Dr Jacky Davis: “It is inconceivable that we will all sit back and watch our NHS wantonly destroyed.  We must make it clear to coalition politicians that we will not forgive their anti-democratic behaviour. There are more than a million people working in the NHS; our votes and those of our friends and families will be used to punish the politicians responsible for this, both locally and nationally. We must also hold Labour to its promise to reverse the legislation when it is back in power.
The fight must go on in other ways too. Many groups have woken up to the dangers of the health bill and joined with campaigning organisations against it. Public health doctors, medical students and patients have all organised to protest and these groups can work together in future. There must be some sort of public statement, possibly a high-profile conference, to decide the way ahead and it must be made clear to politicians that the fight is not over.
We must monitor the changes to the NHS once the legislation comes into effect. By its very nature it will be increasingly difficult to know what is going on, as the service fragments and financial dealings and patient outcomes are lost behind a convenient curtain of ‘commercial confidentiality’. It is essential that we keep track of the bill’s effects if we are to show we were correct in our predictions of its dangers. The coalition will certainly not be telling us about the problems that arise, their predilection to massage the truth being only too apparent in their introduction of the bill in the first place.
Finally, we need an urgent inquest into the abysmal failure of medical ‘leadership’. Early and united opposition would have seen off the bill long ago. Instead our leaders, in trade unions and professional bodies, saw ‘opportunities’ and decided they could work with it on our behalf. When they were finally persuaded to see the dangers, their policy changed to seeking ‘significant amendments’, despite the fact that the government showed no sign of conceding any.
Few organisations conducted a proper campaign, even after being mandated to do so. The leaders of the professions were only moved to opposition after internal struggles and grass-roots organisation. They have not represented their members. They must be held to account for their failure and the whole structure of representation needs critical examination.
In sum, we will need a combination of actions such as continuing media coverage, evidence about the detrimental effects of the bill, protests, occupations and perhaps a refusal to co-operate with the legislation – for example, a boycott of the private sector. This battle may be over but the war is just beginning.”
Jacky Davis is a consultant radiologist and British Medical Association council member. She is writing in a personal capacity

Jonathon Tomlinson: “The first priority must be to protect patients, in particular those who are least able to articulate their needs or access care. The health bill is intended to convert healthcare and patients into commodities. GP will be pitted against GP and hospital against hospital, vying for patients. Patients will be expected to compare GPs and hospitals in league tables and shop around, competing with each other for increasingly limited resources. Hospitals will be allowed to succeed or fail according to the values of the market, irrespective of patient need.
Since it is far more efficient and profitable to care for people who are motivated and able to care for themselves, it is those patients who are lacking motivation and ability who will be the first to suffer. Services for people with mental illnesses, dementia, drug addiction and language barriers are being cut first because those who depend on them are least able to complain. We will need to take urgent action to protect them. ‘Occupy Healthcare’ as a movement will exist to show that healthcare for vulnerable people cannot be run according to the same business ethics as industrial healthcare. Day hospitals will need to be occupied. There is now a daily picket at the gates of Chase Farm Hospital to keep it open, with a view to occupation to prevent the closure of A&E and maternity.
The NHS has entered the political consciousness of the public more than at any time since it began. One urgent need is for all of us to get involved with the new democratic structures, however toothless they may seem. These range from patient participation in GP surgeries and GP commissioning groups, and membership of Health Watch and health and wellbeing boards to standing as non-executive directors at foundation trust hospitals and so on.
Finally, we have to reject industrial healthcare. It is unsustainable, unhealthy and immoral. It’s time to bring humanity and sustainability back to the NHS.”
Jonathon Tomlinson is a GP in Hackney.

Nevertheless, what Henry really wants to talk about is his son, just out of prison on a methadone script and looking for rehab. I was hoping to discuss Henry’s worsening renal failure – a consequence of his uncontrolled diabetes and high blood pressure. His wife wants to talk about his depression and worsening memory. The jar of bloody urine stands on the desk momentarily stalling any conversation while we sit waiting to see who will speak first and about what. Nine minutes remain of the ten-minute consultation.

General practice has developed during the past 60 years of the NHS to allow GPs a monopoly over the provision of primary healthcare. Because of this we are able to develop lasting therapeutic relationships with our patients that can extend over lifetimes and generations. It is possible for me to look after Henry and his wife for the rest of their lives, guiding Henry through what will, quite soon, be his final illness, his wife through her bereavement and their son through his drug detox and subsequent relapse.

The long-term relationships that GPs have with our patients result in continuity of care. This allows us not only to manage ongoing ill health, but also to be prepared for serious illnesses. How Henry might react to a diagnosis of prostate or bladder cancer and how we might then manage it cannot be understood without knowing about how he has managed (or failed to manage) his diabetes; how his wife aids him and helps with his medication and appointments; how his depression affects his behaviour and how the chaos and distress their son brings affects them all. A familiarity with the latest guidelines for managing haematuria is essential, but negotiation and adaptation are essential if I am able to help Henry.

I’ve decided to focus on the bloody urine for now, but take time to arrange to see his son 15 minutes before my Thursday afternoon surgery (I’ll be glad of an excuse to miss the end of the meeting in which various imaging corporations pitch their services.) I send an email to our practice nurse to ask if she can fit him into the next diabetic clinic before bringing the conversation around to the jar in front of us. Six minutes remain.

I test the urine sample and decant some into specimen pots to check for cancer cells and infection. I ask about other symptoms and perform a physical examination. My ten minutes are up, but he still needs a referral. At the heart of the coalition government’s ideology is ‘patient choice’, so instead of referring Henry to the local hospital, I am obliged to spend valuable time guiding him through a range of private and voluntary providers offering services for his bloody urine.

Meaningful choice needs to be informed and considered, but Henry doesn’t know what most of the 14 tablets a day he takes are for, he can’t recall whether his blood pressure is too high or too low and he only comes to appointments if his wife reminds him on the day. Usually when I ask him why he has come to see me, he says, ‘I don’t know, you’re the doctor!’ In so many ways he is like my own father who, despite being considerably more affluent and educated, is equally ignorant of his treatment, happy to trust his GP and my mother ‘to worry about all that’.

The new commissioning organisation has made the job a little easier by restricting us to a short-list of ‘approved, value-for-money providers’. The provider I believe to be in Henry’s best interests – the local hospital – is not approved but may be ‘negotiable’. Negotiation will involve spending valuable time writing letters trying to convince the commissioners that because of Henry’s depression, diabetes, renal failure and long history of missing appointments he needs to have his care there.

Unfortunately I later discover that the urology department has been ‘decommissioned’ for being too ‘inefficient’. The ‘one-stop’ heamaturia clinic has become ‘two-stop’ because a private company has the contract for day surgery and the cystoscopies (bladder scopes) are being done at another hospital, while the local operating theatres are concentrating on more profitable gynaecology. I no longer know what is in Henry’s best interests.

What Henry wants, and more importantly needs, is to be looked after, but he’s told he must ‘take responsibility and choose’. As his advocate I must help him choose and also fight to keep the services he needs. As his GP my days may be numbered. More efficient providers will move in to provide convenient care for young healthy people who will choose not to spend time waiting to see a doctor whose clinics run late because of complicated patients like Henry. Instead of waiting, they will register with Virgin, or any number of competing providers who know healthcare is most profitable when the patients aren’t really sick.