Rights, Choices and “Free” Healthcare

Today I took part in a really fascinating hypothetical discussion forum with women from across North Lancashire. We looked together at the “right” of choosing to have a Cesarean Section instead of a vaginal birth when there is no clinical indication at all to have one. We also discussed the “right” of having a home birth against the advice of clinicians and current, sound clinical guidance. Unsurprisingly it sparked some good debate but it is this kind of conversation and indeed much wider ones that are vital if we’re going to continue having a National Health Service in the UK that is accessible to all, safe in its provision of care and sustainable for the future.



The human rights agenda, if we are not careful, becomes a platform for each of us to act in a way that leaves no regard for the impact of our decisions on the ‘other’ (be that professionals involved in our care, or other people who will now have less choice available to them due to decisions we have made). But we must differentiate between choice and rights as they are not the same thing. In maternity services, a woman has the right to excellent maternity care in which she makes shared decisions with her midwife and obstetrician. However, does a woman have the “right” to demand care which is way outside of what is clinically safe, or to demand a much more expensive treatment option when there is a lack of evidence that she truly needs it, especially when resources are limited? Tough questions! The truth is, she does , of course, have that right. But a more difficult question is whether or not it is then within the gift of the NHS to then provide that kind of care.

So, for example within maternity, let’s take home birth. Two of my 3 children were born at home and it was a beautiful experience (says the man). It is really important that this choice is offered as widely as possible on the NHS. However, there are certain situations in which a home birth becomes extremely risky to the mother and unborn child and the clinical evidence really backs this up (see NICE guidance). So, as an example, a woman who hasimgres previously given birth and had a massive haemorrhage afterwards and in a subsequent pregnancy has gestational diabetes, obesity and a twin pregnancy would not be advised to give birth at home. For the best outcome of a healthy mum and baby the evidence would suggest that this birth would be better under closer supervision than can happen at home. However, what if she takes all this information in and still demands a home birth as her “right”? Well, currently, she would come to a shared care agreement with her midwife and obstetrician, come to an understanding of all the risks involved and have a home birth. And there is a huge part of me, as a feminist, that loves this. It is her own body and her own baby and she can make informed choices. But the cost implication of the time and resource taken from what is an understaffed and overworked midwifery service might then mean that very few other home births can happen in the week or two surrounding her due date and puts the clinicians under significant stress. So, the woman makes the choice to hold onto her “right”, but the impact on others is that their choices are now more limited.

So too with Cesarean Sections on demand. I understand the fear of some women about going through labour and various other reasons for choosing a section. The conversation is not about removing the choice for those who really need it, but the current rates of 25-27% of all births through C. Section is not sustainable in the long-term (nor is it supported by the Midwifery 2020 document). The NICE guidance has been interpreted very liberally by some obstetricians who do not want the hassle of saying ‘no’ and commissioners have in some places not been clear enough about what their own guidance is. But, vaginal birth is natural and safe and perhaps we need to see it as the norm for every woman unless there is a clear clinical reason (be that physical or psychological) as to why that can’t occur.

The tough question facing those who commission services for the NHS is whether or not choices should become more limited in certain situations so that the gift of the NHS can continue to be sustainable in the future for all. If choices were limited in order to protect everyone’s rights to free and excellent maternal care, it is not that women could not then go against guidance, but they may either have to go through an appeal panel or pay for the kind of care they want themselves……ouch (especially as this won’t be equitable for all).

Much of this comes down to good communication skills. I have been really heartened to imgresspend some time with AQuA (Advancing Quality Alliance), who are helping clinicians learn how to use better consultation skills to really share decision making with patients. It is based on a model of care which we use a lot in General Practice called “Calgary-Cambridge” (more on this another time). But it is vital that clinicians communicate choices better and come to shared decisions with their patients, so that they understand the impact of their choices both on themselves and their loved ones, but also on the system itself and therefore other people. We cannot have a situation where people can simply demand whatever they want without any thought of the implications and so good information sharing is vital. Equally, we cannot continue with patients being forced down one path of treatment or not understanding the choices available to them due to poor communication or a lack of humility on the part of the clinician. The clinical-patient relationship is a partnership.

If we are going to develop a new love-based politics, our own “rights” must also take into account the needs and rights of others.

Democracy Day?

UnknownSo yesterday was BBC Democracy Day. Maybe it was a wistful longing for what might have been. Democracy? The rule/power of the people in a day when the richest 1% own 99% of the world’s wealth? When the 50 richest corporations now hold more wealth than the 50 richest nation states? When we hear of unbelievable governmental cover-ups across Europe? When the vox populi is increasingly silenced and the powerful elite rule through a feudalistic system of land ownership and the ‘rights’ to resources.

Democracy is only a veneer. It is the icing on a cake, which is mouldy to its middle. It is, as my friend Roger Mitchell so clearly highlights, just enough multiplied sovereignty to make us believe we have power when in fact we have very little. Rather, we have an increasingly oppressive and sinister system of domination and control, held together through a strong alliance of economic debt, military violence and law (truly enforced by the State of Exception – Giorgio Agamben).images

And we are waking up to this. This is why we see the political turmoil stirring throughout Europe. And the politicians cannot understand it. There is no doubt, that we will see a kick back and a reaction towards the extremes of left and right. But this is not the answer.

I quite admire the Australian system in that they have to vote. But I especially like the option to vote for ‘none of the above’. I don’t hold hope in any of the political parties, because the system itself is utterly broken, corrupt to its core and does not serve the future of humanity and the planet.

But if we do see a shaking, and the political systems we have known become shattered and changed, with a new type of economics coming to the fore, what is it that we can imagine? With power comes responsibility. What would we dream of and what would we do differently? How would we stop exactly the same thing happening again or stop our selfish motivations from plummeting us into war? What would be our ‘new politics’?

There are some exciting conversations emerging. We do not have to spiral into years of violence and war. A revolution of love is possible. I believe it is in the very heart of God for human beings to love one another and to prefer each others needs. To embrace and to be changed by ‘the other’. Our current politics is one based on fear. Fear of the other. Fear of lack. But love drives out fear and those who live in love, live in God. Fear enslaves us but love sets us free.

imgresMaybe we will see a ‘kenocracy’ emerge? A rule of love? To find this would be to align ourselves with the story of God through the ages. Love poured out for others, daring to embrace those different from ourselves and together finding hope and peace. Fear enslaves us but love sets us free.

Have a read of ‘Discovering Kenarchy’ – available from amazon. Once our imaginations are alive with possibility, nothing is impossible.Unknown

NHS in Crisis?

imgresAnd so it begins……the year of a General election and the NHS takes centre stage. Some serious hyperbole. According to our tabloids we have ‘A 3rd World A&E’! Please! I’ve worked in the developing world and this is nothing. Despite all the rhetoric, the WHO still says the NHS is the best and fairest health system in the world…..so perspective is important.

But is the NHS in crisis? It is, and it’s not just the emergency departments. General Practice continues to be in a major crisis too and so if the answer to the A&E (ED) crisis lies in General Practice then the crisis in the community is doubled! But my ED colleagues are having an horrific time and the answers to the conundrum are not easy ones.

Labour have called for an emergency summit on Accident and Emergency and the NHS in general, as if the writing has not been on the wall for quite some time. Short term solutions will do nothing to create a safe and sustainable NHS, accessible to all.

We do have some hard truths to face in the UK and we have to understand the cost implications to some of the possible solutions. But I do believe there is real hope and that there are creative solutions available. It is time for a revolution in our thinking.

The problems are as follows:

1) We have an aging population with increasingly complex health needs.

2) Our social services at at full capacity and we have a break down in a sense of community in how we care for and love our ‘neighbours’.

3) We have adopted a health philosophy that is about ‘killing disease’ instead of ‘promoting health’. This is due to a combination of far too much power being given to the advertising, fast food and alcohol lobbies, taking exercise out of schools and too much screen time generally for kids and adults alike.

4) We have adopted a way of life that has driven up stress significantly causing a rise in mental health issues.

5) We have deliberately under trained doctors and nurses in this country, relying on free market principles that we could recruit staff more cheaply from abroad, (not caring that we are seriously destabilizing other health economies in the process). In the same way, we are losing many of our young doctors and nurses to other nations who will pay more for less hours (like Australia and Canada).

6) In order to keep the NHS afloat, managing structures in the NHS have become increasingly bullying, creating low morale, high sickness records for staff and a sense of despair. This is turn has a direct effect on poorer care for patients.

7) We have over-medicalised life and given far too much power to the pharmaceutical lobby. Targets have been set which are meaning tighter and tighter control of people’s health with medication, creating ever more health anxiety and increasing illness behaviour.

8) We have developed a sense of entitlement and self-centredness overall, which puts huge strain on systems, especially A&E. There is a huge abuse of the system and misuse of services without consequence.

9) There has been a significant lack of local people being able to be involved in any way with how taxation is spent whilst greedy corporations and banks can act exactly as they please, leaving a lack of investment in healthcare to the tune of several billion pounds.

10) We don’t trust our own immune systems to work and have become over reliant on antibiotics.

11) We are afraid of death and having conversations about it in any kind of mature way. We keep on treating people endlessly with antibiotics in nursing homes, when we should allow people to die (not be killed) in a dignified manner.

12) We have far too much waste and too many barriers/walls within a complex system, leaving key sections of the system in direct competition rather than collaboration/cooperation with one another.

13) Oh yeah, and we had a 2 billion pound reorganisation of the NHS which happened despite a ‘listening process’ which strongly warned against it.

And some solutions-based, hopeful, practical thinking?

1) Change the way we think about health. We have to live healthily andimgres
promote healthy living from time of conception to time of death. We need healthy pregnant women, more breast feeding and healthy diets and exercise from a young age. We need to be more responsible….

2) Change the way we think about health. The biggest breakthroughs in medicine by a mile were clean water, sanitation and immunisations. We need to trust our immune systems to do the job they do very well, and care for our selves better before needing to run off to the health professionals to fix us.

3) Change the way we think about health. Try being grateful for the incredible healthcare we already have.

4) Change the way we think about health. We need to understand the impact of our chosen way of life on our physical, mental, social and spiritual health. We have become slaves, the fodder, the raw material of an economic system that eats us up and spits us out, allowing 85 people to hold more combined wealth than the poorest 2 billion on earth. If we haven’t understood that this awful injustice crushes our spirits and therefore our well-being on a daily basis, then we have understood little. The mountains must be brought low and the valleys raised up. It is a proven fact that people are least happy where the gap between rich and poor is widest. The UK has the widest gap in Europe by some margin! We go to work to earn enough money to pay our debts which drive the system. We come home, hypnotize ourselves in front of the TV and return to the same thing the next day, not wondering if we actually destroying the planet, other people and ourselves in the process. And if we don’t live this way anymore? Perhaps we could find more creative ways to live that bring a more beautiful future to the fore?

5) Change the way we practice healthcare. We need to transform tired systems and help them integrate to provide far more stream lined and effective care. The walls between primary and secondary care must come down and new collaboration be found.

6) Change the way we practice healthcare. We need to create a culture in the NHS which is life giving for staff (see earlier posts).

7) Change the way we practice healthcare. We need to allow people to die with dignity, especially in conditions like end stage dementia, rather than keeping people living on and on, just because we can.

8) Change the way we practice healthcare. Involve local people to create a groundswell of change, with a far greater sense of caring for the ‘other’ and our ‘neighbours’ with greater local decision making in how money is spent.

9) Change the way we practice healthcare. We must see a reduction in  power of the pharmaceutical lobby in parliament. The influence of this lobby on healthcare policy and provision is utterly corrupt and has caused much of the unsustainable mess we are in.

10) Change the way we practice healthcare. We must train people more effectively and make the NHS a desirable place to work in once again.

And the list could go on. A revolution in our healthcare system is needed. Transformation is really possible. We must not seek answers which lead to death elsewhere. We have some tough choices and changes to make, but there is so much hope.