Andrew Lansley will announce a plan to save £1 billion in the NHS today — by cutting what he calls central bureaucracy.
The plan as I understand it is as follows. First, the primary care trusts that currently coordinate GP services will be abolished. Their job will go to GPs — who will coordinate themselves.
Second, strategic health authorities will go.
Third, all hospitals will be encouraged to become not for profit companies.
Fourth, and maybe incidentally, some organisations such as the Food Standards Agency will be abolished — assisting release of an epidemic of obesity.
I have some interest in this issue and should declare an interest: my wife is a part time GP.
So let’s first of all applaud some good news in this. GPs will no longer have differential contracts — some on something called GMS and some on another contract called PMS, that latter paying £10,000 pa more than the former, for no difference in services. That was always illogical.
Second, GPs will not longer be allowed to own pharmacies. That’s very good news indeed. Thee pharmacies have been abused by some GPs for personal gain at cost to the NHS. It is very welcome that this conflict of interest will go. But some practices will be £30,000 a year worse off as a result.
Third, GPs will no longer be able to set up service companies they own to provide minor operations to the NHS, undercutting hospitals, creaming off profit and (I think) sometimes prejudicing patient care on the way. I am very pleased that this change is happening: it always created a conflict of interest in patient care that had to be abolished. But of course many GPs will be worse off as a result.
I’d add, my family is unaffected by these welcome changes. My wife has left practices because of concerns about prescribing and independent treatment centres. She now works in a GMS practice that does neither. There’s no personal gripe on income going here.
That’s the end of the good news. From here on in there is only potential disaster to relate.
First, these cuts are almost bound to mean more than 20,000 job losses. These people will simply add to the register of the unemployed — even if some made redundant get new work others will be deprived it as a consequence. But on this occasion that’s not the biggest deal (amazingly). The big deal is the assault this represent on the NHS — for it is nothing else.
The claim is that GPs will now direct some £80 billion of funds to hospitals through commissioning groups they must set up and manage by next April. let me assure you — GPs are quite unable to fulfil this task. I have met a lot of GPs. I doubt some can run their own personal bank accounts — and the lack of information most have on running their practices is staggering. Nor do they need much: they have fixed income (near enough) that they expend. To suggest that GPs have the skills to manage budgets of the size suggested is ludicrous: they don’t, they don’t have the training to do so, and what is more they don’t have the inclination to do so. That is, after all, why they became GPs. That is not something that happens by accident: it takes years of hard work where conscious decisions to reject easier and much, much less stressful ways to make a living (accountancy, law, the City, public health physician, being a politician) are rejected along the way.
They also have no time to do so. Good GPs (and many are: not all — but many) work very hard. A typical day will include 32 to 36 patient appointments — at over 10 minutes each on average (especially if a woman GP — and more than 50% of GPs are women now — because they tend to see women who need more time). That’s 6 hours of patient contact time. Then there are at least 8 patient phone calls a day — another 40 minutes or more. Plus three visits, taking up to 90 minutes of time. That’s over eight hours before the GP then has to deal with all the correspondence arising from that lot, reviewing results and actioning follow up, dealing with training (of junior doctors, which most GPs do), staff management, practice management, NHS interaction e.g. with the PCT and other parts of the NHS, personal training and reading needed to keep up to date, and even occasionally getting time for sandwich. For a good GP that’s at least an eleven hour day, on average, to then come home and worry most of the night about the patient they did not send in to hospital and they now wish they had done — who they will call in the morning just to make sure “they’re all right” — but which is actually to make sure they’re still alive — and I promise you, they all do this.
Sure they’re well paid. But make no pretence — before 2004 when the contract changed you could not get new GPs for love nor money. Even now a considerable number of new GPs are foreign graduates because it is incredibly hard to get UK medics to manage the enormous uncertainty which is the normal daily fare of the GP.
To suggest that there is time in this day to manage £80 billion of budget is ludicrous. It is not possible. My wife has been asked to be on one of the new commissioning boards. There will, I gather, be six doctors on it. She has been allocated a maximum of 4 hours a month to do this job, if she wants it. So that’s (after holiday allowance) 40 or so hours a year — and just 240 hours for all the GP’s involved. That’s about 1.5 months a year to allocate the budget for a large area. So let’s not pretend this is going to be possible. It isn’t. And if no pay is going to be allocated unsurprisingly GP services will come first. Of course. That’s the bit she can be personally sued for if she gets it wrong.
Anyone with any sense and the time to ask can find this out. I presume Andrew Lansley. He must know this cannot work.
So what’s really happening? I suggest it is this. He is setting up a system that is intended to fail: a system which will result in outsourced contracts to the private sector in two years, which will contract with NHS hospitals that will by then be limited companies and ripe for takeover within another two or three years so that by 2016 those hospitals will be up for sale at knock down prices — “essential to clear the deficit” will be the argument.
And what will happen to NHS services? Broken legs, routine operation and the like will do just fine. The private sector can deal with such certainties, drop them into a spreadsheet and allocate funds to match. But what of the 30% of all people who present to the NHS, even with long term chronic illness, who never get a diagnosis because they fit into no known box - simply because medical knowledge has not yet found one? What for them?
Or the depressed?
And the old (often called the “crumblies” I note by those doctors most keen on the market)?
And the lost and the lonely for whom the GP is the only advocate — but who now cannot advocate for fear of running out of budget?
What of the conflict of interest every GP will face — and be sued for — when the patient claims they were not referred because the GP was seeking to preserve the NHS budget by not doing so — and as such had compromised medical judgement? What then for the risk that GPs face — already enormous and crushing for many? This is the treason for the difference between primary and secondary care as I see it.
I could quietly weep at the injustice of all this — and the callousness of it — and the blatant lies that will claim this is about efficiency when it is about private gain for Lansley’s friends.
But I don’t do quiet weeping. I get angry. And I’m very angry indeed. For the people of the UK, and the fact that yet again public good is going to be captured for private gain. Which sickens me.
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This is the Modus Operandi.
If something in the public sector is not broken, it had better be fixed.
Many will say that the NHS has been hamstrung by a bloated and inefficient bureaucracy. And make no mistake, there were plenty of jobs in management and quangos for the boys/girls in the upper echelons of all paid for by the taxpayer including blatant abuse which involved hopping from one trust to another.
I am not sure what you are on about as far as the owning of pharmacies is concerned – I assume you are referring to dispensing doctors. If this is the case, how do you envisage people getting vital medicine if there isn’t a chemist nearby?
Finally, my experience is that the availability of a NHS GP diminished when the previous government gave doctors their new contracts and they cut their hours while earning substantially more.
@JayPee
Note the point I made: up to 2004 GPs could not be recruited
It’s the market – heard of it?
And asking people to work 24 hours a day is not legal
Hmmm
Look at who Mr Langsey’s donors are :
http://www.telegraph.co.uk/news/newstopics/mps-expenses/6989408/Andrew-Lansley-bankrolled-by-private-healthcare-provider.html
Share price of Care UK is looking quite healthy as well…
Thank you for this – I hadn’t appreciated all the implications and now I do, I too weep. But I’m getting angrier. Of course GPs don’t have the skills for this. Nor the time. Certainly not the inclination as it will all ultimately blow up in their face.
How long before we have to pay for healthcare?
This is idealogically driven. Why so quick too? It simply will not work and then what? Remember care in the community?
I agree we shouldn’t tolerate it. So what shall we do? People definitely did not expect this from the government.
[…] Lansley is spearheading the Tory attack on the […]
@Richard Murphy
Where is your evidence for the assertion that GPs were expected to work 24 hrs a day?
The fact is that the 2004 contract was a disaster, a fact that the NHS Federation have alluded to on many occasions.
@JayPee
24 hour on call is 24 hours
Excellent article, and spot on, thank you. One additional angle is that, yes, most GPs won’t have the time or skills to commission services on this scale. Therefore quite probably some PCT staff will be retained and GPs will be able to buy in commissioning services from them. They’ll also be able to buy commissioning skills from other companies – PRIVATE companies. Private companies will be both commissioning and providing services – anyone else see the potential for (very lucrative) clashes of interest here?
And Jaypee, yes there’s some overpaid quango-ites knocking about (and most commissioners don’t earn that kind of money by the way, any more than your bank tellers and local bank managers earn what the Hedge Fund managers do) but the “bureaucracy” was put in place because of the introduction of an “internal market” to the NHS. It’s no more a “bureaucracy” than the marketing, service development, contracting, accounting and legal teams in the average private sector company are. The breaking up and privatisation of the NHS has been underway for quite some time; the ConDems have just stepped it up a gear…
Although PCTs lacked democratic accountability at the local level, the Lansley reforms look like a mess and Richard is right – it’s a preliminary step towards private sector management. If this debacle has a silver lining it’s that the public will be extremely angry about reforms that have a negative impact on the quality of care – and it sounds like this new healthcare management model will hit a crisis point pretty soon. Along with the row over cuts to school refurbishment funding, it’s all contributing to the defeat of the LibCons in the next general election – probably by a very wide margin. Unless of course Argentina wants to have another go at invading the Falklands… 😯
[…] Lansley is spearheading the Tory attack on the […]
Hi – someone from the Guardian’s CiF pages put a link in to you within comments made on a piece about GP’s new responsibilities – can you replicate this article there so more people can read it as everyone should. The BBC Radio 4 Today programme on its website has an interview with two health practicioners at 8.10am this morning – it’s well worth a listen and will show you how Lansley is privatising the health service through the back door. Like Jacqui Martin above – I like many others want to do something about this – can someone start up an online protest group or whatever – just an idea but something is needed. You could do it through the Guardian CiF pages maybe – I don’t know – just some ideas…..
I find this attack on the public service ethos very worrying. Despite all this ‘Big Society’ rubbish, it’s clear the Tories want to destroy public service. They don’t believe anyone should be motivated by anything other than money and so want to turn GPs into grasping capitalists. The GPs don’t have the time or resources to do this job and will inevitably turn to outsourcing. The end result will be another coporate takeover and we will be left with a choice between Tesco or Virgin GPs making huge profits which will end up in Caribbean tax havens.
Tories may love their ability to choose a private hospital, but your average NHS patient justs wants to get better and not burdened with choosing where they receive care.
Public service is the backbone of a strong and caring society and the government meddles with it at their peril. Whatever next? The police? The judiciary? The military? Education? (oh, that’s happening already).
These sort of budget holding models are not exactly unique to the UK. There are several countries where this is either already in use or are being trialed. Unfortunately the reports that I can find on the comparisons are all behind paywalls.
There are those who will always see these things as plots by some interest groups of the other, and it does make me despair of the people in this country show see everything as a political conspiracy and then retrofit their particular prejudice to whatever proposal comes along judging it to be good largely on the basis of who proposes it.
The NHS as currently structured is not the only way to provide for state care. Other countries have other systems and, arguably, provide better results in some cases.
Also, as for this not being able to provide GPs from UK resources and shopping abroad, that’s fundamentally a failure of the UK education and training system. For a long time there were insufficient medical training facilities and some unhelpful trends in school education.
In the meantime, we need to be open minded about other models. It’s very easy to fall into the trap of self interest groups who can create a mindset where their personal interest is somehow aligned with the population at large. There are precious few organisations that can’t be improved in some way.
Note that I do have concerns, but it’s more about the transition than the destination. Very large organisations with top-down structures have a tendency to be very unresponsiveness (speaking as one who used to work for one). Not everything can be done from a demand-lead basis. There is still a need for some central strategy, standards and policy setting, but the game here is to avoid the organisation itself becoming too much of its own reason for existence. I’ve seen very many organisations with self-serving arguments to always be a bit sceptical about such arguments. Not many people will volunteer their own redundancy.
There are some more balanced views by some of the academics who can see value, but also see the problems being in implementation and transition. It seems to me that many of the people issues can be eased through the movements and redeployments. It’s often not the people that are the problem, but the mechanisms, drivers and personal interests of management units that are the issue. Something that more closely associates those with direct patient impact is to be welcomed in principle. But it will be very difficult to do – no doubt of it.
@Richard Murphy
Being on call for 24 hours a day is manifestly not working for 24 hours. There are many, many people on call out arrangements for all sorts of essential services. That include IT systems, telecommunications, power, water, transport and a host of othere things required to keep society going. Those people often earn a very small allowance for that. In any event, it seems to me a very poor scheduling system in a practice that would require every GP to be on call for 24 hours for every day of every year.
That’s not to say the GP contract didn’t need reworking, but I’m under no illusion that any profession is likely to do other than negotiate for the best terms they can manage. Professional bodies, whether for doctors, accountants, actuaries, lawyers or any number of others are also there for their members. Middle class professional bodies are often closed shops, and in some cases, not all that good at controlling standards. Witness the simply amazing results of the Panorama investigation into dealing with incompetent teachers.
I, for one, am deeply sceptical about any group that claims its own members interests are fully aligned with public ones. I worked for a government owned business, since privatised, and I too went through this exercise of seeing our role as a public interest one when now, on reflection, it was there to serve the role of the people working for it and the whims of certain politicians. Those paying for the service came a distinct third in the priority list. It’s only when you start understanding the vectors that drive an organisation and decision making from the inside, and your own past role, that you see where priorities come from and how they change from a command-driven, top down approach to one which, imperfect as it is, is far more targeted to requirements than ever before. The industry in which I now work has achieves more in 5 years than 50 years under the old regime, at a fraction of the cost. (I add this is not an organisation that was ever in receipt of government largess – just an exploitation of customers paying for the sort of shoddy, third rate service that was normal for much of this country in the 1970s).
We are in need of a wake-up call in this country. There are many, many well trained people in developing countries perfectly capable of doing service jobs in the UK (and where I work, the IT area is a huge example of this). The reality of international competition is all around, and we need to be very careful about special protections for some professions. I know of many (often from the subcontinent) all to willing to take a trip to India for their medical, dental or opthalmic treatment. Those market rates of which are talked – well those are the ones protected in the west by practices and supply controls. It will most certainly not remain like that. Ask the ship builders, the iron workers, those in TV manufacturing plants, the call centre workers and (increasingly) certain professions. IT workers are one, engineers partly and finance will surely follow.
@Steve Jones
I presume you are a paid lobbyist – and for that reason was tempted to reject your comment
I didn’t because it shows the enormous degree of misinformation that people like you put our – either through ignorance or more likely through wilful desire to distort.
To suggest a GP on call is like an IT worker on call is, let me put this kindly, crass.
A GP on call will be called – frequently, often all night. When called they will frequently make life and death decisions (yes, I mean that) for which they are personally liable and the consequences of which may live with them for life if they get it wrong
An IT worker tells someone to reboot the computer
There is no comparison whatsoever
And a GP might do one night on call a week
Imagine how that impacts care in the day as well?
I’m sorry – if you engage in debate drop your free market dogma and understand the issues you are talking about. You clearly do not at present
I would also second the idea of some kind of action group – as I’ve posted on CiF, maybe such organisations as Keep Our NHS Public, Save our Public Services or the Socialist Health Association could take some action.
They all have websites easily found online. Do you know anything about these and/or have any other suggestions?
@Steve Jones
On-call for doctors is very different to on call in other lines of work – it’s a bit of a misnomer really. On call for doctors is more often than not much more intense than office hours type work. This is due to the fact that a doctor will be dealing with emergency work and the demand is very high i.e. constant.
@Alison
Keep our NHS Public is Good
I support them
@Rich
True!