Complex Very Complex

A brilliant midwife, whom I hugely respect, posted this link on her Facebook page recently (if you don’t have time to read it, it details how North Wales is going to lose its special care baby units, so babies needing such care will be transferred over to England):

When we lose local services it causes a sense of anger and disempowerment. What about not being able to give birth in your local area, if you have a complex pregnancy? What if a mum’s baby is taken miles away from her for special care, only hours after having a caesarian section and it is a few days before they are reunited? What is the impact of this on the mental health of the mum and child? What about partners who can’t afford to keep travelling 40-50 miles to visit mum and baby and have to look after the other kids? What about the loss of jobs to the local economy and the sense of belonging that having things available in the local community can bring? What about the dangers of being transported to somewhere so far away to receive specialist care? It seems like a dreadful and unloving thing to close local services.

Sadly, it’s not that straightforward…. I thought it was, until I became the lead clinician for maternity for Lancashire North CCG. When looking to provide services for an area we have ¬†a backdrop of three key factors to consider: 1) Safety, 2) Affordability, 3) Accessibility.

1) Safety: Research suggests that survival rates of babies with complex needs are higher in specialist tertiary centres, which deal with such problems far more commonly. Travel times from studies seem comparatively safe. Women, who have complex pregnancies have better outcomes in more specialist environments. The equipment is better, staff are more specifically trained and due to seeing and dealing with very poorly babies and mums more often, the care is better and survival is higher. Currently, the UK has some of the worst maternity and neonatal data in Europe and there is a hope to change this. I am grateful that none of my children needed this kind of care when they were born. I was also grateful, that if they had, I happened to live in Manchester where there is some of the best care available in the UK. But there is a difficult question for those who live more rurally (as I now do). If your pregnancy is complicated and you need more specialist obstetric input, or your baby needs highly specialised care, do you want that care to happen locally with a team who may not have lots of experience in that specific situation, or would you rather be transferred, potentially some distance, but be able to receive more expert care and have better long term health outcomes?

2) Affordability: Currently in the UK, the litigation budget for maternity and neonatal care takes well over 40% of this whole budget area. They are also hugely expensive specialities. We would all love to have highly specialist units on our doorstep or at least fairly local. But we have to face to some difficult facts that we have a lot of hospitals in the UK, which are extremely expensive to run and we can’t afford them all to be specialist centres for everything….We don’t have the staffing levels needed for this and with the way we currently do economics and due to our strong culture of blame and litigation when things go wrong, we don’t have the money. We have also hugely over-medicalised birth as a process. The Midwifery 2020 document implores us to help birth become a more natural process again, to take out too much over involvement and encourage (more affordable) midwifery led units and home births…..We could also train our midwives and health visitors (and even surgeons) to higher levels of expertise, as they have done in Scotland…..Complex cases could then be handled in larger regional centres…..

3) So, when we talk about accessibility (and for me this is especially important for the marginalised poor and for those for whom mobility is a real issue), we have to have that discussion in the light of safety and affordability. We also need to factor into our budgets the need to help those who can’t afford travel and child care…..

This doesn’t stop with maternity and neonates. Only yesterday we have also seen the Health Secretary, Jeremy Hunt, decide to close large parts of Mid Staffordshire Hospital and redistribute services elsewhere, after the recent scandal involving substandard care. We are seeing ED’s closing and will see many more such ‘reorganisations’ happening.

I believe that leadership can be self-emptying and loving and sometimes hard medicine does not always feel like love. Personally, however, I feel that the way Mr Hunt acted was neither self-emptying or loving but rather dictatorial, bullish and driven by a very different ideological objective.

We do have some significant challenges ahead and there are some changes to our systems that are necessary in order to provide the most excellent and loving care. It will take some serious re-imagination and the breaking down of some current mindsets we hold.

Not that my opinion really counts for that much, but for what it’s worth, some of my ideas would be as follows:

I really believe in participatory economics (sounds fun, eh?!). There has been a lot of rhetoric about devolving of budgets and allowing local health boards to make decisions about how money is spent. Firstly this isn’t really happening, as any time a decision is made on something the ‘powers that be’ don’t like, they come and crush the idea and tell the boards what to do instead, with the threat that they will replace the board if they don’t comply! Secondly, it doesn’t go anywhere near far enough and it lacks integrity because there is no joined up thinking. If local people are going to make decisions about their local economy, then it must be the whole and not just a part. Currently we spend an enormous amount of money on treating disease (or preventing it through vaccinations), but nowhere near enough on promoting health in our communities. Isolated budgeting doesn’t work and we waste an enormous amount of time and resource. We know that maternity care and neonatal care are being made so much more complex by our astronomically rising rates of obesity and diabetes, but we’re not putting the money into the places that could help turn this tide. We are also not collaborating between areas like health and education but are rather putting them in competition with one another, which is genuinely crazy. So, if the people of North Wales want an amazing special care baby unit near by, which provides brilliant care, they could decide to do so, but there are cost implications on other services, and cost implications on keeping up the expertise of staff and giving them enough time and exposure to complicated scenarios to know how to handle them efficiently…..So, less learned helplessness, and more engagement…..

Within that, we need to watch out for selfishness and all wanting our own rights. For me there would need to be priority care for children, women, the marginalised poor (especially including destitute asylum seekers), prisoners, the elderly and the mentally ill.

I also believe in gift economics. Towns and cities within a region can gift things to one another. This is already happening in healthcare and could happen more and in many other fields. For example, in North Lancashire, Blackpool has a gift of cardiology and cardiac surgery. It is a regional centre of excellence. There was initial resistance and concern about losing and moving local services but survival outcomes after heart attacks and many other conditions, both in terms of mortality and morbidity (how well you are afterwards) are far better across the region. Preston has a gift of neurology and neurosurgery and again provide excellent care. We don’t all need to have everything. Learning how to work in partnership and collaboration is key.

We need less of a blame culture. We need more compassion and understanding when things go wrong. Even if all the complex care is put into regional specialist centres, things will sadly still go wrong at times, mums and babies will still be poorly and die sometimes and nothing will change this……so some would ask, is all the reorganisation therefore worthwhile?

The redesign of our current systems is necessary and complicated. Sometimes, in the face of the economic beast and within the suffocating nation state environment, we can feel hopeless of change and helpless in our learnt disempowerment. Foucault says that we’re not really disempowered…..we just think we are. Revolution doesn’t have to be violent and bloody. Revolution can occur when enough people chose to engage, to love and to become the change they want to see…..

In the mean time, my plea would be this. Let those who are making tough decisions do so out of love and goodness, and not look to make healthcare profitable for private company share holders. Secondly, let those who don’t make decisions be kind to those who do….

The Complex Commodification of Healthcare

Not the most eye catching title, but bear with!

I’ve been thinking quite a bit about what on earth has happened and is happening to healthcare, particularly in the UK, but globally, also. My musings are being particularly influenced at the moment by the writings of William T Cavanaugh, Georgio Agamben and Michael Foucault. More from WTC and GA another time (when thinking more about healthcare and the nation state)….

Foucault, speaks of biopower, i.e. the commodification of life itself, so that even what would have been considered within the private sphere of our lives, is now the fodder of the economic machine. Truthfully, healthcare has become utterly commodified and in such a complex way that we find ourselves entangled in a sick web and it takes some major diagnostic work to make sense of what is happening.

Firstly, the system of healthcare has become commodified and is itself driven by economic greed. I have yet to find any clinician who thinks that the top down reorganisation of the NHS in the UK at the hands of Andrew Lansley, (but started by the government of Thatcher and most certainly compounded by Tony Blair’s team) has been in any way a good thing. It has cost literally billions of pounds, and has led to and will lead to more private companies, limited by shares, owning and running the health care services. This is driven by the EU-US trade agreement and is based on an utterly flawed philosophy that competition will improve patient care. Except, it won’t. The problem is that share holders don’t give a toss about the needs of the chronically sick or the marginalised poor. Rather they want to protect and guarantee their ‘income’. So health care will worsen. The WHO recently stated that the NHS is the best health system in the world and yet our government has thought it best to dismantle it! The claim is that the system is costing too much money! The thing is that the NHS is and has been ‘in profit’ for a long time. It isn’t run badly. All the cuts that are being made (which the Tories won the last election by promising they wouldn’t make) are in part due to the fact that many corporations are paying such little tax, and also because we have such an utterly corrupt banking system. The reason that successive governments have not stood up to the banking sector or these corporate giants (and are now cutting public services instead of challenging them) is because they are not really the government! The banks and the corporations are (well they are not either, but they act as though they are)! That is why the healthcare system itself is becoming more commodified! At a corporate level it is simply fodder.

Secondly the patients have become commodities. Do not be deceived. We have a healthcare system based on a Pasteurian philosophy of healthcare. Kill the disease. You are a commodity. Your children are a commodity to the advertising companies, cheap supermarket trash and fast food chains, which are driving up childhood obesity and diabetes, whilst we take exercise out of schools. You are a commodity to the pharmaceutical industry and when you reach 40, if you’re not there already, you will be offered a free NHS health check, which will tell you that your BP, Blood Sugar and Cholesterol are too high, so you will shortly be needing some medication to control it all. But here’s the thing…’s mainly too little, too late. What happens in our early life far more affects our health in older age. We need to be majorly cheerleading the promotion of healthy living to our kids, especially our young women, as the health of your mum whilst she is pregnant has a huge impact on your future health, far more so than drugs you take after your mid-life crisis. You are also commodified by the breakdown of the welfare system. We don’t have time or money, apparently, for you to be off sick. We need you back in work to get the economy going. You will notice that most therapies are being extremely cut back – we don’t have time for you to get really healed, we just want you functional……

Thirdly, there is the commodification of the health-workers. Burn out, low morale, tired and flagging. The pressures are mounting and we are not taking care of our staff, and the sad truth is, it will get worse and not better. One reason is that we are becoming increasingly self-centred and demanding as people, due to a multiplied sovereignty in our history, which leaves us feeling like we have the right to behave like mini-emperors. Another is a kind of learnt helplessness due to the breakdown of community. A third is the anxiety driven nonsense we find daily in our media, a kind of chicken-licken hysteria about every mild ailment. And fourthly, there has been little foresight or planning to think about where on earth our workforce is going to come from if we don’t train them. We have a 50% trainee doctor¬†shortage in the Emergency Departments. We will shortly have a national shortage of over 30000 GPs (and yet the government is promising 7 days a week cover, 8-8, just incase you want to discuss your piles on a sunday afternoon), but little thought is given to exactly where we will magic the workers up from. And if we take them from the EU? What then of healthcare in those countries? Ah yes…..multiplied sovereignty, we don’t really care. That’s why we continue to complain bitterly about the health services in this country, and yet we have the same population as South Africa, and ten times as many doctors. How do like them apples? Try being grateful!

Complicated, huh?

So we and our health are commodified. So what? How does knowing do anything except add to our already felt sense of powerlessness?

Well, we have some choices and some options.

We can choose to subvert the system wherever possible.

We can create some exciting alternatives.

We can protest.

We can radically love Andrew Lansley

We can vote out this government at the next election, though we must press for a new way of doing government, and allow our selves to completely reimagine how we do life.

We could have a revolution.

We can treat patients as sacred beings and refuse to treat them as commodities.

We can treat workers as gifts and not use them or abuse them.

We can be thankful that we have the best health system in the world and change our attitude somewhat.