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Every couple of months, some prominent media personality suggests people should pay upfront for more of their healthcare. This is not, the pundit usually hastens to add, to fund the service, but to discourage people from using it frivolously. Suggestions range from £5 to see your GP to £100 for an inappropriately-called ambulance.
On days when we’ve dealt with someone casually misusing the NHS – and yes, I have known a patient to call an ambulance for a broken nail, and I’ve worked in the A&E where a mother arrived demanding that staff clean dog poo off her child’s foot – it’s very tempting for healthcare staff to agree.
The management-speak term for this approach is ‘demand management’. It’s a polite way of saying that making it harder for people to access healthcare will put them off, and maybe they’ll get bored and go and do something else.
There’s considerable truth in this, and as the ratio of demand to supply in the NHS rises to ever giddier heights it’s an approach that can look tempting. Cutting services completely always generates unfavourable headlines, whereas merely making them a little harder to get at is less dramatic.
And it doesn’t even have to involve a monetary transaction: there are plenty of more subtle ways to stop those inconvenient patients turning up demanding care. But the trouble is, the people we discourage are not the frivolous, the ‘worried well’, the over-entitled: more often than not, they’re the people who need our care most of all. This is no less true when the chosen ‘demand management’ strategy is non-financial.
In my current community paediatrics placement, parents of children needing therapies, hearing tests or parenting support receive a letter. Their child has been referred for (as the case may be) speech therapy. If they would like to take up this offer, please will they reply to the letter within a fortnight? Otherwise, they will be discharged.
Then, if they like, they can start again at the beginning of the lengthy referral process, and see if they do better next time. Or they can fall off the service’s radar completely.
For the sort of people who make health policy decisions, or who provide health services, this sort of thing wouldn’t be a problem. Of course we’d answer the letter, arrange the appointment and make sure our child got the help they needed – it’s simple. Only it’s not so simple if you don’t speak English, or you do but you can’t read very well, or you have your own undiagnosed learning difficulties, or your life is just so chaotic and difficult that an extra letter to answer feels like an insurmountable challenge.
And guess whose children usually have the greatest need for support? It’s not the sons and daughters of health service managers.
That’s why my recent clinic included a boy with wholly incomprehensible speech who, at seven years old, has never had his hearing checked. That’s why I regularly see nonverbal, profoundly autistic children who have not yet got around to ever seeing a speech therapist. That’s one reason children of poor, or poorly-educated, families persistently do less well than their prosperous peers.
The therapists and doctors I work alongside want, without exception, to do their best for the children we serve. They care deeply about helping people and most of them, even as the last-days-of-Rome atmosphere grows in the NHS, love their work. The opt-in letters are not their idea.
This is the way a struggling system has found to ‘manage demand’: to restrict the number of people receiving care to a number we can just about cope with. If that doesn’t always include the children in most desperate need, well, that’s just too bad.
The gradual erosion of the NHS is happening in ways that, to the comfortable middle classes, may not even be visible. But to the people barely coping with life, who need health services the most, what the socially secure experience as a barely perceptible inconvenience may, for them, become an impregnable wall.
Miranda Barry is a junior doctor. She writes under a pseudonym
NHS is a right for every body rich or poor but it's failing because the goverment spend our money on over sea aid and the EU instead of our own infrastructure we need and want our NHS back and not the NHS the government wants
I have found that unless you are prepared to challenge the system even as far as bypassing the GP and contacting a consultant yourself when I thought my wife's treatment was not appropriate is difficult. It is only because I am computer literate and understand my wifes conditions that I was able to do this. If as the article says you don't speak English or poorly educated or have speech or hearing impediment it would be impossible to get the treatment needed. Barriers to getting help should never be used to limit access the NHS.
If a child has not had his hearing checked then WHY didn't the parents notice a problem, whe didn't they take him to see a doctor, did the nursery/school not pick up on it???? Mostly down to parents. The misuse that annoys most of us is turning up at A&E with a cold, I don't feel well, can't go to work, can't get a doctors appointment etc etc. The NHS came about for severe accidents and life threatening situations not for mollycoddling. Definitely not for operations such as weight loss, boob jobs, uneccassary ceasarians and other ops and unlimited IVF. People have to start taking responsibility for themselves not looking for the easy way out or a quick fix
I was One of the Lucky Ones Who Had NHS Assistance from An Early Age !When it came to The time I Went out To Join. The Working Population, I PAID NHS INSURANCE LIKE EVERYONE ELSE ! I WAS SO PLEASED TO GIVE BACK SOMETHING TO THE SERVICE THAT HAS HELPED ME MY WHOLE LIFE!! SO, in an age of FOODBANKS,HOMELESSNESS &Clothes BANKS ,Also Charities doing ALL they Can! THE WEALTHY WANT TO CHARGE TO SEE A DOC?WHERE WOULD THEY FIND THE MONET FOR THIS? I KNOW THERE Are A LOT WHO DO ABUSE IT !THESE ARE THE ONES WHO SHOULD HAVE AN INSTANT FINE ADMINISTERED TO THEM!!
Disadvantaged families should be targeted by children centres whose family workers can help ensure appropriate support is provided. For expletives one children centre I know of has SALT come into the centre regularly to assess and support individual children without need for referral by GP . On another subject I have felt for a long time why don't GPS have voluntary donation boxes. I'd happily give as long as it bought resources for the surgery
I agree with this. I recently received an invitation to make an appointment for a repeat endoscopy check, previous abnormalities having been treated twice before. The letter said I had to reply within 7 days, or I would be taken off the waiting list. Fortunately I was not on holiday, mentally ill, illiterate, too scared by debt to open my post, dependent on someone else to open my post every fortnight due to disability, or otherwise prevented from reading the letter in time.
one commenter said - " it's failing because the goverment spend our money on over sea aid" - when all that we're experiencing clearly stems from the conservative government deliberately strangling off badly needed funds. Nothing to do with overseas aid, nothing
Thank you for your dedication and giving your time to write this article. Never give up or give in. Xxx
This is how it works for people who have severe mental health problems. They get letters, if they have family or support they ring and get an appointment which on the day they can't get to because they can't leave the house. They get a phone call but can't answer the phone or they get another chance at an appointment. this time it's way to far from a safe place and they can't use public transport or have no money. They get discharged back to the GP. These are the people being failed and often end up trying suicide. Some just die and that is one less, others end up in hospital costing significantly more than a visit from their GP to see how they are and why they have been discharged, perhaps home therapy the right type by a properly qualified therapist. The situation is out of control and out of the care system that only exists for those clever enough, supported enough or wealthy enough.
I can only comment on the treatment I have received myself under the NHS as an elderly women at times made to feel that I was wasting the Doctors time. However When required the consultants at the hospital could not have been more attentive sometimes under difficult circumstance.
Would not like to see the demise of the NHS but would be more than happy to pay to see the Doctor, bearing in mind that I am only on state pension which I work to supplement at the age of 72 to keep the NHS alive.
Very astute...thanks for taking the time to share your thoughts and experiences...
Sorry but no. If you love your child and get a letter you can at least recognise their name, so you know it is about your child. Go to the school, the CAB, the library, even the local shop if you have to, and ask for help if you can't read or understand. Telephone the number on the letter and say that you don't understand it. If you can't get to the appointment, ring up and tell them, they will give you another. If you can't answer within the time span given, don't take that as a "I have to start again", if there is good reason many departments will give you an appointment beyond the 7 or 14 days.
The problem with funding is not the overseas aid, it is the NHS failing to monitor the 'health tourists' and get money from them BEFORE treating them.
Whilst most doctors might wish to serve, the fact is that many others in the NHS do not, including nurses...whilst my husband was dying in hospital, I heard a nurse say (about another patient) "he's been written up for pain meds but Report is in 5 minutes, so let the next shift do it." 5 minutes is a long time if you are in agony. If the Report then takes 15 minutes and the next nurse takes another 5 minutes before she actually gives the meds, that's 25 minutes that someone has been in pain that they didn't need to be in.
I agree with one of the comments - if you don't think the treatment is appropriate then challenge it - the internet has information in many different languages, so it's not confined to those with English as a first language.
Having said that, if you're not paying into the system, you shouldn't be benefitting from it, so if you can't speak/read English, do you have a job, are you paying tax and NI? I doubt it. The whole point is that the system was intended to be funded by tax and NI - see the leaflet when the NHS was conceived museum.hackney.gov.uk/.../v0_web.jpg
'if there is good reason many departments will give you an appointment beyond the 7 or 14 days. '
And many won't. I have mental health problems and I'm sorry, but your 'just do it' attitude would be lovely if it worked, however if that was the case nobody would be mentally ill in the first place cos we'd all just go out, make those important phone calls, have everything sorted. If you're too messed up to open a letter (or make a phone call) you're also probably too messed up to admit it (or possibly even realise that you have a problem), let alone spend half an hour on hold to speak to a CAB adviser who eventually asks you to come in for an appointment in a packed building. Any of those things on their own could be insurmountable.
What an excellent article, thank you. Thank you especially for showing compassion for people who struggle to manage their daily lives. Too often people like us (I struggle because of severe mental illness) are just blamed for not behaving like more capable people with no effort to understand the underlying difficulties that might exist. What critics also don't seem to realise is that often we painfully aware of our shortcomings, but that doesn't help when you are so overwhelmed that you have little choice than to bury your head in the sand. We are gradually being sidelined by the NHS and by the welfare state and it's extremely worrying. My long term psychotherapy has been discontinued and I am not getting any care at all now, not even from my GP. I spent many years in therapy learning to live without medication so I don't have any contact at all with any health professionals. I don't really know what to do about that because I'm not the type to demand attention, even though I am aware that I have relapsed and am getting worse. Part of me knows I should ask for help but other parts of me can't justify doing so. I have been consigned to 'self-care' so there is no-one to monitor me and prompt me to get help. Anyway, even if there was the help isn't there anymore... Last days of Rome indeed.
is another subtle way to tell you that you are 'out of area'? This just happened to our family regarding our son's requirement for a peadiatric referral. An appointment was made with the help of our local surgery after much confusion about who could and would be able to do a consultation with a 14 year old child in south ribble health authority: this in itself was a pantomime. And when the conclusion had been reached that the services required were available in bolton at the bolton one clinic: and an appointment made, the appointment was then rejected by the bolton one clinic: 'out of area'. We now have an appointment thankfully however if I wasn't the grumpy old 55 year old white male that i am i could very well have given up on this at various points. It isn't good enough, not by a long way...