Leading Article: Cherry-picking fails the 'difficult'

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THOUSANDS of patients have been struck off doctors' lists against their wishes, the Association of Community Health Councils says in its report today. Once removed, they find themselves reluctantly passed between practices. Meanwhile, scores of children are being excluded for months, sometimes years, from school with little or no educational provision. It seems bizarre. The National Health Service is meant to be freely and easily available. Young people are supposed to receive primary and secondary education. Surely, these are articles of faith in this society?

Yet reality does not always live up to the promise. Indeed it never did. Since the NHS was created, homeless people, alcoholics and drug addicts have had problems finding family doctors. Disruptive, demanding and sometimes insulting, they can be unattractive company in the waiting room. So they have often been quietly cold-shouldered. Similarly, the most difficult children have had blighted, fragmented educations and been transferred from school to school. Swollen prison populations testify to longstanding failure in both systems.

But ministers must recognise that unless markets are carefully designed, they can make matters even worse for pupils and patients who fail to fit the norm. Under local management, school funding reflects the numbers of pupils attracted. Troublesome students damage league table results and put off parents. Little wonder exclusions have increased. Such pupils are more bother to schools than their funding makes them worth.

Thirty per cent of general practices now manage their own funds. If they underspend, doctors are entitled to reinvest savings in their practices. So they have a fresh incentive to 'cherry-pick' relatively healthy, trouble-free folk and remove the expensive ones.

Of course, neither teachers nor doctors have suddenly become money-obsessed entrepreneurs. Most strive far beyond the call of duty even for offensive pupils and patients. But if they receive insufficient support with the hardest cases, pressure on time and nerves may tempt them to give up trying. If special needs provision is relentlessly cut back, disruptive pupils destroy the harmony of classes. If doctors have too few community nurses they are unable to cope with mentally ill patients and the chronically sick who haunt surgeries. Markets in public services could work wonders for improving value for money. But these do remain public services: welcome improvements in cost-effectiveness must not be secured at the price of excluding the most difficult cases.