Commissioning
The other day Dr Grumble, quite by chance, happened to meet John Savings, the man who taught Prince Charles to lay hedges. Dr Grumble asked how he got into hedgelaying and he told the story of a lady who wanted Mr Savings to build a fence at the end of her garden where there was a scruffy hedge. Mr Savings explained to the lady that it would be much cheaper for him to relay the hedge. The lady was doubtful. She needed something to keep her children off the road. Mr Savings showed her how he could make the hedge secure. The lady was over the moon and commented on Mr Savings' honesty. He could have charged much more for grubbing up the hedge and supplying his customer with a brand new fence. But he didn't. Mr Savings is just not like that.
What is the purpose of that story? It is to explain that in a purchaser-provider relationship the provider usually knows much more about the product that the purchaser. It shows that in traditional relationships trust is the key element. And it shows that people like Mr Savings don't just try and screw what they can from the customer. They try and do what's right. They are not motivated just by money.
Dr Grumble has long suspected that those who commission services for the NHS do not know what they are doing. They do not know any more about the sort of NHS service Dr Grumble provides than the lady who wanted a new fence knew about hedges. Because providers tend to know more about a product than purchasers, customers ask those selling them things for advice. When your car is on it last legs you ask the garage man whether it is worth spending money on it or if you should sell it for scrap. In general you take the advice you are given from somebody you trust. It is odd then that no commissioner has ever asked Dr Grumble for advice about what they should be purchasing from him. And it is a shame that the main interest of the Grumble hospital is in extracting as much money from the purchaser as we can. Our managers no longer see themselves as custodians of the taxpayers' money. They see themselves as a quasi-private organisation whose main purpose is to make money. This is not the fault of our managers. It is the fault of government. There can be only one reason why New Labour and now the coalition government want it this way.
Last week Dr Grumble met a very senior NHS figure. He cannot say who but he is a titled man with first-hand familiarity with the commissioning system. Devilish Dr Grumble plied him with a few drinks and then asked him whether those responsible for NHS commissioning were up to the job. The answer was an instantaneous no. Clearly this important personage knew that, despite their £100k salaries, these people do not know what they are doing. It is not a surprise really. It is almost inevitable.
So is this why Andrew Lansley is now going to give the job to GPs? Does it make sense? What does the senior personage think? You might think he would be pleased. Who better than GPs to know what patients need? But he is not at all pleased. He doesn't think that jobbing doctors have the necessary skills to spend £80 billion of taxpayers money. And some of them just don't want to. The trouble is that those who do want to may not be the best people for the job. If you are good at being a doctor why do something else?
Could there be a better way? Of course. Instead of giving the money to jobbing GPs and getting them to buy the services they need from the hospital you could give the money to the hospital and ask them to provide the services the GPs' patients need. That way you could get rid of all that expensive commissioning and the people who really know about the services, the providers, would decide what is needed. Why has nobody thought of that?
The reason, of course, is that this is not about value for money. It is about privatisation. The problem is that Big Business will not behave like Mr Savings, the honest royal hedgelayer. Goaded by shareholders they will set out to screw as much money from the taxpayer as possible. That is the raison d'être of Big Business. Why can nobody see that? OK, some can but they are very much voices in the wilderness.
15 comments:
the public dont want our NHS privatised, but politicians take no notice of us
What are we to do ?
The public may not want the NHS privatised, neither do they want the NHS run by grossly overpaid bureaucrats who know very little about hospitals, which is probably far worse than privatised hospitals.
I have mixed views over private hospitals, they have both state and private hospitals in Australia and they seem to work well side by side. My wife's experience in getting weekly (warfarin) blood tests carried out in the state hospitals when we were there on holiday was better than here. And she only needed to produce her passport for free (reciprocal) treatment, no messing around with E111s like when we go to Europe, another bureaucratic nonsense!
I fear that if you privatise it all you will need even more bureaucrats to regulate and monitor the private hospitals - which is what we are already seeing in preparation for the sell offs.
Privitasing hospitals would entail higher costs and prices of services for the public. This could lead to more people not being able to afford hospitalization. So, what could happen to the citizenry? Isn't the role of the goverment to look after the people's welfare?
Curiously, Mark, governments often think privatising services will make them cheaper and better.
I can see how if you privatise, say, a state airline it will either fail or make sure it survives in a tough market place. But a service like a hospital is quite different. Letting it fail might be problematic and while government contracts could, in theory, be tough a hospital serving an NHS community is not really in a real market like an airline. An airline has the whole globe to get customers from and it has choices. It can go up market, it can go down market, it can entice more passengers and so on. The private providers of a public service like a hospital are tasked to provide just the public service. Their options to expand are limited. Their focus has to be on maximising profit by minimising cost and maximising the amount they can get from the government for providing the service. In most cases there will not, in a public service, be much competing for patients from a neighbouring town - though this is what the government would like.
Take a look at the example of the PFI hospitals and you will have no doubt that we should all be concerned about these changes. PFI has shown just how clever private industry can be at screwing the public purse. In fact they have the government well and truly over a barrel - for decades to come.
http://www.telegraph.co.uk/health/healthnews/7832796/Controversial-PFI-hospitals-may-have-to-cut-patient-services-NAO.html
Curiously, Mark, governments often think privatising services will make them cheaper and better.
I can see how if you privatise, say, a state airline it will either fail or make sure it survives in a tough market place. But a service like a hospital is quite different. Letting it fail might be problematic and while government contracts could, in theory, be tough a hospital serving an NHS community is not really in a real market like an airline. An airline has the whole globe to get customers from and it has choices. It can go up market, it can go down market, it can entice more passengers and so on. The private providers of a public service like a hospital are tasked to provide just the public service. Their options to expand are limited. Their focus has to be on maximising profit by minimising cost and maximising the amount they can get from the government for providing the service. In most cases there will not, in a public service, be much competing for patients from a neighbouring town - though this is what the government would like.
Take a look at the example of the PFI hospitals and you will have no doubt that we should all be concerned about these changes. PFI has shown just how clever private industry can be at screwing the public purse. In fact they have the government well and truly over a barrel - for decades to come.
http://www.telegraph.co.uk/health/healthnews/7832796/Controversial-PFI-hospitals-may-have-to-cut-patient-services-NAO.html
English Pensioner: the E111 is not purely bureaucratic nonsense. Every country has its own version of cost to the punter at point of receipt. I find here in Italy that handing over the little card works fine to get the treatment needed and then I have to go to the office before I leave to pay the bit that is my responsibility - just like all my neighbours do as well. I can save all the receipts up and get them reimbursed in the UK if I want to, that's my choice. And most of Europe has both private and public healthcare in some shape or form and they generally work well together - the public bit tends to piggy-back on the private patients bit with fancy equipment being paid for by the private half but also being used for the "public" patients when it isn't in use by the private ones. Used to be called "pay beds" in the UK.
Tut tut, Dr G "plying" senior officials with drink indeed!
For what its worth this is an old trick .... much beloved of a former House Governor (hospital administrator) I worked for in Leeds many decades ago. He was a "gentleman" in every sense of the word but also very cunning.
It was amazing how he could get officials from the DHSS (as it then was) who may have arrived only to castigate, to leave promising more largesse instead.
We termed this "Administration by Alcohol". My part in all this was as one of the trainees who from time to time would be present to ensure glasses were topped up ... oh and at the end of sessions to make sure the House Governor did not fall over (too many times).
I'm not sure if you ever experienced "old school" hospital administrators like this but perhaps some of your colleagues might remember these characters from the past. I have fond memories of them becasue they always had the best interests of the hospital at heart rather than the interests of career politicians and snake oil salesman offering voodoo economics, which is sadly all too prevalent these days.
I didn't experience those administrators of old directly but I have always had the feeling that they were as you describe, Prisoner of Hope. As a very junior doctor I never had any doubt that these people had the best interests of the hospital at heart. Nobody ever even hinted it might be otherwise. I don't want to comment on whose interest today's equivalent is most keen to serve but I do have a view.
I am a social care commissioner, reluctantly'integrated' with the local PCT, i.e lots of ignorant over promoted individuals suddenly assume they can tell me what to do even if they have no idea. When I commission as service I like to ask the front line what they would like to see. There is massive puff about consulting the public but little about consulting the front line who see numbers of real people and know exactly what is needed. I am looked on as rather eccentric for listening to th efront line as realy managers, it seems, ignore and patronise them, but perhhas my time is will come again. I am waiting to see how all the pct commissioners who have spent a few years slagging off GPs will behave when it comes to applying for jobs under them.
Why can't I commission my own health services? That is, why do I have to have my money confiscated in order to fund a government-provided service that must by its nature be run for the sake of those "grossly overpaid bureaucrats"? Why can't I come to a private agreement with a doctor I trust? That's a rhetorical question of course, but the actual answer is that I can't find a doctor I trust, because I can't find a GP who doesn't work for the government. How can I be sure that the pressures placed on my GP by government targets and PCT managers won't outweigh her own best judgement as to what would be best for me?
I think the public needs to know we are in grave danger of losing hospital doctors as public employees and in a few years most will be in private practice. Medicine in the private sector is different with different “ethics” and in Psychiatry we have all seen what it was like in the private sector without having to mention names. I worry for the future of the hospital service. It is more important to make sure quality is good.
Can you imagine the nightmare of charges and funding and what if it was decided that GP consortium will not refer the psychotics as they would be long term and expensive and GPs can prescribe the same antipsychotics. In children, GPs may just prescribe Ritalin without referring to a Child Psychiatrist.
Then there is demographics: one of my clinics used to have three times the referral of another one. Yet we do not have the IT system to tell us.
If it is about history or recent usage, the ones that did not refer much to hospitals may now lose out. I could go on………….
I cannot see Mid Staffordshire becoming Royal Marsden and not even the once great Great Ormond Street.
The trouble is many of the bright young ones no longer want to be hospital consultants and those that did wanted to emigrate. Soon, British trained doctors will not be exportable though. Was there a conspiracy somewhere?
What can we do?
The Cockroach Catcher
Actually I have heard it said that GPs above all recognise the value of psychiatric services. But I share your concerns.
The reality is that none of us can know how this will work out.
Eileen seems to think my comments about the E111 are unjustified.
I still believe it to be bureaucratic nonsense. If all UK citizens are entitled to treatment within the EU, what does the E111 tell them that your passport doesn't? The Australians want to see your passport because you are only entitled to free treatment as a visitor for 3 months, and it gives your date of entry as well as proving you are eligible under the reciprocal arrangements.
Thank you for a good article. I'm one of the lone voices you mention, and it does get very demoralising trying to convince people what the end point of these changes will be, people just say "but they cannot privatise the NHS".
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