Tell us your diagnosis, Mr. Milburn

THE SUNDAY TIMES April 30, 2000

So the prime minister and his health secretary are to travel the country to hear how people think the money that new Labor is pumping into the health service can best be spent. Good idea. Except that The Sunday Times has already done part of the job for them in the 11 columns that have been published in this series, The Cure.

The real question is whether our suggestions, and those to come during the politicians' tour, will be given a respectful hearing. So as a test we have persuaded Alan Milburn, the health secretary, to respond "yea", "nay" or "perhaps" to our suggestions next week.

When I opened the series by proposing that patients be allowed to seek NHS-funded treatment abroad to avoid long waiting lists, there were many letters defending the quality of NHS care. Nobody doubts this. It is the unavailability of that care on a prompt basis that led to my suggestion that international markets be used to add to the supply available to British patients.

This idea was endorsed by Frank Field, MP for Birkenhead and a former minister whom the prime minister asked to "think the unthinkable". He did, and lost his job. Field calls for the establishment of an NHS International, to purchase services for patients anywhere in the world. And he notes that a constituent, doomed to wait a year for a consultation and longer still for treatment, while going blind, had two choices. He could, and did, get his MP to use influence to enable him to jump the queue. Or he could have had his cataract removed in India at a cost of Pounds 420, including air fare, compared with Pounds 3,000 for private treatment here.

The health department, apparently not comfortable thinking the unthinkable, told Field it was "neither sensible nor practicable" to consider "sending sick people abroad", a reaction shared by a Treasury official to whom I spoke. It will be interesting to see what the secretary of state thinks.

Another set of recommendations concerns the organization of the NHS, which many contributors consider suboptimal, to put it mildly. Peter Wilde, clinical director of cardiothoracic services at Bristol Royal Infirmary, would end the split between those who allocate funds and the healthcare providers who spend the money. Providers, he argues, know where the need for more funds is greatest, not managers who "are never exposed directly to clinical pressures".

Wilde is alarmed that the new money will be allocated by a top-down command structure responding to centrally set targets. "Doctors are seemingly to be entrusted with patients' lives, but not with the decisions about funding their care." I wonder what Milburn will make of that.

Margaret Cook, a consultant haematologist and former wife of Robin Cook, the foreign secretary, has another idea for reorganizing healthcare delivery. She deplores the increasing specialization that allows for more sophisticated treatment but delays diagnosis, and would introduce a new breed of diagnostician, "a new specialty that crosses the medical-surgical divide". These would be troubleshooters, moving from hospital to hospital to diagnose ailments promptly.

Paul Simkin, an occupational health specialist, wants to go further and eliminate general practitioners, whom he argues "add nothing except an extra wait and a letter of referral". In place of the GP he would install a personalized smart-card system, containing the patient's medical history. Both the patient and the specialist would have access to this history, filed in cyberspace. Notice a lump in your breast? Go directly to an oncologist, who would pull up your history on his computer and prescribe the indicated treatment.

Well, prescribe yes, but treat no. For, as Karol Sikora, professor of cancer medicine at Hammersmith hospital, wrote, there has been a "continual under-investment in cancer services". What is needed is an integrated system of cancer centers linked to every hospital, which translates into an extra 600 oncology nurses and 400 cancer specialists, as recommended to the last Tory government by the previous chief medical officer.

Sikora also proposes supplementary charges for the most innovative care, an idea that is supported by Ruth Lea, head of policy at the Institute of Directors. She would give patients who elect private-sector treatment "credit notes" from the NHS, so that they do not pay twice. She would also end NHS funding of trendy treatments, such as "talking things through" counseling.

A cutback on services provided is also the fix of choice for Roy Lilley, former NHS trust chairman. He would deny free treatment to the 20% of patients who have lifestyle-related problems. Someone who "spends his life sprawled on the couch, eating deep-pan Hawaiian pizzas and chips, washed down with a six-pack of lager and 50 cigarettes a day" is a "walking cost Centre". If the patient persists in his or her self-destructive behavior, no more free care.

Finally, we have the recommendations of my colleague David Smith, who says the NHS is run on a failed model with decisions being taken by civil servants "and imperiously handed down to local areas". Neither Stalin nor successive British governments could make that model work. Smith proposes that trusts be given greater autonomy, that their management be put out to contract, and that patients be permitted to change GPs at will, to stimulate competition to retain patients.

These are only highlights of the many suggestions that our series has elicited. We have relayed the complete set to the secretary of state and look forward to his reply next week.