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Rapid Responses: Rapid Responses published:
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Time to wake up and smell le café
- Paul E Shannon (29 July 2007)
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Re: Time to wake up and smell le café
- L Sam Lewis (30 July 2007)
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Real improvement is possible
- stephen black (30 July 2007)
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Paul E Shannon, locum consultant anaesthetist Doncaster Royal Infirmary, DN2 5LT
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Excellent and true! I, too, have worked in France so I know from personal experience that the French system works better than the UK's. One reason is that in France surgeons work twice as long in theatre than in the UK. Lay-people in the UK are usually flabbergasted to realise that full-time NHS surgeons spend less than 10 hours per week operating. In France, it is over 20 hours. This simple fact explains nearly all the difference in production capacity. Of course, it is perfectly rational for NHS doctors to behave like this. As John says, why work harder and smarter if it brings no reward, or worse, undermines private practice? The solution is simple too. Establish a link between productivity and remuneration (so-called 'incentivisation'). It's not rocket-science, but it works! Whenever 'fee-per-case' or 'pay-for-performance'-type policies are introduced, you see enhanced productivity. Until the BMA, DH and NHS Employers grasp this, will the last doctor to leave the NHS please turn out the lights? Competing interests: None declared |
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L Sam Lewis, GP Surgery, Newport, Pembrokeshire SA42 0TJ
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Petri and Shannon are quite right .. where are the incentives for productivity ? Was it not all too obvious to Gerry Robinson - the NHS may not be easily fixable - the dead hand of NHS management, the job-protection of Consultants ( with no incentive to change), and the fixed-funding envelope of the PCT ? But wait - what if Petri and Shannon get togetther and hire a private hospital, or an NHS theatre for weekends ? Instead of seeing private patients - why don't they stack some hips and knees high, and knock 'em through - under NHS Tariff, and some form of payment-by-results contract ? It can be done ! - How do the French do it ?? Of course, petri and Shannon, in their new Worker's Cooperative, will have to fight all the suffocation of local NHS management protectionism and red-tape - designed to ensure failure and continued expansion of the State Apparat.. And according to Ham ( Chris Ham - What to do with insolvent hospitals: Will politicians allow providers to fail? BMJ, Jul 2007; 335: 170 ; doi:10.1136/bmj.39277.790775.2C ), the weak and ineffective may not go quietly to the wall.. But Heath's lone plea for the central role of the GP of old to save the NHS is entirely compatible with this incentivisation through market choice.. if only she would but realise it ! Our social solidarity, guaranteed through an entirely tax-funded free-at-the point-of-need system, can utilise spare capacity, root out inefficieny and ineffectiveness, and again become an international exemplar. How ? Through NHS GP commissioning, answerable to Locality elected bodies (cf. Nordic countries). We are already answerable to four separate devolved national jurisdictions. Why isn't it happening ? Partly it is too poorly understood, fairly ambitious, and heavily dependent on competence ( the cock-up theory : Presumed consent Fiona Godlee; BMJ 2007;335, doi:10.1136/bmj.39287.684086.80. But what of the conspiracy theory? Our burgeoning and self-serving NHS management will have to be brought to heel, chained, and required individually to justify their survival through effective performance management !!! Isn't that what they expect of us doctors ? Maybe that should be Brown's big idea, and Ara Darzi's big task ! Dr L S Lewis. Competing interests: NHS GP, potential Commissioner, and one-time fundholder |
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stephen black, management consultant london sw1w 9sr
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Those of us who try to bring outside persepctives to the way medical care is delivered are often ignored or ridiculed when we say big improvements are possible. So it is refreshing to see a surgeon demonstrating real bottom-up change. What is disturbing is the extent to which the rewards for efficiency flowing to hospitals (more efficient hospitals will have bigger surpluses) do not translate to individual medics. Hospital managers really ought to get a grip. Another problem is that many representatives of the profession are in denial. They seem to assume that if everyone is motivated and works hard, the outcomes will be as good as they can be. And, somehow, badly organised work doesn't impact their efficiency. The BMA, for example, state early in their anti-reform rant (A rational way forward for the NHS in England) that "efficiencies can only account for relatively small savings" (paragraph 9 on page 10). And this critical assumption drives a large part of their thinking. How does this stack up with John Petri's demonstration of efficiency improvements of between 50% and 90% (depending on whether the point of view is overall throughput or consultant utilisation)? If hospitals could tap even a fraction of this improvement they could eliminate financial deficits and waiting lists at the same time. Competing interests: Management consultant working in health |
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