Wednesday 20 November 2013

Stuffing the Doctors' Mouths with Gold - Again?

You have to hand it to the medical profession.  Really: I mean, you just have to.  Hand it over.  It's the only way to get them to do, well anything.

When Nye Bevan was asked how he managed to win the doctors round to cooperating with the creation of the NHS he famously replied that he had "stuffed their mouths with gold".  Yes, the doctors always have a pragmatic solution on offer. 

This time, with winter coming on and heating bills on the front pages for weeks, suddenly we are warned that A&E will be chokka with the elderly as soon as it turns cold.  Disaster for the coalition looms. But what's this, do we hear the clinical cavalry riding to the rescue ?  Yes, right on cue the doctors are to get new contracts, under which, says Jeremy Hunt "all NHS patients over the age of 75 must be assigned a named, accountable GP who will oversee their care".

Remarkable !  Is there an over-75 in the land who doesn't have a named GP ?  Is there anyone ?  (Aside from those not actually eligible for NHS care, who just stride into A&E or a walk-in centre anyhow.)  And does this mean house visits as in days of yore, or out-of-hours attention from the GP ?  Errr, no - but the GP must 'monitor the effectiveness' of other agencies' out-of-hours provision.  That'll keep the over 75s in their own beds.

And for this new contract, minister, what about the money you'll be giving them?  Turns out, that's not what we might call transparent: it's certainly not mentioned in this short guide to what's going on.  Or this one.  And Jeremy Hunt is a bit oblique here, too.  “The public will know what salaries GPs are taking home for NHS work. This will give the Government more confidence to hand more funds to GPs in future.”  

And the timetable for all this change ?  Will it be in place by, say, the end of the month in time for the really cold weather ?  Nope: it commences April 2014.  And publishing the salaries ?  That'll be 2015-16.



DJK said...

I think it's pretty clear who will come out better in civil servants vs doctors. The line being spun about named GPs for oldies is exactly that --- a line. I first realised this was an expensive mistake a few days ago when someone said that the new contract would allow GPs to opt out of even more of what GPs normally do. Still, I suppose we must wait and see the details.

And yet healthcare/medicine is one of the ares of life set to be turned upside down in the coming robot revolution. Costs should come down as the doctors' expertise is devalued by machine learning. So I expect the half life of the latest contract to be even shorter than the previous one.

Anonymous said...

They wouldn't be capitalists by any chance??

hovis said...

Anon: No, they are not capitalists they are just part of another self serving monopoly trade organisation like any other, it just happens they've got good PR and fear on their side and a state to milk.

DJK: working with several software people on the medical background and we concuded that most GP functions can be done by flow chart, they are grossly overpaid (see above).

dearieme said...

They have a beautiful feedback loop in their favour. The extravagant contracts they were offered under Blair bumped up their pensions so that many could well afford to chuck it in early. Bingo: there's a shortage of GPs, so we'll have to pay them more.

Or, at least, so a pal claims. Is he right?

Bill Quango MP said...

I have mentioned before but a relative of mine was on the negotiating committee for the medical men when the last government wanted the doctors to cut their hours amid all the junior doctors falling asleep in CAT scanner stories.

The docs were fully expecting to have to take a 20% pay cut in order to not to have to work weekends. They were determined to hold out for no more than a 15% pay cut.
Their starting position was to be 7%, but no weekends and no out of hours and no late nights.

The government started at a 5% pay cut for all of those demands and a few more.

The healer's grabbed the contracts from the civil servants , signed them, slapped each others backs and ran home to get their golf clubs.

Who wouldn't take a 5% pay cut for 14 hours less a week and no evenings, bank holidays, weekends ?

Clive said...

Anonymous is quite right !

I can't help but noticing the title of this blog. "Capitalists (at) Work".

Well, capitalism is -- amongst other things -- maximising your pricing power, exploiting the scarcity of commodities, goods or services which you possess and adhering to the clearing price of whatever it is you have to sell.

Sorry ND -- you can't have it both ways.

Clive said...

Always worth reading "11 Questions You Should Ask Libertarians to See if They're Hypocrites" first before posting an article here !

You fell foul of "Is our libertarian willing to acknowledge that workers who bargain for their services, individually and collectively, are also employing market forces?" with this one I think.

Nick Drew said...

No Clive because I make no claim to be a libertarian

CityUnslicker said...

It's not capitalist either - its socialism. there is only one NHS and one Government and in many weays they are the same thing. they are negotiating with other peoples money about how much they should all pay each other.

I am not surprised in this situation that we have a poor outcome every time.

If a capitalist element was introduced - say doctors having to compete to get paitents to get paid, then we might get somewhere.

I really hope Dearime and Hovis are right ree medical costs - without that revolution Western Deomcracies will be bankrupted before I retire purley on rising health costs alone.

Clive said...

"If a capitalist element was introduced - say doctors having to compete to get patients to get paid, then we might get somewhere."

Yes, just like in the US where there's no state provision, just private healthcare providers, HMOs and insurance companies. People there just love this un-socialist arrangement. And it works so well at preventing exorbitant healthcare costs and overtreatment.

Oh... wait a minute...

Elby the Beserk said...

Well, Nick - I've been having trouble with my right hip recently (a few years back, fixed by a debridement of the Femur), having slipped down the stairs up to our extension loft, hammering my right foot down on each step whilst trying not to let go of the bannisters. Symptoms are similar to those I experienced before the op, so I am suspecting that the impact on the hip has damaged cartilage on the acetabulum (mouth of the hip socket).

Fed up after a couple of months that no change had taken place, I called the Frome Medical Centre to make an appointment to see my doctor, who was very good regarding the above and two other joint ops.

You can't see him, I was told. But he can telephone you in two weeks.

Hmmmm. I wouldn't be so sure about named doctors. I'm happy to see whoever when appropriate, but given that this doctor oversaw this op, I wanted to see him. And was told I couldn't. I will, when he phones, be explaining to him exactly how I feel about this.

Regardless, yes - money, money, money. I have a GP friend in Oxford, college contemporary, who said when he got the new contract from Labour in 2004, he burst out laughing. Loads more dosh. Far less work (he is, I am sure, I very good GP). Now, when suggested that they might have to work weekends again, they say - ah, but we will want more money.

Huh. So do we all.

DJK said...

What the doctors are doing is not capitalism. It's not really a free market either, since there's a monopoly on both sides.

Like most people here, I'm happy to allow capitalists their legal privileges, since in general they are contributing to the common good. But that doesn't mean I enjoy seeing naked greed, or think that government shouldn't be stepping in to promote competition, efficient markets, and all that good stuff.

hovis said...

CU: "will be bankrupted before I retire purley"

I would move away from purley before then CU :-)

Budgie said...

Clive said: "Yes, just like in the US where there's no state provision, just private healthcare providers ..."

No, Clive, according to Wikipedia "62% of the hospitals are non-profit, 20% are government owned, 18% are for-profit." "60–65% of healthcare provision and spending comes from programs such as Medicare, Medicaid, TRICARE, the Children's Health Insurance Program, and the Veterans Health Administration."

Oli said...

Big fa of the blog, first time commenter, because you've got the facts on this quite wrong.

First, on a point of informatoon, no-one has a named GP. Every patient had a named GP until 2004, when the GP contract was rejigged to "practice based lists", so that you are now registered with a practice, not an individual doctor.

I suppose you could concenivably have a named GP if you were registered with a single handed GP who employed no salaried GPs, but that is pretty rare. So the answer to your question is "Yes there is an over 75 in the land who doesn't have a named GP - hardly any of them do."

Secondly, there is no new money being paid to GPs - if there is I will eat my hat. GPs will complain about this but they need to look at the fact that GP partners are already extremely well paid given the lack of risk they have to take (i.e. guaranteed work and the state paying the rent on their premises). So you may take the view they are already having thier mouths stuffed with gold, but they won't be getting any more for the foreseeable.

The government's strategy is to avoid having to pay extra by making GPs publish what they earn, so that the public will go "Really? £110,000?" and give no support to any further pay demands. Quite clever, I'd say.

Clive said...

@ Budgie

The 20% government owned element is mostly for veterans ( so that doesn't count as it is not accessible to the general population.

And when did "not for profit" become state-owned ? BUPA is "not for profit" but I can't walk into one of their hospitals or see one of their panel of clinicians without paying. Try getting treatment at any of those US "not for profit" hospitals and I can guarantee that before they let you past the front desk, the first thing they will want to know is, where is the money to pay for your treatment coming from.

So please explain again where the state healthcare provision in the US is ?

DJK said...

Budgies said, Wikipedia says...

And yet, with the most capitalistic health care in the world (arguably) the US has easily the most expensive system of any, and some of the worst health outcomes.

The NHS is famously the British religion, and in my more optimistic moments I do think that it can evolve in the usual British muddle-through way into one of the best providers in the world, provided we can save it from politicians and civil servants with ideas, who think that they are blessed with a unique insight into what health provision should be.

andrew said...

Disclaimer: My OH is a consultant geriatrician.

There has been a lot of discussion about how doctors are overpaid and that they should be available to work 24/7 etc.
There is discussion here about how they are a vv effective bargaining body and will get their pound of flesh.

It does not feel that way to her or her colleagues.

Yes, her GP friends now seem to get paid ~40% more than her - so saying 'Doctor' as a generic label and assuming all Doctors get paid the same is not right. It seems the GPs got a v. good deal. She hasn't had a pay rise for 4 years.

She took a 10% pay cut to get out of working nights and when younger was one of those who worked 120h weeks.

She feels endlessly put upon by the NHS trust / managers.
When she moves hospital she will not have an office - or a desk. So when she wants to talk to you about why your mum is dying it might be in a corridor. The managers have offices.
She is under continual pressure to do more with less and has less control over what she does.

There is growing pressure to move to 24/7/365 working - and more transparency.

What is not being mentioned is that this means Nurses, Cleaners and all the other allied services - like social workers - will have to be there too, otherwise there is no point.
And this will cost 7/5 = 1.4 - do you see anyone being willing to pay 40% more for the NHS + Social services? – me neither.
Alternatively, you just re-align things so that some people work weekends and not in the week.
You will have to pay those who work weekends more - if you don’t, they wont do it - or they will move to the private sector and get a nice pay rise.

So some will get a better service on sat and sun, but others will get a worse service over the week and it will cost a bit more

Having been with her in a hospital when she was ill, the biggest problem I saw was the apparent difficulty of getting all the right people in the right place on time ( basically one person out of 6 seemed to be ~45m late and so everyone sat around - that is a 10% loss in productivity ).
If there are fewer people present and less redundancy (spare people) this will happen more often.

So all this named doctors / more user friendly hours -

will just end up making things more expensive and worse.

Demetrius said...

Ever since my rugger days playing against Hospital sides and alongside local GP's in my home team I have had slight reservations about the quacks, sorry, doctors.

Clive said...

@ Andrew

I think that's one thing that all side of this debate can agree on -- there's too many managers. There's too many manager's because there's too much targeting / tick boxing. There's too much targeting / tick boxing because the agencies responsible for getting value for money -- be it taxpayer's money or insurance company's money -- don't know how to mindfully manage a system and the people who work within it.

As with a lot of what ails modern Britain, the root lies somewhere in poor management.

CityUnslicker said...

Clive - where did we say the USA was the best system. OK, as it happens, when I was very ill in the US it was great, much better than here - but whatever, its a much richer country for starters.

All we were saying is that the Govt response to GP's (very insightful comments Andrew, thank you) is crazy, as it has been and always will be in the monopolistic scenario -France and other countries have a part-pay and part insurance system. They have lower costs and better health outcomes.

DJK said...


My sympathy to your OH, being run ragged and asked to do more for less. But the answer would seem to be better organisation, or additional technology so that people aren't kicking their heels, waiting for six people to get together before anything can be done. Fact is, there isn't going to be an additional 20% slack put into the system so the only answer is to work smarter.

Nick Drew said...

Oli - in all the scrum, let's remember our manners: welcome! And thanks for the comments. Andrew, too

Elby - get well soon ! And point taken

Clive said...

@ CityUnslicker

Yes, totally agree. I'm not at all keen on increasing payments to GPs. We must be at the stage of diminishing returns by now -- if not well past it !

But what I'm still not able to understand is why you think that it's okay for, say, you to maximise your earning power by negotiating up to the highest price point that the market will stand... but it's not okay for the GPs to do the same (which was Anonymous's original question).

Okay, in this case the rent extraction is paid for out of general taxation and as such there's some moral argument in there about why it's not cricket. But as a principle, what exactly is wrong with what they are doing ?

hovis said...

Andrew: are you asking what is wrong with rent seeking per se or what is wrong with moral blackmail (shroud waving is always a health industry tactic), special pleading and (as you hinted at) extortion of rent by implied force via taxation?

Any group who employ these latter methods will attract the same distain no matter the industry. Also those maximising income in a rigged/rigid market, tends to be unpopular.

hovis said...

Oops I meant Clive, apologies

CityUnslicker said...

Clive - its not a market, its a monopoly. there re no marekt forces, see Hovis above.

Ryan said...

Doctors are very well paid. Unfortunately this also means they are highly taxed. This in turn means they can decide to do fewer hours work. Actually, I'm not even sure their contract enforces hours - it used to be a contract per patient on the books.

One of the intersting effects of the doctor's monopoly is the impact on getting penicillin. You can't have it without a prescription. Why? Because you might not finish the course and therefore be responsbile for breeding a superbug. OK, but since when has a doctor checked you to ensure you have finished a course of antibiotics and are now clear of infection????

In most EU countries pharmacists are the first port of call for health matters.

But the whole thing is very Victorian and needs to be opened up at every level. Hip replacement ops should be "production line" operations for instance.

Generally just too much faffing around.

Bill Quango MP said...

On the small point of pay more for nights and weekends or they won't do it I can give the retail answer.

And that was to pay more for a limited period until new working hours become the standard. So today there are almost no payments for working nights or Sundays.
And even boxing day is only paid out as double time by the best employers. Many treat it as a normal day, normal pay. Yet as little as 10 years ago it would be almost impossible to find anyone to work without a triple time day in lieu bonus.

* and retailers are greedy buggers because Boxing day is generally a massive earner for the stores. Incredibly,{to me} one of the busiest shopping days of the year.

And ..sorry to labour the point, but when BQ was tasked with bringing in the compulsory boxing day openings and finding many old school managers wouldn't do it whatever the pay,
I went to the hospitality sector and took the best cafe and pub managers i could find. They were grateful for the 'short hours'.

So for the NHS there is always Rio, or Moscow, or Manila to recruit from.

dearieme said...

"when younger was one of those who worked 120h weeks": my wife once met a woman at a party who said that her surgeon husband worked a two hundred hour week. My wife replied that seven times twenty-four was one hundred and sixty-eight.

I must say that when I had a job, long ago, that required me to be "on call"from time to time, it did not occur to me to claim that I worked all the hours when I was on call.

Anonymous said...

I think the internet may have changed peoples perceptions of working hours. It's not lonely anymore to be on different hours to everyone else.

Not to mention that unless they're in a strict 9-5 job everybody seems to have crazy sleeping hours these day.

Clive said...

@ Cityunslicker

Ahh... The recurring problem with capitalism through the ages ! It all works just fine "in the lab" (usually in the economic theory textbooks, it's some lucky small island community exchanging bananas for horseshoes or some such artificial construct).

Bring in real, live people -- wanting such things as protection from exploitation from natural monopolies or a regulatory body imposing minimum standards because consumers lack and cannot possibly have perfect information (e.g. your child is sick and you want a diagnosis then and there, you don't have the opportunity for comparison shopping) and it all starts to get a bit messy doesn't it ?!

Nick Drew said...

Clive - I would argue that capitalism, together with some of its typical adjuncts, the rule of law, freedoms-under-law and liberal-ish democracy - has delivered most of what constitutes modern civilisation

the debate will always rage as to the exact form of governance structures that best 'contain' the creative capitalist dynamic

and of course China hopes to show it can be done without the 'freedoms' part

but the fact of ongoing debate over which model of health-care delivery is best, shouldn't cloud the entirely practical (i.e. nothing-to-do-with-labs) fruits of capitalism

here endeth the lesson

Budgie said...

Clive, you made a statement that there was "no state provision" in the USA. You were wrong, stop trying to wriggle out of it. Neither do I endorse the USA healthcare system; I merely highlighted your prejudice and error.

The original post was about GPs in the NHS. It was a critique of the government badly running any enterprise. Indeed NHS faultlines are similar to those of statist systems everywhere in the world.

The reason is that human beings are neither perfect nor perfectible. Consequently incompetence, greed and corruption occur in all systems - "capitalist" or socialistic alike. The difference is that when a state system fails, as the NHS is doing, it affects the entire nation.

It is much safer for serfs like me if power is spread around in small doses, ie in capitalist businesses, rather than concentrated in the hands of a corrupt state, whether run by a King, or by a socialist.

Electro-Kevin said...

I doubt very much that anyone becomes a doctor for the money.

What happens once they get older, wiser and crustier might be another thing though.

With the loss of unionised heavy manufacturing/mineral extraction the NHS is the new industrial wing of the Labour Party and doctors are its skilled shop workers.

Health workers are much harder to demonise than those who worked in the mining, motor, print industries were. Especially with the Labour Party's own broadcasting wing - the BBC.

Tories are skewered and they are having to do deals.

Electro-Kevin said...

...And yes. Doctors are wanted Down Under so they can walk if the terms don't suit.

Apropos BQ's earlier point about getting retail workers in on Boxing Day.

Such is the demand that all sorts of minions should work the Christmas period for no extra pay I suggest there isn't much left of Christmas spirit.

Both days should be withdrawn from the holiday calendar and everyone made to take annual leave if they want to celebrate it. I've always been happy to work it (and have done so on the railways too. Maybe this year as well.)

This is the general direction of the consumerist push is it not ?

Another subject raised a little too early - I digress. Sorry.

Bah humbug.

Ryan said...

"I doubt very much that anyone becomes a doctor for the money. "

Well I have three doctors in my family and I would say "status" plays the biggest part in wanting to be a GP.

Apparently the level of education required is not that high to be a GP, but the medical schools in the UK limit their numbers. Presumably they are trying to enforce a cartel situation whilst the Labour government simply used that as an excuse to import more doctors with dubious foreign qualifications.

Electro-Kevin said...

Ryan - To become a GP one has to become a doctor first. I don't doubt that less altruistic motives take over later.

My comment about the BBC:

The dramas Casualty and Holby City are both BBC and both meant to be up to date social comment (such was the anti police sentiment I couldn't watch in the '80s) - asylum seekers on the run, racist coppers, nasty white middle class patients, hard pressed doctors and nurses battling on in spite of the cuts and bastardly capitalist managers...

Not one episode featuring surly nurses, foreign doctors with poor English, bed sores, shitty linen or pensioners having to drink out of vases.

This is how biased and propagandarised the BBC is. The North Koreans would be proud of it.

Ryan said...

EK: "Ryan - To become a GP one has to become a doctor first. I don't doubt that less altruistic motives take over later. "

I just wanted to separate out doctors/GPs from surgeons. I think being a surgeon is an entirely different kettle of fish.

As for the Beebs Holby City/ Casualty - agreed. As is Waterloo Road - laughably inaccurate propaganda (they forget most of us actually went to a comprehensive!)

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