The bill,
put forward by Secretary of State for Health Andrew Lansley, has been accepted
in its final vote in parliament, is about to be sent to the Queen for royal
assent, and is expected to become law by the time you read this.
“An awful lot of NHS structures have already
been dismantled. It would be as hard to turn back now as it is to carry on. The
thing we have to do is make sure it works for us.” – Jane Anderson
One of the
odd aspects of the furore around the bill is that many of its reforms are in
fact supported and have even been proposed by doctors and other healthcare
workers. The government’s biggest problem is that the reforms are happening in
a time of economic recession and that every reform is suspected as being a way
of making cuts. Hence the fears expressed by GPs and patients groups that local
health services will be taken over by large commercial healthcare companies who
will provide care for straightforward patients and bundle off anyone who has
complicated or expensive health needs to hospitals, or into an untreated limbo.
What will
GPs be in charge of? What if I’ve got something like chronic hepatitis B, which
has always been managed by my hospital? Or diabetes, which is already managed
by my GP? Who will take ultimate responsibility for my health?
A very good
set of questions; particularly in the context of the ageing of the HIV-positive
population. We’d be asking them anyway, but the NHS reforms have perhaps given
a chance for us to codify responsibility in more detail.
The London boroughs of
Lambeth, Southwark and Lewisham (LSL), which have the highest HIV prevalence in
the country, recently published a report on who should ultimately be
responsible for the care of people with HIV in the area. They interviewed local
professionals and discovered that, far from people with HIV being disowned, everyone
thought they were in charge of their care: HIV consultants, GPs, social workers
and key workers in voluntary agencies all thought they had ultimate
responsibility. LSL’s report said that, in line with the NHS reforms, the
person who should be in charge of co-ordinating the care of the health and
social care needs of people with HIV should be their GP, but gave little
guidance on how this should be achieved. “The assumption that GPs will
automatically be able to fulfil this role is tenuous given their performance in
this area historically,” commented THT in their response to the LSL report.
“The direction of travel is
inexorably towards shared care, but the problem is that in all the reports I’ve
seen on how to achieve treatment and care co-ordination, accurate analysis
mixes with a desire to cut and save money.” – Yusef Azad
The issue
is not just one of better communication, but of real power and of money: it’s
about which professional has the power to decide whether someone should get an
expensive drug or social support programme and who should pay for it. On the
one hand, at present people are often left dangling in situations where, say,
their HIV consultant recommends a treatment but the GP won’t refer because it
would be expensive; on the other hand we don’t want to see a situation in which
every professional involved in someone’s care has to refer decisions to their
GP.
We are not
likely to see GPs take over deciding which antiretrovirals you take, however;
apart from anything else, the problem that non-exempt patients would have to
pay prescription charges has not yet been sorted out.
In
addition, central HIV commissioning and cash shortages are likely to mean that
you are less and less likely to get treatment and care for conditions that are not
directly related to HIV from your HIV clinic. HIV doctors are not necessarily
experts on the sort of common conditions like heart disease, diabetes and
dementia that GPs see every day and HIV patients over 50 may miss out if they
don’t visit their GPs for a health check now and then: GPs have to offer
regular ‘MOTs’ for older patients. If there are confidentiality reasons that
mean you don’t want your GP to know you have HIV, it should next year become
easier to register with a GP in a wider catchment area than is currently
possible, or even in the area where you work.
“Testing seems to be a lever for
creating genuine interest in HIV in GPs. Once a patient comes back with a
positive result then the GP has a patient they already have a relationship
with; it’s beginning to unpick the circular argument that GPs aren’t interested
in HIV and HIV patients aren’t interested in seeing them.” – Claire Foreman