The Secretary of State for the coalition government elected in 2010 has introduced yet another “reform” to the NHS which will place general practitioners in charge of commissioning. Initially there was silence from much of the medical profession, with a gradual swell of revolt ranging from GPs who didn’t want to do it, but just get on with their jobs, to hospital specialists who were surprised and hurt to find they were barely mentioned in the plan. In our locality, which is a “pilot” the GPs have elected as their head someone who is avowedly against hospitals – the same Dr Stoate who wrote the Fabian Society pamphlet “Challenging the Citadel: breaking the power of NHS hospitals”. This could be interesting. Are the barbarians at the gates of Rome? It was interesting, and worrying for hospital doctors, that the Bexley pilot was lauded by the Secretary of State for health as an excellent model.
The law of unforeseen consequences
You need to develop a sharp eye for detail if people are planning things. You might not think a little change will affect you but it could. There are two classic ways of looking at this; the traditional one of the butterfly fluttering its wings in Brazil that sets off a tornado in Texas, or the difference between space rockets and chess, as above.
When my hospital was threatened with downgrading as part of a reorganisation it was decided that, instead of it retaining a “step-down” medical unit (which had been the original plan) all medical work would move off site. The unforeseen consequence was that this instantly put my rehabilitation unit at risk as there would be no day-to-day or out-of-hours junior staff cover. No-one doing the planning had thought of this. I spotted it in time but for want of a nail the battle was almost lost.
Actually it turned out that no-one had properly planned the medical bed numbers, and at the eleventh hour it was found necessary to retain “step-down” beds – about 80 in number, which is not insignificant. We waited eagerly to see how many patients who are not really fit for moving to the step-down beds end up being shuttled back; as I wrote this the whole of the South-East was paralysed by snow, which I thought would bugger up everything. Actually it didn’t, exactly. However after the snow had gone there was chaos. Our A&E was now shut, so all acute work went to the other two sites, which silted up everywhere. On one day 65 patients were awaiting admission overnight; there were delays to be seen in A&E of up to 10 hours, and waits for patients in ambulances of up to two hours actually to get into the A&E department.
The A&E closure was forced through on the grounds that it was safer for patients to be seen in bigger, better staffed units. Because, in advance of the closure, ours had lost its educational recognition, it was no longer possible to re-open it. Indeed although the initial closure was billed as temporary, the department was immediately emptied of all its equipment. But is it better, or worse, to go to a big unit and not be seen for hours than to go to a slightly understaffed unit and be seen on time?
 See Bamji AN (letter in “The Times”, 18th January 2011)