Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Most of the clues are in sight.
- Steven Ford (25 May 2003)
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Failures of contracts
- Huw Llewelyn (29 May 2003)
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The failure of the consultant contract
- Nicholas AV Beare (29 May 2003)
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GP contract betrays inner-city
- Jonathan Fluxman (5 June 2003)
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Stiffled debate, and who spins on the GP contract
- Dafydd H Thomas (26 June 2003)
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Sir This editorial and 'Patients and the new contracts' and 'Why clinical information standards matter' have an important common thread. Each contains clues that can lead to progress and yet none of the authors seems to see the greater picture. Government's frustration must be acute, given their espousal of many appropriate themes for reform and the substantial funding provided. When will the message sink-in that the problem lies not with government nor workforce but in the interposed layers? As with any task, if you employ the wrong tools then a poor outcome is assured - QED. What is the NHS for? The alleviation of pain, suffering and fear might be the original aspiration but now we must append interminable navel gazing, self criticism that reaches pathological degrees of abnegation, the prevention-of-everything and a measure of social control - all whilst fending off, apologising for, pandering to or circumventing the manifest idiocies of management. A clean, fresh, cogent and succinct definition of the purpose of the NHS would be a useful foundation from which to build. The Treaty of Utrecht, at 1.6Mb in pdf, is shorter than the documentation covering the new GMS contract for GPs but it is eclipsed by every NSF. The Geneva Convention is the merest wisp of a document at eight and a half thousand words and the Treaty of Westphalia scarcely more at fourteen and a half thousand. Magna Carta, including all the orotund phraseology, is just over four and half thousand words. There is an important message here, I wonder if politicians and civil servants get it. The brick-like documents, such as the NSFs and new contract material, are indisputably not the right building materials for the NHS. Complexity in any undertaking bears a direct relationship to the likelihood of failure. The labours of those who have composed the new contract have been Stakhanovite but if the entirety of the new contract cannot be contained within, say, two thousand words and be readily understood by everyone at first reading, then all is in vain. The third leg of the NHS milking stool is the patients who are not an inert substrate upon which the NHS acts but a critical dynamic component in the machine. Without positive action by patients, in using the system correctly, then failure is inevitable. Most patients are keen to be as obliging as possible but others fail to attend appointments and fail to use proffered interventions correctly. Neither government/management's nor doctor's nor patient's freedom of action can be wholly limitless, there is a need for recognition of the limits, responsibilities and duties of each and for equal effective sanction for all. Smith, in his closing sentences, approaches the kernel of the issue. 'Clash of values', '- main job is to care for the seriously ill unencumbered with bureaucracy.', [not] corporate citizens [but] valued professionals.' Defining the limits and purposes of the NHS is important. Allowing professionals to work, free of distraction, is crucial. Employing the right tools to operate the NHS is a lesson for government to learn urgently. Recognising the vital part that patient behaviour plays in the efficiency with which their own health service works is an overdue epiphany. Yours sincerely Steven Ford Competing interests: I am a PMS GP toying with the prospect of earlier-than-planned retirement. I still love the clinical part of the job but I despise, with all my heart, what is being done to health care in the UK by the culture of managerialism. |
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Huw Llewelyn, None Glantywi, Llanegwad, Dyfed, SA32 7NL.
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The failure to agree NHS contracts signal deep problems[1]. Deeper problems may occur if individual NHS Trusts ignore existing contracts. The BMA and MDU were helpless when the Carmarthenshire NHS Trust stopped a legal inquiry into allegations against me because it was not going the Trust’s way. This was before I could speak in my defence and before the chairperson could write her report. I was then dismissed ‘summarily’ from my post as a consultant physician with no notice or pay in lieu and refused an appeal, apparently to save money. An Employment Tribunal declared that I had been unlawfully and unfairly dismissed. The Trust’s actions gave the false impression that the GMC had struck me off. But the GMC decided that the surprising allegations against me had not actually raised any issues about my fitness to practice. Not one example of wrongdoing could be produced. Ironically, the GMC considered that the cause of my problems was a disagreement about issues connected with employment legislation. I had warned the Trust to no avail that there might be a tragedy if job descriptions were not clarified for some in my team. Unfortunately I was proved right; there was a tragedy; and then this happened. It is one thing to dispute details in contracts, but quite another to completely ignore their existence. If one’s word is not to be one’s bond, then even reforming the NHS will fail to attract staff back to work, or keep them. I really do hope that my situation is a sorry aberration and that I will shortly be reinstated so that we can all move on. 1. Smith R. The failures of two contracts. BMJ 2003; 326; 1097-8. Competing interests: DEHL is personally involved. |
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Nicholas AV Beare, SpR, Ophthalmology St Paul's Eye Unit, Royal Liverpool Univ Hospital, Prescot St, Liverpool, L7 8XP
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Like the BMA negotiators, Smith[1] has missed the crucial issue that made present and future consultants finally balk at the proposed new contract. It was not "being required to work unsocial hours", which is done already for emergency work. It was the provision to have consultants doing ROUTINE work during unsocial hours at ordinary rates of pay. Whilst this is still included, the contract impasse is likely to continue. Nicholas Beare 1.Smith R. The failures of two contracts. BMJ 2003; 326; 1097-8. Competing interests: NAVB is an SpR in the NHS and likely to be subject to contract arrangements |
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Jonathan Fluxman, GP principal Harrow Road Health Centre, 265 Harrow Road, London W2 5EZ
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Sir, One of the failures of the proposed new GP contract not mentioned in Richard Smith’s editorial of 24 May is the failure to address the problems of deprivation and the systematic provision of services for vulnerable groups in the inner city. For this reason I and many other inner city GPs will have little choice but to vote against it. The last minute promise to include deprivation in the basic funding formula, (in 2006 no less) and the downgrading of services for vulnerable groups to non-essential “enhanced” services is a significant policy shift in the delivery of primary care in this country. Nowhere in the contract document is there a coherent policy statement or strategy addressing the issues of deprivation and the need for additional resources to provide basic level care to vulnerable groups. The omission of deprivation as a factor in the Carr-Hill formula is both extraordinary and a huge step backwards even from the Jarman index, which although imperfect, at least recognised the principle that additional resources are needed to provide core primary care services for deprived groups. The argument that funding for these groups will come from “enhanced services” is disingenuous. Extra resources are required to provide basic care for vulnerable groups given the range and complexity of their health and social problems. Refugees need extra time, and to be provided interpreters for consultations, for example, or their essential basic needs cannot be met. Without extra resources the heavy burden of illness and social problems experienced by drug users and homeless people, i.e. their basic care needs, also cannot be addressed by the practice team. This is why we have fought long and hard locally for additional resources for the care of these patients through local development schemes etc. LDS money is not used for any “enhanced” service for these patients, but for their basic care. We have also tried to ensure that these services are extended to all or almost all other practices, i.e. become mainstream primary care. This latter aim is an essential step if the needs of vulnerable groups are to be properly met in the inner city. If all GPs provide services the additional workload, properly resourced, is manageable. If only a minority do so, as at present, there will continue to be restricted access, overburdened practices and unmet need. The new contract effectively scuppers attempts to make these services mainstream. Downgrading the health needs of vulnerable people to non- essential enhanced services sends a clear political message, whether intended or not, that the care of such people is not essential, it is an extra which GPs can opt out of should they wish to. (Even PCTs are off the hook, according to the recent guidance from the GPC, which states only that PCOs “may seek” to commission these services locally.) This is a dreadful message to give the profession and to the public; it panders to and in fact legitimises the disgraceful practice of discriminatory registration carried out by some practices, who refuse to register homeless people or refugees but who will then go on to accept other people with less complex problems. The new contract will encourage such tendencies, indeed it will provide a legal basis to do so. At best some patients from these deprived groups will be treated as temporary residents by practices who choose not to provide the “enhanced” service, while others will be turned away altogether by other practices on the grounds that providing such services is not in their contract. This raises serious issues in relation to the basic right to health care, as well as being ethically and morally indefensible. The problem here is not so much that small group of dyed-in-the-wool GPs who will resist providing care to such patients no matter what, but rather the larger group in the middle who will elect not to provide these services on the understandable grounds of inadequate core resources and lack of priority from the centre to do so, in the face of overwhelming workload. The government and the GPC must be in cloud cuckoo land if they think that PCOs are going to be able to meet the needs of vulnerable groups under this framework. Indeed there seems to be no strategy at all to do so. To whom will PCTs turn to provide these services? Those of us who provide these services at present are already overburdened and in no position to increase capacity. PCTs who are financially able (and who choose to) commission services will be forced to set up “special” PMS practices to try to deliver services. This already tried and discredited model of care for vulnerable groups deprives people of care in some areas and ghetto-ises them in others, and will be far too costly to have any serious impact on capacity. The contract pays lip service to the problems while essentially endorsing the present very unsatisfactory position in relation to services for these groups: poor access and unmet need. There is an added negative dimension to adopting this model of care for drug users in particular: the local community will pay a heavy price as victims of crime by drug users unable to get into treatment. Grouping the health needs of vulnerable people together with enhanced services also has important financial implications: the budget for enhanced services will not be ring-fenced like that for core services, and will therefore be subject to outside economic pressures. Services will thus continue to be planned and run on the shifting sands of variable funding, an exhausting process for those involved in organising services while effectively preventing the development of reliable long term services and interventions. The new contract does address the intolerable workload pressures we all face as GPs and there is much in the contract framework which is valuable. If the government and the GPC are serious about addressing the needs of deprived groups however, their care must be made part of “additional services”, i.e. those services most practices would normally be expected to provide. GPs who want to can opt out with a financial penalty. The understandable concerns about workload and lack of skills in providing care for these groups can be addressed through proper levels of funding (core and additional services), together with training and peer and other support, along the lines of many local schemes. Over several years, the care of such patients will become mainstream general practice, which will ensure improved access and manageable numbers across practices. It is regrettable that the GPC has decided not to do this and to push ahead with ballot by 20th June, leaving little choice for inner city GPs but to vote against the new contract. In its present form it is nothing less than a betrayal of inner city general practice and the communities we work in. Yours sincerely, Dr Jonathan Fluxman. Competing interests: Clinical Lead for Mental Health and Substance Misuse, Westminster PCT |
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Dafydd H Thomas, GP partner Woking GU21 8TD
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Dear Sir, I have today contacted my bank to cancel my direct debit to the BMA. It is with some sadness that I do so, as I was a HJSC member and briefly Chairman for S Wales in my past. I feel however that I am unable to continue to pay for an organisation that has managed to provide me and my GP Colleagues with such a poor deal on the new GP contract. I am aware that the argument is with the Government but I do not expect my representatives to end up providing me with a pay cut, or substantial extra work and staff expenses to retain my present salary . The Government is a master of spin and negotiation but it seems to me that my representatives have been out spun, out presented and out negotiated. With a shortage of GP’s and an overwhelming majority one might have expected:- 1 to have ended up with a pay increase not a pay cut, we will loose at least 140,000 from our practice of 14,000. 2 to have full details of our pay claim before the media. They naturally gave banner headlines to a pay increase for GP’s of 33% , which later turned out to be erroneous. A significant own goal as a result of being “out spun” by the government!! 3 to not have a stop gap measure (MPIG) which will mean practices being disadvantaged if they opt for it 4 to have expected our negotiators to get the government to be make some visible concessions given the relative positions of the parties 5 to have achieved more on pensions when this was one of the stated main objectives of the negotiations 6 I am also very concerned that we have given away the control of our computer systems. This together with the need for mountains of quality data will render the GP’s role into that of a “medical data grease monkey” and we will have very little to do with provision of medical care. The BMA is needed to represent our views and successfully achieve a workable and sensible new contract. I am saddened to see how far the BMA House has drifted from supporting the grass root GP and have been out manoeuvred by this Government to appear to become an organ of the Department of Health and it’s policies. My practice will need to make significant economies if the new contract comes about. One of my first is to resign from the BMA who seemed to have got us into this mess when handed a very strong negotiating hand. My other action is to start looking for an alternative job or early retirement even though I am only 46. Yours Faithfully, DHV Thomas membership no 6816698 Competing interests: Recently resigned from BMA after 20 years follwoing mistakes re GP contract |
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