential to put more power in the hands of practicing doctors who can better respond to their own patients needs. But, given that all this was announced without prior consultation, the real intentions are not that clear – and worse, and as always, the unintended consequences of such a drastic move are unknown.
I have no idea what will happen. But I would like to explore a potential problem in that such a move may lead to the greater provision of superstitious and pseudoscientific medical treatments within the NHS. At present, services such as homeopathy, acupuncture, reiki and chiropractic are fringe options, mostly reduced to a few residual clinics centred around dispersed groups of enamoured doctors. Private clinics provide many of these fringe services, and are used mainly by those who can afford them, with occasional PCT funded referrals.
Private hospitals, such as the Breakspeare in Hertfordshire, provide diagnostic and treatment services that are at the margins of science. But thrive because their is patient demand for them. If you believe you have an illness that your GP is failing to help, such as electrosensitivity, or you believe you have an allergy that does not show up in regular tests, such clinics can provide you with an explanation for your illness and offer you a treatment plan – all at a large cost. Although most doctors might view such diagnoses and treatments as speculative, at best, some patients appear to find comfort in the fact that ‘someone is taking them seriously’. For many people it would appear that it may not matter that their homeopath’s diagnosis and treatment is superstitious and nonsensical, the fact that they are being treated is paramount.
Could the new GP consortia start commissioning such fringe services? Or refer patients to homeopaths and herbalists? At the moment, there are tight restrictions on the amount of referrals that are possible. PCTs provide several brakes on the growth of the pseudomedicines. A PCT has to feel that such services are a priority, are effective and provide value for money. One of the mechanisms that they use is to look at the decisions that the NICE make – the independent body charged with reviewing the evidence base for treatments and deciding if they are cost-effective.
But all this is likely to change under the new funding mechanism. Firstly, in the name of choice, patients will have greater freedoms in choosing who their GP is. This sounds like a fabulous idea, but it runs the risk that people will ‘shop around’ finding the doctor who gives them the answer they want. A good doctor is not always going to give you good news or indeed offer advice and treatments that please. Patient satisfaction can easily be raised within a GP service, for example, by stopping doctors telling their patients they ought to drink and smoke less, eat better and exercise more. Even better, a doctor can dish out pills on demand, whether or not they will have any benefit, if that is what the patient is asking for. Patient satisfaction with a GP service may not correlate well with better advice and treatments. A good doctor needs to be able to tell you things that you don’t want to hear.
Quacks fill this gap quite nicely. They spend longer with their customers and always end up giving them an explanation for what is wrong, no matter how absurd, and will always offer a treatment, no matter how ineffective. Allowing unfettered choice for your personal GP turns people into heath consumers, who can expect to demand what they want, and get it, even if what they want may not be good for them.
And there are signs that this consumerist approach to what is forthcoming is indeed at the forefront of the government’s mind. David Willets, a government minister, has told GPs that they should expect to offer treatments according to patient demand and this demand might overrule what NICE has said about a treatment. Consumer choice will be sovereign in this new regime and could trump evidence, science and clinical judgement every time.
Of course, this does not mean that the health service will be overrun with popular quackery any time soon. Most consortia will undoubtedly prioritise services that offer the best clinical outcomes. Cash is still going to be scarce and outrage will follow if GPs cannot fund a broad level of standard care. However, we will be seeing a new market, and it is possible to imagine that consortia that do not offer some level of ‘complementary’ services may not be chosen by a significant number of customers.
In an extreme scenario, we can imaging a consortium of GPs set up to specifically cater for people with strong demand for homeopathic sugar pills, acupuncture needles and other ‘wellness’ techniques. As there appears to be no requirement for a consortium to be associated with any geographical area, there may well be enough doctors with beliefs in superstitious forms of medicine to aggregate together and create enough clout to fund public provision of all sorts of nonsense. Dr Michael Dixon, formerly of the late Prince’s Foundation for Integrated Health, already shows how his small surgery in Devon might attract like minded GPs and patients, grow, and form a consortium to publicly fund many of the weird things he now offers privately.
Undoubtedly, such a consortium would take on the voguish language of quackery at the moment and say it is offering an ‘Integrated Health’ service, meaning it mixes real medicine with pseudoscientific forms of treatment. The recently renamed Royal London Homeopathic Hospital has now adopted this language and might indeed find a lifeline from such a GP purchasing service.
Could such a consortium become reality and thrive? That is not certain – as nothing is really certain about how the new GP funding will work in practice. Some have suggested that consortia need to have a customer base of about a million people – large city size – in order to be viable business entities. Too small and a consortium would not have the clout to negotiate favourable contracts and may not have the financial scale to withstand uncertainties in operation. However, a quack consortium may not be too bothered by this in that they may not feel the need to commission many expensive services. “If you are really ill and need proper treatment then find another GP – I only do ‘holistic’ stuff.” The quack consortium could fund the bizarre, bonkers and unscientific end of the medicine market and attract the customer base that want to use such services and fund it.
You might well ask, and you would be quite right to demand of me, why I think such a system would be wrong. If patients are able to chose what they want from their doctors and the state is able to fund that service then isn’t everyone happy? The answer goes back to the basic problems and dilemmas associated with quack medicine as described so well by Professor Colquhoun. Take homeopathy. If a doctor prescribes a homeopathic pill in the genuine belief that it could have a real specific effect then that doctor is prima facie incompetent. As homeopathic pills are just sugar pills then they cannot work. If a doctor gives a patient the pill knowing that it is a sugar pill but believes it may help through some sort of placebo appeasement, then the doctor is talking part in a deception. Neither option is too appealing. But if patients are happy does it matter? I say yes: quack medicine appears to work through deception. A patient may feel that they have benefited from a treatment, but that benefit is illusory: either, the illness would have improved anyway, another conventional treatment is working, or the patient is misled into believing their situation would be worse without the treatment.
Nothing is to stop a patient becoming a consumer and buying their quack treatments privately. And I support people doing that. But a publicly funded healthcare system has a duty to ensure the money is spent on treatments that can be shown to be effective and based on good science.
What can be done about this possibility? It is not clear that the Health Minister is in any mood to enter into any debate about how this all should happen. His priority appears to be speed rather than thought. But removing requirements to follow NICE guidelines appears to be particularly worrying. It is not just that this allows quackery to creep in. It also removes one of the big barriers that prevent large scale manipulation of health care funding by pharmaceutical companies. Already, huge pressure is put on NICE, through patient groups and the media, funded by drug companies, for approvals to be given to drug treatments that have failed to demonstrate clear cost-benefits. We can expect much greater astroturfing to whip up patient ‘demand’ for drugs that are currently not funded. GP consortia may not be able to withstand the media hysteria so easily when sob stories of cancer patients denied the latest marginally effective but hugely expensive treatment hit the Daily Mail.
And will the newly formed Royal London Hospital for Integrated Medicine find a lifeline in quack GP consortia? Will the remaining homeopathic hospitals in the UK look forward to a new world of mass public funding for them based on patient demand rather than evidence based decisions? Again, I am not sure. GP commissioning is still several years away. And in the meantime, these facilities are being squeezed very hard by PCTs and current budget constraints. If they can survive a few more years then these changes may indeed be good news for them. It is a race against time, and I am sure it is one of the factors why the London Homeopathic hospital rebranded itself in a far more GP-consortia friendly way.
It is going to be a crucial few years for the future of publicly funded superstitious medicine in the UK. Which way it will go is anyone’s guess. In the meantime, those that care about having rational treatments well funding in public healthcare need to keep pointing out the absurd nonsense still lingering in our healthcare system.