Thirty pieces of silver

My practice has just accepted a bribe.

£10,000. No questions asked. All we have to do is agree to use the Clinical Advisory Liaison Service. (CALS).

That sounds good. We get a “service” and £10,000. What does using CALS mean? It means a new and “more efficient” way of referring our patients to our hospital colleagues.

There are two local orthopaedic surgeons who do hip replacements. The senior one is Mr Brown. He is well known. He has a merit award. The junior one is Mr Patel. He does not have a merit award.

When Dr Crippen has a patient who needs a hip replacement, he refers the patient to Mr Patel. He has never met Mr Patel, although he has talked to him on the phone many times. The patients who see Mr Patel comment on how kind he is. After their operation, Mr Patel goes to see them personally before they are discharged. His wound infection rate is low, much lower than the national average. His complication rate is low. Mr Patel has a large private practice (and Dr Crippen sends him a lot of private work) but he still gives his NHS patients a square deal. Occasionally, Mr Patel phones Dr Crippen to tell him that there has been a problem with patient X or Y and to advise on follow up.

When Dr Crippen needs his hip replacement, he will be going to see Mr Patel.

Mr Brown’s NHS waiting list is shorter than Mr Patel’s. His complication rate is higher. His wound infection rate is higher. Dr Crippen knows that if a patient has been treated by Mr Brown it is likely that there will be problems. Mr Brown does not visit his NHS patients after surgery. He lets the juniors do that. He also phones Dr Crippen, but only to discuss the private patients. Dr Crippen has met Mr Brown several times, because Mr Brown makes a point of coming down to Dr Crippen’s practice on the pretext of talking about this, that and other. And he always leaves his card with the number of his private secretary. Mr Brown is a member of the local golf club and is a Mason. He networks seamlessly with the local great and good.

Dr Crippen does not refer patients to Mr Brown. He suspects that Mr Brown does not wash his hands properly. When patients specifically ask to be referred to Mr Brown, often because they have met him socially, Dr Crippen politely refuses and directs the patients to Mr Patel.

Dr Crippen is a discriminating and educated consumer of specialist medical care.

None of this information about Mr Brown and Mr Patel is available to the public. Indeed, as Mr Brown is the more senior, and has a merit award, many conclude he is better. He is not.

Under the CALS system, Dr Crippen will no longer have a choice of consultant. All GP referrals will go to a central office for “processing”. The decision as to who the patient is seen by will be made by a PCT bean counter who will direct the patient towards the doctor with the shortest waiting list.

It gets worse.

The CALS mission statement is to reduce the cost of “unnecessary” referrals from GPs. This means that the bean counter may decide, and is authorised to so decide, that the patient does not “need” to see a doctor at all, but can instead be dealt with by a “nurse-specialist” or one of the many other plausible amateurs who now front-end the health service.

CALS is a cost cutting exercise, masquerading under the guise of “greater efficiency”. It purports to offer "advice". In reality it is yet another control mechanism. It will remove the GP’s autonomy to advise patients on the best specialist care. At the moment CALS is not compulsory, but GPs are being offered cash incentives to use the system. Once enough have signed up, it will become compulsory. This is the same strategy the government is going to use to foist identity cards on an unsuspecting public.

Is there any hope? A little, maybe.

The government’s Stalinist obsession with centralised data means that CALS has its own new computer system which, to date, is a disaster. See the report from North Oxfordshire MP Tony Baldry here.

And CALS is incompatible with the patient choice allegedly offered by “pick and mix”.

Dr Crippen fears however that CALS will survive and triumph. Choice of specialist will be restricted to the private sector. Rather like the eduction system.