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A letter from Sussex Place, August 2011

Richard Warren, Honorary Secretary, writes....

Whilst representation and governance within the College, and the future working life of consultants, are ongoing issues for RCOG working parties, it is the NHS that continues to make the headlines; a huge strapped for cash organisation that is demanding more for less and no one quite knows how this will be achieved.

We have, over many years, witnessed huge changes in NHS healthcare service delivery but I continue to wrestle with a recent one, in particular, “choice”. Not that I don’t agree with the principle.

Most people, when they, or one of their families, are ill, want the best quality care, delivered by a skilled and experienced clinician, as close to home as possible. However, I believe that present healthcare changes are restricting rather than enhancing choice. Besides, is choice truly beneficial to an individual and or healthcare system?

From the care received following a routine gynaecology referral through to a caesarean section without medical justification what is choice?

It is easy to support the concept of choice, the option of choosing your preferred centre, preferred clinician and personalised treatment, but very difficult for the NHS to make provision to match the expectation. Not every local centre can have the facilities for expensive, state of the art treatment and how does a patient know the attributes that allow a considered, fully informed, choice? The new “choose and book” system operating locally, to me, in East Anglia encourages a convenient appointment to be made but does not allow referral to a specific consultant. “Dear Colleague” letters are now the norm and when the patient requires, or chooses, surgical intervention the permission of the PCT is required; but the PCT does not allow choice as the justification! In an increasing number of cases, therefore, despite a woman and her specialist having considered all the issues, the final decision lies, through another bureaucratic process, with the commissioners whose present priority puts finance before choice.

What about a woman’s choice to request a caesarean section when she is fully informed but there is no medical justification? Here, both medical and financial arguments may exist but the patient may choose to the contrary – perhaps following a previous bad birth experience about which she struggles despite reassurance. The NHS doesn’t promote the concept of “modified choice” but arguably in many areas the NHS is trying its best to curtail such choice. The result is a populous with high expectation of choice but increasingly being told what care they will receive. It is the clinicians who have to explain such limitations and it is often a struggle.

The new RCOG Ethics Committee under the Chair of Dame Susie Leather, Chair of The Charity Commission, has just held its first meeting. I was privileged to attend and was enthused by the discussions. The issue of surgery without medical justification surfaced as an area where, I suggest, guidance could be well received. Does a patient have the right to demand treatment or a doctor the right to refuse? What are the arguments for and against these “rights” and how is it best to handle the dilemma in an all too common clinical situation?

So as time goes by these weighty questions will be considered further and the NHS will try to balance its books. But for now, it is important to consider other things. After a lovely spring, August is here (and it is less than a year to the London 2012 Olympic Games) and with it, so far the English weather has been as variable (= bad) as ever. Never mind, there is always sport! The Irish seem to have the best golfers and over the next few weeks the test match series against the Indians will arguably decide which test team is the best in the world. For those who are following the series, the run out and reinstatement of Bell in the second innings for England has shown sport at its best. It was a magnanimous decision, as he was certainly out, that has surely reinstated belief in the phrase “it’s just not cricket” and putting the game ahead of most others in moral principles. Well done to the Indians.

To those in the northern hemisphere I wish you a good summer and, for those in the southern hemisphere, an easy winter.

I will be back with you again next month, sadly for the last time as Honorary Secretary.

With very best wishes

Richard Warren
RCOG Honorary Secretary

If you have any comments, please write to letterfromsussexplace@rcog.org.uk