[GCW]

But GP's are private businesses aren't they, the only difference is that the majority of the time they invoice tax payer man.

It's probably the most bizarre business model around.  Money comes from various different sources eg CCGs, local LaSCA style groups, area team etc plus via the QoF framework.

What holds them back at the moment is the starting point for decision as to how to manage the system appears to be that the datum point is that it is the system that this important rather than the needs of the patients.

I think I see what you are saying, just about.  There have historically been various contractual obligations which mean direct competition between practices can't really happen.  Over recent contract changes, and future changes, this is being gradually chipped away.  Once competition opens up, private companies will take over.  A good size GP practice will only have an annual turnover of, roughly, a million pounds. Which in business terms is fuck all.  How can one practice realistically compete against Virgin?  Can you see where that will go?  I certainly can.

The NHS seems to be the only entity where litigation does not drive improvement in practice / radical reform.

Not sure about that either.  Don't forget, the budget is the same so if you have a pay out from litigation there's less left in the pot to make changes.  In some ways, the more litigation there is then the less money is left to address the issues.

[Ru]

GPs are currently hamstrung by masses of red tape and constant funding changes that make any forward visibility for business planning very difficult. Add in the cash flow issues created by having massively complicated payment arrangements then sacking everyone at the Primary Care Trusts that knew how they worked only to be replaced by private firms that employ too few staff.

"Market forces" in GP land are a good idea in principle, but where you have a monopoly contract provider that can (and does) unilaterally change the contracts every year and can't keep up with payments, running a GP practice in a way that barely resembles a normal business is extremely difficult.

Sloper - imagine the Jackson reforms, every year, coupled with an unannounced rule change that says that costs will suddenly only be paid in 6 months time, maybe.

[rich d]

An interesting piece of evidence is the number of successful claims for clinical negligence; I can't recall the exact numbers or range but from partner instructed by MDU / MDS which accounts for pretty much 90% of his practice (i.e. he should know) and has been for 30 years (so he's got a fair data set) is that the incidence of clinical negligence in the NHS has been on the increase since the late 1980's / 90'.

Don't think that's what that shows at all/ Litigation of all kinds has increased as we follow the US into a more litigious society. That's a bit like basing a hypothesis on the population's necks getting weaker whilst at the same time driving standards are decreasing by analysing the increase in whiplash cases for the same period of time.

[Sloper]

I'm not sure as to volumes of litigaiton generally, but I deal with risk in law and when we f--k up and have to notify our insurers the first question they ask is what have you done to stop it happening again.

That the vincristine deths in the NHS, all well publicised and yet it took a gross negligence manslaughter case to drive a change, the previous what was it 6 or 7 deaths and the litigation that followed clearly weren't enough.

Ru, JFW (now there's a need for one of the symbols along with JFCOAB) is it that bad? If so then we definitely need a revolution int he system, what would be so complex about simply allowing each person a certain £amount from central funds?

[GCW]

Ru, JFW (now there's a need for one of the symbols along with JFCOAB) is it that bad? If so then we definitely need a revolution int he system, what would be so complex about simply allowing each person a certain £amount from central funds?

There's a lot of other factors for weighting, such as deprivation indices and things like MPIG (although this is going, and so will a few practices that have a high proportion of MPIG income) in order to allow the system to work.  GP surgeries are too small a business to be competitive.

[andy popp]

step 3. Market forces work. 

 

Are you suggesting that market forces don't work?  really?

Perhaps Stubbs was suggesting markets never work perfectly and often work very imperfectly.

To simply say that markets work is as trite as saying that they don't.

[fatkid2000]

We've been approached to buy 2 single handed practices - but we couldn't make it work financially.

Private companies have also turned them down from what I can gather.

We are now absorbing patients from these 2 places as we offer more services than the practices they are currently registered at.

The competition things is interesting - as there currently aren't enough GPs to cover the demands is it really going to be any better if you see a private company? Will private companies be interested in visiting the housebound? 

I've just be recruited to be a clinical commissioner - so my knowledge in this area is about to spiral. I predict the down grading of lots of hospitals and the centralisation services - like trauma , cancer etc - which will mean your primary are doc will need to be even better to make sure your care is properly coordinated. Interesting times ahead .

[Sloper]

step 3. Market forces work. 

 

Are you suggesting that market forces don't work?  really?

Perhaps Stubbs was suggesting markets never work perfectly and often work very imperfectly.

To simply say that markets work is as trite as saying that they don't.

Of course, it is a simple statement and as such not wholly correct; however in general terms  (and we can go into the concept of 'proving' rules, Zeno, Rawls, Popper and so on) the evidence that markets work is positive and overwhelming when taken agains the contrary proposition; further the evidence where market's are supressed further demonstrates adverse outcomes when compared against the state where markets operate in less constrained environs.

The notion that the market is, or has ever, been 'free' is deluded.

[Stubbs]

The idea of 'competition' and 'market forces' seem to have failed to produce good outcomes in everything else that has been denationalised, but I'm sure it will work great for the NHS...

[Sloper]

Nonsense.

Privatisation of BT was worked incredibly well, Gas & electricity less so but still very well (because there isn't the same scope for technological innovation as telecoms) it used to be routine for MPs to raise questions about delays in installing phone lines, connecting gas & etc in Parliament I don't think that's happened for a very long time. 

And while we may rage against the call centre's and the like, the system is now more modern, more flexible and we as consumers have more choice.  None of that would have happened without privatisation and market forces.

In fact the only privatisation that's performed below expectations is the railways (and many had pretty low expectations from the start!).

You're also making a false analogy between privatisation and the (greater) introduction of market forces the two are in no way the same.

What you also seem to fail to recognise is that the absence of market forces & competition within the NHS is one of the reasons that dysunctional practitioners and practices can persist for so long.   I am sure that you can with very little informaiton dig up a major scandal in an NHS operation pretty much every other year since the 1950's and remember back then the deference in th media & etc

The support for the NHS border's on the theistic which is a dangerous approach, we need to idenitfy what's wrong with the NHS and deal with those problems, and ohh my giddy aunt, if a provider can provide a better service for less and make a profit, is that really such a bad thing?

[GCW]

The support for the NHS border's on the theistic which is a dangerous approach, we need to idenitfy what's wrong with the NHS and deal with those problems, and ohh my giddy aunt, if a provider can provide a better service for less and make a profit, is that really such a bad thing?

A free at the point of access service can not cope with today's demands on healthcare.  C'est tout.

[Obi-Wan is lost...]

I struggle to understand how introducing several layers of bureaucracy such as commissioning and the whole recharging/coding debacle (which has huge potential for corruption) plus a percent age of the budget being creamed off to the shareholders is likely to improve the service.

I can see how a private hospital specialising in finite pieces of care such as hip ops can be super efficient production line  however for more complex areas such as mental health, we are already seeing private companies in Sheffield putting their profits before the best care for the patient.

[fatdoc]

The issue in healthcare is what we expect from a NHS.
Yes, the any willing providers in Sheffield either win tenders, or pay to take overspill from the tertiary centres, do simple proceedures in the relatively well, and do it to high standard. When there are inevitable complications, that gets pushed back to the NHS... The tariff kept by the private company.

Why do the NHS institutions there abouts not keep these profitable cases?

Because the centralisation of services, often not for improved end results but for political gain ( remember the fall out from the attempted closure of Kidderminster and the 4 decade plus cross party desire to lower the power of the medical profession in healthcare planning - more on that later) means the tertiary centres sell off the little cases to make room for new trauma / cancer / vascular empires.

However with the sub specialisation of medicine, for the greater good,OOH specialist work needs to be staffed by a functional rota... 10 to 12 consultants.

The move to super hospitals is thus inevitable. The utilisation of private health care providers facilitates this, pressures the  now dwindling in size DGHs and will force closures.

Here is the trump card.... Because the commissioning is now DR lead.. It will never be a political figure on the news being blamed for a local DGH being down graded or shut, but a dr.

Perfect storm.

As I've said on another thread.... law is a better career choice.

[webbo]

I struggle to understand how introducing several layers of bureaucracy such as commissioning and the whole recharging/coding debacle (which has huge potential for corruption) plus a percent age of the budget being creamed off to the shareholders is likely to improve the service.

I can see how a private hospital specialising in finite pieces of care such as hip ops can be super efficient production line  however for more complex areas such as mental health, we are already seeing private companies in Sheffield putting their profits before the best care for the patient.

Mental health is in absolute chaos I suspect in most areas. I spent most of yesterday afternoon looking at protocols for administration of medication in the community. The responsibility lies with the lead nurse in each time, which in my team is me. However as I am now at risk due reorganisation and they want me to be either a manager or on a lower band. We won't have a lead nurse so I wonder how it's all going to work.
Mental health also has the elephant in room of the mental health act which in Forensic services is being cherry picked by private companies. But these services rarely provide community follow so they lock up the patient for months / years and when the patient is discharged out in to the community it's back over to an under funded and under resourced NHS community team. Who are then supposed to keep both the patient and society safe.

[Sloper]

Ahhh scare in the community, just remember after every entirely predictable system resultant fuck up and murder you can have a nice serious case review.  All I can say is I'm f--king glad I don't have your job and glad that there's people like you who do.

On a very limited scale I've seen the 'place of safety' detainees being brought into custody and it's not a pretty sight.

Yep, it's a can of worms and only a short step from the next tabloid outrage, as to proposing solutions I haven't a clue.

[webbo]

Your reply both suprises me and at the same time fills me with gloom. I sorted half expected a reply saying " the mentally ill, their all possessed they need burning" But you of all people not having any answers no matter how off the wall or tongue in cheek sort of means there is no hope.

[Sloper]

Well on sober reflection and to lift your mood, what about a new Channel 5 series 'I'm strictly a non treatable personality disorder get me out of celebrity Rampton' where the seriouslly ill get to compete against each other in a group therapy dancing session to earn equipment to stage an escape from a special hospital.

I bet Dirty Des would cream at the very thought.

If 50% of the profits from the plebs voting went into front line mental health care it wouldn't be a panacea but it would be a big help.

Plus there's the 'after hours' version where the escaped patient's are pursue by the plod with personal cameras for the point of view voyerism pleasure.

There, normal service is resumed.

[webbo]

Ah that's better, cheered me up no end and prepared me for another day being shouted at and abused.
I might have to stop going to NHS future planning meetings.

[Sloper]

To cheer you up a bit more, why not agree with the next patient who thinks that they're Jesus and see if you can arrange a suitable crucifiction and resurrection (obviously the last bit will be tricksome)?  Channel 4 would pay a fortune to screen that live, working title 'NHS reforms make me cross'.

[tomtom]

If it involves a crucifixion I suggest a slight modification in the title:

To cheer you up a bit more, why not agree with the next patient who thinks that they're Jesus and see if you can arrange a suitable crucifiction and resurrection (obviously the last bit will be tricksome)?  Channel 4 would pay a fortune to screen that live, working title 'NHS reforms and my cross'.

Anyway - we already have a TV show were mentally unbalanced individuals are locked up and watched be (a small part) of the nation. PMQ's.

[duncan]

Before embarking on yet another wholesale reorganisation it is worth recognising almost every healthcare system in the developed world is in some kind of financial crisis. This is largely a consequence of health cost inflation running at double background inflation for the last 50 years. As far as I'm aware, this has occurred in every mature developed country healthcare system, irrespective of degree of market involvement versus central control, whether largely private insurance or largely tax supported, independent of political hue of the government. Market efficiencies, if they occur, seem to be offset by insurance costs for example (20% of US healthcare costs when I last checked). The only exceptions, as far as I am aware, are those in small population countries with large oil revenues.  This suggests that increased free market involvement is not a great panacea.

Do I have a solution to all this? Well, greater healthcare rationing is clearly inevitable. We can't pay for everything we could do. I don't mean the tokenistic irrelevancies that sloper proposed a page or two up. We could let the market do the rationing, which I suspect would lead to about 20% of the population getting exceptionally good healthcare and the remaining 80% getting emergency cover from the rump of the NHS. I'd suggest a far more fundamental shift in resources away from expensive secondary (hospital) care into primary care. This will provoke howls of rage from certain vested interests of course and a host of politically unacceptable headlines in the usual papers.

[tomtom]

This graph is always interesting in the debate... gives an idea of which health system is more or less cost effective...  (there are also cultural steers in the results)

I think all health systems suffer heavily from legacy issues.. treatments, patients, technology, issues are all changing - and what might be the best way to fund/run a health service 50 years ago is probably not the best now. But changing from that old model is tricky - and that I suspect is at the root of most of the NHS issues.

[Stubbs]

Love where the US is on that graph! Lots of great (scary) articles about the costs of healthcare in the states around e.g. http://www.npr.org/2013/08/07/209585018/paying-till-it-hurts-why-american-health-care-is-so-pricey 

It costs $13,660 for an American to have a hip replacement in Belgium; in the U.S., it's closer to $100,000

[tomtom]

Love where the US is on that graph! Lots of great (scary) articles about the costs of healthcare in the states around e.g. http://www.npr.org/2013/08/07/209585018/paying-till-it-hurts-why-american-health-care-is-so-pricey 

It costs $13,660 for an American to have a hip replacement in Belgium; in the U.S., it's closer to $100,000

Yup. Cuba is missing from that graph too - it has a high life expectancy but very small cost. Make of that what you will Comrade Sloper

[slackline]

I've posted similar graphs before but don't think life expectancy is that great an outcome so did a quick search for plots of health care expenditure v's quality of life...

...couldn't find anything in the few minutes I had.

It did however throw up a more comprehensive version of the life expectancy v's health care expenditure that doesn't just focus on OECD countries...