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Thoughts and opinion from the wards
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Fighting one corner- NHS reform and my clinical perspective
NHS Reform-A Clinical PerspectiveAll of us are waiting with bated breath for the result of the Government’s ‘consultation’ on NHS reform, and hope that the powers-that-be have not only listened to us but have actually heard the supposedly innumerable frontline staff, GPs, managers and members of the public that they have been ‘‘consulting’’ with. No one is against the idea of reform-a cursory glance at the multitude of opinions, comments and blogs out there conform to the view that NHS reform is needed and needed urgently before this giant of an organisation runs out of the very food that has helped it sustain itself over the decades-the tax payer’s money. How it needs to be reformed is what the debate has been all about-or at least, should be. Let us today discuss one aspect of the proposed GP commissioning that could potentially affect a considerable number of patients-those in chronic non-malignant pain. Chronic pain could be simply defined as pain anywhere that lasts more than six months, and has had a negative impact on the individual’s physical, financial and mental health and has adversely affected social life. This definition is a gross simplification by this author but does cover what most experts agree on what chronic pain should be defined as. An estimated 7.8 million of the 62 million people who live in the UK suffer from it (approximately 13 per cent of the population). For those of you who do not like statistics, let me put it in perspective-if you were walking down a busy street, and were feeling very cheerful, and were to smile at total strangers, at least two to three persons out of every twenty that you would smile at would actually be suffering from chronic pain. Not enough for you? A cursory glance at a busy supermarket on a weekend will perhaps help you appreciate the incidence of chronic pain (and help you update your counting skills). Did I hear someone ask me about the smiling? Smiling, nay, laughing, has shown to release natural endorphins to help combat pain. If you were to walk down a busy street laughing, there are more chances that you would be sectioned rather than comprehend statistics, hence the smile. Coming to the point, how much does chronic pain cost Society? It is estimated that chronic back pain alone costs around 5 billion pounds to the exchequer. Add to it, the cost of incapacity benefit, prescription charges and other such unavoidable expenses, and the NHS spends in the billions on these unfortunate patients. Research has shown that in the long-run, a psychological approach that educates the patient is the only effective approach in dealing with this complex sub-class of patients. Before I go so close to the tree that I lose sight of the forest, let me come back to GP Commissioning. If GP commissioning comes of age, and GPs are given a ‘fixed’ budget, what do you think a GP would prioritise? A 65 y-old who needs a new hip to help him walk pain-free, or a 40 y-old lady who has been in ‘‘ non-specific’’ back pain for the last 3 years and has recently lost her job? In other words, a clinically measurable end-point and value for money would soon become the goal (understandably), and conditions with poorer clinical outcomes or nebulous end-points would lose out in priority to those with clearly demarcated end-points, and therein lies the problem. In this era of austerity and global economic uncertainty, I agree that we cannot, and should not, expect the NHS to be handed over a blank cheque by the exchequer. We all have to provide value for money for the services we offer. Socialism and Medicine have, however, never been a good friend of Economics. In our quest to do the best for our patient, we now have to factor in the cost of the treatment we offer and perhaps, to offer a ‘‘cheaper alternative’’ first. This is already happening at most hospitals and PCTS. Let me give you an example- although both Gabapentin and Pregabalin are licensed for neuropathic pain, clinicians have been requested by local formulary bosses to consider the cheaper alternative first and that is gabapentin. Academicians will tell you that pregabalin is more potent and effective at lower doses than gabapentin and also has a better bioavailabilty, and a better side-effect profile. Whoever told you that the best things in Life are free has never seen a desperate patient in chronic pain or was not a pain physician. This dilemma, I am told, is also faced by most other specialities. What comes first-your patient or the economics of healthcare? Where in the Hippocratic Oath have we been told to consider the cost of medication that we prescribe for the patient? We are all told to ‘’first do no harm’’, and would prescribing a cheaper alternative with a greater side-effects profile stand that test, only because we are to consider the costs of treatment? Definitely not, in many circumstances.In these trying and economically turbulent times, it is only prudent that we weigh the pros and cons of the GP commissioning very carefully. I would welcome a system of checks and balances to ensure that we all, as a part of the NHS, treat a patient as an individual as we ought to, and not a condition or an easily-manageable disorder.
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