“Patients will have choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment. We will extend choice in maternity through new maternity networks.”
This is taken from the executive summary of the government White Paper 2010, and is carried over into the Health and Social Care Bill going through Parliament.
It sounds nice, what’s not to like about it? The problem arises when you have to implement this in the actual world.
It is very important to keep in mind a number of inter-related issues when reflecting on this matter: the quality of a service, the capacity of a system providing that service, the resourcing or resources available to the system providing the service, the access to the service, and the safety of the service.
Take the example of the consultant-led team. These teams consist of a consultant (sometime two working together) and their junior staff (registrars, house officers), secretarial support, managerial support. Part of their work will be outpatient treatment (outpatient clinics), some of it inpatient treatment (surgery in the case of surgical specialties), planned elective admissions, but also emergency admissions. They will also spend time handing over, discussing cases, writing clinic letters to GPs, and perhaps teaching medical students. This team has a finite number of professionals. It is important to view this consultant-led team, together with the service they provide, as a system. And it is important to remember that dynamic systems have an ecology. This consultant-led team will have a capacity: that is, they can see so many new patients in the weekly outpatient clinic. If you increase the numbers you want seen in the clinic, then something has to give. The consultations have to speed up, the quality of the consultations will at some stage decline. The team will have a capacity when it comes to looking after inpatients: exceed a certain number of patients, and the quality of the service declines, and there also comes a time when safety is compromised. You might say, well just hire in more staff. That will work to some extent but remember that as the system gets larger it no longer behaves as it did previously, the ecology has changed. This is what happens if access (choice) is unlimited. You gradually slip into a situation which is Kafkaesque, which becomes a Herculean task.