Monday, March 03, 2008

Surgery Communication Breakdown


I am become Gordo, the destroyer of General Practice


The Doc is fed up with being bashed by media chatterati like Joan Smith and David Aaronovitch. As we know, these left-wing journos have gleefully jumped aboard Labour's hysterical and hypocritical campaign to blame GPs for the destruction of our traditional GPs' services: poor old Joan is complaining today about being forced to "wait in biting wind and rain" for the Doc to open.

We've blogged this many many times, but let's recap the main points:

  • That mad GPs pay deal was dreamed up and pushed through by Whitehall commissars, not the Docs, nor even their trade union
  • The commissars were so fixated on implementing their box ticking "plan" (aka the Quality Outcomes Framework- QOF) that they never considered how it might affect the overall behaviour of GPs or the work choices they would then make (see this blog)
  • NHS Commissar Warner- now working for gzillions in the private sector- reckoned the commissars had "taken their eye of the ball" (see this blog): more truthfully, they wouldn't have recognised the ball if it had come along and whacked them on the bonce
  • GPs couldn't believe their luck - BMA negotiator Dr Fradd said of the loathed (by Docs) Out of Hours service (OOH), "We got rid of it for effectively 6% of the value of the contract. It was just stunning. Nobody in my position had ever believed we could pull it off but to get it for 6% was a bit of a laugh."

And now, having screwed up right royally, the commissars and their left-wing journo supporters are finger-pointing the Docs, citing in evidence patient surveys that show millions of patients are unhappy with the shorter opening hours. The Docs respond by citing other surveys (or maybe they're the same surveys- we've lost track) to show that actually millions of patients are blissfully happy with the opening hours.

And the patients?

As per, we were never consulted about the changes. Or even informed, until one day we tried to get a Saturday morning GP appointment and found we couldn't. And many of us are not at all happy.

But who should we blame? The Docs were obviously the ones who actually put up the "Closed" signs, but as we've said before, if we were NHS GPs we'd surely have taken the commissars' deal as well.

We're back to that old problem of the Simple Shopper intermediating himself between supplier and customer.

We taxpaying patients have no effective way of signalling our wishes to our GP suppliers. With Tescos we can signal dissatisfaction by not shopping there next week. But, other than through those opaque polls schmolls patient surveys (and have you ever been asked?), the only way we can signal our GPs is by replacing one set of elected clotheads with another.

And then, only once every four or five years.

And then, only if we live in one of those 100 important swing constituencies.

And then only if the clotheads decide they want to take any notice of our views on GPs opening, rather than, say, invading Iraq.

And then only if the particular clothead who decides to take some notice isn't immediately moved on to the Home Office.

And then only if he actually knows which levers to pull to achieve the required result.

Etc etc etc.

Customer-supplier communication it ain't.

The Doc has long argued that there should be a charge for seeing your GP, on the grounds that "free" services are never properly valued, and customers think they can just take as much as they fancy.

We agree. As we blogged here, free at the point of use GP services worldwide are as rare as NHS dentists in Surrey. Here are the charges in some comparable countries:

  • France- €21 (£14) per GP visit, with 70% being refundable by state social security. Co-payment is a basic operating principle of French state healthcare, although most people take out private top-up insurance to cover some of the personal contribution.
  • Germany - £7 (since 2004)
  • Australia- A$55 (£23), with 60% refundable by Medicare
  • US- pretty well what the market will bear- up to around $250 (£127). But as long as you've got insurance and/or are over 65 on Medicare, you pay a lot less- reportedly as little as $10 (£5).

Back in The Old Days things were different here too. Pre-NHS GPs did charge their patients (see this blog). So why did we drop it?

Well, we know why- it was all part of that New Jerusalem cradle to grave fantasy.

But the thing is, that got abandoned virtually as soon as it started, with the introduction of charges for specs and false choppers (see this blog). And today many of us pay for a great deal of private healthcare to fill gaps in NHS provision. Reform recently estimated the average British family is spending £1200 pa on private healthcare, over and above the £3,850 pa it pays for the NHS via taxation.

So why not simply add GPs to the list of health stuff we already pay for directly?

Too expensive?

Hardly. When last sighted, in 2005-06, the NHS spent £7.7bn on GPs services in England (on top of prescribing costs of a further £7.8bn). On that basis, we reckon GPs services are currently costing us £160 pa each. Against which, CityDoc offers a twenty minute private GP consultation in central London for £65, or £85 for "more than 30 minutes". And when did you last have more than 30 mins with your NHS GP? They just don't have time for that kind of carry on.

If we got the money cut off our taxes most of us could afford to pay direct once again. And the big BIG advantage of paying direct is that the patient becomes the customer. Not the commissars as the customer, but The Patient.

And if we had to pay for GPs - either in total or as a co-payment "excess" on an insurance policy - it would sure concentrate our minds on when and how we access the service.

Would we want and pay for a return of OOH? Maybe. But the following ONS chart shows that patterns of GP access were changing long before the pay deal, with home visits declining drastically from over 20% of consultations in 1971:

Perhaps it's all too late anyway. Perhaps traditional GPs are doomed, just like the Doc predicts.


But the people who should decide that are not the Commissars. Or even the GPs themselves.

No, the people who should decide that are the paying customers.

So how can we arrange it?

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