Charging for Healthcare – Closing the Doors on the NHS

I initially wrote this post for Pulse Magazine, with an audience of GPs in mind, so please forgive the fact that it sometimes slips into jargon. The debate on healthcare for migrants is not something just for GPs to consider, however, as it affects us all. How we care for those who arrive in this country from abroad says a great deal about our nation, and we should all have a voice in the discussion. Here is the post:

I don’t know about you, but I’m swatting up on public health and maternity care – it might seem an odd combination, but it looks like we’re going to need it. The Department of Health – renowned for its undying faith in the virtues of general practice – has decreed that only primary care will remain free at the point of delivery for non-EU migrants, while A&E and secondary care will be withdrawn behind a solid pay wall. This is seen by some as a U-turn, bowing to concerns that charging for all medical care could lead to serious threats to public health, such as outbreaks of TB – as has already happened in Spain.

The Department of Health has reassured the public by stating that, in keeping GP consultations free, everyone will have ‘initial access to prevent risks to public health such as HIV, TB and sexually transmitted infection.’ That’s all right then. There’s no statement, of course, about what is meant to happen after this initial access. When I’ve made my initial assessment that the impoverished patient sitting before me could well have TB, can I order a chest x-ray before I obtain their credit card details? And when the report of a cavitating apical lesion arrives on the fax machine, should I brush up on treatment regimes for mycobacterial disease when my patient informs me that he can’t afford hospital care? Perhaps I should learn bronchoscopy and start offering it as a minor op? Oh, but they plan to charge for that too, don’t they? Oh well, it’s not like TB is making a bit of a come-back or anything.

Then there’s maternity. Apparently no-one will be turned away, but they will be charged. How does that work then for a pregnant woman with no money? Cross your legs until you’ve saved enough? Visit Wonga and ask for a labour day loan? Or try a home birth with a cost-free GP and hope you find one that’s been around long enough to remember how to do it? Even if the moral argument doesn’t grab you, it makes poor economic sense – obstetric catastrophes are very expensive as well as tragic.

The thinking behind this, of course, is that the NHS is broken (it isn’t), and so-called ‘health tourists’ are the cause (they aren’t). The real reason, however, is more ideological. Read the DH document in detail and you find a recurring argument that goes something like this:

We’ve considered Situation X; we recognise there are moral and ethical difficulties, but we are going to charge anyway because the Hard-Working-British-Tax-Payer can’t put up with the idea that someone, somewhere might be getting a free ride.

The document makes a clear distinction between medical tourists (those who choose to travel for better health care, but are willing and able to pay for it) and health tourists (those who have health needs but cannot afford to pay for it). They want to encourage the former (the rich), while denying healthcare to the latter (the poor) – how very like this Government.

Now I’m not that keen on people being able to take cynical advantage of the NHS, but neither do I wish to see the most vulnerable in our society shut out of receiving healthcare; the new rules will apply to asylum-seekers – many of whom have genuinely fled from horror to the safety of our more tolerant society – and even people who have become victims of human trafficking may have to pay; the Government is still consulting about this, and is clearly stuck with how to identify the ‘worthy’ immigrant from the ‘unworthy’ one.

It will not be long before doctors will have to decide which is the higher calling on their professional duty. When faced with a sick patient – not quite an emergency, but not something to ignore – will it be Government policy that will prevail? Or the urgings of a hospital manager desperate to balance the books? Or should we insist that, whatever the political will we are up against, our duties are laid out by the foundations of our profession as laid down in the World Medical Profession declaration of Geneva:

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.

Or our own GMC:

MAKE THE CARE OF YOUR PATIENT YOUR FIRST CONCERN; Protect and promote the health of patients and the public; Respect patients’ right to confidentiality; Never discriminate unfairly against patients or colleagues.

Or the United Nations Human Rights Treaty:

States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy.

When these charges start to bite doctors will be faced with dilemmas on a daily basis. Do we do as we are told, and turn away patients whom we know we can help on the basis of their nationality, or do we consider something more radical? When Iona Heath reflected on the above statements recently on Twitter she had no doubt which was the right way for the profession to act, and recommended civil disobedience. Are we brave enough to follow her lead?

The Friends and Family Test – a Distortion of the English Language?

The Friends and Family Test has now been live for over a month. How long will it be before we are presented with a league table, complete with some unfortunate NHS Trust languishing at the bottom, ready to be held up for a flogging in order to ‘drive up standards’? Six months? Maybe 12? Allowing for the inevitable teething problems and gremlins that affect most public sector programmes, we might be spared for a little longer before we find out who is top and who is bottom – but as sure as the Health Secretary gets all his new ideas from the Education Secretary, we can be certain that the tables are on their way.

If we have to have a league table that pits one Trust against another, then I have no problem with the idea of asking patients. What I do object to, however, is deceiving patients in order to use their voice to beat the NHS about the head.

The Friends and Family Test appears straight forward at first glance. The actual question, ‘How likely are you to recommend our ward to friends and family if they needed similar care or treatment?’, couldn’t be simpler. The possible answers, though, start to make things a little more complex with a five-point range from ‘Extremely likely’ to ‘Extremely unlikely’, and a sixth option of ‘Don’t know.’ What the Department of Health has not shouted from the rooftops, however, is how the scores are then calculated.

Whenever I explain the scoring system to someone, I always get the same reaction – their jaw drops open slightly, their brow furrows as they try to work out if I’m serious, then they shake their head and declare, ‘That’s ridiculous! That’s so biased!’

Because that is what it is. The only responses that score in the Trust’s favour are those that are graded as ‘Extremely likely’. Those patients who respond ‘likely’ are all thrown out with the ‘Don’t know’ cohort, while all the others – ‘Neither likely nor unlikely’, ‘Unlikely’ and ‘Extremely unlikely’ – are lumped together as a black mark.

The explanations I have heard for why the scores should be skewed in this way are that patients are inclined to be too generous, and so Trusts would all scored too highly.

In other words, the Department of Health wants to know what patients think, but doesn’t trust them to say the right thing. The scoring is a distortion of the English language. When someone says they are likely to recommend a hospital ward or department, do they expect their answer to be ignored? If they say they are unsure, would they anticipate their response being tied up with the reply of another patient who says they are extremely unlikely to make a recommendation?

Will the scoring system be explained to patients at the time of the test? If it is explained then it will soon be apparent that the five-point scoring system has been reduced to three points, and patients will answer accordingly. What if some Trusts explain the scoring to their patients, while others do not? The league tables could reflect how savvy Trusts are when they administer the test rather than what patients actually think about the care they have received.

The test has been sold as a tool to give patients more choice – it is nothing of the sort. Tellingly, the word ‘choice’ only appears twice in the text of the Government’s implementation guide, while the word ‘drive’ crops up no fewer than 12 times. The Government is spending public money on private companies to implement this test, in order to obtain distorted data with which to continue its assault on the NHS.

Our only defence is to highlight the inadequacies of this test, expose its hidden deception, and join with Peter Lynn of The Guardian in declaring it unfit for purpose.

This post was originally published in Pulse (free registration required)

Epanutin Scandal Picked up by The Daily Telegraph – Now MPs Need to Know

I am delighted to say that my previous post concerning the scandalous increase in the price of Epanutin, an important epilepsy drug, has been picked up by the mainstream media and was reported in The Daily Telegraph today. The increased exposure that the story will now receive is greatly welcome, as it is vital that the pharmaceutical industry realise that when they try to manipulate the price of important medical treatments in this way it will not go unnoticed. What we now need is for MPs to become aware of this misuse of a monopoly position, in order to try to put real pressure on the companies involved.

I have written a draft letter below which I will be sending to my MP, and to Jeremy Hunt, and it would be fantastic if as many people as possible could join me and do the same. Please do copy and paste the letter below if it is helpful.

Stephen Adams, the medical correspondent at The Daily Telegraph discovered some interesting facts during his investigation. The first is the full cost to the NHS of the price increase – a cool £44m each year, or, to put that figure into perspective, enough to employ 1800 extra nurses. The second is the exact nature of the loophole Flynn Pharma have used to be able to get away with it, which relates to changing the drug from a branded formulation to generic.

The price of branded medications such as Epanutin is negotiated between industry and the Department of Health, which means the industry cannot unilaterally determine the price. For generics the market is supposed to keep prices low through competition, so prices are not negotiated. The problem with the market in health care, however, is that is not like other markets, and it sometimes throws up odd quirks where market dynamics cannot work – this is one such case. The fact is that there is no generic market for phenytoin. This is partly because currently there is only one manufacturer – Pfizer, who are now selling their drug to Flynn Pharma – meaning there are no competitors out there. However, even if a new company started manufacture straight away, we would not be able to switch any of our patients to the new brand, because the British National Formulary advises us to prescribe by brand only. We would be able to start new patients on the alternative brand, but this is an old drug and not that many new patients are started on it – it would be impossible for an alternative provider to develop a worthwhile market share.

If, like me, you feel that we should not stand by and watch this improper use of vital NHS resources, please consider using the letter below to send to your MP. And if you do decide to write, it would be great to hear about it in the comments below – and to let us all know of any reply you get too! Thank you for your support.

Dear

At this time when the NHS is trying to make significant efficiency savings, I am writing concerning an abuse of monopoly position by the manufacturer and distributer of a vital epilepsy drug, which is set to cost the NHS an extra £44m per year – the equivalent of employing 1800 extra nurses.

The drug is Epanutin (phenytoin) which helps to prevent epileptic seizures, and the scandal was reported in The Daily Telegraph on 13th October 2012 (http://www.telegraph.co.uk/health/healthnews/9604683/Pharma-firm-hikes-cost-of-epilepsy-drug-24-times.html). On 24th September this year all GPs received a letter  from a company called Flynn Pharma (http://www.mhra.gov.uk/home/groups/comms-ic/documents/websiteresources/con185674.pdf) detailing their acquisition of the marketing rights for Epanutin. The drug was still to be made by Pfizer, in the same factory and in exactly the same way, but would be packaged and distributed by Flynn Pharma under a new brand ‘Phenytoin Sodium Flynn Hard Capsules’. The letter neglected to advise GPs that the cost of 28 tablets was set to rise from 66p to over £15 – nearly a 24-fold increase.

Flynn Pharma have been able to impose this phenomenal price rise by relaunching the product as a generic medication. The cost of generic medications is not regulated, as the market is supposed to keep prices down through competition. The problem with Epanutin is that there is no generic market, due to the unique situation with epilepsy drugs.

There are two reasons for the lack of market forces for epilepsy medication, and phenytoin in particular. The first is that quite simply there is only one manufacturer of phenytoin capsules in the UK – Pfizer, which means that GPs have no alternative generic product available. However, even if a new company were to start manufacturing an alternative, or supplies could be obtained from abroad, GPs not be able to switch any of their patients to the new brand, because the British National Formulary advises them to prescribe by brand only. This is because even a minor change to the prescription for phenytoin could cause changes in blood levels of the drug, with catastrophic consequences – a seizure is not only hazardous for the patient, but a single seizure would cause an epilepsy sufferer to lose their driving licence for a year.

Flynn Pharma are therefore calling their product generic in order to vastly inflate the price, when in fact such a concept does not exist for this medication. In fact they must recognise this, as they actually direct GPs in their letter to prescribe their own brand.

I am sure you are as concerned about the proper use of NHS resources as I am, and would be grateful if you would consider raising this issue in parliament, in order to try to obtain a review of this situation with the Department of Health. This is important not only for the current situation, but also to prevent the pharmaceutical industry from exploiting this loophole with other epilepsy drugs in the future.

Thank you for considering this matter.

Yours sincerely,