Sunday, June 24, 2007

Midwives, MTAS and the NHS

Continuing in the medical theme, as we seem to be, here at The Kitchen, there was yet another very telling comment left on Katy's Midwives post.
Apalling but not surprising, unfortunately. When I was a medical student, every single midwife I came across (in three different hospitals in SE England/London) had a shocking attitude towards epidurals. The woman would ask for one early on in labour, to which the midwife would either reply, 'It's too early, you may not even need one, wait a while', or 'The anaesthetist is busy in theatre' (without even checking to see if that was indeed the case). A few hours in, the woman would be screaming for an epidural. She would be told by the midwife that an anaesthetist was on his way, before the midwife would take me aside to say, triumphantly, 'by the time he gets here she'll have delivered'.

I never saw a single epidural given. The midwives used tactics including blatant lies, bullying and delay in order to deny women pain relief (other than 'gas and air', which the majority of my friends who have sprogged tell me is next to useless). I found the general attitude towards women who cried out in pain was, 'Oh don't make such a fuss. It's natural.'. Women who wanted epidurals were viewed as being weak and whingy. The overall atmosphere was one of 'midwife knows best'.

It's enough to put you off having children. Luckily for me, I suppose, I am a pushy middle class doctor and I will damn well have an epidural if I want one.

The comment was by a doctor who writes (although not for a while) at Layla's Space. Having a scan through the posts, another interesting aspect, which I had not seen raised before, of the now-defunct MTAS system was brought to light. [Emphasis mine.]
I assume [my old job] will be filled by a shiny new 'ST3' person at the end of August. I have my one guaranteed MMC interview on Tuesday, also in London. Yet another ridiculous consequence of the new system is that, because I applied to MTAS prior to taking my final MRCP exam, I had to apply at ST2, ie SHO level. The fact that I now have MRCP, and am indeed about to start working as a registrar, doesn't matter. I can't change what level I have applied to, so if I get the MTAS job, I will effectively be resigning my registrar job a month early in order to take up a medical SHO job for another year. Resigning my registrar job to go back to doing what I have already been doing for two years.

How fucking stupid is that?! Every single doctor who passed PACES at the same time as I did will be in the same position - forced to remain at SHO grade for an extra year. And 'they' said MTAS would help to 'streamline' training, ensuring that nobody spent too long stuck at the same level. Priceless.

Surely it is some kind of enfringement of employment law, only being able to apply to four jobs per year? Surely everyone should be able to apply for as many jobs as they like, as many times a year as they want to, at the most appropriate level of seniority? There are so many stupid, probably illegal, foolish fuckwittish elements to the whole system, I don't know whether to laugh or cry.

The state runs things badly; therefore the state should not run them at all. And the NHS is something special; one of the largest state organisations in the world and subject to its very own inefficiences.
Patricia Hewitt is right on this one...

I never thought that I'd ever see that sentence written or said...
... the NHS is simply too big to be manageable.
...

There are economies of scale, but there are also diseconomies of scale as the hierarchies of bureaucracy grow, and so efficiency against size forms a curve[2]. This happens in all organisations whether public or private. Any organisation as big as the NHS would be inefficient and there is absolutely nothing going to change that unless they also do something about dividing it up into more manageable sized chunks. Maybe still as a state run system, but run by local government as in Sweden. Perhaps a multi-payer/multi-provider system as in France[4] where the hospitals are all independent organisations and the state just provides a basic universal insurance. Or if you want to be radical get the state out entirely and just have it recognise that because some things are important they should not be taxed as in the Singapore system for healthcare. It is the NHS's obesity that is killing it. The crisises might individually be dealt with, but unless the root cause is too then they will just come back.

Chris is, of course, quite correct and the NHS does need to be pulled down; as does the system of funding solely through tax. Matthew Sinclair explains why.
Two factors drive an increased demand for healthcare. First, older people require more healthcare and the population is ageing. Second, technology is vastly increasing the potential of medical science. There is huge demand for new treatments which promise incredible results but are very expensive. This effect is massively outweighing technological advances that cut costs.

The same is true in education. Rising demand for education is driven partly by people wanting to be on the right side of a growing skilled-unskilled divide created by the entry to the world market of cheap labour, particularly from India and China. Another major factor is the growth of a ‘knowledge economy’ where the kinds of analytical skills taught in higher level education are becoming increasingly important.

Healthcare and education are representative of a broad trend. Services which are currently largely the responsibility of the State are seeing increased demand across the developed world. In healthcare, Britain has doubled spending, to roughly the EU average, and health costs in America are also rising. Germany’s social insurance based healthcare system has been under huge financial strain.

The prospect of this new demand being satisfied solely with taxpayers’ money should horrify the Right. Such an expansion of government would require a massive increase in taxation which would cripple our economy and take more money from hard up taxpayers.
...

If the sacred cow of healthcare, education and other services being funded purely from taxation cannot be challenged, a crucial battle with the Left will have been lost and the struggle to stop the State expanding will become increasingly hopeless.

Do go and read the whole thing; but there is one element in which I disagree with Matt. If the NHS is not reformed, it will not just be the Right who will suffer—everybody will. Increasingly poor people will be asked to pay more and more for the treatment of those who do not look after themselves.

In some ways, I have been unfair on Dr Rant and the other medicos; heavy drinking, for instance, does, undoubtedly, damage the body. The only way in which you are going to make people take responsibility for that, though, is to make them pay for it. Right now, everyone is forced to fund the NHS and they do not do so according to need but by ability to pay. The more you earn, the more you pay in, irrespective of whether you look after your body or not.

Legislating street-drinking bans will not help: making people pay, even partly, for their medical treatment is the only way to ensure that they do actually take responsibility for their actions. As long as people perceive health treatment as being free (even though it is not) or as being "their right" no matter how much they continue to damage themselves (which they will as long as they are forced to pay no matter how healthily or otherwise they live), they will continue to make choices that distress doctors.

It is ironic, therefore, that those who fight most fiercely for the retention of our current system, the medical profession, are precisely those who simultaneously rail against the actions that the system's perverse incentives engender.

6 comments:

Ed said...

What do midwives use for contraception? Their personality.

The NHS is clearly badly run, but is it as badly run as the US system? Will people respond to "incentives" to look after themselves? Probably not because most people try to look after themselves anyway, and the people who don't aren't going to pay anything.

I agree with Blair when he said the result of not reforming the NHS would be its collapse into a safety net system - which middle class taxpayers would resent paying for because they would pay for something better for their own families. Blair's reforms have been counter productive and we must look to other countries which have "free" healthcare for ideas.

Devil's Kitchen said...

Fucking hell, why does everybody assume that anyone who wants to reform the NHS wants to go to the US system.

France, Switzerland, Singapore, Sweden etc. all have rather better systems than the US (and, indeed, ourselves).

And many, many middle-class taxpayers already resent paying for the NHS; but at least it might be affordable as a safety net system.

DK

iznogoud said...

I can tell you why ... because it is an easy simplistic and very fashionable argument that pleases the crowd.

By the way, France has a "better" healthcare system than the US because it is relatively "free". That doesnt mean it is financially viable. The current account deficit is now above the ten billion euro mark ... compare that to the "positive financial balance of the NHS" ... of course there are no waiting lists in France, hospitals are better staffed and like to keep their equipment at the cutting edge of technology, oh yes a lot more new expensive treatments are available too and there is no postcode lottery ... you get what you pay for.

Dr Rant said...

"Legislating street-drinking bans will not help: making people pay, even partly, for their medical treatment is the only way to ensure that they do actually take responsibility for their actions."

Er, these people often die from alcoholic liver disease (or they bleed to death from varices. If they are too ignorant (and I'm using this term non-pejoratively this time) for this threat to stop them, then I don't see how worrying about having to pay for their terminal care is going to make a difference.


(Oh, and as an aside about advertising not working, I only have two words for you: American Express).

Dr Rant said...

Oh, and many, many madwives are evil fuckers.

The only people they hate more than doctors are men, and the only people they hate more than men are 'weak' women who experience pain in childbirth.

I developed an approach of 'shoot first, ask questions later' with madwives after one particularly evil troll had me removed from the maternity unit at night by security for having the audacity to say I would sit in the midwives' station overnight and read a book (her usualy policy to fuck up medical students was to send us to the on call room with a false promise to call us, and then lie in the morning that there had been no deliveries the night before).

The dean of my medical school ate her department for breakfast the next day, but I never turned my back on a midwife again.

Neal Asher said...

Hang on. People are already paying heavily for their 'unhealthy' habits. I don't know the precise percentage, but cigarettes cost £4 a packet more here than elsewhere in Europe. And the difference in prices of booze aren't far behind that. Guaranteed the anti-Midas Brown takes most of that. Maybe if that money was spent on health care rather than more bureaucratic bullshit...