The NHS reforms promoted by Andrew Lansley are inherently flawed. One of the most blatant flaws is that GPs are not only given control of much of the NHS budget, they're also given the opportunity to blatantly abuse that control.
If a GP wants to refer a patient for secondary care now they do this:
The patient sees the GP. The GP forms an opinion. If they think it appropriate to refer they do. They can do so directly to whomever they think appropriate, having discussed that with the patient to ensure their wishes are respected. The GP is not financially involved in the decision to refer, or not. That has always been the glory of the NHS: doctors who can act independently of the patient's finances and their own finances. Medical concern comes first.
But now it's going to look like this:
The GP sees the patient. They form an opinion and they do a referral. The referral no longer goes to the person the GP addresses it to. It goes to a referral management company. These are owned by the GPs but are designed to confirm collective group think - that the GP is not independent but subject to collective control on their behaviour. The GP management company can then decide to ask the GP to alter the referral - to stop it if thought necessary, to make it more urgent if appropriate. And in future, no doubt to change its destination.
This last point is vital. All over the country GPs are setting up their own GP owned treatment facilities. These do simple operations in GP practices - things like endoscopies, cataracts, carpal tunnel operations, pain management and some urology. They have competed on price. What they can't compete on is service: there is no crash unit if things go wrong, many are an ambulance trip from serious resuscitation units, and they don't train - giving them a massive cost advantage. They also skim off all the simple work on which people have been trained, denying a training route for next generations of doctors.
And it is, I am sure, to these that work will be referred in future. So, GPs who want to keep work in the NHS will have their referral diverted by a management company which they'll have no choice but be a part of to a treatment facility which they'll have no choice but be a part of. And from which they'll profit, like it or not, and conflict of interest or not.
Should the patient trust this? Why should they? How do they know their referral is going to the right place? What happened to patient choice? And how do they know the procedure they're being asked to suffer (everyone suffers an endoscopy) is necessary? Or just designed to profit the GP?
If this model is put into place that's the end of the patient relationship with the GP.
I fear there are GPs - already well paid - who are rushing down this route motivated by greed. They need to think a little more. When the patient trust in the GP has gone so will the status of the GP and their role as independent contractors standing for all that's good in the system. And with that goes this edifice - off into totally contracted hands, entirtely out of the NHS as we know it - but with the excuse that the reform at that stage will be needed to restore the independent status of the GP.
It's all too easy to imagine.
And that's why the NHS reforms must ban GPs from owning any referral management system and any treatment or commercial diagnostic service in the NHS.
Only then will be patients be able to trust them. And when GPs already earn full time equivalent of more than £100,000 a year I don't think that's too much to ask.
Disclosure: I am married to a GP. The opinions are my own.
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Interesting summary. Do you think it’s possible that the first and second diagram are functionally the same, it’s just that in the first diagram, all the details of referral and confirmation of referral happens inside the confines of a hospital, and in your blackbox diagram it’s considered minutiae and hence not summarized in the first diagram?
Okay your point on the profit being woven into the structure is taken, but perhaps (gasp), it will be more efficient this way instead of having the hospital deal with this minutiae? Perhaps right now that function is a bottle-neck? How much back and forth is there right now between doctors and the hospitals that they have referred to?
They’re completely and utterly functionally different
GPs don’t own hospitals
There is no bottleneck now – at all
And consultants don’t divert referrals to businesses they own
You utterly miss the point at every stage in the argument
Richard –
Under the current system, when a doctor makes a referral to a hospital, then what happens (inside the hospital)? Is that referral acted upon with no push-back? So the GP does not questioned at all? Or does a committee of doctors and administrators meet, review the referral, and collectively decide what to do about the referral? ie. agree with it, modify it, reject it, etc.
Do you understand my question now?
Kimbjo
No there is no review or kick back
The consultant trusts the GP had good reason to act and acts on it
And reports back
Or refers on within the hospital sometimes if reason to do so is found
But no committees, reviews or haggling. Just action on the basis of mutual trust to sort out the patient
Which will go
The potential confusion between the motives of a doctor referring a patient is horrendous: are they referring on medical grounds only or on a combination with financial benefits in favour of the doctor, bad enough as regards what is economic to the patient. How would you know exactly what is what? Already elderly patients may feel the cost of an old people’s home for instance is not worthwhile and simply give up. The GMC guidance says the Doctor must inform the patient where the Doctor has a business interest. Health will become a commodity, a great investment but we should not be gambling with people’s lives. Every patient is a life: pateints are discussed as if they are someone else but they are us. I have doubts as to whther they can continue to deliver good frontline care under the pressures to come and they need help to do so not to be given additional financial temptation.
I cannot support an arrangement where doctors make money from another organisation as a result of me personally: somehow it doesn’t seem right. It would be like a solicitor making money out of the value of my house as opposed to the amount of work he does. The GP function must be kept separate and this is my greatest objection to the health bill. I don’t mind if Gps are seconded to consortia and welcome interaction between commissioners and frontline GPs. I find the idea of someone telling someone to go into a home (a GP did tell a relation of mine that) and possibly benfitting financially totally abhorrent. Oh, I forgot, it will be provider choice, itself relying on providers worth choosing from. Well there is only one good Old People’s Home near me so not much choice here. I don’t mind paying doctors or consultants for their expertise but many cannot afford it and people with ongoing conditions cannot get insurance. I submitted evidence on the bill (HS77) becuase I feel so strongly about this point. This and other points have been glossed over by the coalition, which itself is why people find it so distasteful and why the Gov merely listening as if we are children to be indulged will be insufficient. The fact that all this started twenty years ago does not justify the steps now being proposed, which should be resisted because they are actually the most significant ones. This is all very serious and very important and has been given insufficient respect by the coaition and they should be ashamed of themselves in my opinion.
They have not been “glossed-over”, they’ve been ignored.
There is a boat-load of money to be had here, the system is, at the moment, near to corrupt.
Just look at the personal interest that ALL political parties have in the NHS….loook at the friends, relatives and ex-politicians involved in the supply companies.
After re-organisation it will be broken apart for personal profit by the “great and good” 👿
ignored will do for me, that’s what I meant thanks