Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Magnificent!
- David Baker (23 May 2003)
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The greyness of government
- Mark Oliver (23 May 2003)
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The DoH knowingly ducked this issue
- Michael F Loudon (24 May 2003)
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Too many targets and not enough archers?
- Chris Manning (26 May 2003)
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Fundamental dilemmas in contract
- Gray Southon (26 May 2003)
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Jaundiced View of Contract
- Arun M Gordhandas (27 May 2003)
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Pragmatic reaction to new GMS contract
- Laurel L Spooner (29 May 2003)
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Bowling green or meadow?
- William House (8 June 2003)
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David Baker, GP Canford Heath Surgery, Poole, BH17 8UE
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Dr Davies & Dr Glasspool have written a masterly editorial that has clearly outlined something doctors have found difficult to articulate. Our contract, even if agreed by DoH and the profession ( +/- last minute revision by Milburn) is doomed to failure, assuming a healthy vibrant General Practice is the intention. I'm not sure it is. Competing interests: None declared |
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Mark Oliver, GP Stafford
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Davies and Glasspool go some way towards explaining why doctors are unhappy with the proposed contracts.It may yet be possible for the leadership of the BMA and the government to buy off objectors to the GP contract, but will that lead to the renaissance of general practice that Smith feels may happen or continuing decline in recruitment and retention? There are interesting parallels with schools.There rhetoric about new delivery of exciting services is met by the reality of schools struggling to balance budgets by sacking teachers and closing early.Teachers' professional lives are now so tightly regulated that recruitment and retention suffer and every GP must have had members of that profession passing throughthe surgery with stress-related illness.Yet the independent sector thrives. I suggest this is largely because the state has had its meddlesome fingers removed from the pie, and professionals are free to contract to provide the services parents want, which in turn makes them willing to invest directly and substantially.For similar reasons dentists left the NHS en masse. The challenge to negotiators is to persuade government to invest substantially whilst keeping a much lighter hand on the tiller and trusting professionals more rather than developing ever more intrusive bureaucratic supervision.This runs counter to all the basic gut reactions of the Treasury, and for that reason the negotiators are going to find it very hard to produce a contract that does not turn off doctors who object to medicine by numbers devoid of the art we all practice against the odds every day of our working lives. Competing interests: A GP principal |
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Michael F Loudon, full time General Practitioner New Ollerton, Notts. NG22 9SZ
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Several years ago the Department of Health [DoH] invited Professor David Eddy of Duke University, South Carolina to London to give them a guest lecture. We can safely assume that senior officials at the DoH were familiar with his work. Eddy had published an outstanding series of articles in JAMA under the overall title "The Ethical Basis of Market-Place Medicine." In this series he explicitly addressed the issues raised by Davies and Glasspool. The thirteenth paper [1] discussed how we might decide what "essential" services are. We must acknowledge that the 'new contract' for GPs does address this matter head on and the division of services into the categories "essential" "additional" and "enhanced" is welcome if overdue. It finally puts paid to the political arm-twisting that the DoH have indulged in over recent years in attempts, for example, to persuade GPs to take on the management of drug abuse patients. However, it is no accident that the twelth paper in Eddy's series, immediately preceding that cited above, first addressed the issue of "Rationing by Patient Choice." [2] In this paper Eddy pointed out the obvious, that people pay for their medical care but will not commit unlimited funds for treatments of marginal benefit. Accordingly it is people (who will later be patients) who must be asked what they want from a service. We can construct notions of cost-effectiveness and of cost- benefit, but only service users can tell us which treatments they value most. Without this input we cannot connect cost to value, and the 'rationing' choices we make are, strictly speaking, unethical. There is an obvious drawback to this notion of allowing people/patients to connect value to cost. They might decide that they want more of their (taxation) money spent on healthcare so that the 'package' includes all the things they value. So we shouldn't be surprised that the people's/patient's voice has not been heard. That way democracy lies, as Shakespeare might have said. 1. Eddy DM. What care is 'essential' ? What services are 'basic' ? JAMA 1991; 265: 782-788. 2. Eddy DM. Rationing by patient choice. JAMA 1991; 265: 105- 108. Michael Loudon Competing interests: None declared |
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Chris Manning, CE Primhe (Primary care mental health and education Twickenham TW1 4JA
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Dear Sir Davies and Glasspool are to be congratulated on succinctly stating some of the reasons for the NHS being on the reefs. Given that public expectations have been cranked up beyond belief by needy and narcissistic power-mongers for many years, are we not kidding ourselves if we think that anything short of a complete revisiting of the core values-basis for health and social care is going to rescue this now task-orientated, target -ridden old tub? The medical model, inter alia, has got us to the point where we are - a state of learned national helplessness, where people and politicians think that health is about more doctors and more hospitals and Shifting the Balance of Power really means the continuing stunting of primary care growth as its life-blood is shunted to meet the insatiable demands of its sibling. Researchers apparently need to do more research to make the country a better place to live in and the needs of those who profit from developing new treatments demand that we become increasingly 'technossified' and removed from any sense of our own ability to help each other in ways that are, in fact, even more advanced, since they involve us in engaging our brains, thinking for ourselves and joining-up to local needs. In truth, we have a Department of Illness and a National Illness Service; health is everywhere else but there. Paradoxically, doctors increasingly wish to work WITH people in partnership; the rhetoric is of partnership and concordance, but even this week in the BMJ, as doctors try to use real English, patients still want the techno-terms. Well, I say tough; let's bite the bullet and get some risk, uncertainty, reality, responsibility and power-sharing back on the agenda. Trust my judgement here BMA, I'm an expert patient. Whilst doctors are exhorted to practise evidence-based medicine, where is the evidence-based politics? MPs are safe and sound in the knowledge of self-elected pay awards and pensions and work beyond eviction. Surely, we now need the essential health, education and transport infrastrucures of the nation to be uncoupled from fickle short- term agendas coupled to populist appeal? No contract is going to save primary or secondary care now, whatever its articulation. Indeed, it is hard to resist the conclusion that driving as many providers and users out of the state system through testing people to the limit of their tolerance is a neat trick indeed. No need really for any formal means-testing bureaucracy. Yes, those bones are rattling indeed, the muscles are wasting by attrition and the staff are increasingly skeletal. Dr Chris Manning Competing interests: I have depression and always view the glass as half empty. |
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Gray Southon, retired University of Technology, Sydney, NSW 2007, Australia
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Davies and Glasspool address a crucial issue, but fail to recognise the complexity of their solution. The public have, in fact, fundamentally conflicting interests. Our desire for a system that is accountable to us through our political representatives, imposes on the system a hierarchical structure which inhibits clinicians in providing the personalised, flexible care that we expect. The system fails because of the complexity, uncertainty and dynamism of the process of providing for health care needs. The political system is unable to adequately establish social goals, and the management hierarchy to direct clinical professional work. The result is that health service requirements as mediated through the management structure have little to do with the needs experienced by practicing clinicians. The much discussed conflict between clinicians and management is but a symptom of this failure. In fact most of the proposed solutions including managerial accountability, purchasing, setting service priorities, a defined social contract or reliance on the free market, fail for these reasons. Any solution must rely essentially on the skills, commitment and values of clinicians of all types to provide for the needs of each patient in a way that is socially acceptable and economically viable. To do this they need to be both professionally and organisationally supported to enhance their skills and to participate in developing social norms and the required standards. It is only on the basis of such quality of work force and their engagement with the community that an effective system can be structured. Accountability is required, but needs to be designed to support, rather than detract from, professional services. Our current pre- occupation with dictating, monitoring and controlling will only continue to exacerbate the problem. Competing interests: None declared |
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Arun M Gordhandas, Retired Principal (occasional locum) Ashby Clinic, collum Lane, Scunthorpe, DN25 2SZ
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Dr Davies and Glasspool, in their editorial (2003;326:1099), take a very jaundiced view of the contractual process between the government and the profession. They feel that the patients’ views have not been taken into account. In support they quote the editorial by Gillon et all who advocated a social contract. Gillon et al were dealing with problems of morality as affecting the profession. They offered their solution of social contract to bridge the moral values of the society versus the professional needs of an individual or a department. They were not concerned with the day to day nitty gritty of treating individual patient. In fact it is this nitty gritty which forms the core of the contract. An individual wants access to the system when he feels that he needs professional advice. It cannot be written in the contract as to when an individual should be allowed to feel that he needs professional advice. Some patients want a chat re: their social problems, some want to medicalise their minor complaints, some want second opinion whilst some actually want to be treated for their illness. No amount of social contracting could accommodate all these different attitudes taken up by the public. It is up to the individual doctor to enter into an informal contract with his patients and inform them as to what services he would offer to them. Most patients respond very intelligently to this kind of approach and reduce voluntarily workload on the doctor whose health and daily presence in the surgery are vital to their own well being. Competing interests: None declared |
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Laurel L Spooner, GP Colchester CO3 3AT
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I would like to add my more prosaic jobbing GP's response to the heartfelt philosophical outpourings from other doctors which you have recently published. I hope my colleagues accross the country will vote out the contract because it is simply "not fit for purpose". What were its original aims? Firstly I thought it was intended to make the conditions in Primary Care more attractive in order to recruit more desperately needed Doctors to work there. Secondly, it was said we needed a remuneration system which was simpler than The Red Book & better at rewarding good performance. To deal with the first issue- how can anyone doing the job imagine this contracts makes it more attractive? It makes my task even more bureaucratic than it is now & it is more certain than ever that I shall have my hands more on a mouse than a patient. It will be a battle not to become a box-ticking automaton. The so called "carrots" are in relation to 24 hour cover & workload control but these have little substance in reality. The former is already largely solved by co- operatives & deputising services & the latter proposal which would permit me to shed workload from time to time by opting out of caring for my patients cervixes etc is an absurdity! All my career to date has been spent striving for "the seamless service" in "the one stop shop." Why put this model in the shredder? Would patient Groups support us? (I am sorry Madam, but it is Practice A for your postnatal check, Practice B for you Baby's, Practice C for the immunistions, & you'll need to take your cervix to Practice D)...."And a patient shall no longer be registered with a named doctor but with a practice." (why??) Now to the remuneration system. It looks ridiculously more complicated, expensive to administer, & appears to offer greater opportunities for fraud & abuse than the current Red Book. Under the present arrangements I am in a PMS practice. We have managed to escape from tedious chunks of the Red Book & substitute our own Service Improvement Programme with our PCT. This arrangement has been much more creative and exciting than old GMS. I hoped the New Contract would draw on this model, but in fact it is a move in the opposite direction being considerably more proscriptive & stifling. I am also dismayed to see how many quality markers involve specified phamacological interventions, some of unproven long term benefit. How long is it since the about turn on HRT & how strong a voice does the pharmaceutical industry have in determining the Quality Agenda we are to work to? In summary we need a much, very much simpler contract. Almost every area of it is overcomplicated, just as in Education, where steps are now being taken to address the harm this has done. We should learn from that lesson. Our poor negotiators have enormous political pressures upon them & they are caught up in a profoundly frustrating game. However I cannot really make allowances for them producing such a poor lame beast of a contract. It looks to me as though the doctors concerned see more of bureaucrats & budgets than they do babies & bunions & they have finally lost sight of what being a GP is all about. I suggest it is back to the drawing board with a paper ration of one tenth that which they used last time round! Competing interests: PMS General Practitioner |
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William House, GP principal (PMS) Keynsham, Bristol, BS31 2BN, UK
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Sir, Davies and Glasspool(1) have eloquently expressed the fundamental problem we face in the NHS: lack of understanding of what medicine in the 21st century should be trying to achieve: it’s core values (2). Of course patients should have been involved in the contract debates, but without posing deep questions it would still have ended in a bog. The negotiators have been trying to pin down in a legalistic framework what we doctors do intuitively. The moral philosopher, Mary Midgley, has explained why this ‘contract thinking’ in an area such as health and illness is doomed to failure(3). Contract thinking is contracted thinking. It is fruitless to apply a rigid structure to the practice of medicine (which defies definition) toward the achievement of health (which likewise defies definition). These are fluid and multidimensional aspects of humanity; human activities and qualities that thread their way through the ever changing web of life. They will always be fuzzy. Of course we must have institutions and standards, but the mistake is to imagine that rigid bureaucratic structures built on the fallacious 'solid' ground of natural science and consumerism will answer the complexity of human needs. The debacles of the contracts are a symptom of this impossibility. The proposed new GP contract is like a bowling green – highly contrived and inflexible monoculture, against the grain of Nature, requiring intensive maintenance: under control, but only good for one thing. We would do better to rethink from the beginning and aim for a wild flower meadow – man and Nature working in tandem, flexible, full of surprises and wonders, home to innumerable interesting creatures and very low on maintenance. Currently we have a bog – almost impossible to move around, a few threatened rare species, good for fossils in a few millennia. If we are lumbered with the bowling green, I for one, will set about planting some wild flowers! References 1. Davies P, Glasspool JA, Patients and the new contracts, BMJ 2003;326:1099 2. Pendleton D, King J, Values and leadership, BMJ 2002;325:1352-5 3. Midgley M, Science and Poetry, London, Routledge 2001, chapter 15 Competing interests: None declared |
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