大象传媒

Ironically the rumoured changes to GP consortia remind me when I was in the NHS of the birth of PCT's which were mainly co-terminus with district council boundaries and were more broadly based than local doctors.

There are doctors and doctors. The type that generally inhabit GP surgeries are private contractors often in partnerships like those found in local solicitors. My experience of 'handing out' funding for all sorts of purposes IT, facilities etc was that there was not excruciating care on governance and in clearly delineating practice (i.e. business) and healthcare interests. Most consortia meetings would have to begin with widespread declaration of interests. In addition the reforms may ossify the current practices of GP's that need challenging when the large majority of patients simply need triaging between the medical power of a doctor and the technical level of expertise of healthcare assistants who can probably and effectively deal with coughing grannies and injured children.

A SIMPLIFIED MODEL

Are alcohol, tobacco and NHS, a continuous, employment and tax-generating loop?

As government is amoral (at best) and filled with immoral individual pocket-liners; starting from here, is it not IMPOSSIBLE to raise the nation's wellbeing?

Many more factors can be added, but by my observation the picture stays the same.

let's face it...it ain't gonna happen, it has as much chance as a snowball fight on Hampstead heath this afternoon, Lansley is now personna non grata in all the Westminster bars...

Friends who are hospital consultants always say that GPs aren't proper doctors.

Richard Murphy has an excellent blog on this today .

I agree with this: "The NHS is riddled with bureaucracy. However, the question has to be asked, why is this the case? The answer is quite straightforward. This bureaucracy was introduced when the NHS was turned into a quasi-market."

Does it matter if you see the same doctor twice?
I think it does. The same doctor knows your history, your ideosyncracies, your propensity for hypochondria, etc.
This is why I tend to agree that your mates on the beach will know their patients better; be more accountable (or at least feel worse) if things go wrong.
Hospitals are full of specialists who know a lot about a specific subject, and full of hi-tech equipment. Isn't this the way that it should be; otherwise, assuming you do not need specialist treatment, you should be in a clinic. Meanwhile GP clinics are full of harassed docs who know a little bit about everything, and inhabit the world of coughing grannies and sick children. Isn't this the way that it should be; the GP is a sort of filter - little problem, little remedy; big problem; specialist rememdy.
It's the people known only from computer that really bothers me. Patients are not data, statistics and information that convert into health or sickness. They are whole, functioning (or misfunctioning) individuals.
As far as "doctors on the make", leaving the NHS to become management consultants, well, these sorts are always going to exist, like a great retail banker going off to some huge investment bank where he can make ten times as much money. It's called "Greed!"
The potential conflict of interest between a GP holding money and making a decision whether to spend it: I don't think I agree with this but my rartionale may differ from yours: I think doctors should be thinking about patients and treatments, not budgets, spending, etc.
"The Committee finds that the evidence provided by the Secretary of State and officials runs counter to the direction of policy. If integration of primary and secondary care commissioning is important, then separating them in order to support the proposed system architecture may cause significant harm to the commissioning system as a whole, and should be reconsidered."
I agree with this. A patient should proceed efficiently and effectively from primary to secondary care as the medical condition demands.
As for the electorate doubt - GPs verus hospital consultants, well...What is it that they want: their own GP operating on their fractured backs or cracking oppen their chests? There have got to be both - GPs and specialists. What I worry more about is the ongoing, continuous relationship between GP (and not his computer but) his flesh & blood patient. This relationship can actually save money in the long run because the relationship itself "reveals".
"The white paper got bounced back because there was no way the Treasury could sign up to a proposal which handed 拢80bn of public money to 35,000 GPs who are basically unaccountable private businesses."
I agree. Too much room for financial bungling, mismanagement, innocent errors and downright fraud.
So, weirdly and by accident, we may now have arrived at a moment many politicians have shied away from: a real, strategic level debate about what we want from the healthcare system. This is not really a debate about what we want from the Health Care System as much as we where we want to place fiduciary responsibility. Personally, I would put it with external accounting, auditing and never let the GPs get their hands on it.
Treat health care management like a business. What sort of business would give expenditurte rights to any department except accounting where expenditures are audited, verified and declined or approved?

I live on the windswept celtic edge of Britain.

I became ill a few years ago.

I have a wonderful GP who I was able to see on a regular basis and I believe that his personal knowledge of my health, my background and the relationship that we built up was a major reason in my recovery.

I would go so far as to say that if I had to keep seeing different GPs who lacked that personal knowledge of myself I would not be here today.

I think there are some seriously wrong things in the NHS when Doctors want to become even richer managers or empire builders of their own mini Trusts.

I think there are some seriously wrong things in both the NHS and our Society when patients no longer have a personal one to one relationship with their Doctor.

The NHS needs to be modernised but it needs to change by bringing back the good ways of years gone by and getting rid of so much of the dross.

The dross includes those Doctors who see being a Doctor as being a licence to print money and not as a vocation.

For many people, in fact most people, for most of their lives, the 'primary care health factory' might work well for them.

However, for those who have a long-term condition, continuity of care is crucial, particularly when it is not a common ailment.

I worry about people like my sister who has a rare neurological condition. When she was first diagnosed 15 years ago she and her then GP had to learn about this condition, do research on possible new and more effective drugs etc and it was a proper partnership between patient and doctor which grew up over the 2 yrs it took to get her diagnosis and then her subsequent treatment.

Fifteen years on and having moved to a new area, she is lucky that she has found a GP at her practice who is genuinely interested in her condition and will do the same - he finds it intellectually stimulating. However, the first couple of years with this practice was exactly as Robert Mason experiences - a different doctor each time with just her notes to go on. They often had not heard of her condition and had no experience in dealing with it; she would spend the bulk of her 15 minute slot explaining her condition to them!

She does see a consultant obviously who monitors her condition once a year but this is a round trip of 250 miles and inbetween she relies on her GP.

Will this continuity of care exist in the future? Only in some areas? The luck of the draw?
And will patients like my sister with complex and rare conditions still be attractive to GPs who might worry about the future financial demands she will make on their bottom line?

I live in Pembrokeshire. I have a long term medical condition plus complications..

I have been seeing the same GP for 20 years. 5 minutes with him is worth 20+ minutes with another doctor. There is also a cooperative relationship with the consultant in the local hospital. My point of contact is the IBD nurse, with whom I have an annual review and can (and do) contact if I need advice.

A friend of mine is a GP in the North-East of England where they operate in a similar manner. So far as I am concerned this kind of care does not need "modernisation".

The much loved NHS is socialist.

The Tories cannot be trusted with it as it is an obstacle to profit.

We need to save the NHS before its too late.
Unfortunately, this will required health workers & other public sector workers (& private sector workers) striking to bring down the government.

I don't know where Mr Lansley obtained the notion that doctors know their patients. They have spent years perfecting the art of avoiding them by implementing nurse clinics with long waiting lists to see 'a' GP, provided of course you are not ill 'out-of-hours' with all the dangers that entails.

As worrying as Lansley's proposed changes themselves is the apparent undermining of the democratic process which appears to be going on in parallel - see eg Telegraph 3 April:

鈥楴HS reforms 鈥榞one too far already to be undone鈥�: .

As Health and Social Care bill hasn鈥檛 yet been passed by parliament (and might be rejected by Lords or fall at its 3rd reading if the 57 LibDem MPs reject even the amendments to 2nd reading proposed by David Owen), how can the 鈥榬eforms鈥� have gone 鈥榯oo far鈥�?

Part of the answer must lie with some GPs/PCTs playing the ConDem game (former have already begun to form themselves into groups/鈥檆onsortia鈥�, the latter to disband.

Ironic that doctors and public-sector health managers could be said to be complicit in undermining of the democratic process. The time for salaried doctors is long-overdue - as Channel 4 revealed last month doctors might even profit from Lansley proposals. Does that partly explain rush to form consortia/groups?

Meantime, here鈥檚 a link to private healthcare connections of some Andrew Lansley, David Cameron and Tony Blair: .

Of course we need a C21 NHS but Lansley's juggernaut will make that impossible. Here's a clear statement of why NHS needs reform, not amendments: .

An interesting overview. An observation. This policy was thrust upon the nation. While some of the ideas were trailed in the Tory and LibDem manifestos, they were not worked out in detail. We are told that Lansley knows the NHS better than anyone on earth, and yet his ideas seem half baked at best.

When Lansley first entered Richmond House the following (hypothetical) conversion took place:

Civil Servant: Minister, what is the recommended size of GP consortia?

[Median size of PCTs is 260k, BMA reckons they must be at least 500k, and studies of other countries with commissioning groups carried out by Civitas suggest they must be at least 300k people.]

Lansley: Dunno. Let's say that they can be any size? That cannot be an issue, can it?

[The current "pathfinder" consortia vary between 14k and 650k]

Civil Servant: If the Minister insists. But what about the boundaries, should they be the same as PCTs or local authorities, or what...?

Lansley: Dunno. Let's say that they can have any boundaries that they want?

Civil Servant: Any? Even allow consortia to contain GP practices that are not in the same geographical area?

Lansley: Oh that sounds like an interesting idea. Yes, let's allow it. We could have a homoeopathic consortia containing those practices around the country that think that distilled water is a magical cure. (Great idea, and so cheap!)

[So far consortia are contiguous. But the DH reckon that some consortia will eventually eject the debt generating practices, and so the DH will have to create a consortia for these - in their words - "crap" practices.]

Civil Servant: And what legal basis will these consortia have? Will they be NHS bodies, or private bodies?

Lansley: No idea, does it matter? No of course it doesn't, they can be whatever they like!

[The initial pathfinders were a mixture of LLPs, CICs, company limited by guarantee and Ltds. Finally, after 9 months the DH has clarified that the Bill insists that they are statutory NHS Bodies just like PCTs.]

Civil Servant: Will patients have to be registered with the GP practice where they live ... ?

Lansley: No, of course not! We want patient choice!

Civil Servant: But won't that lead to boutique practices in city centres attracting young healthy people to the detriment of suburban practices?

Lansley: Why not, sounds like a great idea: "join our practice and get a free gym subscription". Great idea. What's the problem with it?

Civil Servant: But GP practices are paid a capitation [per registered patient] and so the capitation for healthy people subsidies the treatment of those with chronic conditions. If the young and healthy register in boutique practices the suburban practices with the elderly will run out of money.

Lansley: Competition, competition, competition! The Market will solve the problem and patient choice will prevail. The suburban practices will have to attract younger people, and compete. Maybe they could offer an iPhone?

Lansley: So, go to it minion! We will have consortia of any size, with any boundaries and any patients who choose to register. Choice, choice, choice! The Market will prevail!

Civil Servant: Very good minister, I am assuming that you don't want to contribute to the Christmas Club, it would be a pity not to be around to collect your hamper...

No 13 - That's brilliant. Are you sure you are not deep throat of the DoH?

Channel 4 News did an excellent investigation into 'doctors in business' showing the obvious vested interest angle. And that didnt take account of how much profit there is in bringing in workers from abroad, stacking up supposed salary levels with uncheckable expenses etc. Obvious way to go. And hugely distorting to employment and medical skills devt here.

(Pity NN cant get something like that together - too busy writing their books, counting their money, and thinking they are the smart people's program)

I thought it was hilarious to see politicians setting up a system that is made for abuse, unless those concerned particularly stick their necks out to choose ethics and honesty.



I really wish you wouldnt keep trying to sound like joe blow Paul while taking no account of joe blow

It all falls down somewhere between a provincial hick dazzled by big city lights - bit like a rabbit - but trying to look/sound like mr zappydoo,
and one of those old blokes who thinks he can look hip if he 'gets on down' with the anarchists.

There's a big bit missing in the middle - and they pay your wages.
Try genuinely listening to the concerns and priorities of normal, get-by, people, rather than sound bite snippets - and see what you can offer in your work.

Paul l'm sure your GP knows who you are and anyone treating you will also find out - and as a result you will probably be treated differently from most others. This is as true as it is for the elderly who have been treated in a shabby way by the nhs and for people like me who have dared challenged their GP's . What is written down on your medical records will define how you are treated true or false. I'm probably labeled it a certain way although not as an out right trouble maker my 'behaviour' will be inferred and am given a wide birth or just plain ignored, just the same as NN ignores us; we would be the least likely to be invited on to NN to give our views, but on here we are most active in making comments and doing research. This is how we are discriminated against we are labeled and then ignored. Just to given an example; when my GP prescribes nasonex for a blocked nose and I inform him that the most common side effect of that drug is headache and that I suffer from migraine and he wells knows that for many years, it kinda sets the tone for how things are going to be. My view is: why should I suffer because my GP cant be bothered to do a better job and is paid a fortune to boot ? Then throw manglish communication issues on the fire along with associated culture differences and you have alienation all round but its us who loose out and the GP's making a mint.

People have realised that GP's are highly paid drug pushers for big pharma and do research online to find alternative safe methods based on good science to treat themselves.

#16
just make sure you don't get DNR on your records.
You probably already have NFN.

#18

"Normal for Norfolk" - abbreviated to NFN, was used on doctors' notes to explain the depth of the stupidity of some of their patients, blamed by some on Norfolk's sheltered gene pool."

Seriously doubt my doctor would know where Norfolk is, how to pronounce or spell it . But he could do NFN .

#17

I was shocked when I learnt how little training medical students are taught about drugs - one Doctor told me that medical students, allegedly, are told to rely on the advice of the drug reps.

The big problem is that the NHS mindset, Doctors especially, is geared towards treating the symptoms and very little on finding the cause.

So you go to the GP with symptom X and you get a prescription for X when really Y and Z are the underlying causes that results in symptom X.

There needs to a change to the holistic in the NHS with much more focus on prevention and finding the underlying causes of illness rather than just dishing out prescriptions for symptoms.

I had my eyes opened, for example, when I learnt about how minor twists and turns in the spine can result in all sorts of symptoms in the chest, heart, lungs, etc, that progressively get worse.

Correcting the spine can make the symptoms go away but if that correction is not done, or not even diagnosed as an issue, then someone can suffer, again as an example, asthma or chest pain like symptoms for years, but is then constantly treated for the symptoms and not the cause of the symptoms.

Unfortunately, when you mention 'holistic' you conjure up images of hippy style people living on vegetables and indulging in tantric sex all day - not that there is anything wrong in that. But it does appear that too many doctors that 'holistic' is a word to be ridiculed.

I am reminded of those two Aussie doctors who were ridiculed by the medical profession for years when they claimed that stomach ulcers were the result of a virus - nowadays, only the most out of date doctor thinks otherwise.

Or the work of people like Professor Michael Hollick of Boston University School of Medicine who has led research into the importance of Vitamin D3 for our health and why so many illnesses stem from chronic D3 deficiencies in the West.

There needs to be a radical change in the mindset of doctors towards illness prevention. If you find a doctor who is up to date in this regard then hold on to him or her.

Oh, and we need to train 4 or 5 times the numbers of doctors than we currently do.

Of course, to do that then the GMC/BMA need to be brought to heel in regard to why this country has had a doctor shortage for 30 years or more and yet the shortages continue and continue?

Double oh, we also need to have nurses who wish to be nurses who nurse, wash, clean and look after patients, rather than graduates with degrees who consider themselves too 'posh to wipe' and who leave the real nursing to the nursing auxiliaries.

An old NHS joke:

Q: what鈥檚 the most expensive bit of equipment in a hospital?
A: the Consultant鈥檚 pen.

OK, doctors usually now use IT to order things but you get the point: it is the thousands of individual decisions by clinicians, mostly doctors, that commit the bulk of NHS resources. Managers seek to influence clinicians鈥� behaviour, with mixed results.

The NHS costs a lot to run 鈥� some 拢110bn, and there is massive variation - between hospitals and doctors, for example 鈥� in how services are run, and their outcomes. Medics themselves run surveys called national clinical audits across many specialties to document this, and drive improvement.

And of course, an ageing population and new drugs/technology means the NHS needs around 3% real growth to 鈥渟tand still鈥�. So short of a bottomless pit of money, there will always be a 鈥渞eform agenda鈥� for the NHS. The key questions concern its value-base and likely effectiveness, and of course the resources available.

Lansley鈥檚 Bill seeks to create a regulated market in health services, mirroring the utilities, to promote rapid innovation and efficiency but encouraging new market entrants (especially private sector) and encouraging market exit of inefficient providers (eg any hospital that has not managed to achieve Trust status, but it also applies to NHS community providers and individual departments within any Trust).

His problem is that every significant interest group in the NHS (and there are quite a few) are actively opposing it. Doctors, nurses, health think tanks, other unions - and now the media and wider public have caught on. Contrary to Paul鈥檚 view above, I would say most GPs are not keen on becoming commissioners (many have only 鈥渟igned up鈥� as a way to mitigate the worst effects). The GP鈥檚 Royal College president is one of the most vocal critics. A cynic might say that GPs don鈥檛 need the hassle of making rationing decisions, as they are paid enough anyway. Amongst GPs, there are perhaps only 500 enthusiasts and leaders for GP commissioning nationwide (out of 34,000 ), and many of these will melt away when the going gets tough over the next few years.

Labour's approach to health reform was actually more evolutionary - and got results: NHS popularity was at record levels in 2009, according to the British Social Attitudes survey, with clear service standards and better outcomes in stroke, heart disease and cancer.

The interesting politics is that the Lib Dem grassroots have now woken up to the threat to the NHS, and have mandated their MPs to neuter the bill. Cameron has clearly come out in favour of the Bill, and explained in January how it is an example of his public services reform philosophy. So will Nick tell Dave he must do a U-turn, or (more likely) will the Lib Dem payroll vote for the Bill amended by token changes?

Would be nice if Paul鈥檚 prediction about the Coalition breakup in 2011 comes true over the NHS.

Broke (and broken) Britain

"GP's are (little more than) highly paid drug pushers for big pharma"

I rarely go to the doctor, but had a very familiar experience of "never mind the cause, here's some pills to treat the symptom".

Just about sums up the whole problem with the NHS and the economy really.

I feel a 'Portugal is bust' post coming on.

Comments broken for the new articles! Is it a conspiracy as the global elite hone in on a potential source of disruption? Has George Bush hacked the 大象传媒!!!

Or incompetence? I'm keeping my tin hat off for now...

Wait for it...Grayson Perry on NN in a nice new frock to explain Portugal and the strategy for avoiding EZmeltdown. Paul's post after this is excellent, presumably we're waiting for the rest of the 大象传媒 to catch up.
[Tawse57 you asked for it!]

Dear All

Declarations of interest:

1. I am a hospital consultant
2. I choose not to do private practice (like 70% of my colleagues)
3. My NHS salary has fallen in real terms by 6% in the past twelve months and has been "frozen" for then past three years.
4. My "gold-plated public sector pension" is being targeted by George Osborne, Rupert Maxwell style - in spite of the fact that doctors' pension contributions give 2 billion pounds each year to the Treasury.

OK. Enough penitential chest-beating.

I believe that the NHS offers the cheapest, most efficient health care system on the planet. If you don't believe me, check the OECD website.

This week, at it's annual representative meeting, the BMA called for the Health and Social Care Bill to be withdrawn. Doctors did this because we are worried about the market of health care; worried about the privatisation of the NHS; worried about our seemingly inexorable march towards an American-style insurance-based system. We are worried for our patients, particularly those with chronic or complex expensive conditions.

Doctors will almost certainly do very nicely out of such a system, but we reject it totally. The provisions of the Health and Social Care Bill are not in the interests of patients or of taxpayers. They do, however suit the health management organizations and health insurance providers who are financing our main political parties.