> >Later in the same programme, I gather that the Minister of State
> >expressed
> >the identical view. Is this a coincidence?
>
> Ring him and ask?

Well quite, but it was a serious point! Doesn't it worry you that
journalists trot out ministerial briefings as if they were facts? There was
once a time when BBC journalism could be relied upon as either factually
accurate (having been thoroughly checked) or a balanced summary of the
debate. This piece of reporting wa either politically biased, (or more
likely) just lazy.

> >6. The sheer difficulty of getting all of these self-interested groups
> >(doctors, nurses, health visitors, midwives, opticians, dentists,
> >phamacists, community health councils, local authorities and social
> >services) to work together for the common good.
>
> Do you mean there are any of them who would deny that they have
> dedicated their lives to working for the common good?
> It may be difficult to arrange for them to work smoothly together, but
> let us not overstate the case.

If they do all claim that they have dedicated their lives to the common good
then it is they who are overstating their case. Taking a job in public
service is certainly not equivalent to taking holy orders.

Clearly a majority of public service professionals have altruistic
tendencies and many will have made personal sacrifices in the course of the
jobs. This in no way precludes self-interest, self importance, latent
resentment or a desire to change myiad other factors which effect their
personal working lives, such as hours, pay, or professional status. I also
suspect that public employees as a whole also tend to hold stronger
political views (towards both ends of the spectrum) than other sections of
society.

Having the same general purpose (public service) is insignificant compared
with these potential sources of disagreement. Not only will there be
different views, there will be too many different views. How can a large
committee constituted with people of widely variant remit actually work
together as a cohesive unit? It would never be considered in the commercial
world because it is a certain recipe for stagnation.

>
> >At a recent
> >meeting of GPs meeting in my town to discuss the formation of an
> >out-of-hours co-operative, feelings ran so high that furniture was
> >thrown!
> Gosh.  COuld you be more specific?  If a grand piano took flight I
> would agree feelings must have run high indeed.
> Did it hit anyone?
> Were the Police called?
> Who threw it, and at whom.  Were they successful in their aim?  This is
> the most interesting bit of the argument yet and you are stopping half
> way.

Only a chair I'm afraid. GP well known for extreme views. Would not consider
a co-op which was a net expense to individuals. It was a turf war over OOH.
Exactly the same will happen over carving up the GMS budget - bitter,
personal, acrimonous dispute. I do not think that I overstate the case about
ability to work together.

It missed the target, but he got his way!

> >The recent midwives conferences recently called for GPs to lose their
> >payments for maternity services.
> Oh come on they do that every year.  It shows their ignorance and
> doesn't make them sound very nice peoplebut surely employing them would
> modify their attitudes favourably?

We won't be employing them - at least in our area midwives are not community
nurses but employees of the hospital trust. Will they have a place on the
board of the PCG? Don't know, maybe not, but if they do they will certainly
use it to increase the "independent" professional status of midwives.


> >7. There is absolutely no way that either I or my Health Authority
> >contacts
> >can see to make wayward practices toe the line in terms of following PCG
> >protocols, prescribing guidelines or any other broader policy goals.
>
> Really?  Absolutely no way?  How unimaginative.
> The rack?  Something lingering with boiling oil in it?  Publishing
> their names on the PCG website?  Paying them less?  Criticising them in
> the most cutting, sarcastic and vituperative terms?  Popping round and
> being nice to them - every day - for 4 hours at a time?
> Auditing their items of service payments with unusual zeal and detail?
> Paying them to retire early?  Kneecapping?  Writing to their patients
> to criticise their organisational abilities?  Offering the senior
> partner a knighthood?  Offering the practice manager an OBE?  Reducing,
> under the terms of the existing SFA, their staff reimbursement to 0%
> and declining to assist them with redundancy payments, (but, being
> fair-minded people anxious to limit collateral damage, offering their
> staff suitable employment in other practices).  Amalgamating with the
> Co-op and then expelling them from out of hours cover arrangements?
> Making complaints about their profligate prescribing?  And hearing them
> promptly.
> _None_ of the above ever occurred to you?
> Or perhaps they wouldn't work?

Thank you - you make my point most eloquently.


> >There is no concievable
> >mechanism to enforce compliance that does not involve denial of clinical
> >freedom and personal judgement.

> Clinical freedom to be in your words profligate, and personal judgement
> that that is in the interests of the patient, the state or one's
> professional colleagues and team members.  Sorry, were you for or
> against that again?

It isn't all about for and against. PCGs will be obliged to live within
budgets. If that means that we have to ration, then I am entitled to expect
that the standard will be applied evenly to all the patients of the PCG. If
one or more doctors won't play by the rules then my patients will lose out.
Protocols/formularies and referral restrictions are obviously a restraint on
clinical freedom. If I have to accept it though I will also be looking for a
mechanism which forces those restraints on my non-compliant collegues. Watch
them yell foul when it happens. Some doctors will just not accept such
restrictions voluntarily.

If the protocols are devised to push up quality rather than keep down
costthen there will probably be a net positive outcome. Of course best
practice can also be cheaper.


> >Once budgets attach to localities rather than individual practices the
> >motivation
> >will be gone.
> You argue that the PCG should give a budget to each practice.  Seems
> reasonable.
> If they overspend you decide how much to contribute.  What was the
> discussion and the conclusion of your pre-PCG when you presented that
> to the meeting?

Apart from nominal budgets attaching to practices there needs to be an
incentive to live within it. I doubt that the government would allow the
same sort of incentives that pertained to fundholding savings (although I
personaly cant see much wrong with premises deveopment). Perhaps there could
be small personal bonuses in the style of the prescibing savings scheme.
Mostly however I would like to see practices being given greater discretion
over portion of their budget (eg 5% is entirely discretionary and outwith
the protocols - so that we don't have to go back to committee and make
special pleading for exceptional referrals and special cases). Any annual
savings could be added to this discretionary pool - it might allow us to pay
for some fertility drugs, or commission in-house services that the group as
a whole can't afford. In some ways it undermines equity acreoss the PCG, but
encourages thrift and innovation. Most importantly it retains the feature of
fundholding that I find/found most motivating - the notion that through
prudent and cost-sensitive practice I can release monies for special
situations thatwould otherwise be unaffordable, such as in-patient pain work
or revision hips at Stanmore. What about your chap who couldn't wait for his
MRI - wouldn't you have preferred that the cost of this came out of a
discretionary fund at your disposal.

> >I predict that referral activity will accelerate as will
> >prescribing costs. Marginal savings in administative costs will be more
> >than
> >offset by a release of pent-up patient demand.
> Do you wish to state for the record that the service you have provided
> has been less than the people paying for it want?
> Better to tell them they need to pay more.  ANd if it melts down, so
> what.

On occasion yes, but rarely, and hopefully only when they wanted the
unreasonable. We limit fertility drug costs to £1000.00 per woman per
lifetime, but currently make no other restrictions other than our clinical
judgement of the effectiveness of the proposed teeatment or referral. The
only factor influenced by money is how long people wait for treatment. In
future I will have less motivation to say no to unreasonable demand (of
course I will refer your teenager to a dermatologist for the treatment of
his first spot). I will also undertake less unpaid minor surgery. I will
give up secondary care procedures (because they wont get paid at Level One).
Why should I spend time and effort on keeping down drug costs. It's much
nicer for the patient to have this new once-a-day preparation at twice the
cost. Papaverine? Certainly not sir, I think you will like Caverject (or
whatever the new intra-urtheral one is called) much better. Cholesterol of
6.5? Hmmm, better have a statin then.

You get the drift.


> It was about not poisoning a child in a specific way which was not
> expected to work and would have been cruel and unusual.

Not how I remember it - HA turned down request for treatment because it had
a low chance of success at high cost.

> If you want a rationing one try my patient who presented several times
> with severe and unusual back pain, was listed for an MRI scan - which
> would be performed in rather more than a year - paid for a private MRI
> scan and has his tumour diagnosed now...
> I think he may want his money back from the NHS.

Quite right - see above.

> Only if they pretend that the funds and resources are sufficinet, when
> they are not.
> To go back a para or two, perhaps the lights will be focussed on the
> surgery door of the profligate prescribing and chair throwing rascal
> you alluded to above.

No - each PCG will have an "accountable officer". Can't pass the buck to
anyone else, even the profligate chair-chucker.


> And again, for the record, do you regard the HA as being more fair and
> competent at allocating resources than a collection of GPs representing
> your 50 colleagues.

Yes - the HA managers will not personally gain or lose according the way in
whichthey distribute the cash. They also use a set of (imperfect) rules
which are applied consistently. My HA has a published policy of moving from
historical allocation of ancilliary staff budget to a capitation based
system.


> Now there is a good idea.  Do you want to give them a percentage or to
> takea  salary yourself?  And ... has the phrase performance related pay
> for FHSA managers ever crossed your path?  Two years ago if I recall
> correctly, is the answer to your question above.

Performance related pay is not the same thing. WE have that in the smear
targets etc. My commissioning manager has (to my certain knowledge)never
been asked to forego salary in order to reopen an ITU bed.


> There is a pilot running within 12 miles from me, today.

No-one waited for the resluts though, did they.


> >15. Many feel that there will be a move before long to make all GPs
> >salaried.
> The GMSC and LMCs conference have bowed to or heeded the voice of large
> numbers of their constituents and committed themselves to acquiring a
> salaried option for any GP who chooses it.
> What was that bit about not being representative?  All?  Perhaps not
> but the logic of sharing work and rewards equitably seems
> uncontroversial to me.

Yes all - hidden agenda. I support the existance of a salaried option - in
fact we're think of employing one.
Would you regard complusary salaried service as a resignation issue?

> >16. In 5 to 10 years time, General Practice will be fundamentally
> >changed.
> Next year it will rain.

Yes but it stayed pretty stable for several decades before 1990.

> >The personal service of a family doctor, .................will be much
> >diminished.

Sorry - but I belive in it and try to practice it.

> Are you talking about Students who have gone on to finish general
> professional training since the White paper was published.

No - a poll of current students in a comic. OK not a study - a survey.

> And if it is published in Panorama everyone will know it is crap.

We might regard Panorama as crap but it attracts headlines, which I think
the issue deserves!

Regards

Mark Pasola



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