19 January 2011

A GP speaks

Dr Grumble always likes to hear both sides of an argument. One of the greatest mistakes you can make in the management of patients is to get fixated on a particular diagnosis and make the facts fit the diagnosis when what you should be doing is fitting the differential diagnosis to the facts. Making decisions on the facts is not always a natural thing to do. It should be but it isn't. Many people, when it comes to politics, take their view about how things should be and then bend the facts to fit. People buy the Daily Mail to reinforce their view of the world. The lesser number of people who read the Morning Star are doing the same. But to come to the right way forward you really need to read the Daily Mail and the Morning Star and then open your mind.

There has been so much concern about Lansley's reforms that Dr Grumble has not needed to flag up his own concerns. The press and the public are realising, too late, that what Dr Grumble has been warning his readers about for many years is about to happen. The policies of the ConDems are not so very different from those of New Labour. Even Cameron alludes to Blair when he tries, to justify taking the NHS in a direction that he knows the public just doesn't want.

Anyway, in the interests of balance, a video with a more positive view.

Here is a GP whose window on the world is that from his surgery. The most important thing he mentions is a transport issue. You have to have some sympathy. But has he any idea about what commissioning for an organisation the size of the NHS is really about? And was there no easier way of listening and acting upon his frustrations?

Dr Grumble might have embedded a video with a more negative view about Lansley's reforms but the BBC haven't provided the code for any of the less pro-government clips. Isn't that odd?


Anonymous said...

I am a consultant. Only yesterday I needed to get a patient with MND transported to the hospital. I wasn't allowed to do it. Only the GP can organise transport.

We all have these frustrations and the system that is being created is only going to make things like this very much worse.

Garth Marenghi said...

The GPs who back this are either selfish and self interested, or naive.

They will not have any real power, the power will lie with the commissioning board.

It is a top down rigged process that will throw money away from the public to the private sector, destroying cohesive public hospital care in the process.

Anonymous said...

The GP in the clip had no control over what was actually broadcast. He may well have spoken of things other than transport. What we saw and heard there was what had been filtered to us via the director.

But now, I'm baffled. I have read here and on various other excellent blogs (Militant Medical Nurse springs to mind) of the problems in the NHS. I also have personal experience of it covering quite a range of exposure. As a taxpayer, I have seen huge amounts of money thrown at it for little or no visible benefit. I also use to travel extensively on business & have seen that other countries provide health care that appears to be at least as good as ours, for less money.

On the one hand, there seems to be widespread consensus that the NHS is badly broken and needs reform. On the other hand, every time any changes are mooted there is a massive resistance to change.

Many - you included - complain about NHS defects. One that I would wholeheartedly agree with is the nonsense of having too many remote 'managers' who know nothing about medicine. It is a similar problem to industry, where boardrooms are stuffed with people who know nothing of the actual business, its customers and drivers.

One of the common denominators of complaint across the medical blogs has been this remoteness and 'disconnectedness'; I would have thought that putting GPs in the driving seat was a good thing. I have a lot of faith in mine and would be happy to see him in that role.

But I am left wondering . . . What you do you want, JD? If these plans are bad, what has been your alternative proposal?

One thing we seem to have forgotten about is that the country is still broke. A few cracks have been papered over, but they'll open up again. The Blair/Brown chickens will be coming home to roost soon, so talking about the NHS in the context of the various "isms" and alternative rosette colours is going to become irrelevant wishful thinking. The luxury of such 'faith' based choices will be replaced by the realities of a growing national debt.

A more important question will soon be "what kind of NHS can we have for sixpence?"


Aneurin said...

I have been through NHS reorganisations for the past 35 years. To oversimplify, I have found there are three types of GPs: (1) the very small minority "a bit bored with general practice - we've done that, got the T shirt now let’s run the NHS" (2) the small majority: "ethical/ clinically enthusiastic who want to concentrate on getting a good income from good quality service" (3)the large minority: "its only a job, important job, but let’s get home and get a life". This group will remain disengaged and let the "others" get on with it. Group (1) is the group that Lansley has been talking to. Group (2) will have kept out of it so far but once they realise that the red braces brigade want to take over the world they will stop them and take control themselves. But they will not want to spend all day in management meetings (these are exceedingly boring diversions) and because they respect the skills of other professionals, including managers, they will quickly appoint their own managers (the ones that they got on with at the PCT). The arrangements will metamorphose into a primary care management agency - small and local at first and then bigger to have economies of scale.
This was the sequel to GP fundholding and why we had PCGs and then PCTs. GPs had every opportunity to hold the reins at PCTs but in most cases let go of the them and full time managers were only too willing/had to take control again. All Lansley had to do was to reinforce the arrangements for sound clinical advice in PCT commissioning decisions - as was intended in the first place. The staggering financial pressures on the PCTs (in the illusory real growth scenario of the next four years) would have taken care of the rest

Dr Grumble said...

Ray, What many of us would like to see as the way forward is not on the agenda even though the Health Committee as recently as March of last year pointed the way.

Look for their take-away message in the last line of their conclusions:

As for putting GPs in charge of commissioning, it might seem to make sense but the average GP only rarely sees quite common conditions like heart attacks. Do you really think they know about how to commission care for the less common conditions? Do they even have a good feel for how care for heart attacks should be delivered? Of course, they don't. It is not a criticism of GPs. I chose this example at random but it shows what is happening in so many areas which is that things are changing very quickly and to commission best care you need those that deliver the best care to be involved.

And do you really think they needed to throw the bably out with the bathwater to increase GP involvement in commissioning? Of course not. There is more to this than meets the eye.

Of course there are painful changes that are needed. Unfortunately it is the public that stop these changes. Hospital closures to rationalise services are needed in many places and never ever seem to happen -especially if you live in a marginal constituency. Most doctors if really ill would like to go to a good large hospital that can cater fully for their needs. The public want a hospital around the corner and fail to grasp that good care cannot be delivered in that way cost effectively.

What kind of NHS can we have for sixpence is the key question. Expectations have been raised too high. People have been encouraged to expect what they want instead of what they need. It is a crazy idea which only makes sense if you want to move the service to a private footing.

As for JD's views, you will have to ask him.

Jobbing Doctor said...

There is room for evolution of the NHS, and this goes on all the time.

This is revolution, however.

I am a conspiracy theorist who believes that since those connected with Private Health Care have been at the heart of Government for many years, then the systemic change is designed to favour the private health care providers.

Look at what has happened to the Royal Mail to see what will happen to the NHS.

Anonymous said...

Thanks for a thoughtful reply. And many apologies Dr G - although the JD typo has given me 2 responses for the price of one :^) . Are you ever seen together?

Aneurin's comment described (nicely) a distribution of types that most people over the age of 50 would probably recognise in whatever their field was (or had been). It's life, possibly as we know it, and we just have to make the best of it.

JD's conspiracy suspicions could be right. When I was younger I might have felt the same, but experience of the public sector (and huge bits of the private, too) leads me to conclude that they couldn't even do that properly. From what I've seen, cock-ups outnumbered conspiracies by orders of magnitude.

The bit I really object to, as a taxpaying MOP, is being treated as a complete idiot by our masters and the MSM. I might not be that bright, but I'm not that stupid either. Given that we are all spread across that Gaussian curve, why do the BBC & their Westminster chums focus only on the dumb tail? The only proper coverage of the issues seems to ocur in the blogosphere at places like this. For which I am grateful.

Perhaps, if there was a TV programme called somenthing like "NHS strictly dancing on ice", we could get that Craig chap to provide some objective critique. He'd be booed, but that's TV.


Aneurin said...

Ray is quite right to say that my description of types could apply to other professions. I think the additional risk with Type (1) GPs is that they run a small business successfully and they believe that this qualifies them to run the NHS - a very large complex organisation with complex relationships with many external agencies; all populated with well qualified and opinionated professionals. This is a bit like the local SPAR shop owner putting themselves forward to run Tesco UK. Their exagerated view of their corporate competence is reinforced by the fact that their dealings are often with the lesser management mortals from the PCTs (and trusts) who may not be the sharpest tools in the shed, may be risk averse and may not feel empowered to show the sort of initiative and take the sort of decisions that GP colleagues would see as necessary and obvious.

The GPs we need to engage very fully are the Type(2)s - not for their business acumen but for their broad clinical insight from general practice and their motivation to work with hospital clinicians and other agencies to get better outcomes for patients.

I am pinning my hopes on them riding to the rescue in the final act of the play. But I know this to be the triumph of hope over experience - the political vested interest is massive.