I was aware of this proposal, as it had been listed in the White Paper, in the same list as the right to choose your GP practice, no matter where you lived. At the time I thought it was a mad idea, and I still think it is mad. How mad? If the KGB had infiltrated the DoH and parliament with operatives whose mission it was to make various services within the NHS malfunction, then this would make sense. It is as moronic as asking a GP practice to register anyone wishing to register with them, irrespective of capacity. The same dynamic is operating here, the same muddled thinking. If a first year GCSE student handed this proposal in as part of his or her course work, one might reasonably expect it to be handed back for further amendment.
Essentially, the problem is this: as GPs we refer patients, when appropriate, to a hospital specialty service (say gastroenterology). Several years ago, we wrote letters to named consultants (usually, but not always, in a local hospital); or we would address it to ‘Consultant Gastroenterologist’, Local Hospital, Main Street. For a few years we have been referring through an online system called Choose and Book: this is, with rare exceptions, a referral to an unnamed consultant within a named hospital. This new development proposes to have the consultants named on Choose and Book so that patients can choose who to refer to. This is a perfectly welcome development because as a GP I often have a preference myself which I would suggest to the patient. However, we run up against the problem of capacity. If too many people request to be sent to Dr Popular’s team, then that team will not be able to continue the same quality of service. The quality will fall. The waiting times will lengthen; because there are maximum permitted waiting times, locums will have to be drafted in. And let me tell you, the quality of doctors you will obtain in this way is patchy: they might be excellent, they are more likely to be be mediocre. I have outlined this problem in more detail in a previous post, if you are interested.
On Wednesday October 12, 2011 I read the following brief article in the Independent (the online version has it at the end of another article, link below if interested):
NHS patients will be able to pick consultant
NHS patients needing specialist treatment will for the first time be able
to choose the consultant to whom they are referred, Andrew Lansley announced
In a significant extension of patient choice, hospitals will be required to
accept all “clinically appropriate referrals to named hospital
Patients will be able to travel to any part of the country to see the
consultant of their choice and hospitals would be required to publish
individual “success rates” for their specialists to help patients
choose, the Department of Health said.
The announcement, timed to bolster public support for the Health and Social
Care Bill during its Second Reading in the Lords, brings NHS patients into line
with private patients who already have the right to choose a named consultant.
But it marks a divergence from past policy which prohibited named
consultant referrals to keep down waiting lists.
Rating individual doctors’ performance has also been rejected in the past
on the grounds that modern medicine is a team activity and individual
performance measures would be misleading.
Sir David Nicholson, chief executive of the NHS, interviewed in 2008, said:
“It’s the team that makes the difference, not the individual. The days of
the heroic surgeon, like Sir Lancelot Spratt, are long gone.”
I can only assume that the text of this article is more or less listed verbatim from the DoH press release. Now I know as a referrer that this policy will simply not work, that it is moronic. But what made me shake my head was this idea that the announcement of the policy was “timed to bolster public support for the Health and Social Care Bill during its Second Reading in the Lords”. Now if the Lords were to be swayed by this news, then they too must be pretty moronic. The article is filled with very odd statements which don’t really make sense. For example, the policy “brings NHS patients into line with private patients who already have the right to choose a named consultant.” Of course they have a choice, it is a private arrangement and they are able to see the consultant of their choice provided their insurer has that consultant on their list. But what the press release fails to say is that in the private sector there is no requirement whatsoever for that private consultant to see all patients within a certain amount of time. There are consultants in the private sector who have long waiting times; people will wait because they want to see that consultant, or they will go to another consultant. And they will see that consultant personally, not some junior member of his or her team.
I had planned to email a consultant at my local hospital just to check with him whether I was missing something, whether there was new efficiency technology or ‘new physics’ which made this policy possible. I would have promised not to reveal his identity. But then I met had a conversation yesterday with a colleague on one of the London CCGs who told me that he had been told by a manager at one of the London hospital trusts that they were awaiting guidance as to how to implement this policy, who felt it was just not possible, that it was Kafkaesque.
So if there are any hospital consultants out there (or, indeed, a DoH operative) with a comment on this issue, this would be most welcome. I promise to maintain your anonymity, as I understand that those working for a trust may feel there are pressures not to speak out freely, honestly. But without an honest look at the policies, without a sensible methodology, we are doomed to failure. If the emperor is wearing no clothes, what are we to do?
Contract implementation guidance: Choice of named consultant-led team
On the Kafkaesque29/01/2011
Kafkaesque: you may be familiar with this term. Not everyone is. I sometimes say to a patient who has brought me a particular type of problem, ‘Do you know the meaning of Kafkaesque?’ Many do not. I then explain that it is a situation where a person feels in a nightmarish situation: they are standing in a queue for hours; then are told that they are in the wrong queue, that they need to go to Section 7 and wait for further instructions; they go to Section 7 and wait; nobody comes for them. They ask for guidance and are told they should not be in Section 7, how silly of them to come to Section 7, they need to be in Section 9a; they go to Section 9a and find a sign which says: ‘Section 9a is closed for refurbishment, please go to Section 7 and await further instructions’. And so on; you get the picture. Patients are usually helped by being aware of this term and its meaning: at least someone has described this, recognised this; they are not alone.
Like the patient who has quite severe, enduring depression; he has seen psychiatrists, is on medication, but feels dreadful, hopeless. He feels physically exhausted and spends a lot of time in bed. He feels ashamed of his inability to get going. He goes to the DWP medical examination (with great effort), and is told, in a letter that arrives a week or two later, that based on the examination (one test was to see if he could fold a piece of paper and put it in an envelope) he has been deemed fit for work, and that his benefit (including his housing benefit which is paying his rent) has been stopped. This is a true story, incidentally, and occurred recently. This is Kafkaesque. The patient appealed the decision; then waited several months (benefits cut off); when he went to the Tribunal they apologised and re-instated his benefit. (In a truly Kafkaesque situation, they would have turned down the appeal….)
The writer Borges said this: ‘Kafka’s most striking talent was for inventing intolerable situations.’
Yes, intolerable situations. Our situation with having to register all patients was Kafkaesque.
The policy of registering with whatever GP you would like, anywhere in England, is Kafkaesque.
That nobody is discussing this policy is, in itself, also Kafkaesque. When I asked about this at a GP meeting a few months ago, I was told, ‘Yes, it is a crazy thing but all 3 parties are in favour of it so there’s nothing we can do.’ They are all worrying about how we are going to form Consortia, grapple with a limited budget, and so on.
1 Comment | General Commentary, Kafkaesque | Tagged: Choose Your GP, Health Planning, NHS | Permalink
Posted by gpprotest