28 March 2009

The NHS and supermarket mentality

What you do not appreciate is not valued, and that which you do not value is soon lost.

Not the words of old Dr Grumble but the words of a junior doctor. But it is a point that worries Dr Grumble. Our government seems intent on undermining the NHS in the eyes of the public. Public expectations are being driven ever higher and nobody seems to realise, certainly not the government, that these are expectations that can never ever be met. Despite bankers demonstrating the catastrophic problems that can result from unfettered markets the government continues to see markets as the solution to the NHS. This can never be. Why the management gurus cannot grasp this escapes Dr Grumble. For them there will follow at the end of this post a little allegory which was stimulated by these words from a junior doctor which set Dr Grumble thinking:

The harridan with the woman then proceeded to say - really nastily - "I think we'll change the whole hospital next time. We won't come here again."

What do these people think the alternative is? Is there a Special Hospital around the corner where their trivial tax payments are magically converted into their own private physician, caterer, and a master of ceremonies who ensures things happen at the moment they snap their fingers?

The alternative hospital down the road is, of course, the model our government favours though, as the junior doctor plainly realises, it is not a realistic or sensible one. Shopping around for healthcare seems to be the government's panacea for each and every problem of the NHS. But shopping around is not what you do when you are ill. Shopping around is what you do when you go, say, food shopping with your own money. You can chose Waitrose or you can go for Asda. If someone else is paying it will be Waitrose. If you are paying it could be Asda but it might be Waitrose depending on how much you are prepared to spend. If somebody else is paying you will moan if they make you go to Asda.

It is a not such a strange thing that if you open the doors of either Waitrose or Asda and tell the customers that everything is going to be free there will be queues at the door and the shelves will soon be empty. Just imagine what happens in this idyllic world of the free supermarket. Inside the shop the underpaid shelfstackers work in a mad frenzy trying to keep the shelves full. But however hard the stackers work to ensure the shoppers have everything they need, the customers keep emptying the shelves. The shop is always thronging with people. It's difficult getting from one aisle to another. The shopping process is inefficient. Cleaners can't clean because the place is so full. This needs a management solution. So the managers limit the number of people allowed to come into the shop. Queues build up outside but people are prepared to wait for over six hours for something that is free. But that is the only way you can control demand. In any other shop you control demand but putting up the prices. But that can't be done in the mad world of the free supermarket.

But limiting demand by controlling the numbers allowed into the shop also has its problems. The queue outside the shop grows and grows. People start travelling from abroad to take advantage of the free food. Soon the queue is blocking the whole high street. This needs a management solution. So the managers introduce targets. People must not wait outside the shop for more than, say, four hours. So they double the size of the shop and employ more stackers. They even open another shop to compete with yet more free food. The stackers find there is more work than ever because as the queue time shortens to four hours all those people who couldn't be bothered to wait six hours decide to go shopping for free food. For the queue to grow despite the management's efforts the managers are convinced that the stackers must have been slacking. The managers whose pay depends on keeping the queue short, unusually, take to the shop floor and goad the stackers who are already working as fast as they can. Shortcuts are forced onto the supermarket workers. At the meat counter somebody starts using the knife used for raw meat on the cooked meat. And for a while everything is OK. But then one day there is an outbreak of illness caused by E coli 0157 and a lot of people die. And very curiously everybody is surprised and wonders how this could possible happen.


ler01kjh said...

I enjoyed this, very insightful and beautiful irony. Although I would suggest this is not about individuals in the NHS being underpaid. Is it? My understanding of NHS pay although not complete is sufficient to suggest that NHS workers are by no means getting a raw deal. So I would see this as a problem of demand exceeding supply. Paying a nurse, doctor or manager more isn't the answer.
My view is we need to move to a medical insurance scheme just like many other countries such as Australia, and might tighter controls over who can and who can't use our services free. Of course people with low incomes should have subsidised healthcare, but we should not be allowing heathcare tourism, and from the backlog of debts run up it is clear to see yet again, Government measures to stop this isn't working. Free at the point of need is a receipe for fraud and wasted resources. We need to get to grips with the true cost of our NHS, and to bring about some fairness to how we pay for it.

Dr Grumble said...

If you pay the staff more you might be able to recruit more staff and provide an even better service which would increase demand still further. Perhaps Dr G should have somehow worked that into the story of the free supermarket. One way of dealing with demand might be to pay staff less, be unable to recruit, provide a poor service, allow waiting lists to grow and force people to go elsewhere or wait so long they die before they get dealt with. But that is the system we are moving away from and what this is revealing is that demand for quality healthcare is a bottomless pit.

Whatever system you have you need somehow to keep a lid on demand and provide care as cost effectively as possible. Insurance-based schemes can readily encourage unnecessary investigations and treatments which have to be paid for somehow. There is no obvious answer to the underlying problem.

Dr Grumble said...

Quite by chance the pay scale for our Foundation Year 1 doctors has just crossed the Grumble desk. Their basic pay is £21,862 which is not a great deal since all the perks they used to have seem to have been taken away and they generally have large debts to pay off.

sam said...

Doc, after 6 years of double volume study @ £21,862, no grants apart from final year 'very misre' one and up to £50,000 debt! Nurse after 3 years of studying 'the usual' is @ £20,000 and loads of grants and no debt!

Proper disgrace! Especially when you consider how much young doctors have to pay out by force for registrations, exams, memberships, seminars, books, equipment and what have you! End result, nurse has lots more money in real terms .. young doctors will be begging on the street and sleeping rough soon if this injustice continues!

Then medical leaders talk about the 'privileges' of being a doctor!! Does anyone know what are those 'privileges'?

And I am is happy you came back Dr G :-)

Dr Grumble said...

Quite right, Sam. But it needed somebody else to point this out. There are some things it is very difficult to say if you are a doctor and pointing out that some of us are grossly underpaid is one.

(Apologies for the access problem earlier.)

Anonymous said...

The banding (usually) bumps up juniors' salaries to a more acceptable level. My FY1 posts have been paid at 40-50% banding this year and, thus, I will (by August) have earned about £32000 gross.

I appreciate, however, that this will probably fall as more rotas become 48-hour compliant.

Andy Cowper said...

Another funny and well-written analysis, but may I offer a challenge to the supermarket metaphor?

100% of the population need food to survive. Unless you are a self-sufficient farmer (which might cover 0.2% at a maximum), the purchase of food is therefore not optional.

Most of the population are going to need and use healthcare at some point in their life; but most of the population are only significant net users of NHS resources in the first two years of life, in any maternities, and in the last six months of life.

It's not clear to me that demand for healthcare is infinite. I would suggest that most people want to avoid healthcare as much as possible because even though waiting times have fallen hugely, an individual's time is not valued in most transactions with the NHS.

I'm genuinely not familiar with anyone who accesses healthcare unnecessarily simply because it's free. According to the 1948 NHS Act, I have a right to a full and comprehensive range of health services, but I'm not going to get my hip replaced because of this, since a) I don't need my hip replaced (yet); b) healthcare involves risk of harm and death; and c) I have better things to do with my time.

The core business of the NHS is people with long-term conditions. If we manage their care better and take some vaguely serious approach to childhood obesity, we probably have a sustainable system on our hands. If we don't, then it's clear that we won't.

If you want to use market-type analogies, then for most people, accessing healthcare is generally a 'distress purchase'. We do it when we are ill.

Even for the reasonably educated, the asymmetries in information about quality that could drive meaningful patient choice remain high. So most people are still involving their GPs in their decisions about choice.

I love the 'if it's other people's money, you'll go to Waitrose' line - it contains a truth about an element of human nature! But I think it also involves a slightly sociopathic reading of civic responsibility. Most people have some degree of understanding that there is a link between income taxation and the provision of public services. Given reasonable information and support, people can make quite sophisticated choices about priorities- even if they are not clinicians, healthcare managers or indeed health economists.

Health insurance is great for insurers - they make money on it. It's like the casino or the bookie - the house always wins. But it drives up transaction costs, leads to risk-skimming and is unlikely to lead to cost-containment.

Supermarkets are quite an interesting metaphor for healthcare, given the obvious market dominance of one major UK provider in the form of Tesco.

Moreover, despite the fairly ineffective Competition Commission, it is reasonably widely known that supermarkets have the whip hand with their suppliers, and can dictate terms to a worrying degree. It is certainly clear that they can lead to small local providers going out of business.

Choice of supermarket is also contingent on what is available near where you live. Culture also plays a part: some people will never shop in Waitrose or M&S because they are for 'posh, snobby people'.

Dr Grumble said...

Thank you, Andy. A well thought out response from the expert that you are.

I don't want to go too far with the supermarket analogy but the truth is that you don't need more than a certain amount of food - especially fresh food which will go off - but make food free and people will take it whether they need it or not. You and Dr G may realise healthcare is not needed for much of our lives but people still queue for hours at A&E with minor conditions. I agree that there used to be an ethos of trying not to abuse the resources of the NHS. I think this is going as government has changed attitudes by saying that people should be able to walk in to any doctor anywhere (Martini healthcare) and have minor ills dealt with at their convenience. I think you could argue that this is not something the taxpayer should fund and that if that sort of service is available for free it will be like the free supermarket in the Grumble make-believe world.

The other mistake I think you make has been made since the NHS began which is that there is only a limited need and a limit to what can be done. Nobody can be ill more than on rare occasions in their life. Deal with the rare illnesses in their lives and that is not in any way a bottomless pit. I am not at all sure that is true. On the other hand it is the case, as you say, that an awful lot of money is spent on the last days of somebody's life and if you die at the end of it all that is, by definition, money wasted. Believe it or not, this is another example of the free supermarket. Nobody worries about massive input of resources into hopeless cases if the money is not their own. But it is like fetching free fresh food that will go off before you can eat it.

You and Dr G may not go to the doctor with them but people have all sorts of aches and pains, headaches and anxieties. They love scans and tests. Private companies advertise the supposed values of screening. Sports people demand MRIs of their soft tissue injuries. Much of this is money down the drain as people like Jobbing Doctor will explain but I am afraid that private systems generate a great demand for tests and opinions whipped up by those making money in the process. We do need to keep the lid on this in the NHS and the key to this is not encouraging shopping around until you find a doctor who sends you for all sorts of fancy scans. Instead we should have focussed on keeping quality GPs whom patients know and trust to educate people that what they really need is a single good clinical opinion.

What I am saying is that we should not be comparing the NHS with 'better' private insurance-based systems which may seem better but have the deficiencies you point out. Unfortunately this seems to be what the government has been doing - goaded, I suspect, by Big Business waiting in the wings to get a proportion of the vast NHS expenditure.

Andy Cowper said...

No, Dr G, thank you for a very thoughtful rejoinder (though I guess we can now stop thanking one another).

It is without doubt accepted that when you do promotional 'giveaways' of perishable food items (such as of ice creams, drinks or snacks), people tend to take all they can carry: far more than they need or could consume.

I'm less sure this is equally true of - say - the free pens, umbrellas, post-it pads, USB sticks and other minor freebies you get at conferences. In my observation, people don't do that with those. Nor do people take more than one copy of the crap-but-it-passes-the-time free newspapers now doled out in every city.

Perhaps there's free stuff and other free stuff?

But there is no doubt a hypochondriac (or, if we are feeling charitable, healthcare-loving) type of patient who is not a minimalist like we who know that in healthcare, as in so many spheres, less can be more. These people will want the finest scans and tests money can buy, and are likely to Know Their Rights.

I have the greatest admiration for doctors who can tolerate such behaviour. I could not do so - it's one of about a thousand good reasons I am not a doctor.

I heard of a good system used by a major London hospital to deal with inappropriate A&E attendances by people with general practice needs. The PCT and the hospital agreed to put a GP front-end on the A&E (they didn't put the GPs in A&E because apparently after a few weeks, they go native and start ordering loads of tests and prescribing really expensive drugs). This system needs a very skilled triage nurse at reception, to filter between the 'straight through to A&E' ones and the 'GP need' ones. They see the GP need patients, but during the process, establish whether they are registered with a GP. A surprising number apparently were not - this could be a London thing.

GP access problems are real, and the Inverse Care Law remains broadly true. This is not because GPs are bad people or run their businesses incompetently (though there are, as in any trade, a few). It is in part because we were training and paying too few GPs for a long time. It is in part because many practices didn't and still don't organise their booking systems as well as possible - GPs know when need is greatest.

It is in part because the 'Monday-to-Friday' NHS has been slow to catch up to changing working patterns.

It is obviously in part because the various initiatives to improve unscheduled 'minors' access (minor injury units, walk-in centres, Old Uncle Tom Cobbley and all) have helped confuse the public. And it is certainly a perverse incentive of the maximum 4-hour wait in A&E.

Unfortunately, we are as far away as ever from a primary care-led NHS. Policy and management remains wildly acute-centric - acute being the most expensive and potentially dangerous bit of healthcare.

And we are coming into a period when tax revenue is dropping like a stone. If we are to stand a chance of containing costs, getting GPs on board is not one of the vital things: it is THE vital thing.

So despite the progress to date, I genuinely believe that PBC has to be the way forwards.

Perhaps Alan Maynard's suggestion that NICE should lower the cut-off threshold for technologies to £10,000 / QALY is the way forward? He is certyainly right in saying that NICE urgently needs to recommend existing but cost-ineffective technologies that should be phased out of NHS use.

Cockroach Catcher said...

A friend just called in distress as her son who is a year after graduation from Medical School in the South of England is moving to New Zealand. Is New Zealand better than England?

The Cockroach Catcher

sam said...

"The banding (usually) bumps up juniors' salaries to a more acceptable level. My FY1 posts have been paid at 40-50% banding this year and, thus, I will (by August) have earned about £32000 gross."

You are a 'really' lucky F1 doc there! .. Because the majority of the F1 rotations in central London at least are unbanded! And so were the majority of F2 rotations too! So, it meant that all you got was your misre £21k and that's it!

And, anyone can do another job or a 100 hour week to earn more money, indeed, you can flip burgers at McDonald's after your shift and make more than whatever the NHS will pay you for 'the extra time'. This doesn't mean that a doctor's basic of £21k is right though, is it?

Especially when lawyers or accountants, engineers, most graduates make way, way more age for age!

And .. An F1s misre £21k is £4k below the national average for graduates, ie, those who graduated after only 3 years of 'very easy' life at uni!


Dr Grumble said...

Sam's right. It depends where you are.

Dr Aust said...

There are, of course, a bunch of highly-trained (6-8 yrs at Univ) elite science graduates who make less than the £ 22K junior docs' basic, a lot less than "lawyers or accountants, or engineers", and quite probably less than most graduates in their subjects. These folk are the ones who complete PhDs and then work in Universities doing teaching and research... including teaching medical students.

Admittedly, being an academic or researcher has its compensations, but the pay is awful to begin with and doesn't get all that much better, unless you are one of the elite few who make full Professor by their early 40s. More musings on academic pay on my Diary page here (see entry for Jan 27th).

Talking of doctors' pay, I would have said personally that the most underpaid (and indeed undervalued) people in medicine were experienced folk working as what used to be called staff grade doctors. But then I am biased, since I am married to one.

There is no doubt the "stealth cuts" in the FY doctors' remuneration via the removal of things like free accommodation etc etc is a gross injustice, as well as a completely dishonest piece of skinflintery by the management. And then there is the damaging effect on morale as well.

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