Feature

1999 — look back in anger

What could the future hold for the NHS if public opinion is unable to alter the course of the white paper? David Hardy gazes into his crystal ball

It is 1999. After 20 years as Prime Minister, Mrs Thatcher is about to call another general election. She is hoping for her sixth successive victory. Much has changed under her rule — including the NHS. Few would have predicted when she came to office she would ever have the power to dismantle the nation’s most cherished institution.

But the government’s white paper in 1989, Working for Patients, punctured the principles of equal access to healthcare for all, free at the time of need. Now, 10 years later, health secretary David Willetts presides over a very different service to the one Aneurin Bevan designed.

Ms A lives alone in a flat at the top of a tower block in a run down estate on the outskirts of a large industrial city. She has suffered from intermittent psychiatric illness for a number of years, but with the help of medication has been able to lead a relatively normal, if lonely, life.

Her GP, Dr Brown, told her recently that she would have to cut down the number of drugs she was taking. He was having to prescribe less for all his patients this year, he said.

That seemed odd to Ms A, but she supposed her doctor knew best. Indeed, she considered herself lucky to be on his list. His surgery was a half hour bus ride to the other side of the city, but her neighbour, who suffered from cystic fibrosis and had been ill for many years, had had trouble finding a doctor at all.

Besides, if Ms A was tempted to question the wisdom of Dr Brown’s advice, she reminded herself that anyone with so many patients must know what he was doing. His waiting room was always crowded, and when you went into his surgery, Dr Brown hardly looked up from his computer or his calculator. He would look at his watch while you were describing how you felt. He was so busy, in fact, that you never got more than a few minutes with him.

It was probably coincidence, but since cutting down her tablets Ms A had begun to feel much worse, and she feared she would have to go into hospital.

It would not be the first time. She had had spells in the Royal Infirmary and at the District General some years previously.

Her time in the Royal Infirmary had been a great help; it was from them that she found she was able to cope with life once again. But she dreaded returning to the District General.

It was a smaller hospital than the infirmary, in shabby buildings more than 100 years old. Everything, even the patients, had an air of neglect. If you could go somewhere else, you did.

But Dr Brown has told Ms A he cannot send her to the infirmary. It is now self-governing. ‘And in its infinite wisdom it has decided not to treat psychiatric patients any more.’

From the ambulance window Ms A notices a picket line of nurses and ancillary staff at the main gate of the District General. They are protesting against the health authority’s decision to close two more wards at the hospital. Later she reads in the newspaper the health authority is trying to save money to give staff a pay rise in order to stop so many leaving to work at the Royal Infirmary or one of the city’s new private hospitals, where pay and conditions are better.

Certainly on Ms A’s ward the staff seem completely overworked. Some talk of getting out quick before the hospital closes altogether.

Ms A thinks it a disgrace that her nurses should have to put up with such a situation. She tells one she will write to her councillor when she returns home to protest that the District General is being run down in this way. But the nurse just laughs, and says there is nothing anyone can do, least of all the council.

That can’t be right, can it, thinks Ms A…

Mr B is a bank manager in his late 40s and another of Dr Brown’s patients. He lives nearer the group practice, in a large detached house in a tree-lined avenue.

When he had first visited Dr Brown about pains in his chest and arms he had been alarmed that his GP tried to conclude the consultation after a few minutes. Mr B wanted a full examination and referral to hospital for tests.

If he didn’t get it he would go to another practice, taking his wife and three children with him, he told Dr Brown. He would also make it known among his neighbours, friends and colleagues (he had a wide circle of each — he was chair of the local Rotary Club) why he had done so.

Dr Brown soon changed his tune. He offered to make an appointment for Mr B at the District General. But Mr B knew the hospital’s poor reputation, and had often driven past its dilapidated buildings thinking he would rather die than end up in there.

Well, there was the Royal Infirmary, said Dr Brown. The practice had a contract to send a number of heart patients there each year and there were still some vacancies.

However, Mr B might have to wait. The infirmary had a national reputation — doctors from all over the country were sending patients there now.

Just because you were local didn’t entitle you to preferential access.

Mr B had little patience with this. What if he paid for a private bed at the infirmary, with a television, phone and better food? Surely that would make a difference?

Strictly speaking, such a payment wouldn’t mean being treated any more quickly, said Dr Brown. ‘But leave it with me, and I’ll see what I can do.’

That evening Dr Brown called Mr B at home. Would the next morning be convenient for his admission?

No, it wouldn’t, Mr B answered, but the day after would be, and that was agreed.

Mr B had not been inside the Royal Infirmary for more than 10 years, when his grandfather had suffered a heart attack. Then it was short of money, and some wards were closed. Now he can hardly recognise it. Private patients seem to occupy most of it, including some from abroad.

He had expected to be in a small separate wing and to have to be transported to X-ray and to the operating theatre. But apparently it is the NHS patients who are confined to the tatty looking block in the hospital grounds.

Mr B is impressed with the speed at which the patients are admitted, treated and discharged. Although many of them didn’t look ready to go home, he assumes the doctors know what they are doing.

Mrs C is 70 years old and in constant pain from a hip Dr Brown had told her needs replacing. She lives with her 80 year old husband, who suffers from Alzheimer’s Disease. He is highly dependent on her and becomes difficult when she is not with him.

The couple have had great difficulty getting a home help, and no one from the social services department has visited them during the past 18 months. Mrc C struggles to the shops with her husband, though she is frightened to leave the house empty for so long — so many have been broken into nearby.

When Dr Brown tells her she will have to travel 100 miles for her operation, Mrs C weeps.

She worked as a cleaner at the Royal Infirmary for most of her life. Why can’t she go there, or to the District General?

Both hospitals have stopped doing hip replacements, says Dr Brown, which can be done more cheaply and quickly elsewhere. It is more efficient and ‘better value for money’ to send patients 100 miles. He has sent dozens from his practice.

’It’s nothing. Only an hour and a bit in a fast car,’ he tells Mrs C. But she is inconsolable.

He ushers her into the waiting room while he takes a phone call from the local newspaper. One of his patients has died en route to hospital after a motorcycle crash.

Neither the Royal Infirmary nor the District General now has an accident and emergency (A and E) department. The infirmary closed its A and E facilities soon after becoming self-governing. Perfectly adequate cover existed at the District General, the hospital trustees had argued, and the infirmary could become a more effective hospital if it was able to concentrate its resources on fewer specialities.

The Secretary of State had agreed.

The District General did its best to provide the city’s A and E cover, but as it began to lose in the competition for resources, the health authority decided to save money by contracting emergency work to a self-governing hospital in a neighbouring district.

That caused much local protest, and the city’s newspaper had run a campaign to reverse the decision.

Would Dr Brown’s patient have lived if A and E facilities had been nearer, the reporter asks. But Dr Brown knows better than to be drawn into a trap like that.

He doesn’t want the regional health authority coming down on him, what with the practice overspending its budget last year. His policy is to keep his head down, and he parries the question with a non-committal reply.

As he locks the surgery door at the end of the day, Dr Brown’s thoughts wander, and he muses on Mrs Thatcher’s chances of winning the next election.