Alice in Budgetland

The NHS year runs from April to the following March. Over the past couple of years, we have been encouraged to take a greater interest in the cost of the medicines we prescribe for our patients. You might think that such interest would be a "given" but it is not so. The NHS relies on doctors to "do the right thing" when choosing which drug to prescribe. At the same time, these same doctors are the targets of the intense promotional activity by the drug companies. Busy doctors have little time to take a calm, measured look as the latest drugs on offer.

One positive move was the allocation of prescribing budgets to GP practices. The carrot has been the offer of allowing practices to keep a proportion of any savings they make providing these savings are reinvested in improving care for patients. At the moment, there is no "stick"; there are no sanctions for exceeding budgets but it is hard to believe that won't come in due course. Last year we saved £70k from our budget. We look forward to using these savings to add to our services. An in-house physiotherapist; an acupuncture clinic, and the like. Our budget this year is £1.33m. That's our share of a total budget of £32m for the PCT as a whole. We have worked hard to make further savings and at about the half-way point (the latest figures available) we have increased our savings to an annualised £130k. Great! We can continue to offer these extra services and add to them.

This week I received a letter from our PCT. They have finally incorporated the changes in payments to community pharmacies. These changes will have to be funded from this year's budget. It means that £1.8m additional funding has to be found. Thats about 5% of the total budget and it will have to come out of all our budgets.

Let me see. Five per cent of our budget is £66k. Gone! Half the savings we have worked hard to achieve. It is the end of month nine of our financial year. What is the point?

It's official. A ruler can kill you!

My own primary care trust has long been careless with the term "Health Inequalities". They always include within their strategic plans the lofty aim of: "eliminating health inequalities within the trust's area". They also have another lofty aim of making sure that our resident's health is at least as good if not better than the London average. To me, the first aim misses the point and the second is at best contradictory and at is also illogical (if we get better then we have shifted to inequality somewhere else).

Whenever someone sees some else getting a better NHS deal elsewhere, they trot out the "postcode lottery" weapon and fire it off in all directions. Well, in terms of primary care, we like differences. We like to think we do things better than average. We like to think that when we refer a patient to hospital, we arrange for all the tests that the hospital are likely to need to have done so that the hospital diagnosis and treatment is not unnecessarily delayed. We know (from feedback) that we are reckoned by hospitals to be one of the better practices. That means others are not as good.

This is an "health inequality". The cure is to set sensible minimum performance standards and then ensure that all of us maintain them. It would be even nicer if they then recognised those that exceed them and held the underperformers to account but I'm not holding my breath.

Now the WHO has passed its ruler over "health inequities" and found out that these measurements can be lethal. Their report contains much sense although some of their conlcusions are less than revolutionary:

"The Commission found evidence that demonstrates in general the poor are worse off than those less deprived, but they also found that the less deprived are in turn worse than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere – not just in developing countries, but all countries, including the richest. The slope may be more or less steep in different countries, but the phenomenon is universal."

God alone knows how much it cost to reach that conclusion!

I just get an awful feeling that somehow using the jargon phrase makes easier reading for those who hold the public purse strings. "Health inequity" is a measurement. It doesn't kill anyone. The actions and inactions of policy makers and politicians lead to changes in mortality (for good and ill). Yet somehow "health inequity" doesn't have the same ring as unhealthy housing, hunger, ignorance and waste. It's softer.

The Lowest Common Denominator - again!

There are good doctors and there are some that are not so good. A few are dreadful. Such things are inevitable when there are so many of them and none of them every get younger. GPs are not except from this. In fact, given that most of them run their own businesses (i.e. their practice) the opportunity for variation is all the bigger.

Enter the "primary care trust". The job of a PCT is to be the part of the NHS with responsibility for signing contracts with these GP practices to deliver the services that the NHS wants delivered. Our contract is three inches (7½ cms) thick.

If you suffer from insomnia, you might leaf through the odd tonne of gumph spouted by the NHS about " ... devolving power to ensure local services reflect local needs, blah, blah, blah ..." It seems such lofty aims stop at the PCT. They simply cannot cope with lots of practices each doing things in their own way, especially when some of them don't do it properly or well enough.
Their response to such variations?? Simple!

Make everyone do it the same way, irrespective of whether or not that is better or worse than what was going on before in the non-problem practices. In other words, find the lowest acceptable performance level that everybody can meet and then make all do it, irrespective of how well they were doing it already.

Bad, like Tesco?

I attended a presentation yesterday about "Practice-based Commissioning". If you don't understand the term, may I suggest you click the "Next Blog" link at the top of the page? It would take too long ...

Anyway, one of the speakers was a passionate GP who explained what he and his colleagues were doing to ensure that the big, bad, Tesco/Boots/Sainsburys axis of evil didn't invade primary care. Why is this so bad?

Well, conventional GP thinking runs alongs the lines: They will open early and late so they will deal with our least-troublesome patients: the young, working people who don't want to take time off work to sort out their minor ailments. Under the present system of funding, we receive annually an equal amount of money for each patient. It doesn't matter what age they are, or how often they use our services. Since children and the elderly use us most, the loss of our least demanding patients mean we will find it hard to fund the same levels of care for these more vulnerable groups. GPs throughout the country are busy defending the status quo. I help ours to do so.

But before signing up to the received wisdom of the evil of Tesco et al, I think we all need to ask ourselves a number of questions about these companies and the services they provide:

1. Would you like your local McDonalds to be as clean as your local hospital?
2. Would you like to wait as long at the checkout as you do at your local GP?
3. Where do you buy fuel for your car and why?
4. Who deals better with complaints; Sainsbury or the NHS?
5. How much does it cost to park at your local supermarket and at your local hospital?
   

If you think I am being unfair, you are probably reciting a long list of the fundamental differences between a retail operation and a hospital. I don't see that cleanliness, punctuality, effective demand management, customer service and smart procurement should form part of that list.

Bureaucracy vs Reality

Just before closing time, the mother of a 14 year-old girl phones us and is very anxious about her daughter's "funny breathing" and chest pains that she had had all day at school. She is asked to bring daughter to surgery where GP examines the lass. As a result of the examination, the GP decides that there is no cause for alarm and that with the medication prescribed, she should soon be well again. However, if Mum is at all worried during the night, then she should not hesitate to call the out-of-hours service.

On the way home - GP is giving me a lift to the station - he says that he won't be at all surprised if Mum calls the OOH doctor although as far as he could tell, there was no cause for alarm. We then talked about the uncertainty inherent in many GP diagnoses and the "ninty-nine times in a hundred" they would be correct. Especially in today's medico-legal climate that leaves me worrying about the other "one in a hundred". I reflected on the two different approaches to such a dilemma: the doctor's versus the manager's.

The GP knows that if he or she refused to take probability into account, our hospitals and emergency services would be overwhelmed within a day. He/she takes responsibility for managing the flow of patients to the next stage of medical intervention be it hospital treatment, medication, or perhaps diagnostic testing. It doesn't get noticed because it isn't a tangible activity; but it is a real benefit of having a well-trained and well-motivated "gate keeper".

The manager is likely to try to remove all risk, if not from the system, at least from that part of it for which he is responsible. His approach will be: "if in doubt, refer". I have some sympathy. After all, he is the one that will have to deal with the "one in a hundred" should it result in a formal complaint.

I don't have a neat solution. Homo Sapiens rather inconveniently presents in an infinite variety of shapes, sizes and combination of physical and psychological variations, most of which are tucked away out of sight or reach.

The NHS only works because doctors assess probabilities and having done so, hope for the best. You may not like the sound of that, but in essence, this is what happens. We can rightly demand that this assessment is skilled, appropriate and that the evidence supports the conclusions that are then drawn. If the assessment is proven to be deficient, then let justice prevail. But, providing it is reasonable, our society and its legal processes should support such doctors and resist the demands of those seeking perfection. The costs to us all would be catastrophic.

Timber.r.r.r.r.r.r.r.r

Everybody and his or her dog reckons they know how GPs work. They don't need to ask us before providing new systems 'cos they already know what we do. They don't need to ask us if the new system will work. Of course it will work. Could anything be more simple? Well let's see.

The "Choose & Book" system had a cleverly designed form that it printed for us to give to patients. It provided them with their reference number, the information they need to contact the hospital of their choice and finally their password. The minimum amount of information requires about eleven inches of text. For those of us in the world of "A4" that's one sheet of paper for the first nine inches of text plus one sheet of paper for the remain two inches. There's lots of white spaces so it could have been condensed with a just molecule or two of design. Now after five hundred referrals and five hundred sheets of (almost) blank paper, we were delighted? to see that they have redesigned the form. Some bright spark at CfH has discovered Text Boxes. Yippeee.

Now two sheets of paper have become three. The second has a little bit of writing. The third has a couple of lines or so.

Timberrrrrrrrrrrrrrr.

I See No Ships

Dear Patsy,

Thank you so much for all your recent communications to us lowly people who look towards you as their leader. My word you have been busy but through this maelstrom of media engagement your new organisation has triumphed. I haven't actually seen the Powerpoint presentation as yet; our PCT's IT department is busy taking down the Christmas decorations at their shiny new offices in Marie Celeste House. Nevertheless I think I have the gist of what you had done. Perhaps you could confirm my understanding?

Your new communications team (the Strategic Press Information Network - "SPIN") have already scored some notable goals for the good guys. Clearly it helps to have a clear and unabiguous target (and what government has more impeccable credentials when it comes to targets?). Having said that, why not come out into the open and say exactly who you mean instead of hiding behind a code name of Greedy Pigs (or "GPs" as they are already known amongst the congoscenti). Let's name and shame. After all, these GP bastards have a lot to answer for.

There's that awful PFI or "Perpetual Financial Indebtedness". I was about to say that only GPs could have come up with so financially awful but then I remembered ENRON who did try the same thing. Still your solution is a master touch. "Put the Blame on Contractors" or "PBC" has solved the problem in one simple yet ever-so-stylish stroke. Of course, PBC only works when viewed against "PBR" (the "Public Sector Borrowing Requirement"). This clearly is no impediment since our almost Prime McMinister seems to have no problem in shuffling the numbers around with the leger de main of a Mancunian croupier.

As any good admiral, you are now reaping the benefit of having thought ahead and deployed your reserve troops ready to deal with the situation as it has unfolded. Operation "Blame" ("Bring in Lots And lots of Management Experts") is as much a triumph as Nelson's was at Trafalgar. Everyone expected you to cover up the mess made by these GPs but oh, no! You simply came right out and did it. "It's all the GPs fault. They have taken all the money."

Brilliant!

I can't wait for next week.


p.s. Just remind me - who were those GPs exactly?

Wow! What a response!!

Patsy,

The speed of your response is breathtaking. Thank you.

Thank you for the names I requested as examples of very bestest practice. I'm ashamed to admit that I thought you might find it a little difficult to find a name but so many?? That's truly impressive stuff. I've already had a preliminary chat with most of them and will update you further once I 've had the chance to absorb the 28-carat nuggets that were forthcoming. However, these are my first impressions:

John Prescott was really helpful (I think). It was a little difficult to find him at first. I wasn't sure which car he was in and to which of his government-provided houses he was being driven but I am nothing if not persistent and, like the mounties, got my man. He had much to say. I must confess that I did lose the thread occasionally but this is only to be expected when dealing with a man who runs much of the country when TB is away (which seems to be rather a lot these days). (Off the record, he really is worth more than the £150,000 a year plus expenses plus cars plus offices plus staff plus pension etc. A bargain if you ask me). Lord Prescott will only add lustre to the upper house (should he need a third).

Next came John Reid. I really struck gold here since he was able to arrange a "four-way" teleconference between the two of us AND Charles Clarke and David Blunkett. This I was able to get the collective wisdom of all the players who had delivered a Home Office which frankly is an example to us all. It also completely clarified what is meant by "fitness for purpose". Gosh, don't we have a long way to go?

Perhaps the most difficult interview was with Frank Dobson who as your predecessor in 1997 can take all the credit for demolishing those appalling Tory gimmicks such as internal markets, devolved budgets, etc etc. It is still a puzzle to see why he came a bad third to Ken Livingstone and Steve Norris in the London mayoral elections. Clearly it has left its mark. Still he did have some words of praise for the Treasury who have always been so supportive of his efforts.

I've left a message for Ruth Kelly at Education but she's not taking calls. I don't have a number for Margaret Hodge so all-in-all Education is a proving a tad tricky.

Steven Byers suggested floating our surgery on the stock market and then cancelling the shares but was a little vague on detail. David Miliband at Defra suggested I could learn a thing or two about making every penny count by looking at his department's work on the common agricultural policy.

I've left the best until last. Our beloved London Mayor was unsparing in his help and was generous in providing me with a text-book study on spending £800+ millions that wasn't in his budget on buses that now run every ten seconds in packs of five meanwhile taxing the overpaid bourgeoisie swanning around London in their 4x4 tanks to pay for it. Surely there is no better example on how to soak those rich GP bastards. You can rely on Ken.

I am so totally energised by your timely response. You have only increased my determination to prove that we in the health service can do just as well as our beloved leader has done for the people of Iraq.

What a team! What results! What an example to us all.

Your greatest fan

p.s. my thanks to my good friend Dick for his input.

An Appeal

Dear Patsy,

I am writing to say how sorry we are to have been the cause of so much inconveniece to you and your team at the Depratment of Health. How could we have been so inconsiderate? How could we have so exceeded your performance expectations and quality targets. Please, please calm yourself. The solution is at hand.

Our partners have cancelled all their sessions for this week in order to focus on re-establishing the "cost trajectories" that had been established in your original plan. In doing so they are helping in two ways: firstly, it will lower our quality indicators scores and start us on a firm trend towards the 777 points you assumed we "average" practices would achieve. Secondly, we will stop registering new patients which will lower our totals thus directly reducing our income. It has been most pleasing to help you achieve these most important objectives. Of course, we need to look to the longer term. God forbid that we should ever be accused of short-term thinking.

We will be issuing redundancy notices to the two health care assistants that we recruited to shoulder much of the administrative and routine monitoring tasks. Such actions have both good and bad outcomes with which we are
wrestling: we will achieve less and thus earn less which surely is a good thing? The trouble is we will spend less so we will still appear to be the same greedy money-grabbing bastards you have led with such grace, such aplomb since your appointment. Our nurse practitioner has now finished her nurse prescribing course and which for the past four months we have been trying desparately to get our PCT to authorise so she could use the knowledge she has worked so hard to learn. We didn't realise that their gross inefficiency is part of your master plan to reduce our prescribing spending. So, our pursuit of the appropriate signature will cease immediately.

Reducing our staff brings other benefits. We now have some spare equipment so if you know of anyone who wants two Celeron P2 PCs with less memory than the average Alzheimer victim, together with two HP 959c printers with worn print heads and wonky power lead sockets and who provided they can outbid our local museum, then they are theirs for the asking.

However, let's not be negative. There are some real win/wins on offer. We have decided only to refer patients if secondary care can be booked via your wonderful Choose and Book system. Thus you will soon be able to claim that everybody is using Choose and Book successfully and you never know, one day it might actually be true. What a day that will be. In the meantime, we continue to enjoy the built-in restrictions that slow down the whole process thus in turn reducing spending. We especially like the way you have camouflaged these sophisticated barriers as technical problems, slow connections and inexplicable log outs. Darned clever those computer boffins.

I'll need your help on the next one. Could you point me in the direction of another government-led organisation that has been too successful and resulted in over-generous incentive payments? I would like to have a "heads up" with your opposite number in whatever ministry they work to get the griff on how to claw back the money whilst maintaining morale and improving output. One will do, although two names would provide me with more depth of experience. No rush on this one.

Finally I do feel the need to confess that we may unwittingly provided ammunition to those who feel that your views on general practitioners may be anything but entirely well-informed and wholly accurate. So, with immediate effect, we are withdrawing our labours from our local out-of-hours service so that we cannot be accused of earning too much from private fees. I have to confess that we failed to opt out and reduce our income by the fifty-odd thousand quid our partners could have spent on you rather than on themselves but it's no use crying over spilt milk. I don't like a "blame culture" any more than you, but quite frankly, it wouldn't have been a problem if our local GP co-op wasn't so damned efficient. Then out-of-hours cover would have cost us the fortune it seems to cost in most other places. Still, I have now hit our co-op manager round the back of the head with a plank and let the air out of her tyres and this should do the trick.

Please find enclosed a cheque from the practice which represents a downpayment on the repayment of the scandalous Tsunami of cash that has come our way. More will follow I am sure. Perhaps we should send it direct to Accenture who nearly lost so much money on NPfIT? Didn't you used to work for them? Perhaps you could let me have the address of one of your colleagues?

Always here to help,

Bestest wishes

A Letter to my MP

Dear Dianne Abbott,

After much consideration, I have decided that it really is about time that you, as my MP, put my interests at the forefront of your thinking. Gone are the days when every four years or so, you could break off from your busy schedule of evening television programmes to remind us all just how great you have been at doing whatever it is that you do. I think it's about time that you put us, your constituents, at the heart of your thinking.

Recently, I got together a group of citizens and we held a "Citizens Summit" at 'The Fox Reformed' on Stoke Newington Church Street. I asked them what they would like to see from you, their MP. Their responses were interesting and I have sifted through them to find those that are neither physically impossible nor morally repugnant. There were a few left.

First of all, we want to see you at a time and place that is convenient to us. I work away from Hackney so I expect you will make reciprocal arrangements with your Newham colleague so I can visit him during my lunch hour. Also, I'm taking the mother-in-law to Prestatyn in the new year, so I would be grateful for contact details of your colleague there just in case I feel like an evening chat.

Now your website doesn't actually give details of your constituency "surgeries" (I think that's the term) but I do have a number of irritating minor ailments, so I need to know where I can make several appointments stretching through Christmas and the New year. At the same time, I wish to be reassured that should I have a short-term crisis with my brown recycling bin, you will be on hand to get things done. Now I just thought I should warn you that I may, or may not keep these appointments.

When I do visit you, it may be that I will need to speak to someone else as well. I would like you immediately to make me an appointment with that person, again at a time and on a date of my choice. Of course, I would expect you to confirm it in writing.

Finally, I am enclosing my proposals for "Payment by Results". This exciting and radical plan represents the biggest shake up in parliamentary procedure since Dennis Skinner said something constructive and no more that mildly offensive. Quite simply, MPs will be reimbursed on the basis of "outcomes" rather than at present. I suggest fifty five quid for a consultation; twenty pounds for writing a letter; let's say thirty quid for each day in excess of fifty days a year that you actually turn up at Westminster and say something .. ( I was about to say "useful" but let's not run before we walk).

Even more exciting will be the Enhanced Payments to which you will be entitled once we have completed a survey of your constituents. We will mail a number of them at random and ask them questions about what they think of you and your effectiveness as their democratic champion. I attach a sample questionnaire but suggest that you pay it little heed. It's not the one we will actually send out to people.

Finally let me offer you some soothing words about those dreadful rumours that have been circulating. Of course at this stage, nothing can be ruled out but I am happy to reiterate that at this moment in time we have no plans to introduce private contractors into the House of Commons to take over constituencies where performance may be below par. That doesn't mean to say that we won't be pushing to expand those parliamentary walk in centres. You know the ones. You turn up; they listen attentively; and then they tell you that you need to see your own MP for that particular problem. Whilst they don't actually add much value, we do think that they sound good and we'll get lots of brownie points from our friends and neighbours.

I look forward to seeing you next Saturday afternoon at about six-ish. I have this nasty rash on my front drive .....