Saturday, 3 January 2009

NHS Management and how it pays GPs not to do work

(This piece was inspired by the stories towards the end of last year of GPs being paid not to refer patients and is provided as an example of how this stupidity comes about in one part of Northernshire).

ND and the team are constantly frustrated by the ability of NHS managers not to use what they have already got and waste NHS money in doing so. If they were standing in the middle of the Kielder forest, an area of 250 square miles of forest in Northumberland, you can bet your bottom dollar that they would be holding meetings to increase the number of trees planted around them as their reports show them there are none. There would also be a sub committee reporting on the lack of water in that area as well.

This is the same with minor surgery provision in one part of Northernshire. For individual surgeries there is a fixed local Politburo or PCT pot of money to pay local GPs to do a fixed number of minor surgical procedures per year. This lasts about 3 months per practice before it runs out.

In today’s modern NHS everything has a cost so GPs have essentially 3 choices when the money runs out. They could:

1) Stop doing minor surgery
2) Continue to do minor surgery by funding it themselves
3) Refer all minor surgery to the local hospital.

Given that most GPs run businesses then to a rational businessman option 3 is the only viable option.

After a few months the local Politburo managers notice that referrals for minor surgical procedures go up. They wonder why and have lots of meetings to figure this out. Of course the root cause must be the GPs so they devise a Practice Based Commissioning (PBC) plan that will reward GPs if they cut the number of referrals for minor surgery.

In other words if GPs don’t treat their patients, by not referring them to a hospital for minor surgery, they get paid to do so because the PCT saves money as it does not pay the hospital for the minor surgery which costs the PCT more than if the GP were to be paid directly to do the surgery themselves.

So the solution to too many patients needing minor surgery is not to use the redundant capacity in general practice to do the minor surgery, by paying them to do it, the solution is to pay the same people who could do the surgery to not refer the patients for the surgery.

Logical is it not?

You have a redundant solution to a problem available so you pay the solution not to solve the problem.

This is how local Politburos reward their GPs for not referring patients. It is a bit like the EEC paying farmers not to farm. This may seem daft but if there is over capacity there may be some sense in it. However, when there is a shortage of the product, then this is daft.

Excess grain can be easily stored but unfortunately excess illness does not go away so quickly. It has a habit of moaning to GPs who will usually refer in order to sort the problem out (that is after all what we are trained and paid to do). In this case the GP gets paid to do the referral under his normal contract but does not earn extra from the local PBC plan because admission rates go up.

In this case the patient gets their treatment albeit at a wait. The Politburo thinks it has won (because it hasn’t paid the GPs to do minor surgery and it hasn’t paid them for reducing admissions) but dear readers there is another way of looking at it.

The Politburo has in fact lost because it is paying over the odds for it to get the surgery done at the hospital and it has failed to meet its own PBC plan. It has also spent lots of new money building new health centers with specially equipped operating theatres to do the minor surgery that it won’t then pay for.

So NHS managers often stand in the middle of a forest not seeing the trees but planning on ways to increase tree capacity and paying people not to make trees.

If you read this last sentence and think this is stupid then you are normal. If however you read it and think it is all common sense then please apply at once for NHS management. They need you.

Praise be to the Party and its ever wise managers who achieve so little by doing so much at our expense. They also can’t see the trees around them or the solutions to the problems they engineer.

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