What to cut: readers’ suggestions

Stop quangos and targets

Peter G Davies, GP principal, Keighley Road Surgery, Illingworth, Halifax

A good place to start would be the private finance initiative, practice based commissioning, Payment by Results, Choose and Book, NHS Direct, Modernising Medical Careers, the National Programme for Information Technology, “redisorganisations,” management consultants, and the regulatory quangos that no one understands and that get renamed regularly to disguise their dysfunction. Then how about losing most targets and also the compliance officers needed to police or fudge the figures?

And is revalidation an evidence based treatment for an accurately diagnosed disease?

End the internal market

Leonard Peter, GP, Harrow

The NHS internal market is as useful and cost effective as our banking system. In the early 1990s we created a whole new structure, which split NHS institutions into purchasers and providers. This is delightful for managers because they immediately underwent replication and needed larger numbers and larger salaries as more chief executives were created.

The whole thing was a child-like emulation of the private sector (where a lot of the new managers were to spend time learning their new ropes). It divided GPs from hospitals, health authorities from everybody, and hospitals from each other.

Competition turned out not to be who could provide the best service most cheaply and efficiently but who could manipulate the rules to squeeze the most out of the system. It is a horrible, costly, and divisive system and one that benefits only managers, management consultants, and clinicians who enjoy that sort of thing.

More piloting; cease incentives

Paul Glasziou, professor of evidence based medicine, University of Oxford

There should be no new initiatives without piloting and external evaluation. Many NHS initiatives seem to occur with little or no piloting. (And has a new initiative ever been submitted for ethics approval?) Most good ideas don’t work. That is why we need to test and evaluate first—it saves enormous waste of effort and demoralisation.

Secondly, cease financial incentives. Don’t treat medical staff as if they were City financiers who respond only to cash. Medical staff are interested in patient care and ways they can improve that, and financial incentives only distort this.

Let doctors manage their affairs

Seshubabu Gosala, chief medical officer and port health officer, Port Area, Visakhapatnam, India

As an outsider who observed the NHS in the early 1990s during its different waves of transformation I feel that one striking aspect was the wholesale induction of various management gurus tampering with medical practice. It was strange to see doctors being lectured on how and what they were supposed to do in rendering patient care. What the managers in North America and in the UK have not realised is that medical professionals are capable of surmounting various barriers that have been artificially created by management consultants and experts. It is the patients who suffer from such tampering. Bringing back medical supremacy in patient care can only cure the ills of healthcare services and make the NHS a healthy organisation.

Measures to reduce litigation

Helen Parkhouse, consultant urological surgeon, King Edward VII Hospital, London

As a former NHS consultant, now in full time private practice, I am dismayed at the exponential increase in expert witness requests over the past few years.

Many of the cases I see arise as a result of failure of systems, poor record keeping, and poor communication with patients rather than bad surgical technique. Despite investment in information technology and investment in new ways of arranging notes in secondary care (care pathways, multidisciplinary notes, etc) it is often difficult to make any sense of medical records. I think all hospitals should have a medical records committee run by senior or retired consultants and GPs to improve this aspect of medical care and to provide a rapid response to complaints.

I am sure that the huge cost of litigation could be contained by simple measures and attention to detail by senior medical staff.

GP partners, not employees

William D Jeans, former GP and radiologist

Can I second Des Spence’s suggestion in the same issue (BMJ 2009;338:b1420, doi:10.1136/bmj.b1420) that the payment structure for GPs should be changed to encourage young doctors to become partners rather than salaried employees. It is hardly rocket science to know that people work harder, are happier, and are more involved if they work for themselves or an ideal rather than for someone else.

Limit salaries

Christopher Burns-Cox, consultant physician, Wotton-under-Edge, Gloucestershire

I would close down the purchaser-provider split, close down strategic health authorities and many quangos, remove most of the targets, and stop the private finance initiative. I would also limit the maximum salary for all staff to £150 000 (€170 000; $220 000) or five times that of the lowest paid staff in the NHS. If people will not work for this amount they are not the sort of people we need in the NHS.

Who pays for treatments?

Richard B Godwin-Austen, retired neurologist, Southwell, Nottinghamshire

• All urgent treatment and all obstetric and paediatric care should be paid for by the Exchequer, as now

• For all elective treatment and non-urgent advice there would be a charge ranging from 0% of cost for cancer surgery to 100% for cosmetic surgery, wholly on the patient’s decision, with (say) three intermediate levels of charging

• For treatment deemed to be not “cost beneficial” by the National Institute for Health and Clinical Excellence, copayment should be charged to the patient according to means and need, and

• A new national insurance fund should be set up, owned by the individual and raised through his or her contributions, plus an annual state allowance, to pay for treatment in points 2 and 3.