Take back your mink, take back your pearls
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7372.1047 (Published 09 November 2002) Cite this as: BMJ 2002;325:1047
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Richard Smith suggests that we "...must remember that the future will
depend on working together". I guess he is right for those who want to
stay and work together.
Consider the following: Working time directives, diminishing numbers
of medical student applicants, gung-ho GMC, malpractice lawsuits rising at
10-15% per annum; a tidal wave of medical legislation, regulations and
policies; QUANGO's dabbling left right and centre; the shockwaves from
Bristol and Shipman; a sense of bullying as a means of getting things
done; racism; nepotism; massive spin-doctoring about everything under the
sun; regular media feeding-frenzies when doctors mess up - who for all the
love of money and wonderful contracts would want to take up work there for
the next 30 years - to exchange glowing youth for a chance to have triple
bypass surgery - if you're lucky. I know. Only the best. “The best of the
best, of course ..only those who love that challenge..the go-getting Type
A personalities...those with real leadership qualities...not the faint-hearted" - I could hear some deluded spin-doctor shouting from on high.
Somebody has got to do the job. It's no better anywhere else - is it?
So, Mr Young bright-eyed and bushy-tailed Doctor - go for it. And caught
amongst a massive mortgage in a super-inflated housing market, a few
mouths that you feed but hardly ever see, your fancy sports car, a
significantly higher than average risk of depression, alcoholism or
suicide, followed by a one in three (or better) chance of eventually
paying alimony and/or child support, and the lovely noose of big fat
pension in your later years - you'll be a very good boy. In fact you'll be
a damn good boy! You'll grin and love it, you’ll walk the walk, and talk
the talk - you'll join them and spin them. You'll be right up there
working together with them – rationing healthcare and humanity. Good for
you.
Some will create opportunities elsewhere for a better lifestyle.
Spare me the mantras from Improving Working Lives – too little, too late
and spin-laden - as usual. I’m sure many more of us whingers who care
about our health and life expectancy will follow, to places where we’re no
obstacle to progress or working together. Good for us. Good for everyone.
Competing interests:
None declared
Competing interests: No competing interests
The analysis of the reaction to the consultant contract fails to
address the question "have we got the role of management right?". Although
health services are clearly a personal professional service industry,
reforms over the past dacades have been based largely on the production
industry. In the meantime, many other industries have been realising that
professional services, with their central reliance on knowledge, requires
a very different organisational structure and style of management than has
been traditionally accepted as the norm. These changes involve a
structural shift from hierarchy to networks, relationship change from
formal to informal, and power shifts from managers to the professionals.
Yet these changes seem to be ignored in the health industry, which is
moving further towards formal hierarchical control.
Why is this?
Gray Southon
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Richard Smith (1) in his editorial on the rejection of the
proposed consultant contract in England and Wales
cites the widespread distrust among clinicians of
hospital managers as a principle cause. In the same
edition Anita Houghton and colleagues (2) identify lack
of adequate training in writing business plans,
negotiating change and getting things done as specific
difficulties for newly appointed consultants.
Clinicians
are often thrust into senior management positions with
major responsibilities for substantial budgets without
the necessary financial ‘know-how’. A fundamental
rethink of medical management is called for . What is
needed is the development of a distinct career track in
medical management at a much earlier stage with the
necessary management training on a par to that
available in the commercial sector. This model has
worked well in Australia. Such medical managerial
posts will need adequate sessional committments for
these individuals to provide a high quality of executive
function.A professional cadre of medically qualified
managers in touch with clinicians involved in the
delivery of service, setting realistic targets for service
delivery in partnership with lay hospital managers
might restore the trust of the medical profession and
deliver the standards of care to which the government
aspires.
References:
1.Smith R.Take back your mink,take back your pearls.
BMJ 2002;325:1053.
2. Houghton A, Peters T, Bolton J. What do new
consultants have to say? BMJ 2002 325:s145-147.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
As a GP I have no particular axe to grind regarding the proposed
contract. However, I was intruiged to read Smith's editorial on the
subject (BMJ 9 november 2002). He briefly mentioned that the contract had
been accepted in Scotland and then went on to promote an argument that the
rejection of the contract in England and Wales was due to the view that
the proposed contract gives more control to managers.
It would have been helpful perhaps to examine why the Scottish
consultants voted in favour. Are there better relationships with managers
north of the border? Or, as we calvanistic Scots like to think, are there
dark forces of greed afoot "down south", where private practice is much
more prevalant? (This was a view that Smith rejected).
Of course, looking at it from the other side, you can construct an
argument that it is the Scots who are actually reverting to (stereo) type
and looking after their wallets by accepting a deal that will mean more
money for those with little or no private practice at the expense of loss
of autonomy.
Probably neither response to the question posed at the ballot
represents a considered response to what is best for the patients. Self
interest tends to rule. Consultants are, after all, only human aren't
they?
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
Richard Smith notes that a central reason for consultants rejecting
the new contract was the distrust of managers' control and in particular
their pursuit of 'targets that distort good care.' [1]
It has indeed often been claimed by some consultants that the target
to reduce maximum waiting times has lead to managers pressuring them to
treat patients 'out of turn' from the point of view of clinical urgency.
This would be a very serious charge if it was not demonstrably the case
that there is a good deal of variation between consultants' clinical (for
which, also read priority setting or rationing) decisions when it comes to
admitting patients from their waiting list and choosing which patients to
add to their surgical lists each week. The recent Audit Commission report
on access to ENT services is just the latest evidence of such variation
[2]. This showed that for grommet operations, for example, all ENT
consultants in one trust considered that no such operations needed to be
carried out within three months, while in another trust the reverse
opinion was held by ENT consultants.
The point here - and the issue for managers struggling to ensure that
patients do not wait unreasonable lengths of time for their operations -
is that there needs to be a more consistent (and rational) criteria
applied to key rationing decisions. Allowing all consultants complete
freedom to make such decisions will not, on past and current experience,
lead to an equitable outcome for patients in terms of waiting times.
As Richard Smith rightly points out, however, doctors, managers and
everyone else working in the NHS are all in this together, and while no
employee wants to feel exploited, no one should take their eye off the
ball: patients are what matter and many, rightly, feel they wait
unnecessarily long periods of time for their NHS care. The much-derided
government targets on waiting times merely reflect what patients want -
and, it could be argued, what they need in terms of their health.
John Appleby
Chief Economist
King's Fund
1. Smith, R. Take back your mink, take back your pearls. BMJ
2002;325:1047-1048
2. Audit Commission. Access to care: Ear, nose and throat and
audiology services. London, Audit Commission, 2002
Competing interests:
None declared
Competing interests: No competing interests
Accepting responsibility for management
I have been very interested in the comments in the last few issues of
BMJ related to compensation for militiary MDs etc. Certainly, the
situation in the US is not as desparate, but in many areas it is getting
to be that way. We are discouraged that our Senate left for holiday
without addressing a serious medicare shortfall amounting to a 5.4% pay
cut on all medicare patients. This is on top of the already extremeley
lean reimbursement already in effect. It does concern me that almost
everyone is only concerned about the "bottom line" and patients care and
quality issues are swept aside. Never mind satisfaction for the individual
medical practtioner. It certainly behooves us to appreciate that our oath
of office commands us to "first do no harm:" I think that the more that
individuals stand up to whatever system they are subjected to, that
justice will eventually prevail. Please, do not be concerned for
yourselves, I was recently "fired" from a postition for not being
productive enough, in spite of first rate reviews and many requests to
stay on and "tough it out,financially". Let us not forget what we have
sacrificed to get to the postitions we now hold. It is up to those of us
who are in the trenches to make a fight for the others, and for those yet
to come. Right will prevail, when I am not sure, but it will come.
Anne Towey MD
UofMinnesota,clinical associate professor
in Ophthalmology ,Lakeview Clinic private practice, Waconia Minnesota, USA
Competing interests:
None declared
Competing interests: No competing interests