The NHS plan
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7257.315 (Published 05 August 2000) Cite this as: BMJ 2000;321:315All rapid responses
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Along with the NHS Plan (1,2), the DoH has published its response (3)
to the recommendations of the Royal Commission on Long Term Care (4). The
Government has not fully accepted the main recommendation of the Royal
Commission that personal care, after assessment, should be free. It plans
to use most of the funds that would be required to provide free personal
care on intermediate care, which, it states, should prevent the need for
long term care. It is unfortunate that the Government has sought to link
intermediate care with funding long term care. While intermediate care,
if properly constituted as geriatric rehabilitation, may prevent or
postpone the need for long term care for some elderly people, it will do
nothing to alleviate the financial hardship incurred by many elderly
people when they need long term care.
The Government has accepted in full or in slightly modified form 23
of the 24 recommendations of the Royal Commission. It has not fully
accepted the main recommendation but is proposing to fund nursing care in
nursing homes. When discussing funding for long term care, the Royal
Commission set out a series of options, including disregarding the value
of the home for the first three months, changing the limits on the means
test, and funding nursing care. All of these were subsumed in the main
recommendation. The Government has accepted all the options on funding
except for the main recommendation. The Government has, therefore,
accepted almost all the recommendations of the Royal Commission.
There are two important consequences of the Government's failure to
accept the main recommendation of the Royal Commission.
a) The current inequity in the system will continue. This can be
exemplified by comparing an elderly person who develops cancer, whose
treatment, hospital and, if necessary, terminal care is fully funded by
the NHS, with an elderly person who develops Alzheimer's Disease, who will
often require a considerable amount of care and supervision, but not
usually nursing care, and who will continue to have to fund this using all
available resources, including the value of the home. The Government's
statement, quoted from the Note of Dissent that the funding necessary to
implement the Royal Commission's recommendation would not result in any
improvement in services, must be read in the context of this continuing
inequity. This type of diagnosis related lottery of care should be
unacceptable in a civilised and wealthy country.
b) Funding nursing care but not personal care will introduce a new
perverse incentive. Under the proposal, nursing homes will receive a
subsidy of about £100 per week. This will mean that nursing homes, which
are intended for the most dependent, will be slightly cheaper than
residential homes, intended for the less dependent, and also probably
cheaper than some packages of intensive domiciliary care. Thus, two
fundamental principles of long term care - that it should be delivered in
the person's own home, and that it should be of no greater intensity than
is necessary, will be directly opposed by financial pressures on
purchasers of care.
These issues will not disappear. It would be best if they were
addressed now as part of the Government's comprehensive package of NHS
reforms.
1. Dixon J, Dewar S. The NHS plan. Br Med J 2000; 321: 315-316
2. The NHS plan. A plan for investment. A plan for reform. London:
Stationery Office, London 2000
3. The NHS plan. The Government's response to the Royal Commission on Long
Term Care. London: Stationery Office, 2000
4. Royal Commission on Long Term Care. With respect to old age. London:
Stationery Office, 1999
Competing interests: No competing interests
Perhaps one might ask Mr. Morgan what the rate of overtime payment is
for employees in the industry or elsewhere a) out of hours weekdays and
b) at weekends; and how does this rate compare with a) the junior doctor's
overtime rate at 50%, 70% and at most 100% for shift work and b) the
hospital consultants'overtime rate of 0% anytime.
Competing interests: None
Competing interests: No competing interests
Dear Sir/Madam
The current NHS reform plans, whilst in parts have merit, in others
are
empty promises, and cannot wholly be supported by the British Orthopaedic
Trainees Association (BOTA). In particular, the New Consultant contract
and
restrictions on Private Practice.
The decision to enter Medicine is often made on altruistic grounds.
Having
completed their undergraduate studies, many doctors come to make career
decisions based on personal interests, ability, ambition, and future
financial rewards. 'Junior doctors' tolerate, albeit reluctantly, years of
poor working conditions, onerous hours of duty, relatively poor
remuneration, exhaustive continuous professional development involving
numerous examinations, financial hardship, and disruption of family life.
Current orthopaedic trainees, due to become consultants in the near
future,
have worked rotas equating to 104 hours, improving recently to 66 hours
per
week. These hours leave little time for outside interests. Additional
hours,
referred to as 'on call' or 'overtime', but more correctly termed
'undertime
' have for years been rewarded by payments of 30% of the normal hourly
rate
(not time and a third as perceived by the public), with payments only
recently increasing to a ceiling of 70% of the normal hourly rate.
Trainees thus feel they have already fulfilled a significant service
commitment, and would consider that the 10 years postgraduate service
exclusively within the NHS prior to appointment as a consultant, is in
itself repaying a significant portion of their 'debt to the state'.
A significant number of trainees feel aggrieved at the suggestion
that they
cannot utilise their free time for a 'second job' for as much as an
additional 7 years as a consultant. Does any employer have the right to
restrict an individual's activities in their free time? Perhaps newly
appointed Cabinet and Shadow Cabinet MPs should be prevented from earning
consulting fees, or holding boardroom positions outside of government for
the first 7 years of their appointment.
Private Practice fulfils professional satisfaction by enabling one to
pursue
interests in a setting that most consultants find more relaxing than
working
within an under-funded NHS. Private practice is carried out in an
individual
's free time, is not compulsory, and is controlled by the individual. The
current NHS income alone does not provide for a lifestyle and rewards that
would be considered as normal 'perks' in comparable professional walks of
life.
It is a shame that when drafting this part of the reform document,
the
people it will affect, namely junior doctors, were not consulted. A number
of trainees would be keen to partake in full time NHS practice if the
quality of life was acceptable, for the many sacrifices made. Certainly
this
lifestyle decision is, and should remain, the right of an individual.
These reforms should only be introduced, without risk of redress, by
applying them to those yet to embark on their career pathway. This would
enable individuals to chose a career path, and make financial plans based
on
the prospective earnings. Medicine may be a vocation, but it is also a
profession.
There is an impression that is promoted by politicians, that
consultants
work less for their NHS commitments than others they might chose to pursue
in their free time. Contrary to popular belief, doctors at all levels, as
a
rule, over-perform within the NHS, as has been identified in the KPMG
audit
commissioned by the BMA. The image of a consultant on the golf course
during
NHS sessions is a fallacy, of similar proportions as that of MPs
universally
failing to declare their interests.
Of equal concern is the hollow threat of introducing a 'specialist
grade'.
The profession and public will always see this as a 'junior consultant'
grade. In effect, tying consultants to the NHS for 7 years is identical to
being a 'junior consultant' or 'specialist grade'. Hobson's choice.
BOTA support the expansion of consultant numbers, as well as
developing a
consultant delivered service. Expansion of consultants through the
appointment of the European 'surplus' is not the way to do this, neither,
BOTA would suggest, is restriction of activities carried out in one's free
time.
As Mr Milburn has stated previously on BBC TV's 'On The Record' on
11th June
2000, " 'In most walks of life employees have got a choice haven't they
about whether they work part-time or whether they work full-time ... .We
are
not going to deny that to consultants. Surely, why should we? It would be
a
pretty odd state of affairs if we said to highly trained consultants, some
of the most expert people, professionals that we have in the Health
Service', 'You are going to be denied a set of rights that everybody in
the
NHS has'."
Yours faithfully
Mr Andrew Collier MB.ChB.(Aberdeen),FRCSEd, FRCSEd(Trauma &
Orthopaedics)
BOTA President
Competing interests: No competing interests
I am the wife of a surgeon. We have been married throughout his
training and have two pre-school children. I am not in the medical
profession.
I have watched the system destroy the drive and enthusiasm of someone
who set out on his medical career with a 100% committment to the NHS.
When I read the part of the NHS plan to ban new consultants from
doing any private work for seven years I made a decision - enough is
enough.
Over the last eight years we have set up home in nine houses. We have
never been certain of being in one place long enough to buy a flat/house.
These moves were a requirement of his training and we received little or
no help with finding somewhere to live when moving to a new job. We have
sometimes moved with the aid of "removal expenses" which rarely covered
the total outlay involved.
We have worked abroad so that he could broaden his training with all the
stress that such a move involves when done on one's own, at one's expense
and not "by the company".
We have paid for surgical and managerial courses, text books and
conferences at our own expense. There are no tax 'breaks' for text books
(not cheap), journals or even surgical 'loops' used to perform micro-
surgery as none are deemed 'necessary' in performing the function of
'surgeon'.
The hours my husband has worked over the years have been in
contravention of the Health and Safety legislation. From my standpoint,
his time and effort has often been viewed by those he has 'worked for' as
a pre-requisite to joining their number later on and consequently
unacknowledged and at less than half time overtime for the 'contracted'
extra hours, certainly unrewarded.
No control but a lot of responsibility. Long, unsociable hours,
weekends on call, nights without sleep, catching up with hospital
paperwork, preparing talks, reading the latest journals, studying for
exams and writing papers in his 'spare' time - leaving little time for
family life. I was prepared to accept this on the understanding that
things would improve once he was a consultant.
On a maximum part time NHS consultant contract I envisaged that my
husband could continue to devote his time, energy and talent to the NHS
and the public but as a family we would be able to see more of him and
settle in one place for a while at least and buy a house. Not a palatial
mansion {which the press seem to think all surgeons live in), the cost of
which is many hours worked in the private system and often a relationship.
On a current NHS consultant wage with no additional income I doubt we will
be able to buy a house in the South East within a contract specified
radius of a hospital (average house price now £185,000).
I am sorry Mr Blair, Royal College, NHS but I do not feel my
aspirations for some family life and a home are ridiculous. If consultant
contracts are to be altered as suggested then I will encourage my husband
to leave the Health Service and if necessary, the UK.
Competing interests: No competing interests
Sir - The analysis in the leader (p. 315, Brit. Med. J.-
05.08.00)concerning the secretary of State's NHS Plan was timely and
clear.
However, the impact of the proposed demise of the Community Health
Councils, as the significant guardians of the patients' rights, by
dissemination of their functions to a number of other bodies in a Regional
Modernisation Board, seems to have been underestimated by the authors of
the leader.
Under the new plan local government councils will take over the role
of scrutiny of family practitioners and the NHS locally which does appear
to be an inappropriate avenue to pursue. Councils have no links to the
NHS, nor do they have any responsibility for healthcare to patients.
Rather is their role to provide housing to those in need and oversee and
remedy risks to health within the amenities in their area.
Having been appointed in June this year for a four year period to the
Cornwall Community Health Council, I was surprised when, in the face of
this appointment, I learned of the impending abolition* of the Community
Health Councils. It was only through the press that I became aware of
these proposed changes. This lack of communication by the usual means
bodes ill for a spirit of co-operation
between the Department of Health, the NHS Executive, the health
professionals and the public. One cannot but be saddened by such a lack
of courtesy.
Constance E. Fozzard
Consultant Obstetrician and Gynaecologist (Retired)
1. Local Government First, Issue 37, 29.07.00, p. 1.
Competing interests: No competing interests
'Royal Colleges must oppose proposal to restrict private practice to
senior consultants' Re: Mr Morgan's response
It is not simple.
Firstly, the only way to train to become a consultant in this country
is within the NHS. In surgery, for example, this involves a long training
programme and a number of additional academic qualifications the pursuit
of which is funded by the individual.It is impossible to 'go freelance'
until you are trained as a consultant and currently most private practice
is developed whilst in-post as an NHS consultant. Consultants are
contracted for a number of hours work within the NHS. The vast majority of
consultants work far in excess of these hours within the NHS. Furthermore,
under the current system they are not renumerated at all for time spent
'on-call' during which, though not resident in the hospital, they may be
required to attend at any time. Private practice is performed in addition
to this work in the consultants own time.
When you were a salaried manager for a food manufacturer I cannot imagine
your employer could object to you working for yourself at week-ends.
The normal rules of commercial logic have never applied to the NHS.
Yours sincerely,
Mr Dickon Hayne FRCS (Co-author, referred article)
Competing interests: No competing interests
Editor
Your editorial welcomes the significant injection of money promised
in the NHS plan and claims the plan true to the NHS's founding principles.
Yet Aneurin Bevan’s greatest achievement, and not one demanded of him by
the Beveridge report, was the nationalisation of the hospitals. He
recognised ownership was important, because with ownership comes control.
The NHS Plan promises 100 new hospitals by 2010 (69 of which are
already in the pipeline). This will involve £7 billion of new PFI
(private finance initiative) investment. Together with the new plans for
large chunks of NHS operating to be carried out in the private sector, the
NHS plan represents a larger privatisation than even the Tories planned.
Curiously the plan also recognises the failure of past
privatisations. I remember unsuccessfully voting against the
privatisation of cleaning at the London Hospital when I was a board member
of the old Tower Hamlets Health Authority. Squalid wards followed and
remain with us now. The plan now recognises that this policy was a
disaster. £30 million of cash is to be injected into hospital trusts
before the next election to pay for the consequences of this mistaken
minor privatisation. How much money will we have to spend in five, ten,
or twenty years time to correct the disastrous policy of major
privatisation we are now heading for. Mr Milburn, think again, before it
is too late.
Dr Kambiz Boomla
Competing interests: No competing interests
Dear Mr Morgan
You raised several points. I would be interested to hear your replies to
these views.
Of course your employer would have been upset if you took
time off work to do the same job for someone else. This is not the case
with private medical practice: If consultants choose to practice private
medicine, it is in their own free time. Why should the government regulate
that? (It’s probably illegal anyway). A fact of life is that the rules are
different for different people: A superficial reading of Hansard Members
interests is revealing: how can some politicians hold so many posts and
adequately fulfil their obligations to any of them? What regulation exists
to prevent journalists doing other jobs in their spare time? Should all
lawyers work for seven years with legal aid before being allowed entering
private practice? How do you view the activities of bank nurses? They work
extra shifts (in NHS or private hospitals) in addition to their normal
jobs. How about members of the Territorial Army who practice their medical
skills (gained from NHS work) with a different employer? What about those
doctors who provide medical cover for concerts, sports gatherings etc? The
remuneration may be less than for traditional private work, but surely the
principle is the same? Which other countries do you know that regulate
practice in such a manner?
Corny as it sounds, altruism is a daily fact of life for many who work in
the NHS (and not only medical personnel). The early starts, late finishes,
extra shifts at short notice, working at home, teaching etc: most doctors
and many nurses will have experienced these, all activities that keep the
NHS staggering along: Do you suggest that we should work to rule?
Incidentally, (a related point not raised by you, but expressed of late)
is that of “paying back the country” for ones training by not undertaking
private practice for seven years. Most doctors have accumulated thousands
of (effectively unpaid) hours work (service and training) for the NHS by
the time they become consultants. Even as consultants, the average doctor
works far in excess of their contract. If the normal rules of commercial
logic worked for the NHS, doctors would be charging American sized fees
(possibly on a fee for service basis). As for working “all NHS or all
Private”, If you were given the choice of a nine to five, well paid job
with no added responsibilities for education, administration, service
development etc, or a sixty five to seventy hour week with unsociable
hours, half pay, and vindictive, misinformed criticisms of your work,
which would you choose? What incentive would there be to remain in the
NHS?
No Conflict of interest (i.e.; no private work)
Competing interests: No competing interests
I am a freelance, I haven't ever worked as staff journalist, but I
used to be a salaried managing director with a food manufacturer. I cannot
imagine my former employer would have been very happy if I had said I want
to take some time out to work privately doing the same activity for
someone else.
Can someone tell me why the rules are different for a class of
employee who happen to work for NHS trusts?
The easy way to avoid the two tier system is to say work for the NHS
or work freelance - but not both.
Is it not this simple?
I don't think this constitutes boring as I haven't responded on this
strain before - naive maybe or just plain stupid - I just want to
understand why the normal rules of commercial logic don't apply - perhaps
the NHS is not a commercial beast and no money changes hands as a result
of this staff/private activity and it's all done out of altruism.?
Brian Morgan
Competing interests: No competing interests
Re: Royal Colleges must oppose proposal to restrict private practice to senior consultants.
I found the recent remarks from the Government that juniors owe a
debt to the NHS insulting, and was astounded that we are to be told what
not to do in our spare time once appointed as consultants.
As trainee surgeons, having completed 6 years in medical school, we
am faced with 12 years of service commitment for the NHS working 80-100
hours a week, resident in the hospital 1 in 4 evenings and weekends,
preparing for 2 major post-graduate exams in our ‘spare’ time along the
way, and out-of hours pay of £6 per hour for the privilege. Surely this
does not constitiute a debt to the NHS!!!???
Once a consultant, one would then work an average of 55 hours per
week (20 hours over the contractual obligation) which over a 30 year
career would equate to 27,000 extra hours of ‘free’ work for the NHS. At
£30 per hour, this equates to £810,000 per consultant career.
Where does Mr Milburn calculate the debt to lie?
Recent negative publicity, and the need for reform of our profession
is no excuse for treating the vast majority of hard-working doctors badly,
and not rewarding them and their long-suffering families properly. The
future generation of consultants will not tolerate being pushed around by
politicians, as the Cardiothoracic trainees have already demonstrated. The
idea of forming consortia similar to Barristers’ chambers may be a move in
the right direction, reducing the monopoly over junior consultants that
would otherwise be enhanced if they were to agree to a full-time NHS
contract.
I am sure it is not beyond our wit to ensure that a fair and
acceptable contract is agreed.
Yours Sincerely
Rowland Rees MRCS
Competing interests: No competing interests