Wednesday, 3 August 2011

Health service rationing

Everyone knows health care is rationed. Don't they?

Whether it is funded, or not funded, by government or insurance companies - or you pay for it privately - it is still rationed because money is finite. It is just not possible to fund every medical treatment under the sun, and people who complain about that are amazingly naive. The difficulty comes when deciding exactly what to ration and how to do it.

Here are a few random tales, all of which were publicised for whatever reason at some point so I'm not breaking any confidences. Let's start with breast implants. I was happily sitting at my desk when the 'phone rang. It never stopped all day. When I put it down it rang again, and my secretary was in and out all day with messages from newspapers, radio and tv stations all wanting me to call them back.

Why? Because one of our local GPs had referred a patient for breast enlargement so that she would be more successful as a topless model. Some background. Well, naturally the NHS isn't - or wasn't - some sort of support agency to the Job Centre. It's prime function is not one that offers surgery to anyone and everyone who feels they might do better in life if they were 'better' looking. Or perhaps, looked different would be a more appropriate description.

And indeed, being referred for surgery to help her topless modelling career wasn't how the doctor got the referral through. His patient was suffering from low self-esteem due to her small breasts. If she didn't have depression then, no doubt it would set in later. The operation cost slightly over two grand. Not huge in the scheme of things.

Working in public sector press and media I found it useful to not have a view on things. It made it much easier to churn out my party line, and not get involved in any discussions and - say the wrong thing. This GP wasn't a fundholder so it fell to the health authority to fork out the £2K+ - and that's why I spent all day politely telling every media caller that a) we couldn't go into detail about individual patients and b) it was up to every doctor to exercise their clinical judgement appropriately when referring patients for surgery etc etc etc. I was quite happy with this line and it was dutifully repeated by everyone who called me when they published or broadcast it.

Some years later on, I can allow myself an opinion. In no particular order:

1) I still think it is up to each and every doctor to decide what is the right treatment for their patient. Up to the patient then to decide whether to take it up.

2) Suffering from lack of self-esteem and/or depression is not good. Just because mental illness isn't obviously visible doesn't negate from the seriousness of the illness and the trauma that people suffer. People who are mentally ill and fall in and out of big black holes do not have a good time - and like other chronic illnesses - it is always with them.

3) I have probably also had low self-esteem from having small breasts, although becoming a topless model wasn't high on my list of career choices. It is not nice to pass people in the street and hear them saying they can't decide whether you are a girl or a boy. Not helped by the fact I was tall and had shortish hair. Then there are the ones who quite bluntly tell you that you have small breasts, that you are flat-chested, that you look like a boy, and that you don't look remotely sexy. And this last point is the issue.

What on earth is it about our (male) society that imposes such conditioning on women they feel they need to have surgery to get bigger breasts? Or that the aspirations of a young woman are to become a topless model? I know that appearances are important and that we are all judged on them. But women are judged in a different fashion.

We all know the ideal woman. She has a slim but curvaceous body. Long well formed pins, reaching right up to her cute and firm arse. Oh, I should add that those pins are immaculately smooth and shaved every day so that a chiffon scarf will drop straight down them. She has long sexy hair, big eyes, and a beautiful Colgate pearly white smile. And naturally her breasts are NOT small, but just the perfect size, firm with a suitable amount of cleavage for men to peer down.

Who creates this ideal woman? Men. She's not a woman. She's a sex object. And anyone who wants breast enlarging surgery is sadly conditioned to believe all this. They are buying into the male fantasy of the perfect woman sex object. And they aren't doing any favours to women who don't want to be judged on the size of their breasts. A few years ago I met someone who had undergone breast enlargement and had her eyes tucked. She looked top heavy and the skin around her eyes was so tight. I think she could have spent her partner's money more wisely.

So these days, I would be sadly disappointed to hear about any GP referring their patient for breast enlargement. For whatever reason. It seems to me to be treating the symptom and not the cause, but maybe that's what medics do. Some helpful counselling and assertiveness skills would be a lot more helpful - IMO.

Some of the longest waiting lists in my NHS days were for plastic surgery - and the two critical areas were for burns, and for reconstructive surgery following breast cancer mastectomies. Technically I suppose one could argue that reconstructive surgery is similar to breast enlargement and could well involve self-esteem issues - but at the end of the day, I don't think there is any comparison between a woman who has gone through surgery and chemotherapy, that was not something of their choosing and a young woman wanting bigger tits so she can appear on page 3. Incidentally, I read later that her modelling career didn't last long. So, in terms of rationing - I would not want to see the NHS spending money on breast enlargement for women, whether for self-esteem issues or not. There are other ways to gain self-esteem.

Onto another controversial area. Fertility treatment. We decided that we needed to introduce criteria for this service. Which is another way of saying rationing the service. We put a paper to the board with extremely tight criteria. The chief executive had primed the chair about it. She was expected to approve the paper.

But she had been lobbied by some of the local fertility action groups. And - she told me in confidence, and quite a few others as well - that she had been unable to have children back in the days when fertility treatment didn't happen on the NHS. So when it got to the critical moment at the board meeting - she deferred the decision for consultation with our local groups. Great, another two months of indecision.

The proposal got watered down of course. The age limit went up to nearly 40 (conception is less likely as you get older so treatment for older women was less effective), we had a clause requiring residency in the area for a couple of years, something about a stable relationship, and there was probably something about only three goes at it, or something similar.

Out of those of us who originally discussed it, there was me - the only woman, and some 40 or 50 year-old men, who had children. Not exactly the most empathetic group for infertile women. Yes, we heard about the angst. The emotional trauma for women who couldn't fulfil their lives by not having a baby. The sheer mental distress of it all and how it affected their relationships. And how wonderful it was for those who did eventually conceive. That's great. Because in a world of limited resources - you stand up and tell someone who is being deprived a few months of life for an expensive cancer drug that your need for an IVF baby comes first. I couldn't.

Next up came screening for Down's Syndrome. But by then I think we had lost the will to ration, and this really was just a long-winded exercise to write down some firm criteria about when and whether pregnant women should have blood tests, ultrasound tests or amniocentesis.

But a few years later, with a change of directors - rationing picked up its lively head again and we decided to hold a public meeting and discuss how to spend our so-called development monies. These were peanuts in the scheme of things as virtually 90% of the budget is already spoken for as soon as it is allocated. Those of us responsible for some of the key services - maternity and child health, elderly services, mental health services, cardiothoracic medicine, and cancer - were asked to present our 'case' for investing in our service.

I have to say it was rather a tabloid exercise. Asking people to decide how to spend money based on a few presentations over a couple of hours? I didn't present my case. I asked a clinical director for cancer services and a breast cancer patient to make the case. I figured they could do a lot better than I could have done. They did. We 'won' the debate. Always choose the right people to give the message. And there ends my mixed post on rationing.

In theory it should be based on clinical effectiveness - ie don't provide services that don't work. Secondly, don't provide expensive services that either don't work or when there is a cheaper and as effective service available.

Most people don't want to accept, or don't like the fact that rationing exists. They also don't want to make the decisions themselves but they sure as hell want to blame those of us who can't make a health service budget into the bottomless pot of gold at the end of the rainbow.

No comments: