Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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GPs are getting too much, for too little
- Alan Luckhurst (2 February 2007)
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More work = more pay
- Hendrik J Beerstecher (5 February 2007)
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Doctors' and patients' self-interest.
- Ian Quigley (5 February 2007)
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Science, Pseudoscience and Efficiency
- Richard Rosin (5 February 2007)
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A view from the ivory tower
- Gavin Bullock (6 February 2007)
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The self-interested argument.
- Adrian G Sutton (7 February 2007)
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Jeopardising trust
- Anne Savage (27 February 2007)
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Alan Luckhurst, retired accountant NW2
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I think generally doctors are comparing themselves with the wrong professionals.I have heard many conversations at social events where doctors have been moaning about their salaries compared to lawyers and accountants. Doctors (UK trained particularly) fail to realise that their entire medical education had been subsidised by the taxpayer. Thereafter,as to the NHS doctors, it is again the money from the taxpayers' pot that eventually go out towards their salaries and postgraduate training. This is totally different scenario to lawyers and accountants whose education and income are far less reliant on the taxpayers' assets. While altruism has its own limits, it is certainly not unjust for doctors, especially GPs to think again about their rising income and decreasing time spent(due to absence of 24hr responsibility) on actual clinical work. Can the GPs honestly assure us that patient-services have risen proportionately with their salaries? I very much doubt, there is real evidence to support that. Competing interests: None declared |
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Hendrik J Beerstecher, GP principal 111 Canterbury Road, Sittingbourne, Kent, ME10 4JA
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Dear editor, Maynard is misquoting the Information Centre (reference 3) with the 30% pay rise caused by the introduction of the Quality and Outcomes Framework. The corrected figure is somewhere in the region of 23%. (1) This, at 20% above inflation, is substantial. However the increase in work –data gathering– caused by the framework has not been quantified and it is possible that extra work simply matches the increase in income. It is not surprising that the quality framework has not resulted in increased efficiency, it was never designed to do so. If it were now perceived to be poor value for money, the blame would have to be directed at the government’s economic advisers and not at doctors delivering on a contract. It also seems illogical to argue that money would have to be clawed back from GPs because the cost of out of hours care rose since its transfer to other providers. It would make more sense to ask the new out of hours providers to work to the same efficiency as GPs have in the past. How doing the best for your patient is a sign of self-interest escapes me. With the capitation funding, money will keep coming in irrespective of effort for patient care. It has always been the case that spending less time with patients means more patients can be accommodated, which translates in higher capitation income. Despite this, the average length of consultations has increased steadily, GPs sacrificing income by providing a better service. The motivation to prove care standards, perhaps peppered with some professional pride, fear of being targeted as underperformer, and a sense of competition, has driven the achievements in the quality framework. Money was never the primary driver and cannot explain why so many GPs have chased every last uneconomical point. The individual doctor cannot oversee and therefore cannot decide what care to ration for which patient. The NHS already suffers from postcode lottery for access to care, it would not make sense to add another arbitrary layer. Rationing of care is a bullet that needs to be bitten by the politicians, ideally guided by their economic advisers. Politicians are unlikely to do this, it would harm their self-interest. The only alternative is to hand the decision-making capacity to the patient, in the form of co-payments. This too is a difficult political decision and it is far easier to find a scapegoat to distract the public until the next election. (1) The information Centre. Technical Note on the Impact of Inclusion of GPs’ Employer’s Superannuation Payments in Net Income Estimates in the 2004/05 GP Earnings and Expenses Enquiry. London 2007. http://www.ic.nhs.uk/pubs/gpearnex0405/technote/file Competing interests: HB is an NHS GP and one of the 20% that voted against the nGMS. HB terminated his BMA membership over this in 2004. |
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Ian Quigley, GP principle Western Road Medical Centre, 99 Western Rd, RM1 3LS
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The Quality and Outcomes Framework has rewarded GPs for doing work they don't like and their patients don't want or value. Part of QOF has made us streamline the professionalism in the back offices. It has put us through hoops to improve processes such as staff management and risk assessment. The other half of QOF has rewarded us for improving surrogate outcomes such as blood pressure and cholesterol in high-risk patients. It has also rewarded us for less evidence-based clinical work like providing checks for people with newly-diagnosed cancers. What QOF has not done is ask us to provide, and fund, what patients really want. Sadly people don't value preventive medicine. People don't appreciate a GPs' surgery tracking down men in their 40s who have been lost to follow-up after a coronary bypass operation. Even less do they value their GPs' work in preventing them from developing heart disease in the first place. What our patients want, as we know from our QOF-driven patient surveys, is immediate access 24/7. QOF has made us work harder. My surgeries feel far harder and more labour intensive than before the new contract. I believe we earn the money we are paid. I am dismayed that our employer is out to discredit the contract it has foisted upon us. I am equally dismayed that it is the workers rather than the employer that the media is gunning for. My solution would be to renegotiate QOF. Throw out the bathwater but keep the baby of rewarding performance in areas of evidence-based medicine. Throw out the clinical areas that look like they were decided by lobby groups such as chronic kidney disease and depression. Throw out most of the practice management and allow us to manage ouselves. Finally, make GPs work evenings and weekends. And then leave us alone for 10 years. Please. Competing interests: I am a GP principle in England, enduring and benefiting from the Quality and Outcomes Framework in equal measure. |
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Richard Rosin, Attending Psychiatrist Westside Mental Health Team, Vancouver BC, Canada
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Alan Maynard's Article " Is doctors' self interest undermining the National Health Service" BMJ 2007;334:234 begs a question which it raises. " Is Health Economist's Self-interest undermining the NHS?" Professor Maynard as usual makes reference to all the Newspeak that defines modern-day health economics; patient outcomes, evidence based medicine and the like: "Doctors' self interest manifests itself in two ways: enhancing personal income and fiercely protecting clinical autonomy—the right to do what they think is best for the patient in front of them." It is significant that Maynard places Doctors' personal income as being their first concern followed by clinical autonomy. But even this is, in his view, tainted: " A doctor's concern for the individual patient and his or her self interest can lead to inefficient practice that ignores the opportunity costs of decision making—a decision to give Jones a marginally cost effective treatment deprives Smith of cost effective care. Such inefficiency in the use of society's scarce resources is surely unethical? " It seems unlikely that Professor Maynard while ministering to the NHS economy has ever looked after patients. Imagine the dialogue: "Mr Jones I am terribly sorry I cannot give you this marginally cost effective treatment as it would deprive Smith of cost effective care," said the Consultant. "But Doctor is there any chance that it would work? It is the only hope I have," sniveled the ailing Jones. "Well the evidence base shows that only 10% of patients who receive this treatment are likely to live 5 years, whereas everybody with Smith's condition survives." " What does that mean, doctor" wailed Jones. "It means that Smith gets the treatment and you don't because if you did he wouldn't and the odds are with him". Suddenly Jones was no longer pathetic. He glared at the Consultant." Do you mean to tell me that Smith is more important than me because his illness is more treatable?" " Well it would be unethical of me to use society's scarce resources.." "You mean waste them on me don't you ?" interrupted the glowering Jones. " Well, I wouldn't put it quite like that," said the Consultant. He laughed softly. It was a nervous laugh, the sort he remembered from his days as a houseman in the presence of his own consultant. He rallied himself just as he had done so many times and continued," It's just that, well if I did treat you, we wouldn't be able to take advantage of the opportunity costs of saving for the NHS". He looked at Jones, sure that this explanation would win him over. But there was no sign from Jones that he had any idea what any of this meant. The kind of "efficiency" that Maynard and others of his ilk obsess about is simply absent from much of medicine. It is an imperfect science. This is partly due to the complexity of the human body but also due to the inherently emotional nature of humanity. It is not always easy to be "efficient" or "productive" in the same way that a production line worker is. There is a part of medical practice that will never be efficient in this sense but this does not make it unethical. This false dilemma is imposed by a society whose priorities are not always clear. For example, the amount of money spent on the war far outstrips that spent on health. But as a social scientist you would expect Professor Maynard to be aware of such inefficiency. It is hardly as though Economics or any other social science is as exact as would seem and this is because of the subject matter - human beings. The problem is that whereas medicine does not pretend to have all the answers but only acts on the best evidence, those who opine on the economics of the system do. Competing interests: None declared |
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Gavin Bullock, Retired Riversmead
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When I read a sentence like this: "A doctor's concern for the individual patient and their self-interest can lead to inefficient practice that ignores the opportunity costs of decision making..." - apart from the management-speak, I know that I am in the presence of someone who drains the emotional and feeling side of general practice from his outlook. Prof. Maynard makes some surprising statements. Unions, like the BMA, have "perpetuated the inefficient use of society's resources while remaining successful in achieving the personal and professional goals of those they represent". While I would dispute the first part, the second part is precisely what a union is for. He also implies the BMA is part of a cartel - what are the other constituents of this 'cartel'? Of course doctors wish to have an income commensurate with their training, expertise and work done. Prof. Maynard omits to mention that the GP contract was arrived at by negotiation with the government and it is the NHS negotiators who got it wrong, if it is wrong. He then goes on to attack Quality and Outcomes, saying its benefits are "uncertain" and that it gives "incentives to deliver what good general practitioners were already providing". Again, this was government thinking - because it can be measured! I agree with some of what Maynard says on clinical autonomy but what is easy to write in the quiet of a professor's study is more difficult to put into practice in a busy surgery. In many cases the information is not there to act on. Furthermore, patients are not always rational and can react aggressivley if they think you are withholding treatment 'just to save money'. To call doctors who do not come up to Prof. Maynard's counsel of perfection 'unethical' is over the top. Alan Luckhurst thinks we are compared to the wrong professions - it would be interesting to hear his views on which particular ones he thinks would be suitable. The Review Body has always been asked to match GPs' pay to "comparable professions" and that means in terms of status, education and pay. That is laid down by parliament. I presume if a solicitor has a law degree and not just done his articles, then, according to Mr Luckhurst, he should not earn so much. Similarly, those highly paid directors with standard degrees should also lose some of their share options while the self-made men take their full wack. And now all medical students pay tuition fees (five years' worth), can they please keep their pay rise? Or perhaps they should pay the total cost of their training - about £250,000. That should keep their nose to the grindstone. Competing interests: None declared |
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Adrian G Sutton, Consultant Chilld Psychiatrist Winnicott Centre, Central Manchester & Manchester Children's University Hospitals NHS Trust, M13 0JE
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In contrast to Buckman, who implicitly equates 'self-interest' with remuneration, Maynard does at least offer one other category of self- interest - 'clinical autonomy'. Given his view that 'Economists regard self interest as the engine of economic development', one might have expected rather more comprehensive definitions and appreciation of the subject's complexities, particularly when ethical issues are considered. In their report on professionalism the Royal College of Physicians(1) decided that the word 'autonomy' was so open to misinterpretation that they should discard it. Maynard illustrates the potential wisdom in their decision. His definition of 'clinical autonomy', "the right to do what [doctors] think is best for the patient in front of them" is fundamentally flawed. O'Neill(2) points out that a right can only exist where there is somebody under an obligation to fulfil that right. The doctor must have at least the patient's authorisation to act, and since the patient is not under such an obligation to the doctor, there is no such right. Maynard's conflation of issues of autonomy into 'to do what they think is best' is also problematic. Gillon(3) describes three different types, autonomy of will, thought and action: appreciation of these differentiations is particularly important in understanding the possibilities of professional roles and responsibilities. A doctor may think a patient needs a heart transplant but be unable to do give a new heart for a variety of reasons. The patient may not want one. The necessary heart may not be available. The doctor may not be trained to transplant hearts. She may be trained, but the necessary colleagues with training for operative and post-operative care may not be available. They may all be available but the funding and facilites may not be. As Maynard points out, rationing is a reality. However he mistakenly describes the situation of rationing as one in which the doctor must 'decline care' when it would be best understood as the doctor being 'unable to offer particular forms of care': since it is a decision over which she does not have sole or final authority, she may not have the power to act even though she thinks it could be of use to the patient. This distinction helps avoid confusion with the idea that the doctor is denying available care to the patient. I believe a patient in the NHS has the right to a doctor who is under an obligation to think and communicate about what is in the best interests of the patient AND about what she is able to do or that others may be able to do (or authorise to be done). The RCP document highlights the importance of understanding the individual professional and the wider context within which health care is provided "2.8 Securing trust is the most important purpose of medical professionalism. Trust – and so professionalism – operates at two levels: • in the doctor providing care (individual professionalism) • in the system where that care is given (institutional professionalism). Both aspects of professionalism matter if a patient’s trust is to be won and deserved." (p15) To preserve the essential foundation of trust on which the doctor can provide care, the patient must have reasonable confidence that, if conflict arises between different lines of responsibility or authorisation, the doctor can and will be able to distinguish between those in the service of this individual as opposed to other lines, and be honest about what is governing the actions recommended. Taking such a position ensures that doctors can fulfil their obligations to patients with due regard to competition for resources and display their willingness to be held accountable for their expressed opinions. It also facilitates communication between patients and other professionals in the Health Service who have authority to sanction or decline care. Even without entering into arguments about whether altruism is only a form of enlightened self-interest, other facets need to be considered. It is in my interests not only to accept my salary but also to maintain myself in a position in my working life with which I can live. One of the greatest challenges in clinical work is living with the ability to recognise need whilst also managing the impact of being with people whose needs are not being met, particularly where mechanisms to meet those needs appear to have been identified. I need a framework for practice which offers reasonable support to meet this challenge. It is in the interests of the whole population to provide a framework within which doctors (and other professionals) can supprted in managing this challenge. Without such a framework the NHS will be (or, perhaps, already is being) undermined. I wholeheartedly agree with Maynard's view that particular forms of self-interest can be undermining.I would go further and suggest the particular form he describes, the indulgence of, or in, greed (whether for money or power),is probably corrupting of individuals and institutions. However, the systemic and ethical analysis required to ensure advances in health care needs to be much more sophisticated if the discourse is to rise above the level of slogans and political spin. References: 1. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP, 2005. 2. O’Neill O. Autonomy and trust in bioethics. Cambridge: Cambridge University Press 2002. 3. Gillon R. Philosophical Medical Ethics. Chichester: John Wiley & Sons 1985. Competing interests: None declared |
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Anne Savage, Retired London NW3 5RA
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I was in hospital when the new contract for GPs was announced and a wide-eyed anaesthetist said 'How did they pull it off?' I don't know, but then I don't know what GPs 'ought' to be paid. Twenty years ago, when I was not working in Africa, I did locums in the UK from Cornwall to the Orkneys. Rural doctors did much more, in the practical sense, for their patients but they didn't have so many difficult and time consuming ones. What bothers me is the opportunities for fraud. A balanced article in The Week lists instances of unbelievably high numbers of cancer patients in one practice and emphysema in another. It would be a great pity if the medical profession lost the trust of the public and every consultation became a challenge. And for what? A fifty year old diary reminds me that my evening surgeries were from 6-8pm, Saturday morning was a must and did our own out-of-hours visits. Admittedly we could only afford self-catering holidays in the UK but life was immensely enjoyable. General practice should revert to being considered a profession and not a business because the criterion of a successful business is the amount of money it makes. Competing interests: None declared |
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