The callous disinterestedness of the NHS
In the last month I've been out ‘on the road’ for three days observing sales representatives selling into the NHS. As with any sales job the days are long and usually frustrating. Busy doctors are always cancelling appointments. The rest of the time gets filled with the strange burden of minor expectations that health care professionals, from the most senior doctor to the student nurse, have of the pharmaceutical industry. Branded pens and Post-It notes have been banned but the ‘drug rep’ is still the conduit for funding for educational meetings here and abroad and for sandwiches (“We prefer a selection of wraps from M&S”) at least once a week.
What struck me hardest was the visible level of stress being carried by every NHS employee. It had been a couple of years since I’d been out in the UK system and I was surprised by the universal interest in the price of the drug being sold. Once upon a time only pharmacists and payers bothered to discuss cost; doctors and nurses didn’t sully their minds with such mundane financial matters. But last week I watched a junior nurse, who is years away from prescriber status, quiz the rep about the comparative cost of rival treatments. The nurse didn’t seem to be aggressive or point-scoring nor was he being clever for the sake of it; he just saw it as part of his job to understand the treatment options from a financial as well as a scientific-clinical standpoint.
I can’t think of another government department anywhere in the world where cost-consciousness pervades so thoroughly through the hierarchy as in the NHS. Of course everywhere there are low-ranking teachers, police and perhaps even soldiers who are aware of their departmental budgets but not so consistently across an entire system. By some counts the NHS is the second largest employer on the planet and every one of those employees has been trained to count the pennies.
The taxpayer in me supposes that this is a good thing but I'm also sure that this cost-consciousness contributes significantly to the stress levels I saw in English hospitals. No one ever went into the caring professions because they enjoyed the budgeting process yet this is now a substantial part of the job.
The reps I shadowed were selling expensive drugs. This is true by definition: the only cheap drugs are ‘off-patent’ and so with insufficient margins to justify the formidable expense of a sales team. With the NHS set up the way it is, any conversation with a drug rep is going to end with him asking for something that is difficult financially. The medicine in question may amount to a revolution in the fight against a given disease but the health care professional is still left with the same old zero-sum game: -
I cannot treat any patient as well as I would like to treat every patient
This has seeped into the organisation’s DNA. Last year when the new Coalition government announced its Cancer Drugs Fund (CDF) the idea was for doctors to stop acting as financial comptrollers and get back to practicing medicine. Yet the initial budget of £50,000,000 for the first twelve months will be underspent by a considerable margin. This is not because Britain doesn’t have enough cancer sufferers to justify the money but because doctors across the country are genuinely suspicious about the long-term consequences of adopting newer, more advanced treatments in case the funding is later withdrawn
I've sat in on those sales calls. I've seen doctors agree that there are patients under their care who would benefit from the drug in question. But when the CDF is mentioned I've watched them narrow their eyes and ask for assurance that they weren't being tricked into changing their practice in an ultimately unsustainable way. The logic being that it would be better to deny all current patients a better treatment if future patients would be denied it also.
At the heart of the global financial crisis is the dawning realisation that for the first time in centuries we have to accept that future generations may lead less happy lives than us. We are faced with the fact that the constant improvement in general wellbeing that the West has enjoyed since the mid-18th Century is not inexorable. If you work in the NHS then every day you're learning this unpalatable truth first hand: Britain cannot afford to keep offering every citizen continually improving health care.
By God that’s a stressful way to work.