All too predictable

From the Guardian:

"Doctor who criticised NHS reforms is threatened with disciplinary action...
...

Prof John Ashton, county medical officer for Cumbria, received a letter from his PCT last week after he joined 22 other signatories to a letter in a national newspaper criticising Lansley's health and social care bill. The letter read: "You are bound by the NHS code of conduct and as such it is inappropriate for individuals to raise their personal concerns about the proposed government reforms." Ashton will have to "explain and account" for his actions at the hearing."

Undercover Care: The Abuse Exposed

Watch this on the BBC: "Undercover Care: The Abuse Exposed". And then reflect on the failings of the Care Quality Commission in this case* and whether they could detect or act to investigate any similar case in the future**:

"A specialist residential hospital in Bristol is being investigated by police after secret filming by BBC Panorama found a pattern of serious abuse.

"During five weeks spent filming undercover, Panorama's reporter captured footage of some of the hospital's most vulnerable patients being repeatedly pinned down, slapped, dragged into showers while fully clothed, taunted and teased.

"The programme decided to secret film after being approached by a former senior nurse at the hospital who was deeply concerned about the behaviour of some of the support workers caring for patients.

"Mr Bryan reported his concerns to both management at Winterbourne View and to the government regulator, the Care Quality Commission (CQC) but his complaint was not taken up.
Ian Biggs, regional direction of the CQC for the southwest, said an opportunity to prevent abuse was missed when Mr Bryan's complaints were not investigated."

* Headed by the former chief executive of West Midlands strategic health authority (SHA) who presided over the Mid Staffordshire scandal lest we forget, so she has relevant expertise in this area!

** Still, at least the unit concerned probably had policies for dealing with dog mess, so it can't have been all bad as far as the CQC are concerned.

Some free advice on achieving 'world class NHS productivity' McKinsey style

Following on from my previous post on McKinsey's recommendations to save money in the NHS, I don't think they've been ambitious enough - where's that blue sky thinking we've come to expect from the cream of Oxford's 20-something PPE graduates?

As I mentioned before, McKinsey's approach is to list every institution in order of cost/efficiency/whatever and claim that lots of money could be saved if all those 'poor performers' performed at the level of the median. I think this technique can be taken even further, and I'll offer my advice for free!

The UK spends phenomenal amounts of money per capita on healthcare compared to most countries in the world - using some figures I had leftover from this set of posts on 'The Spirit Level' - we can see that in 2006 the UK spent some $2.5k per capita on healthcare compared to a world median of around $200! That's a potential saving of over £80bn!

What is that you say, other countries don't necessarily have great healthcare from that $200? Well McKinsey don't deal in trifles like cost-effectiveness and health outcomes, but I suppose I can stretch to looking at that if you insist - I like to think all those years at university were good for something. Using that leftover data I was talking about above we can see what sort of return you get for $200 versus $2.5k. Below is a figure plotting data for life expectancy (in 2007) versus health expenditure per capita (in 2006):

I've fitted a regression line (which is logarithmic to better reflect the shape of the data). At $2434 the UK gets a life expectancy of 79yrs (versus the predicted 81yrs) while the median spend of $218 would predict a life expectancy of 69yrs (versus a median world life expectancy of 72yrs) - countries spending around $200 include Venezuala (74yrs), Malaysia (74yrs), Kazakhstan (65yrs), Thailand (69yrs), Tunisia (74yrs), Tonga (72yrs), Gabon (60yrs), Fiji (69yrs), Guyana (67yrs), Equatorial Guinea (50yrs), Namibia (60yrs), and Swaziland (45yrs).

So there you go, save £80bn and 'cut the deficit' or bail out the banks, and it'll only cost you a predicted loss of 10yrs in life expectancy - good value I'm sure you'll agree. No? Maybe that's a bit too radical for you, but there's another approach we could take - look at that figure above again, doesn't seem like you get much of a return for you investment when your expenditure goes past around $1.5k per capita (where the graph flattens out) does it? If we cut our expenditure to $1.5k per capita we would predict a life expectancy of 78yrs and save £36n - thats a reduction of life expectancy of 1-3yrs for billions saved, an absolute billy bargain!.*

So basically I cannot see how nearly halving UK health expenditure could possibly have any down sides - I've proved it with numbers and graphs and everything! I wonder if McKinsey are recruiting?




* If you think this proposal is a joke, consider that it is the natural consequence of the putatively 'progressive'  reasoning used in 'The Spirit Level' that increased health expenditure has no beneficial effect on health outcomes like life expectancy for richer countries such as the UK (I disagree) - no wonder David Cameron likes it.

McKinsey save the NHS

McKinsey in shock discovery that if you put things in numerical order half of them will fall below the median. What tautology will they demonstrate next?

Via DNUK again - here's a terrifying presentation from McKinsey*:

In February 2009 McKinsey was instructed by the Department to provide advice on how
commissioners might achieve world class NHS productivity to inform the second year of the
world class commissioning assurance system and future commissioner development. The
advice from McKinsey, in the form of the following slides, was provided in March 2009.

I recommend having a detailed read to see what a bunch of 20-something Oxford graduates with no experience of the health service can come up with. Basically if everything was done cheaper and more efficiently it'd all be fine - who'd have thought?

In slide 17 we see how if we just reduced all clinical staffing levels to the median we could save a few billion - no mention of whether staffing levels have an effect on quality of care (another race to the bottom) - indeed they later go on to argue against any attempts to ensure minimum staffing ratios:

"Some Royal Colleges are recommending introduction of mandatory staffing ratios on safety
grounds that will lead to increases in staff required above the activity growth e.g ratio of
1/28 per midwife 

Certain service reviews are also recommending more staff is required e.g. stroke, children"

But they argue we should "Limit introduction of mandatory staffing ratios" to save money - they can't be arguing for minimum staffing ratios for any reason, I'm sure it'll all be fine.

Highlights include slide 28 where they show how you could cut 'bed days' by 10% in mental health if only length of stay could be reduced to the median in the poor performers. I wonder whether those trusts with longer lengths of stays admit more severe patients and don't admit less severe patients, perhaps managing them in the community, and thus have already saved money over the other providers who are admitting less severe patients but getting lower average lengths of stay? Well I'm afraid McKinsey can't tell us because they are analysing data in the same way you would expect someone who has no idea of the context and a money-making axe to grind to do.

Presumably we could save money by abolishing all those specialist tertiary and quaternary hospitals with their high risk procedures because DGHs get better results for the same procedures. If only these specialist centres could be as good as those small local hospitals, the difference in performance couldn't possibly be because all the really difficult ones get sent to the specialist centres - how are we supposed to show that on our pie charts?

On slide 53 we can see some of the "procedures with limited clinical benefit" which are "relatively ineffective" or "potentially cosmetic" that we can 'de-commission' to save nearly £1 billion. Femoral hernia repair for instance, as someone on DNUK points out, the risk of strangulation is 45% at 21months in a femoral hernia, this is not a 'cosmetic' procedure!

A particular highlight is slide 60 where we find out that US physicians who do imaging (e.g. x-rays) in their offices do more investigations than those who need to refer to a radiologist. Presumably this means that we are going to massively increase the training places and consultant jobs for radiologists so we can save a few quid on chest x-rays by running each request past a radiologist first?

On slide 64 we can see that as digoxin in heart failure doesn't increase life expectancy only improve symptoms we shouldn't fund it at all. Move over NICE and the controversial QALY, if it doesn't stop you dying it isn't worth a penny.

As someone on DNUK points out, all their reasoning is based on using publicly available data to rank everyone, and then claim that £X million can be saved by making the 'worst performers' as good as the best performers. Conceptually difficult ideas such as figuring out if the factors making worse performers are actually amenable to intervention (e.g. you aren't going to make the people in rural areas all close together and nice and efficient for home visits like in a city however many graphs you draw) are just so much irrelevant detail.

I wonder how much we could have saved by getting some people who know what they're talking about to do a review instead of McKinsey and their one-size-fits-all Panglossian musings?

* This isn't new, for instance, the Ferret Fancier reported on it last year, but I think it is timely to revisit what facile idea people like this (yes Lansley, I'm looking at you)have about 'reforming' the NHS.

The GMC is not fit for purpose

Via Doctors.net.uk (DNUK, the site where doctors go to bitch) I came across this story:

"A YOUNG doctor who tried to sell her staff pass for free hospital parking can only work as a medic again under strict conditions, watchdogs have ruled.

"...a foundation year doctor, put her free permit to park at Southampton General Hospital up for sale for £5 on the website Gumtree, the Fitness to Practise Panel of the General Medical Council (GMC) was told.

NHS fraud investigators found out she later claimed a senior colleague made a sexual advance in exchange for ''looking more favourably'' on the problem.

"During the meeting, on October 14, 2008, Dr White alleged she was firstly warned she could get the sack by her employers, the Southampton University Hospital NHS Trust. 

"But the more senior colleague is then alleged to have gone on to say: ''I can ensure that the trust looks on your case more favourably'' and put his hand on her knee before adding: ''What will you do for me?''

But Brian McCluggage, counsel for the GMC, told the hearing in Manchester the allegation had ''no basis'' and was a ''defence mechanism'' to counteract her difficulty over the parking permit.
The doctor, who is in her 20s and qualified after completing her medical degree at the University of London in 2007, was not present or legally represented at the hearing.

She was also accused of breaking a ban on her entering the hospital and failing to attend an examination by a psychiatrist as requested by the GMC." 

Now obviously what she did was naughty - you shouldn't be selling your free parking permit, even for just £5, but this is a trivial matter that should have been dealt with between employee and employer with a slap on the wrist. This is the consensus amongst the DNUK commenters.

So what are we to make of her claim that she was sexually propositioned by her educational supervisor? Most of the senior doctors on DNUK think this is highly unlikely and agree with the GMC that this is probably a "defence mechanism". Well I am not so sure. Medicine is stuck in some kind of 1950s time warp where casual racism, sexism, and sexual innuendo are commonplace. Many female junior doctors of my acquaintance have been sexually propositioned by senior doctors (usually their clinical or educational supervisors) and several have been offered inducements (e.g. authorship on publications or attendance at conferences). Even I've been questioned about my sexuality by a consultant on a ward round in front of patients.

The GMC is commonly used as a tool by hospital trusts and senior doctors to keep juniors in line (paying over £400/yr for the privilege) - how many employees making an allegation of sexual harassment against a senior work colleague are required to to attend a psychiatric evaluation? It wouldn't be possible if this was a simple employer-employee industrial dispute where this kind of punitive action would be illegal, but is just fine when it becomes a 'fitness to practice' issue.

But compare and contrast:

"...had all restrictions lifted on his ability to practise after a General Medical Council panel reviewed his case.

"The former Royal Navy surgeon was convicted at Manchester Crown Court in 2003 of making indecent photographs of children, ordered to sign the sex offenders’ register for five years and given an 18-month community rehabilitation order."

Or here:

"...admitted making inaccurate records after the operation and was slammed by the GMC panel yesterday for “significant departures from good medical practice”.

The panel cleared him, however, of serious misconduct and found that his fitness to practise was not impaired.

The panel also decided against issuing the surgeon with a warning."

Liar, liar, pants on fire!

Via Dr Grumble:



Addressing the Royal College of Nursing conference in 2009 according to the New Statesman.

'Efficiency' is in the eye of the beholder

From the Guardian:

One of the big debates around the NHS is whether its budget should be allowed to grow in line with "healthcare inflation", a rate above the national standard that factors in people living longer and demanding more from the service. But Sir John Oldham, the Department of Health's national clinical lead on quality and productivity, has little time for the argument.
"It's a cop out, is my response," he says. "The challenge we face is one we can't face by doing things as we do now.
"When people give that challenge to me in a room of clinicians, I ask them each to write down, if they can, one or two things in the last week, in their personal day-to-day frontline experience, with a waste. And I have never walked out of a room without everybody being able to put something down."
This view is popular with government ministers, who are increasing England's NHS budget by normal inflation and trying to obtain £20bn of annual savings through the Quality, Innovation, Productivity and Prevention (Qipp) programme. It is less popular with many staff and unions, who believe that Qipp means cuts. 

Unfortunately it isn't these frontline clinicians who get to make the savings, its the managers and bureaucrats and the only way they know to save money is to sack people, they have no idea what is going on at the frontline. This is the absolutely best part of the article:

All of this would add up to a shift in care for long term conditions equivalent to that which started in mental health a quarter of a century ago, when patients went from institutions to care in the community. He says there are already examples of the openness to change required, such as Tyne, Wear and Esk Valleys mental health foundation trust, which has trained nearly 50 of its staff in use of the Kaizen method for continuous improvement. This involves often simple changes, but made promptly: for example, after staff noticed that nurses were clustering at a station rather than walking around their wards, the trust removed the station the same night. (my emphasis)

Hah, as a doctor I've already had my office taken away (an office for some six doctors or more) and given to one modern matron to twiddle her thumbs and drink her coffee in (I now have to use the nurses' station), so I'm well aware what a massive time wasting pain in the arse it is to have some moron take away your desk space which you need to complete the tedious reams of paperwork the NHS now requires. Nice efficiency saving geniuses, maybe you could ask why they were all clustering at the nurses' station, probably all filling out  the mandatory risk assessment and care plans that are now required for all patients.

Heads I win, tails you lose

I just learned today that the head of the Care Quality Commission (the health and social care services regulator) is the former chief executive of West Midlands strategic health authority (SHA) on whose watch the Mid Staffordshire affair occurred.

I suppose you can look at that in two ways, either it is a tacit admission that regulatory authorities cannot be expected to know what is really going on in the organisation they supervise and so bear no culpability for their failings, or, it shows how catastrophic failure is absolutely no bar to career progression for NHS bureaucrats because they take no responsibility for the direct clinical failings of their administrative decisions - heaping all the responsibility onto the front line staff because they can always hide behind the claim that ultimately everything is a 'clinical decision'*.


* I'll reproduce a comment I made on Neuroskeptic's blog:

"I love this quote:

"The Department of Health insists that although Primary Care Trusts can issue guidelines on the amount of drugs GPs prescribe, it is up to the individual GP whether he or she wants to follow them.

"Hazel's Primary Care Trust, NHS Enfield, admits it changed its guidance to GPs in January but insists doctors were not obliged to follow it."

Classic administrator response - they will relentlessly hound the GPs who don't follow their guidance to reduce script length yet when they're called out on the negative consequences of their decision they basically say it is all down to the GP and not their fault.

I'm seeing this behaviour more and more in the NHS - bean counters and other non-clinical staff make decisions that directly affect patient care, usually without any clinical input, and then when the shit hits the fan they blame the clinicians because, after all, they're the ones with clinical responsibility (but no power).

Heads I win, tails you lose." 

Nurses have more balls than doctors

The RCN is usually a pretty spineless union but they've shown more balls than the BMA:

...this meeting of the RCN Congress, in the light of Anne Milton's Congress address, has no confidence in Andrew Lansley's management of this Coalition Government's NHS reforms

Result

For:       98.76% (478)
Against:  1.24% (6)
Abstain:    (13)

Read: 'The Plot Against the NHS'

Read The Plot Against the NHS which rather nicely details the progressive and deliberate destruction of the NHS under Labour and now the Tories:

Prices will rise. On the one hand, the cross-subsidisation that is practised inside NHS hospitals will come to an end as the less costly activities are taken out of them, forcing them to charge more for what remains. On the other hand, Monitor will have to ensure that prices are set so that all providers make a profit. To keep the NHS budget down, what is covered by the NHS will decrease. More and more treatments will be ‘decommissioned’ and will become ‘extras’, which you can have if pay for them. This is already happening in one particular way, thanks to another New Labour measure – personal budgets, or lump sums given to patients with chronic illnesses to buy their own care with. If you want more care than the lump sum will cover you can pay for more, if you can afford it. Inequality in health care will be restored.

If you were to ask me how I thought the NHS could be improved one of the things I would emphasise is that a fundamental priority is to ensure that people brought into hospital as emergencies are treated quickly and effectively - and this means moving away from a 9-5 culture (plus massively scaled down 'on-call' emergency staffing) towards 24hr care where consultant review and radiological investigations don't keep office hours.

However, government has never been very interested in emergency care, preferring to focus on the 9-5 routine elective operations because they are easy to count and put a price on - paying hospitals fixed tariffs for these. This emphasis has been such that most general hospitals are subsidising their emergency care with routine work like elective surgery or outpatient clinics. After all, it takes a huge number of doctors, nurses, and allied staff to provide even the scaled down 24hr emergency care we have now - getting some money back from this necessary excess capacity by providing elective care is paramount to make ends meet when the remuneration for the emergency care itself doesn't cover the costs.

Unfortunately the new model of health care, initiated under Labour, and now brought forward by the Tories, envisages that everything will be broken down into its constituent parts and tendered for by various private providers. The Independent Sector Treatment Centres were the start of this - and since elective work is subsidising the huge fixed costs of emergency care there is obviously profit to be made for those who agree to take the routine elective work but don't have the same emergency care commitments. If your patients get complications after your elective surgery and you can just ship them to an NHS hospital ITU without having to cover the cost of that care from the fixed tariff paid for that operation how can you fail to be making a profit over and above the NHS?

But providing A+E services and receiving unselected acutely ill patients needs more than just A+E staff, it needs the back up of general medics, general surgeons, orthopaedic surgeons, anaesthetists, paediatricians, gynaecologists, radiologists, physiotherapists, ward nurses etc so that once A&E have stabilised and triaged them someone else can actually treat them. That means, at a minimum, all the services of your average District General Hospital - you cannot hive off A&E as an isolated service.

So what will happen as the DGH revenue streams begin to dry up as more and more of the easy and profitable work is taken over by the private sector? Well since every hospital will now be part of a Foundation Trust they will either have to save money or go bust. Saving money entails cutting services below the already bare bones one we have now - probably a return to the trolleys-in-corridors NHS of the last Tory government - and the rationalisation of services to fewer and fewer centres*.

Competition isn't going to improve emergency medical care because there can be no market in it - already it is run at a loss because NHS hospitals can cross-subsidise from other revenue streams - they do this because they aren't run to make a profit, they are still, despite Payment By Results and other market 'reforms', trying to deliver good healthcare to the local population. When the NHS becomes just a franchise for private companies to compete for provision it will remain a monopoly provider of local emergency care (if you can't financially sustain one local A+E you're hardly going to open a competing one) so the best the market can deliver is a private company taking over the running of that A+E. But since they won't be able to cross-subsidise emergency care anymore - because other companies will already have cherry-picked the profitable elective work - there will be less money available and standards will have to fall.

We are moving inevitably to a two-tier NHS where private companies cream off large profits from over inflated centrally determined tariffs for simple elective services like outpatient work and routine operations while complex and difficult or emergency care is provided by an under-resourced remnant of the old public system.


* For some services, like complex poly-trauma, a rationalisation to fewer centres would improve outcomes as more specialist teams have better results - but this would only be a fortuitous unintended consequence under the Tory plans, and for many other conditions which require less super-specialist provision the extra travel time is likely to prove detrimental.

More illness = Good practice

I have had my attention drawn to this remarkable document distributed to all GP practices in London:

An Introduction to a Pan London Approach to Improve Quality, Access and Patient Experience in General Practice


It includes all manner of cunning wheezes to improve General Practice in London. On particular piece of genius includes using predicted* versus the actual GP reported prevalence of various diseases as "an indicator of general practice performance":

Organisations in the top quartile ranking within London are examples of good practice. Monitoring, intervention and support would be required for those organisations within the bottom quartile ranking in London. Monitoring and support would be beneficial for those organisations within the mid quartiles within London.

That's right. If you are fortunate enough to have a population with a lower than predicted rate of an illness then you will be judged to be an example of bad practice and failing. But if you happen to have higher rates of illness for some reason, then well done you, you're an example of "good practice"!


Now I'm no epidemiologist but population level models like this cannot be used to accurately predict the prevalence of disease at a local level** - to tell you what the real burden of disease is that those crappy GPs are failing to detect. A five variable* regression model does not capture all the variation in human disease however much you want it to. The tail is wagging the dog here.




* "Expected prevalence data are derived using expected prevalence rates provided by ERPHO which take account of age, sex, ethnicity, smoking status and deprivation score at practice level."

** They are based, of course, on taking all that local level data and then finding a best fit line between all the real data points - you can't then go back and say that those data points that don't lie on the line are now wrong. What kind of statistically illiterate fool came up with this idea?

Administrators take over the asylum

I went to visit one of the low level administrators in my trust today. For reasons that are not entirely clear to me she has swipe card access to all clinical areas of the trust including secure units and happily uses it to turn up at inopportune times to bother people (much to the chagrin of the nurses).

I went to visit her today for a dull administrative reason, turns out trust policy states that doctors aren't allowed access to the administration corridor - we have to ring the person we're visiting and have them let us in.

Somehow I'm trusted with access to all clinical areas in the local general medical trust (who I don't even work for) such that I could just stroll into the ITU or paediatric ward, yet my own trust won't even let me in to see the woman who arranges leave. They truly have taken over the asylum.

NHS reform myths

Richard Blogger of the torylies blog has a good site addressing some of the 'myths' around the 'reform' of the NHS, here's an excerpt from Myth 10: Private providers will just cherry-pick the easiest cases, undercutting the NHS:

The Government's Claim:

The less complex the procedure, the less someone – including in the private sector – will be paid. Unlike Labour, we will not rig the market in favour of the private sector.

The Rebuttal

 

"The less complex the procedure, the less someone – including in the private sector – will be paid"

This shows a stunning lack of understanding about how Payment by Results works. Each procedure, for example, cataract removal, is paid at the same rate (the tariff). However, not every patient is the same. There will be some cases that are more difficult than others even though they are covered by the same tariff. There is plenty of evidence where this has happened with last government's Independent Sector Treatment Centre programme (ISTC). 

...

The problem with the ISTC programme is that the provider was paid for referral, not for treatment. The government says that providers will be paid for treatment, but they do not say that once referred the provider must treat the patient, since there is no such provision in the Health Bill it means that once a private hospital receives a more complicated case they may refer the patient back to the NHS. The NHS has a responsibility to treat patients, private providers will never have this responsibility because they know that the NHS is always there for the more difficult cases.

...

This means that if the private providers are cherry picking we will not know about it because such data will be "commercially confidential". There is nothing in the Health Bill to prevent this, indeed, the Health Bill enables private providers to be even more secretive and apply "commercially confidentiality" clauses to their contracts with the NHS.

The Health Bill will not prevent private providers cherry picking because it does not mandate that once referred the provider must treat the patient. The Health Bill also strengthens the use of commercially confidentiality and so the public will not know whether the private sector are cherry-picking.

The fundamental priority of a national health service

Read this article today from a consultant working in the ill-fated Mid Staffordshire Trust:

In my opinion a major underlying cause of the ‘Stafford scandal’ was that most of us, including politicians and healthcare professionals, had lost sight of the fundamental priority of a national health service. That is to provide excellent and immediate care to those who become suddenly very unwell. There have been tremendous improvements in many areas such as cardiac, cancer and orthopaedic care.

However, the importance of the care of sick elderly patients who make up the bulk of our medical ‘takes’ have only rarely grabbed the headlines. Care of these patients is expensive in staff time and resources, it is often difficult and tiring and can only be delivered in a high-quality way by departments which are equipped appropriately, are well staffed by motivated individuals and led by enthusiastic consultants.

Unfortunately I fear that all these wonderful new innovations in privatised 'integrated care pathways' are going to fragment care and undermine that goal, there may be winners, but it won't be the elderly patient with pneumonia and a hip fracture in A&E.

Politicians and the NHS

Baroness Murphy blogs on the NHS 'reforms':

Given the recent Ombudsman’s report about the quality of care for older people, which everyone acknowledges is poor/ disgraceful in many NHS hospitals, and the lack of improvement we have seen with massive investment, I find the idea that the NHS does not need to change difficult to accept.  Could it be that doctors have a vested interest in maintaining the status quo?  (A doctor speaks!)

This wonderfully highlights the problems with politicians and their view of the NHS (and she's an ex-doctor). First, like so many others who utterly fail to look at the evidence, she makes unsubstantiated claims about how the investment under Labour hasn't translated to increased 'productivity nor outcomes' - this is just untrue in the latter case (and irrelevant in the former case*) - but is a standard trope trotted out to argue against increased funding of the NHS (because, you know, our health expenditure, at the mid-to-low end of the European scale, is clearly so profligate). Secondly she makes the mistake of thinking that because you think something must be done then what you're proposing to do is going to improve things - unfortunately there's just no evidence to say that the governments 'reforms' are going to do any good, and plenty of reasons to believe this thoughtless vandalism of the NHS is going to fuck it up big time, as even the most timid of GPs could tell you.

Could it be that politicians just don't know what they're talking about when it comes to the NHS?


* A large part of the increased funding for the NHS went into improving the historically low pay of employees like nurses (which by definition will adversely affect productivity) and in disastrously badly managed GP pay negotiations (which also resulted in less activity for a given amount of money, and thus decreased productivity. 

Sharing the risk - creaming the profits

The King's Fund demonstrate their true colours again, according to the GP magazine 'Pulse':

The King’s Fund has called for entire care pathways to be outsourced to private firms, claiming GPs do not have the time to make the required service re-design in primary care demanded by the NHS reforms.

What I don't understand is what all this talk of 'risk sharing', e.g.

‘GPs can set the standards but consortia will ultimately want to commission organisations to take on the risk.’

...a risk sharing model which would see private firms take on service re-design and practice performance management in return for receiving financial incentives

Now I understand the concept of paying someone for a service, say 'service re-design' or 'practice performance management' but what does it mean to 'share the risk'? It sounds rather asymmetrical, as if you pay a company to take on service commissioning and if it goes badly, well hard luck, you've already paid them, and if it goes well they get a nice big slice of 'performance bonus' to ice the cake - 'heads I win, tails you lose' - and that model's never gone wrong before, and certainly not in the NHS. Good job there will be no financial incentives or conflicts of interest to motivate GPs to adopt that model.

Of course I have absolutely no idea what these ‘integrated pathway hubs’ even mean:

...musculoskeletal, respiratory, and frail and elderly care the first three pathways lined up to go out to tender.

Does this mean that GPs will no longer be required to know any respiratory or musculoskeletal medicine, or to deal with older patients? The patients will refer themselves to the right 'pathway' presumably ('I've got pain in my chest, I guess that's my lungs, better go to the respiratory pathway hub').

One wonders how efficient it will seem when all the respiratory or elderly care outpatient work is taken away from the general hospital to be focused in the 'integrated pathway hub' - when suddenly the acute hospital has no money to keep a respiratory team going, no one to put in chest drains, no one to give expert opinion on difficult chest cases - instead they're having to purchase services from these private providers under their 'service level agreement'. What is the ultimate goal - A&E as a glorified NHS call centre referring you to this or that private company and 'care pathway'? Each care pathway 'integrated' with itself but absolutely no flexibility to cover the messy multiple comorbidities that cross the individual pathway boundaries and make up the real cases seen in everyday medicine. Still, at least it will save money.

Or is it that a 'care pathway' in this case is just one of those referral centres we've seen implemented in areas like musculoskeletal medicine? Staffed with clerical drones who click 'computer says no' and sends the referral back to the GP to ask a physiotherapist to waste their time looking at for six weeks before these moronic box-ticking gate keepers will approve the referral being sent back again - presumably hoping the patient has died or given up in the mean time. For those interested it looks like these care pathways will be like this sort of thing - if my experience is anything to go by they will be vague, inflexible, allow referral centre drones to bounce back anything remotely complicated (because they don't know what the words mean and thus assume it doesn't matter) and ultimately end up with enormously wasted time and duplicated effort. Vive la Revolution!

The future of the NHS

Duck on the Badscience forums asked me to blog my concerns about the future of the NHS and how what we are about to see is wholesale privatisation.

What I was saying there is that GPs don't have the time, resources, or infrastructure to suddenly take over all the functions of PCTs next year while carrying on with their day jobs. So, naturally, they will be looking to contract out the commissioning function. But this is just one aspect of the overarching drive towards privatisation.

Something worth remembering when considering GP consortia is that these are consortia of GP practices, not individual GPs. And GP practices are no longer partnerships of equals but increasingly becoming small businesses which differ from the larger healthcare companies purely in size. The last Labour government introduced the idea that GP practices were not partnerships of GPs by removing the need for a certain number of GP partners for a given number of patients (or rather a given amount of money). Instead they were to be treated as small businesses contracted to provide GP services. This has lead to GP services being increasingly provided by salaried GPs (who are usually more recently qualified GPs) employed by the GP practices which are owned by GP partners (who are usually older GPs). Since these changes were brought in the majority of jobs available for newly qualified GPs are salaried positions and not partnerships.

So general practice has moved from being an ostensibly private but effectively collectivised system of equals (at least as far as medical staff go, the position of ancillary staff was different) to become a business like any other - the older generation of GPs have taken advantage of the new rules to become small businessmen increasingly acting as employers and screwing profit out of employees rather than acting as traditional family doctors while the newer generation of GPs become wage slaves. It won't be long before the traditional GP practice disappears (as the old partners retire and sell on their stake in the small business they own) as they are swallowed up by larger healthcare businesses - and then who is going to control the NHS budget? It won't be the workaday GPs who will just be employees of these big companies. **Poof** de facto privatisation.

The words of Liz Kendall (Labour) from the Commons debate on the upcoming NHS cluster-fuck (via Dr Grumble):

Our health and our NHS are not the same as gas, electricity or the railway. That the Secretary of State believes that they are shows how dangerously out of touch he is. What is the likely result? GPs will be forced to put local services out to tender even if they are delivering good quality care that patients choose and like; hospitals and community services will be pitted against one another when they should work together in patients’ interests; care, which as many hon. Members have said is vital as our population ages and there is an increase in long-term conditions, will become more and not less fragmented; the financial stability of local hospitals will be put at risk, and they will have no ability to manage the consequences of choice and competition in the system; and the whole system will be tied up in the costs of red tape, as GPs and hospitals employ an army of lawyers and accountants to sign contracts and fight the threat of legal challenge, huge fines and the potential of being sued. Let us also be clear that the Bill gives Monitor the same functions as the Office of Fair Trading, so it can fine organisations up to 10% of their turnover.

The more we see of the Bill, the more the truth becomes clear. The Secretary of State says that he wants clinicians to be more involved, and “no decision about me without me” for patients, but when the Royal College of General Practitioners, the Royal College of Surgeons, the Royal College of Nursing, the Royal College of Midwives, the British Medical Association or anyone else tells him that he should stop, think again and halt his reckless NHS plans, he refuses to listen. When the Alzheimer’s Society, the Stroke Association and Rethink tell him that his proposals will not give patients a stronger voice and improve public accountability, he simply tells them that they are wrong. When health experts such as the King’s Fund warn that driving competition in every part of the NHS will make it more difficult to commission the services that best serve patients’ interests, he simply puts his fingers in his ears and walks away. What makes this Secretary of State think that he is right when professional bodies and patient groups know that he is wrong?

Doctors and nurses do not support the Government’s plan, patients do not want it, some Conservative Back Benchers and members of the Cabinet do not like it, and the Liberal Democrats hate it. They had the sense last Saturday to see what the hon. Member for St Ives (Andrew George) called the potential catastrophe as far as the future of the NHS is concerned, and to ask for amendments to the Bill. I hope they have the sense to join us in the Lobby tonight.

'Doctor' says screw the NHS

Via the Jobbing Doctor, according to this BBC story:

"Dr David Bennett, head of the economic regulator Monitor, has told the BBC he expects to see many more private companies and charities treating NHS patients. If NHS services cannot attract patients they will be allowed to close.

"BMA chairman Hamish Meldrum said the full implications had been poorly understood."

As JD points out, 'Dr' Bennett is not a medical doctor*, he's an ex-McKinsey man, and was formerly Chief Policy Advisor to Tony Blair and head of the Number 10 Strategy Unit. Funny how this is not made clear in the article, yet Hamish Meldrum, GP and BMA chairman doesn't seem to warrant the 'doctor' label.


* I can't find out what his title derives from, e.g. a PhD.

Preventing access to psychological therapy?

Interesting article in the BMJ on the Improving Access to Psychological Therapy (IAPT) initiative started under Labour and continuing under the Tories. It remains unpopular with GPs while being heralded as an outstanding success by central government:

"The impact assessment on the expansion of the programme, signed off by Mr Burstow, estimates that the cost of providing a course of treatment is £136 for mild mental health problems and £754 for moderate or severe cases. This, the assessment says, is substantially lower than the estimated costs for talking therapies before IAPT, which are quoted as £255 and £1298.

"Quite where these figures come from is a bit of a mystery because they conflict with those collected by a team led by Professor Glenys Parry of the University of Sheffield, which evaluated the first two pilot sites for the programme, in Doncaster and Newham, comparing them with neighbouring services (Wakefield and Barnsley and City and Hackney). They found that IAPT treatments cost more, not less, than those provided in the neighbouring boroughs, and that it was not possible to say whether the extra costs were justified by better outcomes."

This accords with the experience of many GPs, mental health professionals, and patients (e.g. see the Shrink here).

Service level agreements in medicine

Apparently:

All aspects of NHS care for entire diseases are to be put out to tender under radical plans to dramatically expand the role of private companies and charities in running the health service, Pulse can reveal.

A pilot set to launch across the east of England will put entire NHS care pathways out to tender, starting with musculoskeletal medicine, respiratory care and elderly care.

As anyone who has seen their local IT services outsourced will be able to identify with, I am wondering what the response time for a chest drain will be under the 'service level agreement'?