Wednesday, June 5, 2013

NHS Sunset: Too late?

Is it too late to learn from the Mayo Clinic?

Is the sun setting on our NHS?

As labour supporters are scrambling to deny that their 2004 GP contract has anything to do with the problems of OOH, NHS111, Harmoni and Serco, GP leaders could be forgiven for protecting the interest of GPs. England is the only country where many GPs earn more than specialists.  

© Am Ang Zhang 2013

Competition does not serve patients’ interests.

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other:  “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.

More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.

In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?

Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. .  .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”

2004 GP Contract:

Rewarding GPs for the services and quality of care they provide rather than just the number of patients they treat has led to an average increase in earnings of 30% from 2003-4 to 2004-5. This is one of the findings of an analysis of the tax returns of nearly 18000 GPs in the United Kingdom.

The figures, published last week by the NHS's Information Centre, show that GPs earned on average a net income (after deduction of expenses but before deduction of tax) of £106000 (€160000; $210000) in 2004-5, the first year of the new GP contract. In 2003-4, when less than 4% of what GPs earned derived from quality of care payments, their average net income was £81566. Under the new contract, between a third and half of each GP's income comes from money earned from the quality and outcomes framework (QOF) scheme, the system designed to incentivise GPs and improve quality.

GPs working in practices operating under one of the variants of the new contract, the personal medical services (PMS) contract, saw their income rise by 27%, whereas the income of those working under the general medical services (GMS) contract rose by 33%. However, the net income of doctors working under the PMS contract (£116583) in 2004-5 was slightly higher than that of GMS doctors (£102437).
PMS contracts are more flexible than GMS contracts. General practices that operate under a PMS contract negotiate their contract locally with their primary care trust and can create their own achievement goals to suit the population they serve, rather than follow the QOF scheme. A practice serving a large homeless community, for example, might choose to operate under a PMS contract.

GPs working in dispensing practices also earned slightly more than those in non-dispensing ones, netting an average of £128000 after expenses had been paid, a rise of 31% from 2003-4. Non-dispensing GPs earned an average of £102000 after expenses, 30% more than in 2003-4.

The new contract was introduced in 2004

GPs were so stunned by the terms offered to them when negotiating their new contract that they thought it was a "bit of a laugh", a doctor has said.
Dr Simon Fradd, who was one of British Medical Association's GP negotiators, said they were shocked by the approach taken by the government.

They could not believe it when GPs were given the chance not to do evening and weekend work for a 6% pay cut, he said.

Since the deal started in 2004, average GP pay has topped the £100,000 barrier.

The final Contract was signed off by Health Secretary John Reid who was never a pushover.

Patricia Hewitt Hindsight.

The deal, which rewards GPs for providing certain services rather than simply according to the numbers of patients on their books, was designed to give practices additional funds to invest in patient care.

However, there have been qualms about the extent to which profits have grown, soaring by 30% in the last year.

Some commentators have argued that the GP contract could become a symbol of the Blair government "throwing money at public services" and failing to get good enough improvements.

Ms Hewitt, who became the health secretary in May 2005, told BBC News that, with hindsight, she wished GPs' earnings had been capped.

She said the extent to which doctors would respond to performance related pay had not been anticipated.


T e a c h i n g  f o r  T  o m o r r o w ’ s  P a t i e n t
Mayo’s combination of culture and technology is potent. The culture makes it okay for highly-trained providers to ask for help; the technology makes it easy to provide the help.
A Mayo Rochester internist speaks to the cultural influence: ‘‘The strong collegial attitude at Mayo allows me to call any Mayo  physician at any time and discuss a patient in a tactful and pleasant manner. I do not feel afraid or stupid when I call a world renowned Mayo surgeon. We respect each other. We help each other. We learn from each other.’’

A Mayo surgeon recalled an incident that occurred shortly after he had  joined the Mayo    surgical staff as the most junior member. He was seeing patients in the Clinic one afternoon when he received a page from one of the most experienced and renowned surgeons on the Mayo Clinic staff. The senior surgeon stated over the phone that he was in the operating room performing a complex procedure on a patient with a difficult problem. He explained the findings and asked his junior colleague whether or not what he, the senior surgeon, was planning seemed appropriate. The junior surgeon was dumb-founded at first that he would receive a call like this from a surgeon whom he greatly admired and assumed had all the answers to even the most difficult problems. Nonetheless, a few minutes of discussion ensued, a decision was made, and the senior surgeon proceeded with the operation. The patient’s problem was deftly managed, and the patient made an excellent postoperative recovery. A major consequence was that the junior surgeon learned the importance of intra-operative consultation for the patient’s benefit even among surgeons with many years of surgical experience.

No Internal Market, no silly cross charging.

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

                                                                                   NHS & The Mayo Model: What if!

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