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Gluten-free gruel

Still practising

Chris Preece

Thursday, 30 March 2017

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rice porridge_shutterstock_594001430.jpgWith a rare lack of foresight, Charles Dickens never quite informed his readers of the precise formulation of gruel issued up to Oliver Twist. There are, apparently, many things you can make it from, rice, oats, or wheat. In a further insult to tired blog writers, Dickens didn’t bother to record for posterity whether Twist suffered from coeliac disease – though, given Samuel Gee wouldn’t bring the disease to the attention of the modern world for another 50 years, I suppose I can allow him a bit of slack.

Still, let’s presume for one moment that Oliver had been enjoying some sort of delicious gluten-free gruel. Thanks to the latest announcement from NHS England that they are considering withdrawing the provision of gluten-free food on the NHS, poor Oliver will once again find himself rejected when asking for more. (Yes, that may win a prize for most convoluted shoe-horning in of Oliver Twist in history, but I couldn’t get his grubby plaintive face out of my mind when considering this subject.)

The announcement comes, as they seem to do with depressing frequency these days, via an interview given to The Daily Mail by Simon Stevens, chief executive of NHS England. The interview seems to have been a sort of warm-up act for the roll out of the “NHS Delivery Plan” on Friday, presumably to allow the headlines on the day in question to focus on the savings to be made through the power of STPs and magical thinking.

Nonetheless, it’s sort of reassuring to see what is, at its heart, the beginning of a conversation about rationing the NHS being conducted at a national level, rather than in random pockets up and down the country. (My own local CCG had already banned the prescribing of gluten-free products – partly after failing to get support for a voucher scheme – and has now graduated to more strident healthcare rationing, such as not allowing any surgery for patients who might have looked the wrong way at a cake.)

Stevens names ten initial products in his hit-list, from the afore mentioned gluten-free goods, to fentanyl, co-proxamol, travel vaccines and the somewhat ill-defined “rubs and ointments”.  Some of these make lots of sense, and are already things we’re discouraged from prescribing anyway, others less so.

What’s particularly unclear is what the additional costs might be to doing this. Most of those people currently taking these drugs are going to need further consultations to address an alternative. Those who are taking “rubs and ointments” that arguably fulfil little more than a placebo function are, in all likelihood, going to want to talk to a doctor about replacing that placebo with something.  (Just because it’s a placebo, doesn’t mean it doesn’t make them feel better…)

Still, some may well work the other way, actively reducing consultations. This seems to particularly apply to the items he wants to look at next – drawn, like the first list, from recommendations by NHS Clinical Commissioners. These he describes as “medicines for upset tummies, haemorrhoids, travel sickness, indigestion…” whilst suncreams, and paracetamol also seem to be in his sights. The aim here is clear – partly it’s to reduce the ridiculous conundrum by which it costs the NHS significantly more to issue a packet of paracetamol than it costs a patient to buy it over the counter, and partly it’s to encourage people to visit their chemist for solutions to these problems instead. In an ideal universe, it could mean less costs to the NHS and less demand on primary care.

Except, and here lies the rub, how many of these people can afford it? At the end of the day gluten-free products are, still, significantly more expensive than their gluten-filled counterparts. So yes, whilst it irritated me that we were handing over vast quantities of bread to people pulling up to the surgery in fancy cars, it equally worries me that we now have patients with coeliac disease who tell me they can’t afford to buy gluten-free and are suffering as a result (and doubtless drawing up a future bill to fix their osteoporotic fractures in the future). Equally, whilst I agree most people travelling abroad can afford to buy their own vaccinations, has anyone sat down to work out the cost of treating them if they come home with something “interesting” that they picked up on holiday because they didn’t fancy paying for a few jabs? (I’m always amazed at the numbers who travel without insurance, I’m guessing just as many will forego vaccination if it means denting their holiday fund.)

Never mind. As I said before, it’s good to get some honest discussion going about the need for rationing. Merely raising the subject is a clear indication to the public that ‘We Can’t Carry On As We Were’. Except of course, it’s not that honest a discussion either. To begin with, they haven’t announced a decision. They’ve announced a decision to have a consultation – which is NHS management language for “we’ve decided to say a thing, and see how much abuse it gets before quietly forgetting it again if necessary”.

More to the point, there’s the saving that this will bring. Stevens’ initial 10-item hit-list is quoted as saving the NHS £128 million a year. Now that’s a number that looks pretty good on paper, but pails rapidly when compared with the £886 million deficit posted by NHS Trusts alone at the end of the third quarter of this financial year. More hysterically it’s less than half the £350 million that Vote Leave promised us would be coming to the NHS once we left the EU. If they’d kept their promise we could have let the coeliacs eat gluten-free cake.

As it is, in reality, any savings from this rationing of care is likely to be pretty minimal. We’ll see what other solutions NHS England produces on Friday, but I think we can safely predict it will consist chiefly of bureaucratic reshuffles, more consultations, a little bit of rebranding and a whole load of gobbledegook. Meanwhile, the deficit will continue to grow, and the strain on the NHS will remain unbearable. 

As the situation gets more desperate, the rationing will become more pronounced, whether it be honest, and nationalised, or quietly rolled out in CCGs up and down the country as it is now. In any case, very soon we’ll all be doing our best Oliver Twist impression.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.

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