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Rapid Responses: Rapid Responses published:
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While Rome Burns
- William G Anderson (22 September 2006)
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Nothing surprising
- Thomas Szasz, M.D. (22 September 2006)
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A call to arms - again!
- Steven Ford (23 September 2006)
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Don`t be a bystander - join the resuscitation team!
- Hazel Thornton, Guidubaldo Querci della Rovere and Margaret McCartney (23 September 2006)
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Re: While Rome Burns
- Steven Ford (24 September 2006)
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While Rome Burns
- roy bannon (26 September 2006)
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Will and Power
- Dr D Mark Jackson (27 September 2006)
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Rotten
- Jonathan Bensley (27 September 2006)
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William G Anderson, Associate Medical Director Southern General Hospital Glasgow G51 4TF
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I think the comments are not looking across a wide enough horizon. The changes we are seeing affect all disciplines not just medicine and not just in the NHS and not just in the UK. Professional practice is in decline almost in proportion to the arrival of genuine evidenced based practice. Doctors roles are changing and we are only at the start of the process. When we did not know with any certainty the best way to help patients we relied quite reasonably on doctors trained in principles and basic science knowledge in the belief that when confronted with assorted issues they would likely make good decisions. That approach was inadequate but the best we could provide. The advance of technology (and more importantly statistics) has given us greater ( though not yet absolute) certainty on how to proceed in a wide variety of situations. Where robust evidence for best practice exists, patients are entitled to access such from wherever, decision making can be delegated to individuals lacking the depth of science based knowledge of a doctor and corporate bodies, whether the NHS or private hospitals, can genuinely accept accountability for selection and delivery of interventions. That is what was intended when we introduced "clinical governance". That the corporate body would accept the accountability was widely debated and accepted. That the same body would require corporate authority in order to discharge these responsibilities was not talked about in polite circles. Clinical management is still poorly developed with unsatisfactory relationships persisting between general and clinical managers. Clinical managers can achieve much only if they recognise the environment and work more positively with their managerial colleagues. Medicine is not alone in facing this issue. Professional Society has declined. There is a daily chorus from the media and politicians requiring organisations of all sorts to explain why this or that occurred and demanding assurances that the organisation will ensure there are no unwanted recurrences. Medicine needs to recognise the reality - we are never going back. Crucially we need to radically re-engineer teaching and training for doctors whose role will focus more on determining and designing clinical care options and for the new breeds of specialists who will deliver most of the care in the future. Doctors are internationally an unhappy breed and this issue lies at the heart of their discontents. We cannot seek to correct the big picture. Leaders need to describe the genuinely exciting vision of how the profession will develop in the future and allow individuals to map a satisfying career path through. These views as ever are of course my own and do not represent in any way the views of my employer, NHS Greater Glasgow and Clyde Competing interests: None declared |
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Thomas Szasz, M.D., Professor of psychiatry emeritus State University of New York, Upstate Medical University, Syracuse, NY 13210
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"Something strange is happening in the NHS," complains Fiona Godlee (23 September). What? Aneurin Bevan promised "that the government would fund the health service but leave its operational running to the doctors," and this has not happened. We are witnessing the iron law of political economics in action: "He who pays the piper calls the tune." Nothing surprising is happening in the NHS. Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Editor Your Editor's Choice piece and Greener's Personal View are to be commended. Look what Prof. Allyson Pollock has had to say in a flyer for a lecture in Durham soon: * On the front cover of this week's BMA News I see that Barry Monk is going to stand at the next election - so that makes at least two of us. I hope to find out what Richard Taylor's views are when I meet him in November at Westminster. Every election in the past has featured a handful of electoral hopefuls from all branches of medicine, so let's make it a particularly hot election next time for the coterie of self-perpetuating ineffectual oligarchs that we laughingly refer to as 'the major parties'. A few weeks ago you kindly published a letter from me (BMJ 2006;333:149 (15 July), doi:10.1136/bmj.333.7559.149-a ) suggesting political direct action. My email inbox was overwhelmed by a response - from The Sunday Times, asking how my bid for Galactic Domination was going. I had to report that, apart from a handful of verbal expressions of positive sentiment, there had been no response. The Electoral Commission has an excellent website that contains the following introductory document about standing at a Parliamentary Election: http://www.electoralcommission.org.uk/files/dms/0906ukgeneralelections21_23315 -11604__E__N__S__W__.pdf I am very happy to throw a few thousand into the project and hope that at least one other healthcare worker in every constituency will feel the same or be able to rally support to achieve a successful campaign. The profession and it's allies have got to get off their collective arses and fight - and yes, I am sure it could get very bloody but either we are sincere in our view that the present course is disastrous and act accordingly or the nation gets what’s coming to it whilst we stand aloof and pretend its nothing to do with us. Yours sincerely Steven Ford *"By the time I give this talk the era of General practice as we knew it will almost be over. General practices will increasingly be owned and operated by corporations or consortia of GPs and venture capitalists and traded on the stock market. For the first time in 60 years money and ability to pay, rather than need, will come between the doctor and the patient. The focus on profits and cost containment strategies will mean that the role of the practitioner is to redefine eligibility for care and NHS care will increasingly be reduced to a core basic package where additional necessary care will be provided through private insurance or top up fees. GP companies, over time will become US HMOs. Practice based commissioning will allow the 80% of the NHS budget which is currently held by PCTs to pass to new primary care companies which in turn will buy and sell services from themselves or in private partnership with other companies. Over time four or five companies will dominate and patients will see existing services close and their rights to care overturned, the open- ended commitment to care will have become sentimental folklore. This has come to pass through the greed of a handful of GP negotiators at the BMA who in turn will be among the first beneficiaries of corporate care. But it is also due to the indifference of many GPs who in failing to inform themselves of what is happening are failing in their own professional duty of care to patients. The conflicts of interest which have now been introduced make it highly unlikely that GPs will unite to champion the needs of their patients for universal health services." Competing interests: I aspire to stand for parliament at the next general election on an Environment & Health platform. Competing interests: I aspire to stand for parliament at the next general election on an Environment & Health platform. |
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Hazel Thornton, Honorary Visiting Fellow, University of Leicester "Saionara", 31 Regent Street, Rowhedge, Colchester. CO5 7EA, Guidubaldo Querci della Rovere and Margaret McCartney
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Don`t be one of those who fiddle while Rome burns! [1] Immediate action is needed to revive the spirit of medical professionalism – it must not be allowed to die. Government interference [2] and unbridled advocacy by the former president of the General Medical Council [3] for even more oppressive regulation of doctors [4] and disbandment of the independent General Medical Council (GMC) threaten to crush its last gasps for life. Where, then, are the medical and public voices raised in protest against the latest proposed even more radical reform agenda? If implemented, it would have serious effects on the doctor-patient relationship and the very soul of Medicine. The blending of art and science, care and compassion, in the practice of good Medicine distinguishes it from all other professions. The public`s trust in the medical profession is high [5]: doctors – do not betray that trust! Professor Raymond Tallis is one of many visionaries who saw this coming. His comment on signing our petition [http://www.gopetition.com/online/9679.html], uploaded 22nd September 2006, to address the threat to medical professionalism is: “I entirely agree that the proposals will be the end of the medical profession to the great detriment of patients. I anticipated this in my book Hippocratic Oaths but I never expected my dire predictions to be fulfilled so quickly.” This is your chance, as a Bystander, to step forward to sign up to our petition for action thereby helping to begin to breathe new life into the spirit of medical professionalism. Mrs. Hazel Thornton, Independent Advocate for Quality in Research and Healthcare. hazelcagct@keme.co.uk Mr. G. Querci della Rovere, Consultant Surgeon. Dr. Margaret McCartney, GP and Medical Journalist. [1] Fiona Godlee. Editor`s choice. While Rome burns. BMJ 23rd September 2006; 333. [2] Ian Greener. Where are the medical voices raised in protest? BMJ 2006; 333:660 [3] Donald Irvine. Good doctors: safer patients – the Chief Medical Officer`s prescription for regulating doctors. Journal of the Royal Society of Medicine September 2006, Volume 99, Number 9. 430-431 [4] Chief Medical Officer. Good Doctors, Safer Patients. London: Department of Health, 2006. [5] BMRB Social Research: Bruce Hayward, Ed Mortimer, Tim Brunwin. For: The Committee on Standards in Public Life. Survey of public attitudes towards conduct in public life. Sept. 2004. Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Editor William Anderson's view seems a terribly narrow technocratic one. Any primary care physician will tell him that the presentation of a patient is invariably an opaque mix of physical, psychological and social features - even the most mundane, apparently physical, symptom has other dimensions. Teasing this puzzle apart requires generalists with the authority and skill to rake over the whole plot before reaching a view about which of several routes might be best advised. Legions of highly competent but tightly focused managers, paramedical staff, therapists of every stripe and other technologists cannot individually or collectively supply an holistic care package for a patient but they can certainly make essential contributions. Anderson's zeal may be preventing him from seeing the wider picture - the boot may in fact be on the other foot. Steven Ford Competing interests: None declared |
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roy bannon, Medical Director west suffolk hospital ip33 2qz
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The junior doctors contract and its mentality of "go home " at the end of a shift because organisations did not or could not afford to pay banding has resulted in a generation of doctors being educated to clock in and clock out. The new consultants contract with its hourly based focus has reinforced this trend . Professionalism is a two way process, we cannot expect to be treated as professionals and at the same time be payed for every minute we "work"! Senior managers do not have this outlook of a time based approach but I have no doubt will take advantage of the medical profession's new approach. The profession must some how get away from this current hours based focus. Competing interests: None declared |
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Dr D Mark Jackson, Consultant Anaesthetist Great Western Hospital, Swindon SN3 6BB
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Dear Editor, You lament the demise of medical professionalism in the NHS (Editor's choice, BMJ 23rd September) and you quote Ian Greener (p 660) who wonders whether the doctors have lost the will or power to stop reforms of the NHS which some believe to be "vandalism". They have certainly lost the power and with it, of course, the will. Everyone knows why; it is because politicians have long believed, as accountable guardians of public finance, that they have a duty to cull the influence of the medical profession on health care provision. The medical profession was uncontrolled by Bevan and thereafter proved to be a source of expanding expense. This is due to its ingenuity and the development of new treatments totally unpredicted by the fabulous misapprehension of the Beveridge Report (1942), which believed that national health care would be so good, that the need for it would soon diminish. The loss of Consultant power started at local level when the "Cog- wheel" system was introduced into hospital management in the late 1960's. This involved the infiltraton of the Consultant dominated "firms" with representaton from Nursing, General Practice, Junior staff and other groups. It was a perfectly reasonable development and the chairmen of these "Divisions" sat on "The Medical Executive Committee", which told Management to implement the priorities for medical care which it had selected. However, it soon became demoted to "The Medical Advisory Committee", but at least there was still democratic representation thereon, and its advice was still respected by the District Management Team, usually comprising about 6 members, which held the ultimate executive power. Then in the 1990's the Clinical Directorate system was introduced; the Clinical Directors were now appointed by Management and were no longer the representatives of their "division" or speciality. They became responsible for implementing management decisions, which gives the impression that the medical staff has condoned these decisions even though they have been taken with minimal consultation or even against its advice. The politicians have an axe to grind; they need re-election and they perceive that their electorate wants top-grade health care, with minimal waiting times and local provision. This Government has been pouring money into the NHS; yet the proportion of the UK GDP put into health is still not much more than 7%. It is 8-10% in France, 10-12% in Germany and 15% or more in the USA. With such minmal funding, some rationing is inevitable. Many managers have been employed to organise things like bed occupancy and waiting lists: at our hospital at least 60 people are employed in the "Bed Bureau" to manage out-patient surgical beds alone. I'm sure that Mr Black, who calls for "More and better management to fix the NHS" (BMJ 12th August 2006) would be happy with this. Yet full bed occupancy has its inefficiencies: hygeine and cleaning may be compromised and patients may disappear because they are admitted at the last minute to a ward where no one expects them. 5 patients on an operating list may be on 5 different wards. Sometimes expensive theatre time is underused when there is a last-minute cancellation, because the obsession with avoiding "queue-jumping" precludes the admission of anyone at short notice if he or she is on a shorter waiting list. On one occasion a manager here wondered why all ruptured abdominal aneurysms could not be day-cases; he had noticed that some of them had not been admitted to a ward, but was unaware that they had gone instead to the post-mortem room. What we "anti-reformers" can't escape is the knowledge that the best bed managers are the Consultants, the Ward Sisters and their Secretaries. They are already employed by the NHS. They know about clinical priorities and they know when to discharge their patients - and that this is only possible if Social Service provision, transport, pharmacies or help at home are available, as Mr Thorpe finely observes in his letter (BMJ 26th August 2006). Management consultants do not seem to understand these things and nor do politicians; unless they can be persuaded to do so, our professional integrity will not be salvaged. But I don't suppoe that would bother them. Yours sincerely, Dr D M Jackson MA, BMBCh, FRCA. Competing interests: None declared |
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Jonathan Bensley, Student n/a
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The NHS is fundamentally broken... and I don't think that without the most severe changes can it survive. One need only look at how NICE rejected carmustine and temozolomide (except with a performance score of 0) in the treatment of glioma. Practically all experts i've read on this issue state emphatically that both should have been funded for this indication. These patients would be benefited for the cost of only a few million pounds at most. Yet, Trastuzumab(Herceptin) was given the green light without too much of a problem after great public pressure for it's funding approval. Cost must obviously form a part of any assessment of a new drug/technology, there has been far too much emphasis on this point, and far too little on the issues of quality of life. Pulling up a recent appraisal from the NICE website (on Bortezomib) the word cost is used 168 times, survival is used 53 times and Quality of life/Quality-of-life is mentioned only 20 times. What does that tell you about the priorities of the NHS? Competing interests: None declared |
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