Home > Uncategorized > The NHS Is Free At The Point Of Use If…

The NHS Is Free At The Point Of Use If…

I believe in the principle of the NHS that healthcare should be free at the point of use and based on clinical need; not on the ability to pay. Thats why I believe that patients should not be restricted in how they gain access to the NHS. The NHS should not be centralised through one set of health professionals especially those who are jacks of all trades and experts of none.

This structure of the NHS leads GPs being overloaded with work as well as plenty of misdiagnosis which means more work for GPs in the long run. It makes far more sense that if someone knows they need a physiotherapist they should be able to go straight to the physiotherapist on the NHS without having to go through their GP.

I understand that in many cases, many people will not know what kind of doctor they need therefore GPs are absolutely essential to any implementation of the health service. Giving patients real choice of how they access and use the NHS, would be an evolutionary change to the NHS, it would, however require a complete overhaul to the way the NHS was organised.

Let me give you an anecdote of why I think this change is necessary. Almost a year ago, I sprained & strained my ankle and did something to my knee. I didn’t feel my knee straight away like I did my ankle but the morning after, I woke up and was not able to put my weight on my knee so on telling my medically trained mother that i was unable to put my weight on my knee, she whisked me off to A&E in case I had damaged the cartilage in my knee. At A&E it was diagnosed as a ligament sprain and that it would heal relatively quickly.

After 4 weeks and a move back to university after the summer, I thought my knee still doesn’t feel great, doubting it was a sprain due to the fact that it didn’t feel like something had been overstretched like in my ankle, a friend recommended the Sports Injury Clinic at my university so I made an appointment with them. They diagnosed it as a cartilage tear as well as ligament damage and would need MRI to confirm. I went to the GP at my university and they diagnosed it again as a ligament sprain, it will heal. In January, I tried some parkour thinking that after 4 and a bit months, my knee would have healed considering my ankle was absolutely fine & that had felt much worse and become far more swollen than my knee, I felt my knee doing the warm-up run & it didn’t help matters that climbing down a rooftop, I lost control and landed harder than I meant to.

I felt my knee more so I went back to the GP, it was a different GP this time and again was told effectively: its a ligament sprain, it will heal, go away. I went away and gave it what my knee supposedly needed: rest. I did no exercise. The only exercise I did was walking. Then two weeks ago, I took to the tennis courts again and felt my knee again, the more I played the worse it got. I set up another GPs appointment, this time at home and finally I’m being sent to an orthopedic review, which has an apparent waiting list of 8 weeks.

Had I been able to go to the Sports Injury Clinic on the NHS, had they been able to authorise an MRI on the NHS, I would know what was actually wrong with my knee and be getting suitable treatment on the NHS.

The NHS is therefore only free at the point of use if:

You go through your GP or A&E.

  1. May 11, 2011 at 17:48

    Interesting. The GP’s role as gatekeeper has been held to be one of the cornerstones of the NHS. It is supposed to insulate specialists from frivolous demand – which is supposed to be an issue with systems that don’t use GPs in this way (most countries, I think). But we are asking an awful lot of our GPs to be competent to diagnose such a huge variety of conditions.

    The problem that I have had is that when my optician diagnosed something that warranted further investigation, it had to go through my GP. Not really a problem, but added paperwork and delay.

    • May 11, 2011 at 18:03

      I realise that GPs do insulate specialists from hypochondriacs which is an advantage but I still envisage a role for the GP but more of a role where people can ask them “Is this something?” and a sounding board like I use my parents who are both medically trained.
      If your optician knew it warranted further investigation, it shouldn’t have to go through your GP, your optician should have the power themselves. Likewise if you know you need a physiotherapist or an obstetrician, I don’t see the harm of being able to go direct and cutting out the middleman.

    • May 13, 2011 at 22:24

      @matthew I’m surprised that the optician couldn’t refer you directly as this is quite standard in many areas. Eg:

  2. Jon
    May 12, 2011 at 23:49

    Well, my Mum’s a physio and my brother a GP, so first I’ll take the side of the NHS: it might just be that you have a bad ligament and not a cartilage problem. The NHS also provides walk-in health centres, so it’s not accurate to say that it’s your GP or A&E that controls access (although of course it’s GPs at the health centre, too).

    But it does sound like either the Sports Injury Clinic should be able to send you for an MRI scan, or the GP should trust their judgement and sign it off. As important as it is that GPs filter out the time wasters, it should also be recognised that they are fallible. Individual GPs will be prone to be dismissive of complaints. It would make sense for something as common yet specialised as sports injuries to have an alternative access route.

    The challenge with opening up access will always be increasing cost. This is where reform becomes essential. If they simply said nationally that any sports clinic could send people off for MRI scans, then it would likely result in a huge cost burden. But at a local or regional level it would be easier to provide more flexible channels and still retain oversight to prevent non-NHS bodies from abusing the service.

    • May 13, 2011 at 00:47

      Both my parents are medical professionals. Most of my relatives on my father’s side are doctors as well.
      There may be ligament damage and immediately after that was probably the most likely thing or at least the most common thing. If it was a ligament then after a year it certainly would’ve healed and i wouldn’t be able to go on the tennis court or basketball court & bring the injury up again. Also if it was a sprain, it would feel like something been overstretched which has never been how I would describe it. Perhaps playing on it might make it hurt if it was a tear but that would’ve been far more painful at the time, far more than the niggling something that was there immediately. i’m sure and would have noticeably swollen up.
      There are things that don’t add up with it being ligament likewise things that don’t add up with it being cartilage which is why the 2 GPs in England didn’t think it was cartilage so I don’t know whats wrong but until there is an answer then not going to get the right treatment & because i played tennis on it then it may well have become a chronic thing.

      • May 13, 2011 at 22:29

        Dear Nicola,
        I’m sorry to hear about your problem with your knee and hope that it is resolved as soon as possible.
        There has actually been a trial to investigate if direct access to MRI for GPs changes outcomes, and it was conducted by some of my colleagues in Cardiff with others. It showed that referral for MRI vs direct referral to orthopaedics did not actually affect clinical outcomes- diagnosis and management- but it did make patients feel better, and hence improve their quality of life. This therefore made direct access to MRI a cost-effective treatment. You can read more here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576309/?tool=pubmed

  3. abetternhs
    May 13, 2011 at 15:10

    Dear Nicola,
    You bring up some really important points which I could not answer via twitter.
    Firstly the gatekeeper role and direct access to a specialist. I am a GP and see a fair few young french patients who are astonished by the fact that GPs rather than gynaecologists manage the vast majority of gynaecology, barring that which requires surgery. The UK system means that our gynaeologists spend more time doing the specialist stuff they were trained to do. The French system, recently reviewed in the BMJ is the most expensive in Europe and is unsustainable. Their solution? To improve and strengthen primary care.
    GPs are experts, we are trained speciaist GPs, not half-baked specialists. Just as a rheumatologist would refer to an orthopod or a physio, when a GP has reached the limits of their managemnt skills they ought to refer on.
    Having said that, in my experience musculoskeletal medicine is very poorly taught to doctors. Between specialist orthopedics and rheumatology lie the majority of musculoskeletal complaints. I have almost completed the diploma from the Society of Orthopedic medicine, so have special interest, but few GPs take this on, and the majority of students on the course were physiotherapists. There is a need to improve the training for GPs and conferences like this from arthritis research uk (which I am attending) go some way towards that: http://www.arthritisresearchuk.org/arthritis_information/information_for_medical_profes/shaping_the_future_of_musculos.aspx
    There is huge variation in the willingness of surgeons to operate, as demonstrated by Jack Wennberg, and thoughtless GP referrals and/or direct access to surgeons is very likely to lead to more surgery, but not necessarily better outcomes.
    Next there is access to MRI scans. GPs in my area have access and can usually arrange within 2 weeks. With reservations, I think this is good for patients. Unfortunatley they are often used to help reassure patients with backpain or headaches (which doesn’t work because the pain remains and the scans rarely alter management) Very few of the scans I have seen ordered for suspected meniscal tears have altered (conservative) management either. I do not use the word ‘hypochondriac’ to describe any of my patients. The most common reason for patients to attend is anxiety, be it of cancer or disability. It is so common, I think of it as natural/ normal, not hypochondria. It is the (difficult) job of a GP to help patients with that.
    Finally there is the lack of robust evidence for muscoloskeletal disorders. It is very difficult to find good evidence. Paul Ingraham is providing a tremendous service at http://saveyourself.ca/ @painfultweets on twitter, as is Neil O’Connell http://bodyinmind.org/topics/about/collaborators/neil-oconnell/ @NeilOConnell

    I am really sorry about what has happened to you. I hope I have explained why it is so hard to extrapolate from the specific to the general and I wish you all the best for your recovery, Jonathon

    • May 16, 2011 at 15:48

      You say there is a lack of evidence in musculoskeletal disorders but why? Its the system we interact most with. We need it to do just about everything. Have to say, it has always been the one part of the body that has most intrigued me especially how to get the most out of it.
      Surely the musculoskeletal system is the system that is most injured. Of course, I would assume that the most world class physios are working with the world class athletes in order to get the most out of them.

  1. May 11, 2011 at 13:55

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