Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
citing letters in the FT
- Sebastian Kraemer (4 July 2008)
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All in the Title
- Peter A West (9 July 2008)
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Re: All in the Title
- Alexandra L Thomson-Moore (10 July 2008)
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Sebastian Kraemer, consultant child and adolescent psychiatrist Whittington Hospital, London N19 5NF
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It's good to see a replica letter to the Financial Times warning us against commercialisation of health services illustrating Delamothe's excellent NHS appraisal; but I got there first, on 28 June 1989. Here is the text: "It is often stated that the government’s proposals for hospital trusts within the National Health Service could create practical difficulties, as if this were merely a risk that might, with good management, be avoided. If this were the main objection, The Heath Secretary would be justified in pressing ahead with his reforms. There are bound to be problems in implementing such a plan (not least its hidden expenses) but these can be surmounted, with a will. What cannot be avoided is the fundamental error of principle in the plan. The intended effect of the proposed trusts is to increase the wealth of units that can offer apparently cost-effective services at the expense of those which fail to attract custom. This cannot conceivably improve the performance of the service as a whole – neither at district nor at national level- because a market requires some units to be failing at any point in time. Not everyone can win simultaneously. The pressure on losers to shape up – or give up – is tolerable in an enterprise which is not obliged to protect lives and may even result in a better product.. But if the product is an integrated health service, then any kind of failure within it is unacceptable, at all times. The unlucky patients who happen to have put their trust in a particular service which is struggling to survive will not be comforted by the knowledge that market forces will eventually weed it out." Competing interests: None declared |
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Peter A West, Senior Research Associate, YHEC University of York
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As one of those involved in its development, it was good to see Tony Delamothe quoting the joint report of the Audit Commission and Healthcare Commission on the NHS Reforms, "Is the treatment working?" Of course, I commend it to all your readers (see conflict of interest statement). Readers might be interested to know that, as the creator of this particular title, I lobbied hard for two others, the well-known Rolf Harris line, "Can you tell what it is yet?" (to be accompanied by a sketch which I hoped the great man would donate, of a hospital in the vaguest outline) and the great Elvis lyric, "It's too soon to know". (No one volunteered to wear the Elvis outfit for the cover.) I would like to see titles of such reports put to a popular vote in future, possibly using your pages! And perhaps see public servants loosen up a bit when drafting reports, or at least titles! Competing interests: Peter West carried out fieldwork, assisted with drafting and came up with the title of the joint Audit Commission and Healthcare Commission report on the NHS Reforms. He works for a contract research company at the University of York |
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Alexandra L Thomson-Moore, Foundation 2 Doctor East Anglia
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I have lived on both sides of the fence of the “intensive command and control regime of national targets, inspection and regulation, and published league tables” of our 60 year old NHS. Formerly a manager in one of the new 21C NHS inspectorate agencies, I am now a junior doctor. My performance as a manager was measured on my team’s ability to deliver efficiency targets, the majority generated in Downing Street rather than locally. Original thinking was commonly stifled. My performance as a junior doctor is assessed on the ability to deliver these same efficiency targets alongside individualised, high quality, evidence based care. The tension comes when the two conflict. I did a piece of work and showed expert opinion guidelines were being ignored in order to fast track patients out of (a Foundation Trust) Accident and Emergency Department within four hours. The consequence was patients were being exposed to unnecessary admission and radiation, but the trust had a net financial saving as a breach in Accident and Emergency is more punitive than unnecessary tests and occupied beds. The trust management did not effect a change from the piece of work. A junior doctor and their patient has less choice and power than administrative / managerial staff chasing after a performance target turning red. While patients now have choice into the who and where of treatment, clinicians are often heard grumbling they have less and less choice in how to deliver this care. The erosion of this is both overt, as seen above, and subtle. In the foundation teaching hospital above 95% of junior doctors were unaware of a guideline for assessing and investigating a common, life threatening presentation. Trust policy, driven by national efficiency targets, is burying the opportunity to see, learn and practise good clinical medicine. It also discourages and thwarts my ability to think. Even the way I write up my assessment of a patient now has to filled into a standard proforma, which in the past year since their conception has mutated into eight proformas depending on the working diagnosis and predicted length of stay. It is self evident that the same sized box does not fit every patient. Through standardisation the nuances of a consultation, a backbone to individual care, are lost. But more dangerously, so are opportunities for me to use that skill crafted at university, the ability to think individually and creatively on behalf of the patient. To me the proformas are the very symbol of creating a monochromatic, uniform NHS and workforce, which of course negates the need for patients to choose who and where. I am, God willing, being developed as one of the senior clinicians of the future. Our conditioned mindsets will lead the NHS at its centenary birthday. Tony Delamothe asks that on this birthday there is a period with an absence of reforms. However on our hundredth birthday in our consumer society we will be desperate for a new policy toy or proforma to implement. Because unless Daddy says, how will we know how to think and what to do? Our patients with their powers to choice and assess performance will be more grown up than the children within, but not leading, the NHS. Competing interests: None declared |
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