One of the great flaws of the current and those of the last 20 or so years of healthcare policy in the UK is the concept of a “market”.
To simple grunts in the field the idea of a market boils down to consumers who can spend as much or as little as you want and get as much or as little of a product as you can afford depending on your means and what is available something called “Choice ®™”.
When the consumer pays nothing to get a service where is the market then?
In Northernshire if you want food there are a variety of outlets, or “providers” in NHS manager bull something speak, of food which will happily take your money, small amounts or large, and provide you with a product which may, or may not be, good quality depending on your personal “Choice ®™”.
In healthcare the local provision of services is less than that for food products and we will confine our arguments to conventional medicine rather than alternative (quack) medical provision. Locally most people have only one “Choice®™” that of the local NHS but there is an alternative called private medicine.
This is (freely?) available to those who wish to spend their own money, the minority, but some of our patients do exercise their own genuine financial free(ish) market choice, but most do this via medical insurance taken out either by an individual or provided by their employers as a perk. As such the concept of a market is limited in healthcare due to its specialized nature and limited number of suppliers (sorry any willing providers).
A bit like the aviation industry where if you wanted to buy a large passenger jet capable of flying from London to New York you would find only a few people able to provide you with this service but a ham sandwich would be much easier to find locally and cheaper too.
The NHS internal market is a true invention of the former Soviet Union for it fixed prices via the central controlled Party NHS Tariff. So if you had your appendix removed in Newcastle or Exeter the cost was the same and hopefully the outcome was the same to the patient who paid the same price for their treatment which was absolutely nothing.
So the NHS consumer is not inconvenienced by price which has an inevitable effect on demand as per any simple supply and demand curve. This simple concept is alien to any NHS manager for any excess use of the NHS is the result purely of GP failings and not as a result of NHS freedom, both politically and financially, of NHS “Choices ®™”.
The price is fixed, as is the market by the Party, and as no-one pays up front where is the NHS “market” internal or otherwise?
If Joe the Plumber wants a steak he chooses his supermarket, or butcher, or restaurant or pub and he goes in and pays for it. If Joe wants more steak he pays more for it. If Joe wants his appendix removing he goes into any hospital he chooses in the NHS and pays bugger all. If Joe is a hypochondriac he pays bugger all too and can abuse it without fear of sanction due to the freedom that is NHS “Choice ®™”.
If the price is fixed by the Party in order for a free market to make a profit on a procedure something has to give. A straight forward appendicectomy should involve certain fixed costs which may vary slightly due to local variation in costs. If the aim of a market is to make profits then if prices are fixed something has to give in order to generate profits. If all prices are fixed via the Party, Soviet style, what can give in order to maintain free market profit?
Quality of course.
So a couple of articles show that the old Party and the New ComDems are so dissimilar they are almost the same and equally deluded regarding any real market in UK plc healthcare aka the NHS.
Commissioning is not about market forces for prices are fixed it is about creating an unnecessary management structure to ensure that “quality” is provided from a fixed price structure and this is ultimately a case of the law of diminishing returns.
Someone has said that you do not need commissioning in healthcare if the cost of a procedure is fixed. You do not need 220 page contracts for NHS provision of any service for which wherever you go in England you will pay as the consumer the same. Nothing.
Anyone else twigged what commissioning is actually about?
This concept has failed in times of plenty and now is being reinvented in the times of lean.
And guess whose fault it will be when it goes belly up? Not those who invented this smouldering pile of intellectual dung but those that they have chosen to implement their 20 years of failure via the free “Choice ®™” so beloved of their Soviet styled predecessors. And those who will suffer will be those unfortunate enough to use it - our patients.
ZaNu Labour, ConDems and the market. Anyone spot the difference?
Or is it a case of ZaNu Labour reinvents the failed market of the Conservatives and ConDems it to the failure of the NHS and it is all the GPs fault for they were given the NHS "Choice®™" (coming soon to a surgery near you) called Hobson’s choice to do GP led commissioning?
Praise be to the Party for recycling failed ideas. At least we know who the fall guys are this time and we will be doing it all in addition to our day jobs as well. Quality service provision by GP led commissioning market forces with Soviet style price fixing?
Don’t cancel the BUPA subscription yet you may well need it.
The team extend their thanks to Jobbing Doctor who has drawn our attention to the return(?) of the Grand Daddy of medical bloggers (as far are we are concerned) a certain Dr Rant.
Much respect and welcome back.
We hope that this will not be a mere flash in the pan but a return at an all ahead at full steam return to posting for the blogger who inspired the team at ND Central to put fingers to keyboards and start blogging.
His, or her, initial post makes us realize that we are not the only ones hoping for a cull of “PCT vermin” the at best bottom third of the English educational system that has so successfully mismanage the local health service via the MHS (Management Health Service) a 100% growth industry over the last 10 years in bureaucracy that delivers bugger all in healthcare.
As some of our American cousins would say, Dr Rant go get some!
There is no Praise be to the Party on this one for this is the antithesis of the Party.
One of ZaNu Labour’s great misconceptions about GPs is that all of us are idle and not treating any patients. As part of the increasing centralization and Sovietization of NHS healthcare, ZaNu Labour introduced the concept of tick box medicine into General Practice via the Quality and Outcome’s Framework known as QOF.
GPs who work under the new General Medical Services (nGMS) contract receive most of their income from a global sum calculated via the Carr Hill formula, which nobody knows what the actual formula is, under the opacity of transparent government and from QOF points which is a performance related pay scheme. Tick certain centrally determined boxes and you get extra money. Don’t tick them and you don’t get money.
When QOF was introduced ZaNu Labour fully expected GPs to only achieve 6-700 out of the original 1050 points available. Most GPs in the first year got to close to 1000 points which upset Tony and Gordon for they then had to pay GPs something which is an alien concept here in the UK where healthcare is free in contrast to poorly paid lawyers like Tony and his wife Cherie.
Not being spiteful or vindictive in any way the Party shifted the goal posts, reduced the number of points in order to pay GPs less and so cut GPs pay while making them worker harder to achieve the same income. There is an expression in the UK that points mean prizes and they do to GPs as they make up part of their pay.
Now QOF is neither Quality medicine nor real Outcomes. It is possible to achieve high QOF points without seeing any patients at all. As long as information is on a hard drive on the 31st March each year you get paid. How that information gets there is immaterial.
Performance related pay is often thought to increase productivity but a little piece in the British Medical Journal looked at the effect that QOF had had on high blood pressure and came to the conclusion that it had had no effect on quality or outcomes. For those not interested in learned journals a more informed piece about this is here.
So here is a big thank to all those practices that have redesigned how their receptionists, practice nurses, practice managers, GPs have worked to deliver the central imposed Soviet style QOF tick box dumbed down medicine.
If you have been invited to come and have your blood pressure checked by your caring GP, then had a load of other tests which have cost you time for no benefit you will be pleased to know that it may be the result of QOF.
And it hasn’t made any difference. A complete waste of time and money to tick boxes.
The research makes the point that UK General Practice was actually delivering the goods BEFORE QOF appeared and DESPITE Gordon and Tony tinkering with (or is it buggered up?) the NHS.
Furthermore medicine is a dynamic discipline and new research and new advances mean that QOF is frequently out of date and sometimes dangerous to patients. Does a good doctor ignore outdated QOF criteria and treat to modern medical standards and forego income or does he conform to outdated Party tick box medicine to maintain income and thereby compromise good patient care?
Praise be to the Party for maintaining high modern medical standards via targets and tick boxes. He who pays the piper plays the tune and when QOF pays who suffers? The patient medically by the doctor conforming to QOF or the doctor financially by not conforming to QOF and delivering up to date medicine by treating patients properly.
Looks like no-one wins from QOFing but at this time of year we bet a lot of GPs will be doing it.
At our last resistance meeting at the infamous Café Michelle a couple of items from the local papers were discussed. The first item was from the local equivalent of the Times Higher Educational Supplement, the Shiteton Sun, and for the less well educated but more culturally and artistically aware, the second was from the Shiteton Stoat Tickler’s Gazette the local equivalent of the Guardian.
The articles discussed were regarding redundancies in those most essential for frontline healthcare provision the NHS managers whose numbers have doubled over 10 years at the same time as overall NHS efficiency has fallen 0.4 % per year and local GP numbers have been static. The figures are as follow as but in order to appreciate them you will have to do some seriously hard maths:
From the Shiteton Sun, it would appear that 50 NHS managers will be lost at the cost of c. £ 3 million or using our finger generated figures just under £ 60,000 a piece.
The Stoat Tickler’s Gazette says that in another part of Shiteton 20 NHS management jobs will be lost at a total cost of £ 2.13 million or about £ 106,000 a piece.
The average wage is just under £ 26,000 per year, a nursing sister earns up to £ 27,190 and your average GP earns £ 95,900 from this source but look how much your average GP really earns according to the Daily Mail - check the bottom line of the article for the "true" Daily Mail figure not the headline.
So these figures suggest that several of us here at ND Central appear to earn less than some now redundant local NHS managers' average wage but we deliver something they have never done in their lives - healthcare.
The total costs of all the managers in these two articles, £ 5.13 million, would provide full time frontline primary care for a total of more than 50,000 people provided by more than 120 staff from a variety of different professions including a total of 35 GPs and 25 nurses at an average cost of £ 40,000 per member of staff instead of just 70 managers. In under-doctored areas this would make a huge difference to peoples’ health.
This week we have also seen the first person made redundant as a result of (rapidly increasing) large local public service cuts. A young person just starting out in life but still upbeat for this was but the end of their first week of enforced redundancy. They felt they ought to let us know although this was not, as yet, their reason for attending surgery.
How will they be in 6 months when it is likely that their partner too will be in the same position? Both patients have a new family, a new house and a mortgage, have been sold a dream but plunged by the politicians into a nightmare that they have no control over? Even those that might be able to help them when the money gets tighter are being cut.
Have we as GPs seen this before? “Back to the Eighties” this film will be coming soon to all Northernshire GPs. Could this be a film with a thumping Huey Lewis theme tune as the legions of the Big Society march forward to save all affected by, but unhelped by, Big Government?
Still GPs are free and they will ultimately be to blame for the ConDem’s health policy success or failure. We will once again become those debt counselors, solicitors, social workers and employment advisers as the cuts deepen as we were in the 1980s. For when Big Government washes their hands of a problem where else can you go to for free?
Praise be to the Party for whom redundancies are short term gains but which will ultimately cost us all more especially in the NHS. Aren’t NHS managers such great value when compared with doctors and nurses?
No doubt these newly redundant NHS managers will be prostituting their "expertise" to the private sector to do what little they did before but for more? And who will ultimately pick up the tab?
Yet another piece in Pulse magazine (thanks guys you’re on a roll lately) caught our eye. We are told by the new ConDem coalition that NHS efficiency savings are required but just have a look at the efficiency gains on this one.
Out goes NHS (re)Direct with its paltry one third of all calls redirected to general practice and A&E just look at the 911 efficiency savings, oops wrong country, 111 efficiency savings.
In a trial site in County Durham and Darlington a massive efficiency gain has meant that the 911, oops 111 number, managed to redirect a staggering 85% of its calls to general practice. Add the 2% redirected to A&E and that is a total redirection rate of 87% almost 3 times as efficient as NHS (re)Direct.
The ConDems are onto a winner with this one to reduce the budget deficient by next Tuesday especially if it rolls out nationally. Another pilot site reports 55% referral to general practice but are 3 times better at A&E redirection and together this adds up to a 61% redirection rate almost twice as good as NHS (re)Direct.
Furthermore this 911, sorry 111 centres, are much more efficient than idle GPs for they don’t have a 48 hour access target to meet they have gone several stages better. So even more bangs for ones tax buck.
According to the article, of just under 2000 calls to the Lincolnshire and Nottingham 111 pilot, 13% were told to see their GP within two hours, 24% were told to attend that same day and only 19% were made to make a routine GP appointment. Excellent the 48 hour target slashed for almost half of all users.
We do not know what happened to the remaining 44%. We would like to think they were given some practical healthcare advice perhaps along the lines of something off and die or better still were told to ring the NHS (re)Direct number to give them a second bite at the cherry?
Certain professions it is said get thicker by experience and we would argue that politicians may just happen to fall into that group. If NHS (re)Direct is replaced by 111 services with a doubling or tripling of redirection services then this will truly be world-class efficiency gains by the coalition no doubt based on Za Nu Labour’s successful piloting of call centres as a means of healthcare redirection and improvement.
Praise be to the Party for building on the sound foundations of failed policies and making them worse. That budget deficient doesn’t standard a chance with ideas this good . . .
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Northern Doc was once a blog originally written by a group of GPs in Northernshire and expressed their experiences and frustrations of working in today's NHS. The pieces were compiled at social meetings after work and published anonymously in a once free society. Following the Government's Medical Council clamp down on freedom of thought, speech and expression by doctors and our belief that the views of a few doctors DO NOT represent the views of the profession as a whole their views will now be written by and published by a journalist who has previously contributed to the blog by virtue of social ties. Any inference that the word Doc means a doctor is now purely coincidental. This is as of the 22 April 2013.