Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Clinicians' priorities vs patients' (and managers') priorities
- John L Appleby (8 November 2002)
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Consultant Contract
- michael p cash (9 November 2002)
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New career pathway in medical management in the NHS
- Ian H kunkler (15 November 2002)
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Rethinking Management
- F C Gray Southon (22 November 2002)
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Losing my religion..
- Russell D. Lutchman (28 November 2002)
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Accepting responsibility for management
- anne W. Towey (1 December 2002)
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John L Appleby, Chief Economist King's Fund, 11-13, Cavendish Sq, London W1G 0AN
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Dear Sir Richard Smith notes that a central reason for consultants rejecting the new contract was the distrust of managers' control and in particular their pursuit of 'targets that distort good care.' [1] It has indeed often been claimed by some consultants that the target to reduce maximum waiting times has lead to managers pressuring them to treat patients 'out of turn' from the point of view of clinical urgency. This would be a very serious charge if it was not demonstrably the case that there is a good deal of variation between consultants' clinical (for which, also read priority setting or rationing) decisions when it comes to admitting patients from their waiting list and choosing which patients to add to their surgical lists each week. The recent Audit Commission report on access to ENT services is just the latest evidence of such variation [2]. This showed that for grommet operations, for example, all ENT consultants in one trust considered that no such operations needed to be carried out within three months, while in another trust the reverse opinion was held by ENT consultants. The point here - and the issue for managers struggling to ensure that patients do not wait unreasonable lengths of time for their operations - is that there needs to be a more consistent (and rational) criteria applied to key rationing decisions. Allowing all consultants complete freedom to make such decisions will not, on past and current experience, lead to an equitable outcome for patients in terms of waiting times. As Richard Smith rightly points out, however, doctors, managers and everyone else working in the NHS are all in this together, and while no employee wants to feel exploited, no one should take their eye off the ball: patients are what matter and many, rightly, feel they wait unnecessarily long periods of time for their NHS care. The much-derided government targets on waiting times merely reflect what patients want - and, it could be argued, what they need in terms of their health. John Appleby
1. Smith, R. Take back your mink, take back your pearls. BMJ 2002;325:1047-1048 2. Audit Commission. Access to care: Ear, nose and throat and audiology services. London, Audit Commission, 2002 Competing interests: None declared |
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michael p cash, GP principal Edinburgh, EH10
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Dear Sir As a GP I have no particular axe to grind regarding the proposed contract. However, I was intruiged to read Smith's editorial on the subject (BMJ 9 november 2002). He briefly mentioned that the contract had been accepted in Scotland and then went on to promote an argument that the rejection of the contract in England and Wales was due to the view that the proposed contract gives more control to managers. It would have been helpful perhaps to examine why the Scottish consultants voted in favour. Are there better relationships with managers north of the border? Or, as we calvanistic Scots like to think, are there dark forces of greed afoot "down south", where private practice is much more prevalant? (This was a view that Smith rejected). Of course, looking at it from the other side, you can construct an argument that it is the Scots who are actually reverting to (stereo) type and looking after their wallets by accepting a deal that will mean more money for those with little or no private practice at the expense of loss of autonomy. Probably neither response to the question posed at the ballot represents a considered response to what is best for the patients. Self interest tends to rule. Consultants are, after all, only human aren't they? Competing interests: None declared |
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Ian H kunkler, Consultant in Clinical Oncology Western General Hospital, Edinburgh, EH4 2 XU.
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Sir, Richard Smith (1) in his editorial on the rejection of the proposed consultant contract in England and Wales cites the widespread distrust among clinicians of hospital managers as a principle cause. In the same edition Anita Houghton and colleagues (2) identify lack of adequate training in writing business plans, negotiating change and getting things done as specific difficulties for newly appointed consultants. Clinicians are often thrust into senior management positions with major responsibilities for substantial budgets without the necessary financial ‘know-how’. A fundamental rethink of medical management is called for . What is needed is the development of a distinct career track in medical management at a much earlier stage with the necessary management training on a par to that available in the commercial sector. This model has worked well in Australia. Such medical managerial posts will need adequate sessional committments for these individuals to provide a high quality of executive function.A professional cadre of medically qualified managers in touch with clinicians involved in the delivery of service, setting realistic targets for service delivery in partnership with lay hospital managers might restore the trust of the medical profession and deliver the standards of care to which the government aspires. References: 1.Smith R.Take back your mink,take back your pearls. BMJ 2002;325:1053. 2. Houghton A, Peters T, Bolton J. What do new consultants have to say? BMJ 2002 325:s145-147. Competing interests: None declared |
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F C Gray Southon, Honorary Research Associate UTS, Sydney Australia 2007
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The analysis of the reaction to the consultant contract fails to address the question "have we got the role of management right?". Although health services are clearly a personal professional service industry, reforms over the past dacades have been based largely on the production industry. In the meantime, many other industries have been realising that professional services, with their central reliance on knowledge, requires a very different organisational structure and style of management than has been traditionally accepted as the norm. These changes involve a structural shift from hierarchy to networks, relationship change from formal to informal, and power shifts from managers to the professionals. Yet these changes seem to be ignored in the health industry, which is moving further towards formal hierarchical control. Why is this? Gray Southon Competing interests: None declared |
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Russell D. Lutchman, Specialist Registrar in Forensic Psychiatry Broadmoor Hospital, RG45 7EG
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Richard Smith suggests that we "...must remember that the future will depend on working together". I guess he is right for those who want to stay and work together. Consider the following: Working time directives, diminishing numbers of medical student applicants, gung-ho GMC, malpractice lawsuits rising at 10-15% per annum; a tidal wave of medical legislation, regulations and policies; QUANGO's dabbling left right and centre; the shockwaves from Bristol and Shipman; a sense of bullying as a means of getting things done; racism; nepotism; massive spin-doctoring about everything under the sun; regular media feeding-frenzies when doctors mess up - who for all the love of money and wonderful contracts would want to take up work there for the next 30 years - to exchange glowing youth for a chance to have triple bypass surgery - if you're lucky. I know. Only the best. “The best of the best, of course ..only those who love that challenge..the go-getting Type A personalities...those with real leadership qualities...not the faint-hearted" - I could hear some deluded spin-doctor shouting from on high. Somebody has got to do the job. It's no better anywhere else - is it? So, Mr Young bright-eyed and bushy-tailed Doctor - go for it. And caught amongst a massive mortgage in a super-inflated housing market, a few mouths that you feed but hardly ever see, your fancy sports car, a significantly higher than average risk of depression, alcoholism or suicide, followed by a one in three (or better) chance of eventually paying alimony and/or child support, and the lovely noose of big fat pension in your later years - you'll be a very good boy. In fact you'll be a damn good boy! You'll grin and love it, you’ll walk the walk, and talk the talk - you'll join them and spin them. You'll be right up there working together with them – rationing healthcare and humanity. Good for you. Some will create opportunities elsewhere for a better lifestyle. Spare me the mantras from Improving Working Lives – too little, too late and spin-laden - as usual. I’m sure many more of us whingers who care about our health and life expectancy will follow, to places where we’re no obstacle to progress or working together. Good for us. Good for everyone. Competing interests: None declared |
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anne W. Towey, clincal assoc. prof. Uof Minnesota, Lakeview Clinic, Waconia, MN USA 424 W Hwy 7 Waconia.MN 55382
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I have been very interested in the comments in the last few issues of BMJ related to compensation for militiary MDs etc. Certainly, the situation in the US is not as desparate, but in many areas it is getting to be that way. We are discouraged that our Senate left for holiday without addressing a serious medicare shortfall amounting to a 5.4% pay cut on all medicare patients. This is on top of the already extremeley lean reimbursement already in effect. It does concern me that almost everyone is only concerned about the "bottom line" and patients care and quality issues are swept aside. Never mind satisfaction for the individual medical practtioner. It certainly behooves us to appreciate that our oath of office commands us to "first do no harm:" I think that the more that individuals stand up to whatever system they are subjected to, that justice will eventually prevail. Please, do not be concerned for yourselves, I was recently "fired" from a postition for not being productive enough, in spite of first rate reviews and many requests to stay on and "tough it out,financially". Let us not forget what we have sacrificed to get to the postitions we now hold. It is up to those of us who are in the trenches to make a fight for the others, and for those yet to come. Right will prevail, when I am not sure, but it will come. Anne Towey MD UofMinnesota,clinical associate professor in Ophthalmology ,Lakeview Clinic private practice, Waconia Minnesota, USA Competing interests: None declared |
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