09-May-2011 – NHS REFORMS From An Informed Opinion


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challenged by this comment in red below a friend of mine married to an NHS Doctor checked and ammended his opinions in the light of both his and her opinion and experience.

The NHS needs a good shake up. Problem is, I suspect its as much about money and targets as it is about ‘don’t care

If the public knew how true that is, politicians would ALL be swinging from lamp posts.

I know one GP extremely well (have done for nigh on 31 years). Her practice is inner-city, predominantly immigrant, and very high on the deprivation index of same. Targets are the bane of her life, as is a meddlesome, politically-driven Primary Care Trust (PCT).

She has the ‘wrong’ sort of patients, so for three years prior to this one she’s had a pay freeze. This time it’s a pay cut (can’t do that to the staff, as they have NHS-determined rates). She’s also doing substantially more hours (nominally 3/4 time, actual hours about 40/week over 4 or 5 days depending on clinic patterns).

This is because they can’t afford another salaried GP, and, when one partner recently retired, they had no applications for the salaried (i.e. income-protected) job. Yup, that’s zero, zilch, nada, none at all. Nor can they recruit a Nurse Practitioner, and at least one other local health centre has had similar problems. Neither can recruit additional GPs, as apparently nobody wants to work there.

If you think that’s surprising, in view of the megabucks GPs are paid, read on…

Many simple things about the NHS are stupidly broken: discharge letters from hospitals, containing the details of treatment and instructions for follow-up care, arrive as physical paper letters: my daughter has a Saturday job scanning them into the practice system! The doctors still can’t get at all the test results from all the local hospitals on-line: most of them sometimes, some not at all. The systems linking the NHS together are terrible, and hospitals’ own records are inconsistent, and often chaotic (they don’t tell you that in the clinics or the X-ray departments!).

The ‘choose and book’ system for arranging appointments is a disaster. Hospitals block-out large amounts of clinic time, and the metrics are such that, once you’re on a waiting list, you are already counted as ‘dealt with’ (or something like that), and actually not on any waiting list for statistical not-meeting-our-targets measurement purposes. Bizzarre, dishonest, and wholly true.

I’m in IT (sort-of). All the GPs in this area have their IT provided under ‘contract’ from their PCT. The service standard is truly pitiful. In the past few years they have gone for days at a time without working computer systems in the practice. Given earlier NHS campaigns for ‘paperless’ surgeries, imagine the ‘fun’ that causes.

Patients could be forgiven for not understanding the reasons and being cross (hell, the doctors don’t understand the reasons!), but that does nothing to help GP’s stress levels, nor fix the problems. If my company served our commercial clients the same way, we wouldn’t be in business any more. The contract is effectively a monopoly – GPs pay, but have no real say in the service level provided. For those in the know, XML and PGP encryption (which would probably sort out the hospital connection in short order) might as well be the Enigma codes.

Whoever runs the NHS’ IT departments certainly doesn’t do so in the patients’ interest.

[Personal disclosure: we’d like to bid for local IT support contracts. We already have several in private healthcare and our customers are, generally speaking, delighted with us. We can’t get a foot in the general practice door though, as the PCT IT structure is incestuous, defensive, and behind the ‘firewall’ of public sector commissioning, meaning in practice small businesses can’t get anywhere near it.]

Regarding the PCT’s other management gaffes, there are endless anecdotes about their meddlesome ways. The most recent spectacular example of waste locally was replacing all the health centre carpets (the place is only about 5 years old!) with lino, as carpets are ‘unhygenic’ in consulting rooms. The facts that, 

(a) it cost a fortune, 
(b) the patients feel much less stressed in a room with carpets (wot, really?), 
(c) the carpets didn’t need replacing, and
(d) the GPs protested (in writing) and were ignored, tells you everything you need to know about the PCT’s priorities.

Now the coalition, in essence, wants to add financial responsibility for hospitals (through ‘commissioning’) to GPs’ already overloaded job description. Why? Follow the money trail:

GPs have already been a convenient ‘aunt Sally’ for politicians. They got a half-decent income settlement from Blair’s last administration that went some way towards stopping the brain-drain. Ever since, successive governments have tried to claw it back, labelling GPs as ‘greedy’ and money-grabbing.

Chance would be a fine thing! There must be greedy, very wealthy GPs somewhere, but I’ve never met one. Her accountant takes home far more than she does, as do the lawyers they so often have to employ these days (employment tribunals, patient complaints and so on. They’ll need one on the staff eventually!). Don’t even ask about management in the local PCT (there’s a surprise!) — oddly, they don’t have any trouble recruiting.

If you don’t want clever, effective doctors, don’t pay ’em. The existing ones are obviously greedy and a bit thick, but don’t worry, they’re beginning to take the hint…

She already has to manage her imposed and artificial drug ‘budget’ (need an expensive drug? Fergeddit!), and will shortly also be funding some care delivery such as the treatment room staff. The budget transfer from the PCT for that function is estimated at 40% less than the PCT spends on it now. Go figure that one!

Nominally, the practice operates commercially as contractors to the NHS. In reality it’s a fantasy world of statistical targets (with financial penalties, etc.), ‘funny money’ (part-subsidised, no-choice services from the PCT, such as the dreadful IT), ordinary partnership accounts (for the Revenue), odd things like NHS pensions provision and staffing rules, pay grades, and so on.

It’s contract service provision, but not as we humans know it, Jim. The commercial world of TAC (total absorption costing), cost centres, budgeting and so on, doesn’t apply. It’s so muddled, I doubt anyone could measure efficiency in any meaningful way, nor say where money is being wasted (except perhaps the carpet suppliers!).

She’s already beginning to talk wistfully about early retirement, or a career change.

Given that reform of the NHS is obviously a priority. The question, for me, is this: Do you want your GP worrying about their nominal hospital budget when they should be finding your tumour, or would you rather the system was run properly in the first place?

Don’t blame the doctors for being human. They’re struggling to be professional in the face of a bl**dy huge, overbearing, expensive and self-serving bureaucracy, that sits like a fat leech on the back of the NHS where it can’t be touched. “No cuts to front-line services” is code for “We’ll dump the blame on the one group of professionals who can’t/won’t fight back”.

The person I know very well prides herself on spotting odd, life-threatening and difficult to diagnose things. She has twice had people drop dead in front of her whilst at work (and actually saved them through CPR – don’t think it’s like ‘Casualty’). She spends hours listening to people’s problems, and visits patients in her free time, presumably because she cares. But she shops at Asda and can’t afford to replace the 9-year-old car.

She tells me she didn’t qualify as a doctor to fight bureaucrats about the carpet in her room, nor to have to log onto the PCT system from home to stay on top of bureaucratic emails (no time in the surgery).

But she’s not superwoman either.

If you want it fixed, go deal with the politicians that caused the mess in the first place. Someone actually voted for Andrew Lansley, but I wonder how many of his constituents actually checked him out first, to find out what he was competent at, and how good he’d be in government.

The one thing about the present generation of politicians is that it’s their job. They do care if they lose it, because they’re otherwise largely unemployable. So we do have leverage, if we use it properly.

Other countries view MRI scans as cost-effective (i.e. cheap) diagnosis tools. Here, although we actually invented the things, we ration MRI time, and rely on charities to supply the machines. It’s beyond ridicule.

You can’t blame GPs for this, but you might, just, fix the people causing the problem in the first place, namely the incompetent and self-serving politicians.

Rant over. Sorry for taking up your time.
I am happy to publish my friend’s opinion as it is a considered view point that needs airing, that does not however mean I endorse his comments and some I profoundly disagree with.
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