Friday, May 27, 2011

NHS & Market Forces: Fund Holding & Medical Ethics

Dawn, anyone?

©Am Ang Zhang 2011

It was an interesting time during the brief few years of Fund Holding (FH). The idea that money should play no part in who gets seen was thrown out of the window. My hospital consultant colleagues all knew that preference will be given to referrals from Fund Holding practices. It was about survival. Less urgent cases would be seen if they come from FH practices.

Our Trust was small and we had to deal with two main FH practices and five non-FH ones. Child Psychiatry used to take self referrals but overnight that was stopped by our managers. Worryingly referrals from one FH practice dropped very dramatically. So the government’s clever idea may have some merit.

Then something strange happened. The other FH practice’s referrals shot up dramatically and this was across all disciplines.

Our managers thought: wow, more income for the Trust.

Not so the Cockroach Catcher and despite my protestation, I had to give their referrals preferential treatment.

“I thought it was based on clinical merit.”

Then, the bombshell: we were owed in excess of £2 million at the end of the second year and special administrator was sent in by the Authorities. We never got the extra money!

I quoted Prof. Waxman in an earlier post :

April 30, 2010  Jonathan Waxman

When I started in medicine, the hospital was run by about three people. Things were so much more simple when doctors and nurses treated patients, doing their best without the guidance of guidelines and targets, doing their best ... yes ... to make the patients better. How did we manage without forms to fill and waiting times compliance? Quite well actually. The medical director ran the medical side of things while matron and the accountant handled the rest. It wasn’t much of a business then: it didn’t have to be, because there was no internal market to manage.

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.
And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.

250,000 administrative staff
There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.
One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.

There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.
The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.

The Nation as a whole
Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.

So what should we do? Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.

Why should anyone worry who provides healthcare? Because the weight of evidence is that private markets in health bring exorbitant administrative costs, lead to cherrypicking of more profitable patients, increase inequity and the postcode lottery gap, generate conflicts of interest, are unaccountable, and increase pressure for top-up payments and "care package" limits.

Keith Palmer on competition and choice
 “…….competition and choice in contestable services may inadvertently cause deterioration in the quality of essential services provided by financially challenged trusts, and therefore widen the quality gap between the best and worst performers. Market forces alone will rarely drive trusts into voluntary agreement to reconfigure in ways that will improve quality and reduce costs. In most cases, the most likely outcome is that financially challenged trusts will suffer a downward spiral of continuing financial deficits, deterioration in the quality of care and a further widening of the quality gap. The NHS will have no alternative but to continue to fund these deficits or allow the trusts to fail.”                    RECONFIGURING HOSPITAL SERVICES: Lessons from South East London

A culture of corruption pervades the links between government and business, fuelled by and fuelling privatisation. These relationships are – as Adam Smith put it – a conspiracy against the public interest.

NHS & Monitor: Toyota & McKinsey

Mid-Staffordshire: Unbelievable! Unbelievable! Unbelievable!

NHS: The Way We Were! Free!
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Email: cockroachcatcher (at) gmail (dot) com

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