Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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And your kicks for free
- Des Spence (23 April 2006)
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NHS Reforms Puzzle: the missing piece
- Minoo Irani (25 April 2006)
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Des Spence, GP Glasgow G20 9DR
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You know you’ve upset the profession when a local colleague stops you in the car park to tell you’ve got it wrong. I merely suggested on a Scottish news program that the GP pay rise was excessive and divisive. We have seen record spending on health care –catch up for years of the NHS under-funding. We were the backward medical child of Europe with our French, German and Italian cousins enjoying much better health care. This of course was a complete false premise – merely doing more operations, having more specialists and taking more medicines does should be confused with quality – but that’s politics. More spending indeed runs the very real risk of over diagnosis and unnecessary interventions. The NHS had for decades made the best of its lot - poverty giving it clarity and priority. We were well paid, with a generous pension and we worked hard. Grumbling was a popular and enjoyable pastime. Unfortunately, this Government has squandered its cash. Wasted on “Bling-bling” waiting list initiatives. A drug culture not only accepted but promoted. Negotiators impressed by the professional muscle and hard street talk shelled out big money for less work and no control over quality of care. A right rock and roll swindle. Now many Trusts are in trouble but wait till next year. Their financial wheels lashed by a 60% increase in quality point payments – the iceberg looms, the band are practicing but the lifeboats are missing. Paying doctors more has no impact on patient care and indeed may reduce the incentive for well paid professionals to do extra. We do need more doctors and nurses but paying GPs a 100 000 pounds a years will only attract status and financially motivated candidates. We need a return to some old fashioned ideals. Become a doctor because its important, its fulfilling and it’s a vocation. If lawyers, accountants or even footballers get paid more, does it matter? Sorry for the offense caused to the profession by such a radical suggestion - see you in the car park. Competing interests: Public servant and a taxpayer |
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Minoo Irani, Consultant Paediatrician Upton Hospital, Slough SL1 2BJ
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I was among the audience listening to the Prime Minister’s speech on 18 April where he asked clinicians to ‘hold their nerve’ about the present healthcare reforms (1). The Prime Minister spoke about four different but interlocking changes which were happening at once; these include practice based commissioning, payment by results system for hospitals, patient choice and new independent providers encouraged in the NHS. There was mention of the need for structural change and a process of re-engineering. The speech was well delivered, there was no attempt to circumvent questions and comments from the audience, and the enthusiasm of the Prime Minister was palpable. I suspect the audience was left with the impression that, whether they liked it or not, change within the health service was now inevitable and the pace of change would be unrelenting. The rationale behind these proposed changes has seen sufficient debate already. However, like most change programmes, this one also concentrates too much upon structures, systems and processes. The missing piece is the ‘culture change’ which somehow continues to elude a significant majority in the health service. Deal and Kennedy define organisational culture as “the way things get done around here” (2). Culture change would, in its simplest form, involve changing the basic values, norms and beliefs among members of the organisation in order to improve organisational performance. To cite one example, since publication of the NHS Plan in 2000, there has been renewed effort to shift the balance of power from secondary to primary care. In the past five years, the emphasis of reform to break down traditional demarcations between different professional groups and organisations (3) did not realise as much as expected; the vision for ‘culture change’ became confused with the more easily achievable ‘structural change’. The result was that secondary care specialists remained firmly rooted within the acute hospital boundaries, GPs preferred to pursue and delivered upon various targets and Primary Care Trusts were eventually ineffective commissioning bodies burdened with huge financial deficits. The Government has tried to be somewhat more prescriptive about shifting care within particular specialties from hospital into community settings in their recent white paper (4). However, the implementation of this seems to be getting muddied once again by debates about the size and structure of proposed ‘polyclinics’ and ‘super-surgeries’ (5). Simply relying upon co-location via Local Improvement Finance Trust schemes to encourage joint working may be another expensive mistake, unless everyone involved shares a common vision. There is a real danger that practice based commissioning and payment by results could create greater division between primary and secondary care unless a more inclusive approach is adopted. Maybe it is time to pay greater attention to that elusive piece which could help to solve the NHS reforms puzzle. References: 1.Day M. Prime Minister tells troubled trusts to ‘hold their nerve’.BMJ 2006; 332: 927 2.Deal TE, Kennedy AA. Corporate Cultures: The rites and rituals of corporate Life. Harmondsworth, Penguin Books (2000) 3.Shifting the balance of power within the NHS: Securing delivery. Department of Health, July 2001; p5 4.Our Health, Our Care, Our Say: a new direction for community services http://www.dh.gov.uk/assetRoot/04/12/74/59/04127459.pdf 5.LittleW. Primary Care-settle for super. Health Service Journal. 13 April 2006 Competing interests: MI is the NHS Alliance network lead for specialists in primary care |
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