The Amanjit Jhund NHS Column
One of the criticisms that is consistently levelled at the NHS is that the management are often viewed as being a hindrance and a liability. There is often a degree of disconnect between front line staff and the management where management are viewed as being out of touch and lacking experience of patient interactions. The management staff are also often viewed as being sub-standard rejects from the private sector and vastly under-qualified in comparison to the medical staff that they manage (most hospital consultants having 7 or 8 degrees in comparison to management where 2 degrees would be an anomaly).
I’ve been asked my opinion before on LabourList as to how we can possibly look to raise the standard of management in the NHS and I believe that we should look to the practices adopted in the United States.
There was an interesting article in the Financial Times earlier this week that highlighted some of the problems inherent in healthcare management. In this sector, it said, it is necessary to have not just “business knowledge but also expertise in an industry that has specialised science, medicine and technology at its heart.”
The American approach to this particular problem is to offer joint degrees highlighted in the article by the Duke School of Medicine and Fuqua School of Business. This approach is increasingly common across the US with Universities from Harvard to Yale offering joint degree MD/MBA (medicine and management) and MD/JD (medicine and law) programs.
In our country we allow medical students to intercalate at University where they take one year out of their medical studies to gain an extra degree in a related field. Much of the time the subjects that are studied are other life sciences such as physiology, pharmacology, immunology and others.
I believe that we must start to look to offer MBAs in our medical schools as an intercalation option. By training the next generation of managers in both medicine and management we can ensure that we have a pool of well qualified managers who understand both the technical and scientific aspects of the role as well as the management principles involved. Most importantly, however, they would also have the necessary experience of providing patient care which would give them a valuable view point when making management decisions.
Encouraging more physicians to gain management degrees will not only benefit those that formally enter the management side of healthcare; many of the skills taught in an MBA from people management to leadership are equally useful and valuable in clinical practice.
As Professor Forman at Yale points out:
“It gives you a language to communicate with the people making the bigger decisions on how healthcare is delivered.”
As we move into an ever-evolving and more complex and specialised healthcare system it is extremely important that both our physicians and managers can actually understand and respect one another.
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Thanks so much for your thoughtful and respectful reply.
Sorry I didn't see it until I posted another comment.
I will try to reply tomorrow again- as rather late now.
Glad we mostly agree on principles.
But from experence, I'll definitely stick my neck out on the communication skills training for doctors- I think it needs to be more extensive.
Wishing you much luck with your writing and campaigning!
But I was questioning the possible assumption that only medics need to learn management or business skills in healthcare(in other words as leaders of the NHS?)
Also- a whole range of skills would be useful, such as crucially- basic counselling/communication skills training for doctors- particularly at senior levels; and GP's.(Mental health is a big issue in primary care.)
I think we must get away from a "medical model" and hierarchical view of managing sevices.
Just to give an example- when I moved from general medicine into psychiatry(at the Maudsley and Bethlem Hospitals)- it was so noticeable how much more multidisciplinary the culture was; management meetings were shared by whole teams and allied professions; all views respected.
I think many of us have extensive life experiences and come from varied professional backgrounds; we all need to pool our ideas and support each other to protect future healthcare.
In terms of a whole range of skills being useful, absolutely but the demands in terms of continuing medical education are enormous given the breadth of knowledge required. Doctors communication skills should be as good as possible but ultimately not as much time can be devoted to this for GP's or surgeons as Psychiatrists can.
I was not assuming that only medics need to learn management but that it was a suggestion focused on the medical field primarily because of the infrastructure that can already be applied to it. I think that if MBA's or other such qualifications can be offered to other healthcare professions then even better and the NHS will benefit as a whole, as I say I meant no disrespect to other professions.
Id agree Hazico that we need a more multi disciplinary approach.
I think that great strides have been made in some disciplines to a multidisciplinary approach notably as you say in Psychiatry but also in my experience in Geriatrics and many medical admissions units.
Some specialties still lag behind notably the surgical specialties but in may ways this is understandable given the often unbalanced nature of responsibility for a patients care with the medical or surgical staff still ultimately responsible and liable.
Things are improving even there though. When I was working in Vascular surgery the Consultant Surgeons always deffered to the senior nurse on matters of woundcare and sometimes scanning acknowledging that her specialised knowledge and experience far outweighed their own.
Your posts are good and informing and is great that you reply , As they say you cant please all the people all the time , Please keep posting
ricki
There's a lot of this going on in education, and can put excessive pressure on staff, to the detriment of resources available to provide good service.
My worry is that as it's been reported as inevitable there will be massive cuts to funding across public services- won't things have to change drastically, and be pared down to the core?
Sorry I seem to be sandwiched somewhere in the middle of a very technical argument going on!
Just wanted to add a bit of my experience and views, having spent about 30 years working in the NHS....there are many of us in this debate!
in his analysis that MBA's are necessary to manage the NHS?
There are a wide range of professionals that have great expertise clinically as well as managerially.
For example in psychiatry: nurse managers, occupational therapists, social workers, psychologists, psychotherapists, and nurses with differnt areas of experise in specialities.
Also what about "Matrons" in hospitals and on wards a couple of decades ago?!
Hospitals seemed to have pretty high standards care and hygene back then!
I have worked in the NHS since 1981, in general medicine, mental health, and community nursing/Health Visiting, so have observed a wide cross section of practice.I too have degrees in sociology and public health, so hope to take a wider view.
What I did notice in the 1980's onwards, were market principles being applied aggressively; eg GP fundholding, and competition between health authorities; also an imposed new culture of target setting."Managers" being externally drafted in; many without any clinical experience or background whatsoever.I see this as having had a detrimental effect, and there is still a hangover of obsession with targets?
In my view it is clinicians and skilled staff on the ground that should be managing their own service, much as teachers should be taking the lead in education.
Also- why is America seen as a model of good practice over the UK NHS? From a personal viewpoint, I spent 3 months working as a nurse volunteer on a camp in New York state, in the 1980's.I was responsible for a caseload of 700 children under 8.What was shocking was that none of them had access to free healthcare, as most came from poor inner city areas like the Bronx or Brooklyn areas.(Most had never had a holiday either.)It was like a 3rd world health care system, for families that couldn't afford insurance.For those that could- yes- an excellent service.
But what percentage of the population in USA can afford the type of healthcare we take for granted in the UK?(Which I believe to be still world class.)
I have great fears for frontline public services should the Conservatives return next year.That includes health, education, policing, social services, ambulance services- and a whole range of other community resources like our libraries....
So little detail is given in the political discussions about huge cuts proposed- why are the public being kept in the dark?
How can we vote consciously if we don't know what's in store?
I certainly don't want to return to the supermarket principles of running the NHS that were introduced in the 1980's.
I think what the public want are excellent standards of care(and that certainly doesn't always involve having a degree!); spotlessly clean hospitals, skilled clinicians(and in my opinion includes counselling/communication skills training for doctors at all levels!);and good access to services.
I think users/patients should also have a strong voice in shaping
local services.
We should all be very proud of our NHS: there are countless testimonials from the public how valuable it is to them.
Fundamentally, we must not lose sight of the principles of the NHS, and a big one for me is quality of CARE!!
My focus on medics was primarily because
1) That is my primary sphere of influence and experience.
2) There is already an infrastructure that can be adapted to accommodate their studies in an MBA at medical school.
I do accept that there are many other professions within the NHS where people do change their focus and go into management and I meant no disrespect or disparagement to these.
If that is what was implied by my article then I apologise.
When you say that
"In my view it is clinicians and skilled staff on the ground that should be managing their own service, much as teachers should be taking the lead in education."
I agree and I hope that even by having more Physicians on the ground with MBA's then we can improve their performance in this respect as I say in the article there are many elements of an MBA that also reflect upon clinical practice and we need to facilitate the discussions between Physicians and managers.
In terms of the comments about America I agree that there are many serious deficiencies in their system but in terms of innovation and development I do believe that we can learn from them as they can learn from our compassionate system. I have written about this myself in the past and again have some experience of the intense deprivation that accompanies their system too. Many of our current drivers from Lord Darzai's innovation fund onwards have been an admission that we need to improve these aspects of our service and we have much to learn from the Americans.
I agree with much of what you say but
I do believe that increased patient choice and empowerment is necessary, although in itself it will lead to an extension of market led reforms within the NHS. (Im not sure if that is what you are referring to by "supermarket principles" or not).
In terms of "counselling/communication skills training for doctors at all levels!"
There is training on these subjects at medical school and assessment but I would say that much like any skill the competency level varies wildly from person to person. It is often a very difficult skill to teach or even assess often complicated by the varying workload and variable time constraints and priorities on a doctors time that can affect the delivery of sensitive information.
But as I say competency varies massively and I would agree that many doctors of all levels need improved training.
In terms of your last two points you will hear no argument from me I agree wholeheartedly.
The problem is that most NHS staff in England see no difference as FT's are still required to do all the form filling for 'clinical governance' much of which is to them irrational and unnecessary.
To attack Amanjit who works in the system and sees the day to day impact on health care staff is naive. I work with people to try and make the daftness coming out of Richmond House workable and can advise you that many see what is happening in Wales and Scotland and are envious because they are stuck with the system that is still, in most respects, the Conservatives' market commissioning model under a trendy New Labour name.
Labour's 1999 Health Act said its main purpose was to enable 'local providers to meet local needs and set the levels of provision' but it never has and as long as ill thought out politicised targets come down from Richmond House, that eat up staff time (both clinical and administrative)in England, it never will.
You either believe in subsidiarity or you don't. The experience of NHS health care in England is Micromanaging New Labour doesn't, so don't tell us front line workers it does - no matter how pretty you think the policy looks on paper.
I could discuss the impact of New Labour's commissioning model on NHS dental services in England but that would probably just cause your brain to seize because it shows up the impact on care provision of New Labour's inability to listen to health professionals.
You are right that FTs still have to meet targets. In fact they have more targets, particularly since Mid Staffs (when FTs were essentially measured on financial probity - that has been corrected now). As a patient and a patient representative I am happy that FTs still have to meet targets. I want quality to be as high as possible.
If you would like to post the details of NHS dental services in England then I am sure Alex will give you space and you will educate us (which is a good thing). But in any case, I still have to point out to you that we are talking about acute and general hospitals here, and we are talking about England (or I was, at least). There is no option in England for a Welsh or Scottish solution. And I seriously doubt that the NHS in England could ever take over private provision. (Remember, we have ten times your population.)
All quality control has targets. It is a different debate as to whether the government's targets for the NHS improve quality.
The problem with devolving responsibility in the health service, is that at the minute there is only one group of people who’s future employment depends on the (perceived) quality of service delivered by the NHS, the politicians at Westminster.
Targets, Charters, Quangos and centrally controlled budgets, all existed before 1997, and will in one way or another continue after the next election whoever wins. In Westminster terms the NHS is too important to be left to the NHS staff, or the people that use it.
There is another more fundamental point, should the NHS be run by the medical staff? What about the wishes of the local community? An obvious example would be the centralisation of services. No doubt from a medical perspective this has enormous benefits, but people (perhaps unrealistically) want to be treated in a local hospital.
So you move to some sort of local management board, but how are these people chosen? Do they represent everyone, the elderly who make up most of the patients will almost certainly be under represented, and the Middle Classes over represented?
Then when localism does deliver, when do variations in local services become the dreaded Postcode lottery?
I don't see what the issue is. There are already qualifications in management in the health service (eg Certificate in Health Service Management). If a clinician wants to go into management (and those I know hate the idea: management is for managers, clinicians treat patients) then they can take an MBA no one is stopping them. However, they will also have to take a cut in salary because (quite rightly) consultants are paid more than managers.
As to whether degrees should be join honours, well why not? The better hospitals will choose to employ those people who have done the most medicine, and personally, as a patient, I would prefer a consultant who has the best skills and "bed side manager". I would use my right to choose to avoid a consultant who spews management speak at me.
But are you saying that the NHS should encourage consultants to get degrees that are transferable to the private sector? Hmmm I am not sure that I like that idea.... the private sector can pay for the training of their own staff, thank you very much.
As to Prof Forman's comment, well, his statement is not applicable to the evolution of services in the NHS. We are heading for a more devolved system, where hospital trusts get autonomy from SHAs and the Dept of Health. This, in my opinion, is a good thing because it keeps the decision making local. Hence there is no need for doctors to have the language to communicate with the people making the bigger decisions. In fact they need the absolute opposite, they need to have the language to communicate with the local community who themselves will be making the healthcare decisions.
www.brunel.ac.uk/about/acad/bbs/courses/ps/mba/healthcaremanagement
or
www.abdn.ac.uk/prospectus/pgrad/study/taught.php?code=int_healthcare
That's two UK courses - I'm sure there are more.
I could counter that by pointing out that there are health care / charity MBA's around that focus on 'not for profit' systems. As part of my post grad QA qualification I looked at core MBA subjects such as open book accounting, servant leadership models, creation of 'smart' targets and their effective achievement and studied in detail the quality assurance, management practices and principles introduced across Leicester Royal Infirmary - flexi-hours in nursing provision being surprisingly effective - and the break down of traditional hierarchical systems to true flat management structures. All of which Labour's present CMO Sir Liam Donald had a major role in.
Then we had Richmond House's response - clinical governance. A 'hodge podge' of QA and MBA ideas that is neither fish nor fowl. The classic let's not upset people civil service compromise which has, in fact, annoyed everyone with its burden of paper based evidence that consumes whole armies of medical secretaries to administer, made even worse by the failed IT structure and common reporting it was supposed to support, for England and Wales.
Leicester Royal worked because it was bottom up - clinical governance has failed because of the top down nature is seen by those on the front line as just more unnecessary bumpf from Richmond House, ergo a waste of time, especially as the compliance checking regime is weak and easily circumvented or ignored.
Properly introduced, with a realistic evidence of conformance trail, I am sure a large number of the cynics would have bought into the purpose of clinical governance as they would have bought the real benefits. The reality for many was summed up by one consultant I worked with, helping his department with compliance issues: "Never has so much been measured, for so little purpose, by so many."
Bottom up is the only way to go. In terms of measurement, some perspective might usefully be gained from feedback from the people at the other end of the drill or stethoscope. In that context I did a little work a few years ago with Paul Hodgkin as he was about to set up Patient Opinion but I've no idea how he's got on since then.
Maybe the should have threatend to hold a vote on the lisbon treaty , We would have got the opt-out just like that then ?
I think as you said this will damage care in the future , I dont know the answer to this , We will have a aging population ,limeted Drs and because of a EU law paitents will suffer.
ricki
I agree it should more local and more in the hands of people , Maybe Amanjit should be the health sec and drive though the reforms Drs and patients want and improve care?
ricki
Historically (prior to the NHS) hospital boards were made up of a balance of health carers and members of the public. It worked simply - the health carers managed all the care services and the members of the public raised the funds. Decisions on expansion or improvement of services could only be made to happen if the carers could justify the expenditure and the public members agreed to raise the capital by subscription or donation.
Because of the National Insurance reforms brought in by the Liberals in 1915 everyone who needed care had access to care, most people in work were members of their 'works' or 'Union' health insurance which meant for many, they and their families had better access to care than they do now - contrary to the propaganda that was put around in 1945. Worldwide the UK was held in esteem for its advanced health care provision and its forward thinking. In 1948 all these funds, insurance schemes and hospital charitable funds were subsumed by the NHS.
The impact of the loss of local control of funding and spending took four years to impact on the 'free NHS' with the Labour Government of 1952 bringing in prescription, optical and dental charges in an attempt to control the demand and the budget. Bevan resigned seeing his 'cradle to grave' promise ripped up and thrown away,(see Michael Foot's excellent biography on Bevin) Labour lost the next election and did not see Government again until Harold Wilson.
Fast forward to today and the NHS is still where it was 57 years ago. Spending out of control, local people campaigning against closures which are for fiscal and not health care reasons, many hospitals reliant on 'Friends' to buy essential new equipment, new hospitals opening unfit for purpose because PFI contract owners do not know how to build hospitals and are only interested in the bottom line and easing the building through to the end of their 25 or 30 year contract when they don't care if it then falls down as it will be some one else's problem.
That Ricki and John is why central control does not work in health care. It is the core problem behind the antagonistic face some patients bring to health care. The system does not care about them, doctors are part of the system, tax payers pay for the system, so the system should do what they 'damn' well want and yesterday.
Everyone knows the current system does not reflect local needs and expectations, the central system removes accountability from local providers because of ring fenced budgets, the blame game bounces backwards and forwards while the patients perceive they are not listened to.
I am not saying go back to before '1948' what I am saying is if you trust local people, who are perceiving they are spending their own money, on services they can see are needed, that meet local expectations, then you tend to get a more effective and efficient service because people feel accountable and are more likely to control their budget.
Evidence - have a look at the positive impact on local services and councillor accountability the SNP / CoSLA concordat has already delivered. From 59 ring fenced budgets to 17 enabling more effective use of the public purse to meet local needs and expectations. PFI has been ditched, councils are looking to buy out PFI contracts to save money, ripped off Glasgow has just been given an additional £80 million from the 'Public Capital Fund' by the SNP to cover its over expenditure on the Commonwealth Games build. The new hospital in Glasgow will be built using traditional public funding methods, as will the replacement Forth Road Bridge.
None of which would be possible if the central command economy model favoured at Westminster had been retained.
Well the leadership changed its mind of childcare vochers last week after a letter signed by some MPS , Could you not organise a campain or letter to the health sec? As i said in myy post further down (on Carers ) ,Carers are not covered by the law so surely the leadership can get a exmption ?
ricki
The government did write to the European Commission to ask if Hospital Trusts could opt out of the EWTD, but this has not bourne any fruit.
Sadly self interest also drives much of this, there is currently an individual opt out of the EWTD but many people would be unwilling to work twice the hours for the same pay as their colleagues even in medicine
Thanks for the reply , If the 48 hour rule is that damaging why would ministers enforce it , Have the Drs union (if they have one or a body that reprsents Drs view) taken this up with the Health sec? .
I dont really know what the torys are suggesting so i cant speak on it ( although i will read all the manifestos when they are relised) , I would like to think that our ministers and shadow minsters and Drs could sit down and sort this out , after all they all want the same , Just have a different way of going about it .
ricki
There is plenty of evidence to suggest that the EWTD is not only damaging doctors training but also patients health.
A report by the Government funded National Confidential Enquiry into Patient Outcome and Death found that the impact of the EWTD and reduction of doctors hours created a substantial reduction in continuity of care and in sernior cover in hospitals especially in theatre's.
Andy Burnham is certainly going to be aware of this study and if he is not then I would suggest that the DoH is either negligent or imcompetent as the Government funded it.
In terms of a doctors association the British Medical Association are really our equivalent of a union but although they have made their concerns evident it has not stopped the EWTD because it will benefit the population at large in their working lives.
I am not convinced at all though, their setup is based upon a profit centre approach hence the need to have strong business skills. In the UK we are a provider of free healthcare and it is a cost effectiveness calculation. The drivers are totally different. An MBA will help those who later on become consultants to increase their earnings. Presently if a Doctor wants an MBA they can go and get one. Making it a requirement if that is what you are saying would be a step too far.
Doctors earn 8 times what I do (and quite rightly so), in the private sector you have to pay, why should the average Joe pay for this when it is the cost of a pay rise for 100 nurses?
If the press are to be believed there is an excess of hospital managers, from what you are saying you think they are weak. My solution would be ensure they who do the managing do a better job and the doctors stick to "doctoring".
I am not suggesting that doing an MBA would be a requirement but that it would be an option for medical students alongside neuroscience, anatomy, physiology or other such intercalated degrees.
I understand your concerns re funding as I have considered doing an MBA myself and am well aware of how much they cost but in relation to paying full fees for an undergraduate degree they compare quite favourably its just that often the undergraduate degrees are subsidised by the state but having doctors intercalating in an MBA instead of a Bsc at medical school will not increase the overall bill to the taxpayer to any meaningful level.
In terms of Doctors sticking to doctoring part of the problem as the FT article suggests is that a high degree of technical and scientific knowledge is needed to effectively manage such complex and institutions and often doctors are the best placed to have this knowledge. Having more in the way of managers who have this knowledge will only benefit the NHS.
Again with respect to your comments on different drivers in our healthcare system of course the profit motive is less pronounced but it is increasing especially with respect to payment by results and the financial awards attached to other targets and this actually does drive much of the services even in our "free healthcare" system.
I am all in favour of doctors acquiring business skills, but feel that the sort of dark arts currently taught in MBAs - ie the mastering of leverage and the maximisation of profit for rentier investors - is not what is required.
As I have often said on LL I believe that the requirement is for a new enterprise model for health and other natural monopolies. Inherent in this enterprise model is a new approach to market disciplines. That would imply an MBA focused on 'Social' 'Not for Loss' business rather than the Commercial 'For Rentier Profit' business which most people recognise is entirely inappropriate.
Absolutely much of the current MBA curricula would not be relevent but with increasingly modualr courses this is less of a conncern.
In addition to this one of the benefits from the American model is that they have more in the way of specialised healthcare MBA's and these are increasing in number.
The partnerships between medical and business schools have driven both the demand and quality of teaching in the institutions. We could similarly benefit here as by implementing MBA's as an option there would also be an onus on the business schools to develop healthcare MBA's with a focus on the NHS and associated business models.
Such courses in the US draw from the medical and business expertise in their associated schools in constructing and teaching their courses.
As such it may help not only those doctors doing MBA's but also other managers either from abroad studying the NHS or prexisting managers in the NHS wanting to obtain higher qualfications.
That makes sence , But if something goes wrong who would be acountable ? How much would the buy-out cost? i agree that niether party would do it and for the reason you state , Surely we must be better than that ?
ricki
As I have mentioned several times on this page, this autonomy already happens with a Foundation Trust. As Peter says, at the diktats go from the Dept of Health to Strategic Health Authorities, who then tell hospitals what services they should provide. Each SHA covers about 5 million people, so the policies set for 5 million are hardly local. Hospital trusts cover smaller populations, half or a quarter of a million. When a hospital trust becomes a Foundation Trust they become autonomous from the SHA and the Dept of Health, and they get to decide their own health strategy. They are still covered by quality standards and by targets (which are treated by hospitals as minimum standards anyway, the Tories are so wrong about targets), but how they achieve those standards and targets is entirely up to the FT with no intervention from anyone outside the hospital.
FT hospitals have a different form of accountability to current hospitals. At the moment hospitals are accountable to the SHA and the SHA is accountable to the DoH. With an FT the hospital is accountable to their governors and to Monitor. Monitor is an independent authority set up mainly to ensure financial probity, but they are now including quality of care provision (through the Care Quality Commission).
To be an FT a hospital has to have a membership. The criteria depends on the hospital. Most say that members have to be over 16 and live in the area covered by the hospital. Some have an opt-out system where all patients (past and present) are members, but most hospitals realise that this can become unmanageable. Members are essentially people who are interested in the hospital and want to help shape the services the hospital provides. Members elect governors. The board of governors are part elected from the public, part elected by staff and part appointed from "stake holders" (representatives from people like the primary care trust, GP representatives, voluntary groups etc). The elected governors have to be the majority.
From my experience as a governor, there is none of the political placements that Peter mentions. If local politicians want to stand as governors they may, but I have not found governors decisions being taken on political grounds. Governors are not paid, but travel expenses are paid.
Governors appoint the non-executive directors and the chief executive. They also have to approve the hospital strategy and the accounts. At the moment, the Health Secretary can remove a chief executive, with an FT, that power is invested in the governors. But on the other hand, as part of their agreement to be a governor, they have to engage with the members and have a duty to communicate with members and to return member (ie community) feedback to the trust.
As you can see, this makes hospital trusts locally accountable. There is no salary and no "career path" for governors so it discourages the sort of shysters that we see standing for parliament. Governors have fixed 3 year terms and there is a two term limit.
So NHS autonomy is a Labour idea. Spread the word.
Micro management of health care by politicians will have to cease for this to work. That means a whole load of redundancies at Richmond House and fewer political placements to reward politicians. At local level it will mean an end to Health Boards and Authorities and political placements for local politicians. It will also require an end to all ring fencing of budgets.
It means giving hospitals their budget and trusting them to manage their funds. It will also require the Government to buy out the politically inspired PFI contracts that are killing front line services across the UK.
Worst for the politicians they will no longer be able to claim any responsibility for the NHS as it will be run by the real stakeholders patients and health carers.
Now - even with a Tory Government I can't see that happening in a month of Sundays.
But would they have the freedom to improve care or would they have hands tied behind there back because it doesnt tick all the boxes , If they were free to change things to improve care then i would agree it would be good but do you think that could happen ? .
On another point if i may (as you are on the front line) how will the 48 hour rule affect Dr training ? and will this change (in your opion) be good or bad ?
ricki
There is always the danger that the political interference in management for short term political gain would have a detrimental effect on the NHS no matter what the qualifications the managers have.
Thats why I agree with Peter below who suggests that we should get politicians "off its back".
In many ways we need to depoliticise the NHS. Sadly as a party we have been outflanked by Cameron as >50% of doctors now support Conservative healthcare proposals as they are seen as giving more autonomy to the NHS its something that we should have done as a party over the past 12 years when we could have dictated the terms but we may now be at the mercy of an incoming conservative government who could have vested interests (ie drug companies and insurance firms) at the heart of their new NHS quango.
In terms of the 48hour European working time directive. I think that it is a real problem and should not be implemented for doctors. Many specialities especially the surgical ones but also increasingly the medical specialities have a great deal of practical procedures at their heart.
In order for a doctor to be competent and stay competent in either performing operations or procedures they need to perform these at regular intervals. Unfortunately you cannot dictate when a ruptured aortic aneurysm or other such emergency will come through the door so doctors must be relatively flexible in their workload in order to maintain this competency and the rigid EWTD will destroy this.
Already our current crop coming through will be less well trained than the consultants of yesterday and this will only get worse as we introduce Junior and Senior Consultants in an effort to massage the figures.
I already know several surgeons who have left for the USA as they do not feel that they will get sufficent training in this country under the EWTD and many more who are thinking of leaving.
>50% of doctors now support Conservative healthcare proposals as they are seen as giving more autonomy to the NHS its something that we should have done as a party over the past 12 years
This statement makes me very angry because this is exactly what Foundation Trusts have done. The Tories say they will embrace the FT programme, yet it is a Labour idea! Please Amanjit, please whatever you do, tell the half of the doctors that you are working with that it is Labour who is bringing autonomy into the NHS, the Tories will do the opposite.
I implore you to have a read of the Tories health policy. There you will see that they are suggesting that they take the autonomy that Labour has introduced and constrain it with their new quango, the NHS Board. The NHS Board will dictate from the centre how trusts should commission services. This is in the opposite direction to Labour's plans. Labour want to make commissioning more local, but the Tories want to dictate commissioning from their new super-quango. I think the Tories will use the NHS Board to tell trusts to commission more services from private suppliers: this is part of their privatisation programme.
Unfortunately the Press are not willing to challenge the Tory lie that it is them who will give hospitals autonomy. The Press seem unaware (or choose to ignore the fact) that hospitals get greater autonomy under Labour when they become a Foundation Trust. Further, the Press have not challenged the Tories over their super-quango, nor their idea to pay hospitals based on outcomes not by the work they do (hence, hospitals won't want to do any procedure that does not an absolute - dare I say "cast-iron" - guarantee of a 100% success), nor their idea of "value-based pricing" (something that simply will not work).
And I am rather disappointed that as a medic you do not know about Foundation Trusts and how they make decision making more local.
1) "I am rather disappointed that as a medic you do not know about Foundation Trusts and how they make decision making more local."
When in my article or my comments did I ever suggest that Foundation Trusts do not make things more local or in fact in any way comment on foundation trusts?
You say that my comments make you angry welll I am quite frankly bloody furious when falsely accused of making statements or comments when I did not, or accused of ignorance for a start!
2)My statement of >50% comes from a recent survey by pulse magazine on doctors so is not my private experience or simply related to doctors that I know most of whom support the Labour party
3)Some Labour initiatives have decreased interference but others such as some of the poor targets ie the 4 hour wait are an invidious blight upon clinical priorities. To suggest that the creation of Foundation trusts has in some way eradicated political interference in the NHS would be (and as you have shown no respect to me I shall show none to you) at best naive and at worst imbecillic.
4) I am well aware of Conservative healthcare policy and I am very concerned at the proposals, as I say I have extreme reservations about the prospect of vested private interests being given control of vast swathes of the NHS under the illusion of autonomy and the damage that this will do. In the past I have written about my concerns on this and also my concerns with regards to the more radical elements such as Daniel Hannan and why I disagree with their viewpoint.
So again I do not quite know where you get off accusing me of ignorance on this subject.
If you want to discuss points Richard thats fine and Im happy to debate any subject with anyone left or right wing, but when you start accusing me of ignorance or falsely accusing me of discussing a subject then I will get pissed off!
I'm not accusing you of anything just saying that I am surprised that the governance model of FTs are not more widely known amongst medics. Your statement that 50% of doctors think that the Tories will give hospitals more autonomy is frightening. It is frightening because it is so wrong and it is frightening because doctors should know that FTs are the main force for autonomy in the NHS (the tweaks that the Tories plan will largely take things in the opposite direction). (Ask yourself, if a government wants to hand over services to the private sector how can they do that if they do not have the power to do so? Foundation Trusts takes that power away from the government.)
You say that my comments make you angry welll I am quite frankly bloody furious when falsely accused of making statements or comments when I did not, or accused of ignorance for a start!
I am sorry that you misunderstood me. I was angry at the 50% statement. I am not disputing its accuracy, just that those 50% are ignorant of the facts.
There is no attempt from me to put any blame on you. Read again what I wrote: it is not a personal attack on you. What I am angry about is that the government are not publicising better what they have done in the NHS. If there is a Cameron government you can bet that in a years time he will announce how a conservative government had given autonomy to hospitals when it was Labour who has done it. Can you now see why I am angry?
#3 is just nonsense, now you are calling me an imbecile in some kind of school yard tit-for-tat. Last week I had a tour of my local hospital's A&E. They fail their 4 hour wait (just). The reason is bed blocking. The reason for that (and I have asked widely on this) is exasperated by social services using hospital beds as overspill for their nursing homes. (Umm conservative council, you see.) The hospital is building more wards to overcome that problem. However, I cannot see why you would think that it is acceptable for someone to have to wait four hours in A&E. Remember that I am a patient representative and I think that a four hour wait is shocking. I would prefer that the target was shorter.
As I said Amanjit, my post was not an attack on you, rather an attack on the poor publicity that doctors (from your figures 50% of them) do not know the facts. When that results in wrong opinions being expressed then I have no option other than to correct them. I have no reason to attack you and I hope in the future you will not regard my comments in anyway as attacks on you.
I will accept that it was not your conscious intention to accuse me of anything but when you write
"AMANJIT, YOU too seem to have ignored the fact that with NHS Foundation Trusts (the only model for hospital trusts, in the future, all hospitals will have to be a Foundation Trust) the NHS has been de-politicised."
then this is a personal accusation based upon an assumption of ignorance on my part as bourne out by the fact that you refer to me directly ignoring part of the health service.
I would also have to say that your comment
"And I am rather disappointed that as a medic YOU do not know about Foundation Trusts and how they make decision making more local."
It is again personally directed. It again suggests a lack of knowledge on my part (whether right or wrong) on a subject that I have not discussed in this post.
Im sorry Richard but your criticisms were personally directed even if that was not your intention and as such I believe that I had every right to take it personally.
As for your points re the 4 hour wait Id agree that it is a valid aim but it's rigid enforcement can and does damage patient care as I pointed out in my article on NHS targets.
Again you move back into personal accusations by your implications. "I cannot see why YOU would think that it is acceptable for someone to have to wait four hours in A&E."
Again Richard when have I said this?
I believe that we should aim to see people within 4 hours but that rigidly enforcing this target damages patient care.
If in future you do not wish to attack someone personally then Id suggest not prefacing such criticisms with the persons name or writing "I implore YOU to have a read" or "YOU do not know"
In addition to this obviously other posters considered this a personal attack such as Peter Thomson in his post above.
I would suggest that if in future you do not wish to engage in personal attacks or what may develop into "tit for tat" retaliation then you moderate your comments more appropriately.
My comments about medics ignorance was generic, it was about the lack of publicity and teaching. When I said
And I am rather disappointed that as a medic you do not know about Foundation Trusts and how they make decision making more local
It was not an attack on you, but on your ignorance, ie the fact that you have not been told. I explained that upthread, I had hoped it would be the end of the issue.
As to this: "I cannot see why you would think that it is acceptable for someone to have to wait four hours in A&E." Yes that was questioning your opinion. Hands up to that. But as I said, it is not acceptable for people to have to wait so long and you say that you agree. So the two of us being in agreement is a good thing, right?
As I said before, I am a governor and a patient representative: I want the best for the patients. When I visit my local hospital that is what I find from both the clinical staff and from the management: the patient comes first. When I first started in the governor role I was surprised to find that everyone put the patient first, I thought that, as a patient, I was lucky to be treated by the rare few who thought this way. But now I realise that it is the majority view in the NHS. However, like everyone else, I have seen so much in the Press about evil targets and excessive paper work and overbearing management.
I read your other article when you originally posted it. As I mentioned in another comment here, my hospital has the same issue. But note: the issue is beds, add more beds and the 4 hour target is far easier to achieve. Why are beds a problem? Lots of reasons. In my hospital's case a higher than national average of elderly in the local population does not help, especially (as I said) with social services using the hospital as overspill for their nursing homes. There are other issues too. A patient (an elderly neighbour who had had a fall) told me that she was in hospital for an extra ten days (TEN days) waiting for social services to assess her and her house. The hospital could not discharge her until social services had completed the assessment, but it took them ten days to get round to doing it. So she was bed blocking, and that had a knock-on effect on the 4 hour A&E target. The hospital was not to blame - social services were - but try telling that to a patient on a trolley in a corridor.
But Foundation Trust status can help here: the hospital can decide what it spends its capital funds on (see later how Cameron wants to take away this ability). It can also borrow money. It has the autonomy to do this.
Then there is the single sex issue. It is costly and disruptive to change wards from mixed to single sex. While wards are converted (typically by adding partitions in the existing wards) the beds are out of use. Fewer beds affect the A&E target again. One could argue that there is no clinical need to do the conversion from mixed to single sex, but it has become a political issue so all hospitals have to do it.
And note that Cameron has made it a priority:
A Conservative government will allow patients to choose a single room in NHS hospitals when they are booking their treatment.
This is absolute nonsense, where is the money coming from and how will he created the extra capacity while the changes are being made? That statement is a political promise. Cameron says:
[Capital] funds already exist for upgrading hospitals with refurbishments and extra capacity, and this is allocated on a needs basis, so under a Conservative government, the Department of Health would make single room capacity one of the priorities for allocation.
So, where is the autonomy? The centre under Cameron will tell hospitals how to spend its money.
Under Cameron, single sex, hotel-like single rooms are a priority over the refurbishment going on at the moment for better infection control. Or that new MRI machine or CAT scanner.
Also, a single room is not one room. It is two rooms (the bedroom and the bathroom), there is no point in having a single room to separate sexes if a woman has to share a bathroom with a man, or if a woman has to walk past men's rooms to get to the bathroom. Two rooms are needed, or at least some partitioning to keep bathrooms single sex and enable patients to get to them without walking past patients of the opposite sex. That will have a drastic effect on the number of beds, not only during the refurbishment, but will reduce total capacity. And hence there is the knock on effect on A&E times.
Now can you see my anger? I can see that the NHS under Cameron will be much worse for the patient. Yet the figures you quoted say that doctors want Cameron, they want a worse NHS. I am aghast, really, I am.
I hope that you do not find anything in the above that offends you. I do not aim any of it (except my comment on A&E times) at you.
I can understand if you do not intend to aim any of this part from the A&E waiting times at me but you do it again in your reply.
If you mean to make a generic point
rather than writing
"It was not an attack on you, but on your ignorance, ie the fact that you have not been told. I explained that upthread, I had hoped it would be the end of the issue."
You should have written
It was not an attack on you, but on the ignorance of medics, ie the fact that you as a doctor have not been told. I explained that upthread, I had hoped it would be the end of the issue.
Again Richard it may seem to be a small point to you but it makes all the difference with the written word between a personal attack and a general statement.
If you can not see that then I really do despair.
Additionally again there is an assumption of ignorance on a subject on which you have no idea of how well or ill informed I may be you simply accuse me of ignorance.
I find this both condescending and insulting.
As it is I have found your lack of decorum disappointing as I have agreed with you on previous posts and found your input useful.
I myself have either been misunderstood or have misunderstood someone on previous discussions and have been quick to offer an apology.
As I say I am happy to debate points with right or left wingers, but I have no desire to waste any more of my time with you Richard given your behavior.
I am not a politician and have no reason to submit myself to your abuse or accusations. I will therefore not be discussing anything further with you.
(In my defence, remember that "your" can be used to mean more than one person. English has some failings.)
I have never intentionally tried to attack you. That you do not believe me is quite disappointing. There was never any abuse meant and no offence should be taken.
I apologise if I gave any other impression, but I assure you that was not my intention.
I read the peice and thought good idea , but (there is always a but) Having Drs doing the management roll and vice versa would give ministers the chancwe to massage figurs and may affect care , I might have misread it but there is always the law of unintened consequnce .
ricki
In terms of ministers massaging the figures Im afraid that this already goes on and I do not think that by having more doctors with management qualifications this would increase in any way.
If they were doing politics degrees on the other hand.....
In terms of affecting patient care it is my hope that by having more managers that have both experienced and worked on the front lines as doctors even if just for their foundation years coupled with specialised management qualifications (which many of the NHS managers lack) patient care will be improved immeasurably.
Make that support group effective and let the doctors get on with doing what they do best.
But Im speaking from experience when I say that becoming a doctor is NOT the hardest thing that you can do in many ways. I had no problem with the workload at medical school and I intercalated myself in Physiology where the entire year was devoted to studying this subject with no impact on my medical studies whatsoever in addition to this many others spend 2 years intercalating for a masters degree during their medical studies. So Intercalating for 1 or 2 years for an MBA would be no problem for the vast majority of medics.
You also have to remember that medical students account for a high proportion of straight A students in the country and only the top 1/3 to 1/2 of any medical student intake are then allowed to intercalate so in terms of intellectual capability those allowed to intercalate already represent one of the most capable in society.
Add in to this the fact that many doctors upon graduating are already studying part time for a masters or similar degree while also sitting professional mermbership exams and working as a doctor and I do not believe that obtaining an MBA would represent much of a difficulty for the vast majority of intercalating students.
For too long the medics who have become NHS managers have been looked on as neither fish nor fowl by either side but your excellent suggestion will be for nought as long as health care management style is dictated from Richmond House. As an ex-dentist with a post graduate qualification in Quality Assurance I can assure you that the biggest problem in the NHS is the lack of modern management skills and ability. Where they arise they are quickly crushed as in the case of Leicester Royal Infirmary where all the excellent use of QA techniques was covered up by the local Health Authority because it 'showed the other hospitals up'.
High quality managers will take one look at the garbage that routinely comes out of Richmond House and do a runner to somewhere their knowledge, skills and talent will be better respected and the NHS will be left with the 'you can't do that cos Richmond House says' folk it has always employed. I packed in NHS management when the Authority I worked for built a £1.4 million outreach dental unit on a PFI contract that will stand empty for large proportions of the time because it is to be 'staffed' by dental students in their final year. Because of the remote and rural nature of the area it does nothing for the 90% of the population that still have poor access to dental care. For the same initial capital cost they could have had ten sophisticated, mobile dental clinics that could have reached the remote and rural areas and the ongoing costs would have been a twelfth of the PFI annual contract cost to the Authority budget.... but Richmond House said and the Community Dental Service was cut back!
If you want a better managed NHS get the 'here today, gone tomorrow' politicians off its back as a first step.