DK is guest blogging over at 18 Doughty Street
In his first post he suggests that doctors should be helping their managers rather than trying to manage themselves.
"The fact is that, whilst we acknowledge that the vast majority of doctors are very good at treating their patients, they are not managers.....ultimately, doctors are a financial commodity, just like any other employee"
DK, never one to let facts get in the way of his opinions, failed to mention that GP principals, who make up a large proportion of the medical workforce, are not employees but self-employed businessmen. And the bit of the NHS that works best (relatively) is General Practice. And the bit of the NHS that is still controlled and run by doctors and not managers is.....General Practice.
Hmmm.
Tuesday, June 26, 2007
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38 comments:
DKs partially right and partially wrong. If we worked for small companies run by boards of directors then doctors would be skilled workers delivering a product. And managers would create the conditions in which we could deliver the product well.
However the NHS has hijacked medicine out of the market. Its managers are largely political minions- (even if they don't realise this the structure of DH to SHA to PCT command makes them so)
The current NHS structures are severely flawed, and actually hinder doctors from delivering good care to patients.
GP is currently best run (cheapest, most efficient) bit of NHS and this is because GPs have a direct financial interest in keeping their costs low.
The state of NHS management makes the idea of GPs becoming employed by PCTs ever less attractive. If anything consultants should move out of the hospitals and into "chambers"
Mmmm...I think I'd dispute the fact that General Practice is working well. I can't get a 'routine' appointment at my GPs for about 2 weeks. To get that I have to ring at 8.30 on a given day when the 'slots' are released. Hardly patient centred....
"Mmmm...I think I'd dispute the fact that General Practice is working well."
Can you get an appointment with a consultant within 2 weeks?
No, which is why I said that 'relatively' GP works better (ie: GP is the best working part of a dysfunctional organisation).
Besides, you can get an appointment with me within 2 hours most days of the week, or you can book one for December if you want.
The point is that good GP surgeries are fucking excellent because we are able to innovate. How you improve the ones that are not as 'patient centered' (without simply providing poor care that looks patient centered) is the big problem.
Can you get an appointment with a consultant within 2 weeks?
Steady now!
All routine referrals to me have all been offered an appointment within 2 weeks, for over the last 2 years.
Some Consultants can (and do) guarantee a responsive service ;-)
As to medics not being managers, some medics are trained as managers, have dedicated time to work as managers and contribute to the process (as Clinical Directors, Medical Directors etc.) so should have a valid voice in damage limitation that's needed to manage that inexorable deluge of change inflicted upon us.
There's a lot of apparent (But I suspect it's actually less than noise around it would suggest)demand for "instant/extended access" to GPs. If I was in a pure consumer market/fee per patient seen system this would be achieved.
Medically most of what presents to GPs is unclassiifiable, not particularly serious and probably didn't actually need seen at all.
There's a danger of making it too easy to see doctors, too easy to get medical labels attached, too easy to get treatment, too easy to end up off work, wrapped up in cotton wool, overinvestigated, overreferred, overcertificated, incapacitated (and who has connived in us having 3 million people on incapacity benefit?) when it's too easy to see doctors.
Up till now NHS doctors have tended to under investigate and under refer and the public have been little worse off as a consequence, and have maybe been protected from the dangers of rampant medicalisation.
Barbara Starfield describes the dangers of overtreatment and over referral very well, and how good primary care is the key part of curbing this.
It is sometimes said that pathology (disease) is finite in any community. So it is, but the prevalence of symptoms is huge (about 90% of us have some symptom or other in any one week) and if all are brought before doctors and investigated the costs will rocket for little health gain.
Some barrier to getting to the doctor (fee or inconvenience) is probably useful, for patients' safety, and for keeping NHS vaguely affordable.
There needs to be a certain severity of illness before it's worth the inconvenience of going to see the doctor.
General Practice working well? Hmm, I'm not sure that I agree there. Getting out of hours care is a bit damn difficult these days, no?
Don't get me wrong, I understand completely why doctors opted out -- I would have done too -- but I wouldn't say that it was good for the patients.
But you should know what I mean, Dr Rant; whilst your surgery might work well, your patient care has been badly compromised by the changes in the NHS structure. Whether you like it or not, that has meant that -- from a patient point of view -- General Practice is also screwed.
It's not your fault necessarily (although I think that we would all like to set fire to the spineless BMA, who seem more interested in fucking over ordinary people and not at all interested in protecting the interests of either doctors or patients) but that is how it is.
And I am not saying that the NHS managers are any good; what the Gerry Robinson programme showed was that they aren't: however, the idea that dotors can or should manage the NHS simply because they are medicos is as ridiculous as the civil service's policy of promotion by time-served rather than competence.
DK
There is a rather stupid school of thought that claims that good managers can manage anything they turn their hand to.
This is utter rubbish. To manage something well you have to understand it in detail in all its complexity.
In business a number of rather astute men have pointed out that a lot of management is an absolute load of shite, management for the sake of management often is.
If the managers running medical services or the NHS have only a minimal grasp of the services/medicine then they will be a hindrance.
In the NHS this is the case.
Medicine cannot be managed as a generic business, like any business cannot be managed as a generic thing, each individual case must be understood in all its complexities before it can be managed properly.
anonymous
compare how hard it is to see your GP to how hard it is too see a dentist?
that may give you some perspective on things
GPs are a great cost effective service, it will only be realised too late
"General Practice working well? Hmm, I'm not sure that I agree there. Getting out of hours care is a bit damn difficult these days, no?"
Now you see, that's the kind of ignorance I'm talking about.
General Practice in hours is largely run by small-business GPs operating as sole-traders.
Out of Hours, as you should know, has since 2004 been almost exclusively out of the hands of GPs and placed into central Primary Care Organisation (PCO) control.
It's amazing how many people who arrogantly run around telling doctors to shut the fuck up and leave the organisation of health care to 'those that know' turn out to have much less of a fucking clue than the doctors (even less of a clue than the medical politicians, heaven help us).
Do you want me to list how often Dr Rant has been right about the running of the NHS and the politicians have been wrong?
-Out of hours costs
-Out of hours complexity
-MMC
-Outsourcing of cleaning staff (leading to higher rates of MRSA and C. diff).
-Closing of beds because 'they won't be needed'
-Mental health 'care in the community'
-Community matrons
-Hospital at night
-NPfIT
In fact it's easier to list how often Dr Rant has been wrong and the politicians right:
-
I rest my case.
re "Besides, you can get an appointment with me within 2 hours most days of the week, or you can book one for December if you want." good if its true, although im sure a lot of docs think its easy to get an appointment cos they dont have to put up with the interogation from the little hitler receptionists
GP services carnt be all that great otherwise they wouldnt be opening "nurse led" walk-in centres, hailed by the nhs as the answer to lack of access to GPs
Anonymous
the money going into stand apart, refer on and redirect centres such as walk in centres is part of reason GP service has been run down.
If the money spent on NHS dire and and walk in centres had gone into extra doctors, nurses and premises in local surgeries you could have the combination of better access and good continuity of care.
However the government knows best and hence you get what DH buys for you whether you like it or not.
This is utter rubbish. To manage something well you have to understand it in detail in all its complexity.
Spot on.
A government doesn't tell a shepherd how to manage sheep, a hairdresser how to do a rinse and set, a baker how to make a bakewell tart. Government puts in frameworks (for animal care standards, health and safety standards, what counts as a cake vs a biscuit etc) but lets the people who do the job get on with the job.
In medicine, a progressive and insanely complex field (where even specialists need to spend inordinates amount of time and energy to keep up to date) how can managers make informed decisions about what they're managing?
For politicians, political advisors and Trust managers to determine clinical practice is wrong.
The level of control being exercised is constraining clinical freedom to such an extent that clinical decision making is being goverened oft times by politicians and managers.
Clinicians have to be involved in limitating the damage of this process.
"im sure a lot of docs think its easy to get an appointment cos they dont have to put up with the interogation from the little hitler receptionists"
They'd have to be pretty shitty for patients not to get appointments with me - we usually have several unfilled appointment slots each day where I do paperwork etc..
There are lots of reasons that I have good access and other, better, GPs don't. Much depends on the population being served, and much depends on the willingness of the GPs to take complaints from people who abuse the system.
One problem is that if you want to be able to see patients quickly, then you need to get your home visit rate right down. Home visits take 2-4x as long as a clinic visit, so if you have 5 visits per day as a GP that's 5-15 patients less that you are seeing per day, or 35 to 75 less per week, than I see because I only do 1-2 visits per week.
Since an average GP will see 25 to 30 patients per day, a low visiting rate can mean an extra 2 days per week of consulting time per GP.
But to get your visiting rate down, you need to be willing to take the usual vitriolic complaints from patients who you have told to make an effort to come to the surgery ("I pay my taxes...."). They can make your life hell.
I call this Fuckwit Tolerance, and it is one of the things that is killing the NHS. We need to be able to deal with fuckwits who are abusing the system without fear of being hauled through the courts for not bowing and scraping enough for some bully.
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