Thursday, February 28, 2008

Extra Money Does Not Necessarily Buy a Better NHS

Whoever negotiated the GP Contract on behalf of the Department of Health should never be allowed near a negotiation again, but knowing this government, the self same person was probably also responsible for negotiating the famous 'red lines' in Lisbon.

I begrudge no one a fair return for their work, but a 60 per cent rise in pay for seeing 40 per cent fewer patients is not something that is defensible. This applies to GP partners, some of whom now earn £250k per annum. Salaried GPs are on £74k, while the average for partner GPs is £113,000.

The problem is not that people begrudge GPs a high level of pay, it is that they see the service they are getting deteriorate, with surgeries closing more often in the evenings and weekends. The government says it is addressing this but it is a problem of their own making.

I was astonished to read in today's Times that Andrew Lansley is promising to outdo Labour in spending on the NHS. He says that spending will rise from 9 per cent of GDP to 11 per cent. Assuming an annual average growth rate in the economy of two per cent, that extra sum is quite staggering. Health Service inflation has always been higher than in the rest of the economy, but even so, for an opposition spokesman to commit to such an increase is, shall we say, 'surprising' to put it mildly.

Such a commitment cannot possibly have been made without the agreement of Philip Hammond and George Osborne. Putting aside my strong view that the Tories should be slashing the overall level of public spending, this really does underline to NHS professionals that the Conservatives are determined to put the NHS at the forefront of their election appeal. I just wish it didn't have to be the case that to do that they have to dangle billions of extra money in front of people. It shouldn't always just be about money and a spending war with Labour. Competence, radical reform and efficiency are far more important.


Tapestry said...

I have published comments by the PM in waiting on my blog this morning about the National Health Service. From today's International Herald Tribune.

My GP wouldn't be worth more than GBP 30,000 a year maximum. In fact I'd have done a lot better if he hadn't existed at all, as I wouldn't have wasted so much time consulting him, thinking he had access to a comprehensive health service - which he doesn't.

He's only the gate-keeper to an increasingly limited service. It took me three years to realise I was wasting my time - just in time, which is why I'm hitting keys still.

Anonymous said...

Hmmm looks like Tebbit is right, Cameron is just Blair after all.

Blue Labour perhaps?

Anonymous said...

That headline figure of GP's pay also includes expenses for running their practice. Unlike politicians GPs don't have expense accounts that they don't have to provide receipts for.

The reason healthcare inflation is so high in this country is a direct result of having the NHS. We need competition and diversity in order to keep this down, but no one is willing to offer any reasonable reform to this money sucking leviathan so we will just have to pay out more and more ad infinitum.

My medic friends tell me of being disciplined for treating sick (properly sick as in in ICU) patients at the expense of some poor muppet who has hurt his knee whilst drunk because he has been in casualty for almost 4 hours. They have new bureaucrats every week with no idea how to run even a whelk stall. Plasma screen monitors and the latest computer widgetry for the bureaucrats and old crappy stuff they don't want for the medics.

Medics don't even get asked what it is they want or need in the way of equipment. It is foisted upon them whether it is useful or not. Money is wasted.
Power of running hospitals and medicine needs to be handed back towards the medical profession.

Almost all the medics I know are seriously considering going to work for consultancy firms or banks. They are fed up, incredibly overworked (+80 hours in some weeks) over work = bad decisions, and get crapped upon by patients and the administrators alike. If they move to consultancy or banking they get paid more and have to work considerably less hours. Ridiculous really.

Anonymous said...

I don't know what all the fuss is about here. A couple of years ago there was panic, stoked up by the Tories, about the recruitment crisis in medicine, exacerbated by the huge numbers of pissed off GPs who were about to take early retirement or bugger off from the health service altogether.

The facile suggestion that one could turn the clock back to the 'old' contract and have better value for money and that everything in the sandpit would be wonderful is execrable. This is a cheap political shot, and I think you know it.

Anonymous said...

Well said. I very much echoed your sentiments on my blog this morning. If we can really find an extra £28 billion, it certainly should not be spent on the NHS until we can get value for money on what we are already spending.

Anonymous said...

What's more interesting is how they'll sell the cuts, as this extra 2% is to be found from within existing funds.

Labour will be able to go into the next election saying "Tory cuts - some things never change"

Also, the Tories have spent ages saying all this extra money has been wasted, but, er, let's spend more anyway. Bizarre!

BOF2BS said...

NHS gets more money but productivity falls

I have always regarded the NHS as a people problem - it has 1.3million employees.

Because of the huge number of employees it is also a huge management problem.

Address these and make improvemnts is the way forward.

On an annual budget of £90bn these must be the priorities

Madasafish said...

Extra money may not buy a better NHS.

But the criticisng muppets had better do some homework before they rant.

Look at the age demographics. The Baby Boom generation Post WW2 (I'm one) are getting into their 60s...and they'll all be OAPs in 10 years.. and in care homes in 15years.

Any half sighted person (which excludes most of the critics) can see what that means.

Anonymous said...

So Iain, cards on the table...what do you believe a GP should earn and how many hours a week should they work?

As usual, this government is now putting out black propaganda over GPs earnings with the highest earners grabbing all the headlines. The reality is pretty far removed from this.

My spouse is a GP in a practice that has just moved from a quite adequate building (£30k a year rent) to a very nice new building that is costing the local PCT around £130k a year to rent under a PFI scheme.

No additional doctors, no extra hours, just a shiny new building where all the fittings were paid for by the GPs out of their own earnings (which have not gone up in two years, despite having to pay receptionists etc more.)

Still, having seen the way that NHS dental care has gone, there's nothing for anyone to be worried about when politicians decide to have a go at other health professionals, is there?

Sorry Iain, but I can't help feeling that you're commenting on a very complex subject that you know little about.

Anonymous said...

Cameron reasons (not without justification) that the Tory blogosphere are now so desperate for power that they will tolerate anything he proposes.

So after years of the Tory right criticising Labour's lavish spending on public services, he now proposes a 2% GDP increase on Labour's own spending plans.

Cameron figures that you won't like it but he's not interested in what you think because he considers that he can take your votes for granted.

Given his stated policies on grammar schools, tax and spending and Europe (ie no promise of a referendum once the treaty is ratified) which differ not a bean from Labour's own plans and your continued support for his candidacy, is he not right to assume that you will vote for him regardless?

The Tory right has never been less relevant in British politics

Anonymous said...

Lansley will be slapped down by the end of the day, mark my prediction.

In fact I hear that overnight, osbourne has already been distancing himself from lansley's comments.

28Bn extra a year??

These wouldnt just cause cuts in other services, but would destabilise the economy.

Anonymous said...

Lansley will be slapped down by the end of the day, mark my prediction.

In fact I hear that overnight, osbourne has already been distancing himself from lansley's comments.

28Bn extra a year??

These wouldnt just cause cuts in other services, but would destabilise the economy.

Anonymous said...

Whoever negotiated the GP's deal certainly wasn't the chap who negotiated the pensioners deal.
Do you know that most pensioners and low paid earners will have their income tax increased in April because Brown abolished the 10% threshold in his last budget!
Also pensioners whose income is equivalent to the average wage will have to pay the equivalent of 30% tax as opposed to those in employment who will only pay 20%.
Measures brought in by Gordon Brown "A LABOUR" CHANCELLOR and now PRIME MINISTER!

Ted said...

Perhaps Andrew Lansley is making a virtue out of necessity. Ageing population and higher treatment costs are driving up overall demand costs - demand in this case being necessary costs to keep people alive and well.
Increased choice and lowering bed usage (allowing time to properly clean between patients and reduce hospital acquired infections) also carry an additional cost, at least for first few years until benefits of competition etc are incurred.

Anonymous said...

For goodness sake Dale, wake up boy. Don't you know that this has been approved by the 'Deep Polling' focus groups Guido has been on about this morning.

How on earth are the Tories going to get back into power without following the fickle fancies of the focus groups?

You'll be advocating 'principles' next.

Anonymous said...

The contract the Government wanted the GPs to accept - which they did - proves one thing comprehensively.

You have to be pretty clever to be a Doctor but any fool can be a politician.

The politicos had no idea what Doctors actually do, thought they could persuade them to do what NuLab thought they ought to do by offering them more cash. As the doctors already did most of this anyway, not surprisingly, they accepted the cash.

Now this isn't working out too well, NuLab are trying to blame the Doctors for accepting the contract they forced on them in the first place!

There's no one in Government who can run a bath, let alone a country.

Anonymous said...

Most of the NHS increases have been spent on criminally inadequate managers and Govt-initiated schemes that turn even competent managers into raving psychotics.

If you read the medical blogs, you will see the level of disappointment with the Royal Colleges who have, with few exceptions, meekly gone along with Govt nonsense.

I have to say I would have more faith in Lansley if he would come up with a convincing overhaul of the complete NHS, along the lines of:

The State purchases episodes of health care and funds training/research, financed by taxation/insurance.

The providers are private individuals and institutions.

Anonymous said...

I'm with anon 9:58. I'd add too that medics, now uni grants are long gone, are subsidising 2 or 3 years of post-grad training before earning under 30k for 2 years - cf. a lawyer who will be paid 10k a year to train post grad and then expect 35k a year for the 2 years before he even becomes a solicitor.

don't forget that a junior doctor will have to sign off (i.e. check and take responsibility for) the work of nurse 'consultants' earning twice what the doctor is paid, having been paid to train...

Anonymous said...

In the last couple of days the papers have reported that common antidepressants are not much more effective than placebos. How many millions, then, have been wasted on these since they were introduced? How many billions of the promised new spending on the NHS will be wasted? Anyone who says zero is deluded or lying. Isn't it time we funded new expenditure from reductions in waste?

Anonymous said...

Iain this is not as straightforward as you seem to believe, as some of the comments above point out.

One further point-the GP contract has been a huge success in one way-it has demonstrated that if you give doctors financial incentives to hit targets, then they will hit them. Among many problem with the negotiation I would point to these 2:

First the government did not believe that doctors were capable of hitting targets (presumably off on thr golf course all the time)

and second that the targets that have been set are generally for doing things which are easy to measure rather than making patients better.

Its not really the doctors fault that the DoH can't negotiate its way out of a paper bag! Over time I think that incentivising doctors to produce the outcomes wanted will be seen to be a good thing, but it is all a question of how great the incentive is and what is the value of the outcome.

In other words if your GP made all his patients live 10 years longer you probably would not begrudge him or her an extra 10k per annum.

Anonymous said...

Your ire may be understandable, but perhaps you could give up shooting fish in a barrel and try for the big game?

This, from your Guardian Newspaper (Author: Prof A Pollock, University of Edinburgh and author of "NHS PLC")

"..under PFI, the cost of capital at the Barts and the London will rise more than eightfold to £67m. The money flows out of the NHS and into the pockets of shareholders..

This higher annual cost - £67m compared with £8.62m - creates what is known in the PFI business as an "affordability gap". This is the difference between what the private-sector consortium charges and what the trust can afford...

Since Labour came to power in 1997, more than 12,000 NHS beds in England have been lost as part of this policy...

But how can a hospital generate more patient treatments and income when it has to close beds, cut services and lay off staff to pay the PFI charge? Without a large injection of public funds the trust will be forced to divert hospital budgets still further from staffing to paying the exorbitant PFI charges...

Take the Queen Elizabeth hospital trust in Greenwich. It is struggling under the weight of a PFI contract that it cannot afford, and managers there estimate that £9m of its £19m deficit is down to PFI. If it defaults on the PFI charge, the government could be presented with a bill for the full £140m bond used to finance the deal.

To date the government's response has been to blame trust managers - easy whipping boys. But as the trust's auditors make clear, the Queen Elizabeth has increased its efficiency over the past five years and, when the excess costs of PFI are removed, it actually outperforms the NHS average"

Elsewhere, Prof Pollock writes:

"The NHS is now a tenant in hospitals it once owned, leasing back buildings and services from private sector landlords at astronomical rents that are currently consuming £500m a

So what about GP’s?

Even the usually rabid Daily Mail with its shock headlines such as “GP Salaries Rocket to £118,00” admits later in its article that “The huge rises are partly due to misjudgments by ministers when they tied GPs' pay to a series of targets in patient care”

The overspend on GP’s is running at about £300m according to Government figures.

Would you rather your GP get a decent salary at £300million or would you prefer that “£500million of NHS money, your money, goes straight into the pockets of shareholders?

If you are still not convinced about the value of GP's, I suggest you become a regular reader of "Dr Crippen"

Patrick said...

The KEY problem here is that government decides the worth of a service that is provided to all free of charge. Command and control socialism.

Anonymous at 09:58 - the value of a GP should be what someone is prepared to pay for that service. If we can't have a truly free market in GP services then a viable proxy should be 'at what level of pay do GPs seek alternative employment'.

If anything serious needs doing the GP will refer up to a consultant. I can't see why it should cost £100,000 to pay someone to prescribe drugs.

We spend way too much on health and not because it is not important but because the focus is not on patient needs and on producer needs.

How about government funded health insurance for everyone (out of general taxation) and ALL health service provided competitively in a free market. Then we'd know exactly how much a GP is worth.

Anonymous said...

General practiotioners have been pushed around, prevailed upon, neglected in the pay-scales, expected to work punishing hours and be on call at all hours for decades. Their pay fell woefully behind other professionals, as they were subjected to moral blackmail by successive governments, because they were in essential, life-saving work. The adjustments made in their pay-scales over the last few years merely correct a massive historic injustice. Who can blame the GMC, when it finally had an opportunity to represent its membership without one had tied behind its corporate back, for extracting the very best deal available?

General practitioners are worth every damn penny they are paid, and then some.

BTW, I am not a GP!

Anonymous said...

Did Lansley really say that?He must be off his rocker. Not to mention off message.

Scipio said...

Nothing will solve the problems of NHS until it is reformed properly.

This generally means being honest about what limitations the current system of funding places on the NHS (i.e. what treatments wil be rationed), until politically motivated targets are done away with and doctors treat according to medical need not bureaucratic dictat, and starting a wider discussion about the role of the NHS within today's society.

The NHS was founded at a time when the world was utterly different. But it has become a leviathan, almost institutionally resistant to meaningful reform, and in many cases, does not operate for the benefits of the people who pay for the services it (or often doesn not) provide.

If David Cameron follows this route of pouring ever greater amounts of cash into the NHS without genuine and real reform, he is simply repeating the mistakes of the past in order to stave of predictable howls from the left.

He is also in danger of advancing the myth that the state can do everything for everyone, and will take care of you cradle to grave.

He needs to be saying the opposite in these policy announcements - that the state is limited in what it can do, and that people must start to take control over their own lives, and once again be responsible for them.

Anonymous said...

They've just read out this blogspot on the Radio Four's World at One.

Oscar Miller said...

Congratulations Iain - your name has just been taken in vain on the World at One, where they read out your post nearly in full. Trying of course to do maximum damage to the Conservatives by suggesting a major split and embarrassing Andrew Lansley - whose words - from the sound of it - seem to have been taken entirely out of context. The BBC is stepping up a gear in my opinion in trying to shore up the fortunes of Labour and inflicting pain on the Conservatives. Oh - the wonderful world of media spin.

Anonymous said...

It may well be true that extra money doesn't necessarily buy a better NHS but the converse is undeniably true. Starving any service of resources as the last government did without doubt makes it worse.

NHS inflation is high because we're slowly catching up other advanced economies 'per head' spending on healthcare. We've still got miles to go before we reach US spending levels for example...

rob's uncle said...

The moral of this that you, Iain, should never believe what you read in the Times without checking it, particularly something as improbable as this. I thought Lansley spoke well on World at One today, so perhaps no harm has been done.

Anonymous said...

The only simple answer is to part privatise the Health Service. People should have to take out some form of private medical insurance to contribute to their medical costs. That way people will take some responsibility for their own welfare.

I can't see the logic in clinging to the NHS - it's a 20th Century institution. People need to stop relying on the State to provide for them and take responsibility for themselves. It's time the Tories began advocating part-privatisation.

Anonymous said...

Patrick said:

If anything serious needs doing the GP will refer up to a consultant. I can't see why it should cost £100,000 to pay someone to prescribe drugs.

Sorry, Patrick, but it's pretty obvious that you have little or no understanding of the work of the NHS or any other health service anywhere in the world.

A GP doesn't just "prescribe drugs."

They do act as a gatekeeper for specialist hospital services, which would be totally over-run if patients had their way.

As the name suggests, they are "generalists" in the same way that a solicitors are "generalists" and barristers are specialists. It does not make their skill set any the less worthwhile or valuable.

The range of skills and experience needed to decide whether a patient needs referring to a specialist means that good GPs are worth every penny they get.

It takes 9 years of study and lowly paid work to become a GP principal. The lack of morale in the NHS for many years meant that GPs were leaving in their droves and retiring early - hence the shortage that occurred.

As a result, the only way to keep GPs in the NHS was to offer some seriously attractive incentives - no different to what any other employer would have been forced to do.

This is what happens when politicians try to impose market forces on the NHS. It rarely works out the way they hope and then they start trying to throw the blame at anyone who's an easy target.

Oscar Miller said...

"Shadow chancellor George Osborne has completely lost control"

Yvette Cooper
Chief secretary to the Treasury

Helpful quote in special inset box on the BBC blogsite next to their report about Andrew Lansley and the NHS. Boy are they doing their best to make mischief. Shame Iain helped them along today.

Anonymous said...

GP's are paid about £110 per patient per annum to provide the service . That is an average and covers those rarely seen and those seen every day .
Try to find a similar insurance quote for your dog or cat . You can do it , just , but most of the items of service eg vaccs are extra . Most people spend a lot more on their pets and think nowt of it .

The figs for income are in fact for turnover of a practice . Deliberately confusing the two is a common way of knocking the GP's . GP income is what is left over after paying all expenses ie staff , premises etc .
Pension contributions are now a compusory 20% of that . Yes , twenty percent and no escaping it .
Yes we get more than we did - we were seriously underpaid for years - but it is not non dom nirvana .

AethelBald, King of Wessex said...

It is my perception that GPs, like the "professions", are an over-protected and wondrously overpaid species. They're job is so awful that they have one of the highest rates of job heritability of any occupation. They have special protections, like the self-sufficiency policy for secialisation. On the whole, they seem rude when compared to US doctors, possiblky because they deal with a herd rather than customers, and to my mind they seem less well-informed when asked a technical question (Yes, I've used both). I would like to see them wholly privatised and fully exposed to global competition. There are plenty of able doctors in the world who would like to make $150,000 per year and who are prepared to work split shifts and nights.

I am quite certain that the BMA will pull out every stop to prevent this happening. So it's like the miners all over again, but this time it's the tweedy, well-rested, over-privileged "nice" people.

Anonymous said...

I have very little knowledge of what goes on in the NHS, all I can say is that in my area we have new buildings, more staff, and better equipment, but that G.P.s have never been held in such low regard.

People say they have become arrogant, greedy, and self-serving. I notice that they also have become rather depressed, they are certainly not the revered figure they once were only a decade or so ago.

Whatever is going on I do not think that more money is the solution.

Anonymous said...

Lets be realistic as the poluation lives longer and ages demographically the proportion of GDP spent on healthcare will rise

Iain Dale said...

Dr Death, you have submitted two comments which I have not allowed through. You say I don't have the guts to put them up. Let'smake a deal, shall we? You put your name to your post and I will put it. But you won't, will you. Because anonymous cowards like you never do.

Anonymous said...

Good evening Iain,

Over to you?

No. I thought not.

Anonymous said...

Have you edited this story?

Iain Dale said...

No I haven't. Feel free to check against an RSS record or a Google cache. Honestly.

Anonymous said...

Iain, old chap:

Are you familiar with the phrase:

"When in a hole, stop digging?"

Doctors are hard work. I know; I'm married to one.

She makes up for it in lots of other ways, though I have to do with out-of-date antibiotics when I get man flu every winter.

Do I get an extra point for the correct use of semi-colon in a blog comment?

Anonymous said...

As I thought.

Sadly, there is no cure for cowardice.

And I know you won't publish this comment either.

Iain Dale said...

You should know. Have the courage to put your name to your comments and I will take you seriously. People like you bore me rigid. Why don't you go and infest abnother blog?

Iain Dale said...

You should know. Have the courage to put your name to your comments and I will take you seriously. People like you bore me rigid. Why don't you go and infest abnother blog?

Anonymous said...


You've repeated yourself. Do you have the hiccups? I have a me...I'm a Doctor.

Despite your earlier promise, you haven't published my earlier comments. Why not?

If I put a name like "Dr John Smith" to my comments would you publish them?

I imagine you would, but only if my comments agreed with your viewpoint. That's how this blog works, isn't it?

If not, you would just post petulant comments like your last one.

Sorry if I bore you. If you have the guts to publish this post, I will go away and infest "abnother" sic blog. Wherever that is.

Iain Dale said...

You real are a grade one prize idiot, aren't you? Half the comments on this site disagree with me in one form or another. If you sign up to a Google account with your name I will happily let your comment through if you choose to resubmit it. Until then, go swing.

Anonymous said...

Lighten up Mr Dale.

I don't know if the University of East Anglia has a Medical School.

If it did, you would know that medics are the worst-of-the-worst pranksters and wind-up merchants.

It's nothing personal! We just get a bit hacked off when politicians have a go at us.

Now.....have the courage to publish this comment and have a laugh about it!

Paddy Briggs said...

I agree that it's not about spending levels but about spending efficiency. But you only get a Health Service appropriate for a rich country (which we are) if you invest. I recently had two eye cataract operations. I have private health insurance and was covered for the operations. I asked the surgeon where he would be carrying out the procedure - at our nearest Private Hospital or at Kingston (NHS) Hospital. “No issue”, he said, “we'll do it at Kingston. Their equipment is much more modern than at the private place!” More money does mean a better NHS – if properly spent. One mini story I know, but there really has been massive and effective investment in the NHS in recent years. Has it all been wisely spent - probably not? But the principle of keeping the NHS properly funded must be sacrosanct - and then the focus should be on efficiency.

Anonymous said...

You're arguing about angels dancing on the head of a pin, which I've noticed the English, especially English men, are prone to. They ignore the big picture and get settled in to quibbling about details.

The big picture is, the NHS should be destroyed. It is a Sovietesque concept and has no place in a free society.

I see Lord Mancroft said this morning that NHS nurses are dirty and slutty. So what's new? They indulge in behaviour that would get them sacked on their first day in private enterprise.

Health care should be the responsibility of the individual. I would give a free pass to OAPs, given that most have contributed all their working lives, and a free pass to children up to age 18, given that they haven't had a chance to contribute yet.

Everyone else pays.

Keep NI deductions, but the owner of the money being deducted chooses the healthcare provider he wants to pay his premiums to.

And 1.3m employees isn't a business; it's a clumsy joke

Anonymous said...

Paddy Briggs - All the private consultants here have the very, very latest high tech diagnostic and treatment gadgetry. If it's new, they've got it. I can't imagine why private clinics in Britain don't have it.

The Soviet NHS needs to be absolutely destroyed and buried at sea encased in lead. It's a loathsome outfit. Let private enterprise take over with more efficiency, more imagination and more accountability and not be governed by rubbish like Patricia Hewitt and whoever's the latest nonentity with no experience in running anything bigger than his microwave in charge. From never having run a commercial establishment in their lives to running the largest employer in the EU. Quite a step.

Private enterprise will always serve the market better. ALWAYS.

Here, I can get an appointment with a specialist within two days - or three if a weekend's involved. If I want a second opinion, I don't have to be referred. I just take my Xrays and test results (which I keep because I paid for them) to a different consultant.

Here, there is a giant pharmaceutical company that manufacturers generics. It has its own outlets, and you can get any prescription drug for half to 2/3 of the price of the brand names.

But of interest from a free marketeer point of view is, at their outlets, they have a doctor on duty. Instead of calling up and making a doctor's appointment, you just go along to one of their stores and take a seat - like going to the doctor in France. You just go and wait your turn. You get around 20/25 minutes with the doctor. For this you pay £1.50. The consultancy is a loss leader for the pharmaceutical company.

Another free enterprise solution is, one of the giant national supermarket chains has opened doctors' consultancies in their retail outlets. And why not? It's a commercial decision. It gets people into their stores. And the doctors' offices are manned for all the opening hours of the store.

The NHS is cumbersome and passé. Other countries are lighter on their feet.

Anonymous said...

I seem to remember reading, not so long ago, that the NHS employed as many people as the Red Army. As one would expect, it seems to operate at the same level of efficiency.

Verity: Boots, in Guernsey, used to have a GP on duty at the back of the store. Perhaps they still do. It seems an excellent system.

Anonymous said...

sorry, testing again