More brickbats than bouquets?
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3977 (Published 28 July 2010) Cite this as: BMJ 2010;341:c3977
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Like most commentators I see both opportunities and challenges in
Andrew Lansley's white paper Liberating the NHS.
A focus on quality and health outcomes, engaging clinicians in the
design
of healthcare delivery, and a recognition of the importance of healthcare
research should all be welcomed. The stated commitment to public health
and integration with local authority will ensure a more holistic approach
to
public health and the wider social determinants of health.
Of concern however is the cost of this radical reorganisation and the
ability and capacity of GP's to act as both commissioners for population
healthcare delivery and agents for individual patients. Also of concern
are
the future role of the private sector in managing consortia, the gradual
fragmentation of the NHS, and variation in healthcare delivery.
In preparation for these changes it will be important to provide GPs
with
the necessary training and experience in population healthcare
commissioning. It would be helpful for closer working between public
health consultants and GPs to support this training and commissioning in
the future. It will also be important that the effectiveness and cost of
the
new NHS remains under constant evaluation and scrutiny so that we can
say at the end of this experiment whether Andrew Lansley succeeded or
failed.
Competing interests:
None declared
Competing interests: No competing interests
The difference between White Papers “commissioning” and “budget
holding” is moot. Both are based on an outdated public health view of a
general practice. It may have been right in the middle of last century
when infectious diseases were the biggest health problems encountered. Now
non-communicable disease has made chronic disease management the major
issue confronting general practitioners world wide and this one fact makes
the consultation an important factor.
The denominator in UK general practice should now be the consultation.
That was recognised long ago by classifiers in primary care. The World
Organization of Family Physicians and even the quirky UK Read codes have
their basis in the consultation. In addition, consultation duration has
long been shown as an important measure of relative value in general
practice and both in the USA and Australia.
Consultation rates are measurable, comparable and finite. There are only
so many consultations that can be conducted in a day. What occurs in that
time period can also be recorded and the length can be varied according to
complexity. Generated costs from consultations can be moderated as has
been shown in Australia. Patients benefit too. Research has shown that by
costing consultations patients can have an informed input into cost
utility.
Competing interests:
None declared
Competing interests: No competing interests
Doctors as NHS leaders
Dear Editor,
I hope that the profession, the public and the Liberal Democrats will
realise that Andrew Lansley's pledge to place GPs at the heart of NHS
decision-making is, as Boomla alludes, a populist Trojan horse(1). This
attractive soundbite is distracting attention from the intended
privatisation of large portions of the core NHS: reforms which lack either
an evidence-base or a democratic mandate.
One benefit however, may be the renewed focus on clinicians'
management skills. The NHS would benefit from a pool of clinicians who
have taken a deliberate decision to develop both leadership and clinical
skills during their training. Current opportunities are limited: the Darzi
fellowship scheme offering 12 months out-of-programme-experience is
restricted to ~40 individuals per year in London (2); the recently
developed Medical Leadership Curriculum (3) is yet to have a substantial
impact.
The NHS needs a clinical leadership training pathway, analogous to
the Walport ladder of clinical academic roles. Such jobs, spread across
specialities and geographical areas, could offer selected high-flying
junior doctors periods of paid time for leadership skill development
during the course of their clinical specialist training. Trainees could
gain hands-on experience of managerial and service improvement roles in
the NHS and elsewhere (including the private sector), study towards an
MBA/MPA, and emerge with a combination of skills valuable both to
themselves and the NHS.
Clinical management should become a prestigious career choice with
for interested individuals rather than an unwanted imposition on those
whose skills and interests lie elsewhere.
Yours sincerely,
Alexander D Douglas
Wellcome Clinical DPhil Fellow, Jenner Institute, Oxford University
1. Boomla K, in More brickbats than bouquets, BMJ 2010; 341: c3977
2. http://www.london.nhs.uk/what-we-do/developing-nhs-staff/leading-
for-health/darzi-fellowship
3.
http://www.institute.nhs.uk/building_capability/enhancing_engagement/enh...
Competing interests:
None declared
Competing interests: No competing interests