Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Why advocate flawed fee system - failure to learn from other's mistakes?
- Nigel Dudley (22 October 2004)
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We hear you Professor Maynard
- John Hopkins (22 October 2004)
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Applied in partnership the contract works for both consultants and patients
- Jonathan M Fielden (22 October 2004)
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Fees for service - ? new terminology for waiting list initiative payments
- Roger W H Skilton (24 October 2004)
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We still need a contract with healthy incentives.
- Dr Adam P Fitzpatrick (25 October 2004)
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Surgeons' fees for items of service
- Ewen F Flint (28 October 2004)
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Nigel Dudley, Consultant in Elderly Medicine St James's University Hospital, LEEDS. LS9 7TF
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Maynard and Bloor's advocacy of fee for service payments seems fatally undermined by pointing out that Germany and France wish to abandon a similar system because of the costs. It is highly unlikely that the Germans would not have gone through a process of exploring whether or not careful control of payment mechanisms would enable such a modified system to continue before opting for it to be scrapped. What makes Maynard and Bloor think that things would be better in the UK? Is this another example of optimistic and woolly thinking with change for change sake in the hope that productivity will be improved in the NHS? The new contract should deliver greater accountability of consultants. If it does not then it is only managers who will have themselves to blame as the agreed job plans can be enforced. Rather than grumbling about the lack of transparent accountability of consultants Maynard and Bloor would be better using their time looking at the accountability of the managers supporting the consultants. The transparency of their system of accountability is about as clear as a cesspool. The underlying issue around productivity is that of quality versus quantity. It has probably escaped the attention of Maynard and Bloor, who do not work at the coal face of the NHS, that the public has become more inquisitve about the treatments that doctors deliver. It is no longer acceptable for a surgeon to tell Mrs Smith that this is the operation that she is going to get on Thursday and now please will she sign on the dotted line. The recent policy decision to allow negligence claims to be taken forward if a consultant fails to disclose the smallest of risk means that surgeons will be spending more time in future talking and explaining about risks and options rather than cutting.[1] The patient gets a better deal as the choice to have or refuse an operation is enhanced. The NHS unfortunately then appears to become even less productive from the much appreciated extra investment put in by the government over recent years. What does the public want - quantity or safe quality? Maynard and Bloor would perhaps choose the former judging from their editorial. [1] Chester v Afshar [2004] UKHL 41 The views expressed are my own and not those of my employing organisation. Competing interests: No private practice. |
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John Hopkins, GP Newton Aycliffe DL5 4SE
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Dear Sir, Anyone who has followed Professor Maynard's writing over the years will be under no illusions as to his opinions about the medical profession. What does come as a surprise is that someone who is, apparently, the Chair of an NHS Trust should understand so little about how doctors work. His suggestion that admission rates are an index of physician's productivity presumably arises from the managerial fantasy that good consultant care of chronic disease reduces admission rates. In fact, consultants manage chronic disease extremely well. Patients are admitted to hospital because the GP feels that, despite this, their condition has deteriorated to the point they need inpatient care. Maynard may retort that is because GPs are idle or incompetent, which they arent, but even it if they were, it is not something the average consultant can do much about. On his substantive point about fees, surgeons need no encouragement to operate. They may dislike outpatient clinics and ward rounds and they may detest meetings. But the one thing all surgeons have in common is that they are obsessed with operating. Without such an obsession they would not have overcome the hurdles that junior surgeons and their families meet in the interests of training. Yours sincerely, Dr John Hopkins General Practitioner Newton Aycliffe DL5 4SE Competing interests: None declared |
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Jonathan M Fielden, Deputy Chairman CCSC Royal Berkshire Hospital Reading RG30 2NN
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Maynard and Bloor (1) fail to bring evidence of benefit for personal financial incentives in health care. Indeed much of the information provided suggests the limitations, divisions and distortions such moves could bring. Most of the radical changes in health care delivery in recent times have not been driven by such incentives (A&E changes, development of day case surgery, clinical decision units to name but a few). The new consultant contract is in its infancy. It is too early to measure success in bringing a better work-life balance to consultants and improvements to patients, but early reports show up to a third of consultants already seeing an improvement. The belief in the new contract from the profession is shown by the substantial majority of consultants who have moved over to the new contract (about 85% so far). In some trusts there has been almost total take up. As we monitor the successes of the contract we will see where there may need to be adjustments, but there is no planned revision of the contract. The new contract gives both transparency and ability to manage performance. Trusts who have negotiated, in partnership with their consultants, job plans that reflect the number of Programmed Activities (PAs) required will soon see this; to the benefit of patients and consultants. Properly negotiated, job plans include both objectives and supporting resources. Trusts that have brought in contracts for a number of PAs only and not undertaken the vital task of job planning have missed the fundamental feature of the contract. We are already urging all consultants to look towards their next job plan, or early job plan review to achieve this change. Furthermore, there is little evidence, and indeed none is cited, that there is growing support amongst surgeons for fee for service payments. Although a review of the present pilot sites is underway, there has been little take-up or interest to our knowledge within NHS trusts. Perhaps the profession realises the limitations of these measures, as shown by the united refusal to bow to immense pressure from the last health secretary to accept fee for service. It is a shame that the fallacy of the widely disputed NERA (2) report on private fees in this country is again paraded, however the accusation of cartels is of greater concern. Thorough investigation of several groups of consultants by the OFT has failed to find any evidence of this. If the Authors know of any such activity by insurers, implied by their statement they should make this available. Otherwise the statement should, at the very least, be withdrawn. The final paragraph states any changes should piloted, an action rarely taken by policy makers. However the effects of fee for service are likely to be minimal when set against the already decided policies of payment by results, practiced based commissioning and patient “choice”. The combination of these three will rapidly create a health service market that will be much less predictable than politicians believe. They have opened this Pandora’s box. It is to be hoped that they are ready for the entry of entrepreneurs, the predictable reconfiguration of services and probable closure of some hospital sites that will inevitably result. Dr Jonathan M Fielden Deputy Chairman CCSC 1 Maynard A, Bloor K Reforming the consultant contract again? BMJ 204; 329: 929-30 2 Bramley-Harker e, Aslam S, Fees for medical specialists: how does the UK compare? London: NERA Economic consulting 2003 Competing interests: Member of negotiators for new consultants contract |
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Roger W H Skilton, Consultant Anaesthetist York Hospitals NHS Trust
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I am somewhat bemused to read an article by the chair of my NHS trust employer that proposes introducing fees for service - particlarly when they have been in effect in his own hospital for several years. Payments for waiting list initiatives (WLI) are fees for service that appear to provide no incentive whatsoever, for increasing patient throughput/activity with existing resources. They can even appear to reward inactivity. The authors speculate on the impact of such personal financial incentives - but they do not provide any evidence of benefit. They acknowledge that Germany and France wish to abandon fee for service payments because of their cost. I'm sure our own Finance manager would wish the same fate for waiting list initiative payments in York. They have had no effect on reducing the overall waiting list. They certainly undermine NHS efficiency and create disharmony, with differential pay rates for different employees. Their editorial also omits the fact that the DoH are introducing their own system of fees for service from next April. Payment by results (PBR) will provide hospitals with a fee for service based on a national tariff . The 2005/06 tariff is based on reference costs from 2003/04. Perhaps they should evaluate the impact of PBR before suggesting more of the same ? Competing interests: Consultant Anaesthetist employed by York Hospitals NHS Trust. |
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Dr Adam P Fitzpatrick, Consultant Cardiologist Manor Lodge, Cheadle SK8 2NT
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A vision of positive incentives for doctors to do more or do better is welcome. Currently, a successful consultant can become engaged in NHS service improvement to eradicate waiting lists and provide first-class treatment in first class facilities, but such improvements might result in falling demand for their services in the private sector. The new contract will not eradicate private practice, and unless there is a massive unforeseen improvement in quality of care and choice in the NHS, the patients who get the fastest, most client-orientated care with a consultant of their choice will continue to be those who afford private health insurance. In other words, you can have high-quality personalised care only if you pay extra for it. The new contract arrangements will not change this fundemental inequality. NHS acute Trusts are not set up to provide bespoke, high-quality, client- orientated care, they are set up to provide on-the-hoof, chaotic, crisis- management. One of the major causes of this is the continuing need to try and reduce waiting lists and waiting times, whilst also catering for the acutely ill. The acutely ill do not appear on waiting-lists, they have no choice about where they end up, and all too frequently, under current arrangements, they are forced to wait far longer than necessary for care because of competing pressures from elective waiting lists. Both types of patient are trying to access the same doctors, beds, laboratories and theatres, and the result is stress, misery, chaos, crisis-management and poor-planning. In tertiary cardiology, many more patients with acute coronary syndromes deserve treatment than currently receive it, and those who do wait to get it block beds for long periods in DGHs. They are waiting for transfer to a tertiary centre struggling to keep waiting times down for elective care. A recent National survey has identified the prolonged waits and waste caused by the resultant bed-blocking in DGHs. Also, we still do not know how many patients eligible for early transfer and treatment are not receiving it because of bed pressures and inadequate capacity in tertiary centres, but it is probably many times the number being treated. At the same time, elective care continues to be delivered, because of inappropriate distortion of clinical priorities by the focus on waiting times. Waiting list targets do not reveal the numbers of patients trapped in the system waiting to get onto a waiting list, or the numbers of acutely ill patients waiting to get urgent treatment. If they did, it would be clear that not much is improving, and there is a need for fundemental changes that the new contract for consultants won't bring about. We have limited skills available to provide the care needed, training cycles are very slow, and the new contract will likely see thousands of consultants opt for early retirement in the next few years, further reducing the skills-base. The answer to this problem is not clocking-on-and-off, not enforcement, not socialist dogma, and not a pretence that every minute of every consultant's time adds equal value. It demands a fresh desire to seek a workable compromise that uses skills as productively as possible, directly rewards those who work hardest, and allows market forces to come to bear to provide real choice for those in a position to take it. In every healthcare system, (including the USA), public hospitals provide a safety net of care for the vulnerable in society, which includes those too sick to exercise a choice. In the UK, we are giving these hospitals independent status and encouraging them to neglect this mission. This is a disaster, and must be re-thought. Acute Trusts should make their primary mission the care of the urgently ill, and leave the elective work to others. Highly sophisticated, costly or developmental work can still be done in these settings, but bread and butter elective work should be done elsewhere, through highly efficient elective units, many of which would not need to be open at night. The argument that this destroys training doesn't wash. Training is best supervised in sick patients who have the disease burden, complications and vulnerability that allows a complete education, not on elective cases that go well. Later, trainees who are more senior can take part in care in elective units, paired with a trainer. Financial flows need to reflect the focussed mission of the acute Trusts/public hospital, and they should be supported for their role in focussing on the sick, who are deprived of choice. How should the urgent/elective split be managed, how should positive incentives be built in to prevent service excellence in one setting disadvantaging a doctor in another setting, thereby creating a peverse disincentive? The Australian system deserves the attention of our leaders and our best minds. A new consultant contract could have been a choice between 12 PAs in an acute Trust versus 8 PAs in an NHS Trust and an open market to offer elective care procedures and operations in the private and independent sector with NHS consultants and NHS standards, which were once respected the world over. Any patient will have the right to treatment for urgent or elective condition through any hospital, free at the point of delivery. Unbridled fee-for-service runs the risk of unneccessary procedures and escalating costs. Time-limited fee-for-service, with time built-in for care of urgent and emergency cases, supporting activities and teaching, feels like a good compromise, as ANY system will have to be. I would propose an alternative new consultant contract, offered to all as an option, whatever the BMA say. This would be an Australian-style working week, with 3 days a week delivering care to patients with no choice, (i.e. the acutely ill, requiring urgent treatment at the nearest hospital), and also delivering the training and CPD agenda. Two days a week would be devoted to providing elective care to waiting-list patients, at 63-75% of BUPA rates, in accredited independent institutions. Finally, if you are not urgently ill you will have a guaranteed choice of provider and hospital, and the urgently ill will have public hospitals devoted to their care, not trying desparately to be an acute Trust AND deliver quality elective care. Waiting-lists, and waiting lists to get onto a waiting list, will be a thing of the past. Long waits for transfer to another hospital for care of an urgent condition will be tackled by increasing capacity, provided with capital raised by independent providers, not dependent on costly PFI and costly PFI consultations. No consultant will work to inprove NHS care at a cost to their private practice. All patients capable of exercising a choice would get one in a system where unhealthy disincentives are replaced by healthy ones. Consultants will not be required to emphasise long-waiters when sick patients languish elsewhere awaiting their attention. Competing interests: None declared |
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Ewen F Flint, Consultant ENT Surgeon Dumfries & Galloway Royal Infirmary, DG1 4AP
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What would happen to my fees if the patient failed to come in for surgery, or was sent home because of lack of beds, or my theatre list was cancelled because of staff shortages.Who would get the fee if a case was operated on by a trainee "flying solo" while the consultant sat at the back of theatre? There are too many anomalies to even consider paying consultants in this way. Competing interests: None declared |
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