What does the coun­try get for bounty be­stowed on doc­tors?


EACH year an unseemly fight breaks out amongst op­po­si­tion par­ties to find a sin­gle ex­am­ple of the fail­ures in the NHS. Even­tu­ally some poor in­di­vid­ual is found who has ex­pe­ri­enced dis­tress in a re­cent en­counter with the NHS. It re­duces the very real experience of in­di­vid­ual hu­man suf­fer­ing to a base­ball bat with which to beat the gov­ern­ment of the day. It’s an in­sult to the ev­ery­day hero­ics of hospi­tal staff who strug­gle to face down el­e­ments be­yond their con­trol and the pat­terns of in­equal­ity in Scot­land which en­gulf the NHS at this time of the year.

It also be­trays a sim­plis­tic at­ti­tude, bor­der­ing on the con­temp­tu­ous, to­wards in­grained cul­tural prob­lems deep within the sys­tem of health­care de­liv­ery. Bet­ter to hurl easy calum­nies over one fam­ily’s dis­tress than prop­erly to drill down into some of the in­sti­tu­tional dif­fi­cul­ties in health­care de­liv­ery.

Each day some­one from the Scot­tish Gov­ern­ment makes a phone call to the chief ex­ec­u­tives of ev­ery health board in Scot­land. They are asked the same ques­tions: how many beds; how many waits; how many trol­leys. This would be fine if our tar­gets were in the right ar­eas but they are not.

The tar­gets should be fo­cused around the de­liv­ery of health and so­cial care. There are cur­rently no tar­gets mea­sur­ing the ef­fec­tive­ness and ef­fi­ciency of so­cial care and none were set when the Gov­ern­ment moved to es­tab­lish its flag­ship pol­icy of In­te­grated Joint Boards in health and so­cial care. The IJBs were sup­posed to open up more so­cial care pro­vi­sion for pa­tients thus get­ting them out of hos­pi­tals. It’s reck­oned that be­tween 10 and 20 per cent of peo­ple in hospi­tal don’t need med­i­cal and nurs­ing care but they can’t get out be­cause there isn’t suf­fi­cient so­cial care pro­vi­sion. One of the prin­ci­pal rea­sons for this is that the money set up to fund the IJBs was in­stead di­verted by lo­cal health boards to keep­ing wards open. Au­dit Scot­land has pointed this out re­peat­edly.

When, too, will some­one in our po­lit­i­cal es­tab­lish­ment ad­dress the cu­ri­ous set of priv­i­leges ac­corded to Scot­land’s GPs? The con­tract that is cur­rently close to be­ing agreed high­lights the egre­gious anom­alies that ex­ist in the re­la­tion­ship be­tween GPs and the sys­tem of health de­liv­ery. I’d sug­gest that Theresa May quickly iden­ti­fies the per­son ne­go­ti­at­ing these con­tracts on be­half of Scot­land’s GPs and parachute them into the Brexit ne­go­ti­at­ing team.

The new con­tract rep­re­sents the big­gest over­haul of GPs con­tracts since 2004. The new con­tracts will make what is an al­ready cos­seted ex­is­tence en­joyed by many GPs even cosier still. It will en­sure that no GP in Scot­land will earn less than £80,430 per an­num. They will also have one ex­tra ses­sion per month (which will be pro­tected) for some­thing called “clin­i­cal lead­er­ship”. How will this be scru­ti­nised to en­sure that it isn’t spent on an af­ter­noon’s golf­ing? The new con­tract will also di­vest these hard­pressed GPs from some mi­nor clin­i­cal du­ties such as pre­scrib­ing and dis­pens­ing con­tra­cep­tive ad­vice. What is the coun­try re­ceiv­ing in re­turn for all of these sweet­en­ers?

If you re­ally want to ask search­ing ques­tions about the un­bear­able pres­sure on the NHS dur­ing the win­ter months then per­haps we should be ask­ing why lo­cal surg­eries are per­mit­ted to close for four days at Christ­mas and New Year at a time of year when the el­derly and the in­firm are vul­ner­a­ble to ill­ness and in­fec­tion. Yet many end up in hospi­tal be­cause our first re­spon­dents in pri­mary care are bast­ing tur­keys on 80 grand a year. Yet if you work in a busy ac­ci­dent and emer­gency fa­cil­ity you will be ex­pected to work dur­ing pe­ri­ods of high pres­sure with the ex­pec­ta­tion you’ll get time off else­where in the year.

Our GPs are granted leave to do this be­cause while they en­joy all the ben­e­fits of be­long­ing to the NHS, such as at­trac­tive pen­sion pro­vi­sion and IT sup­port, they are not ac­tu­ally part of it. They are lo­cal en­trepreneurs who run their surg­eries like busi­nesses. Thus they are not re­quired to work week­ends or work be­yond nor­mal of­fice hours. On those oc­ca­sions that they do they can claim up to £1K a ses­sion.

The av­er­age an­nual wage of a skilled worker in Scot­land is around £27K. Many, es­pe­cially those who are self­em­ployed, ac­knowl­edge that a cer­tain amount of un­paid over­time will be ex­pected. I don’t know of any­one on a salary that ex­ceeds £80K a year who doesn’t ex­pect to put in some un­paid over­time for such a quan­tum.

The con­cept of a pa­tient-cen­tred NHS be­gins to fray when you fac­tor in Scot­land’s pat­tern of in­equal­ity. The Scot­tish Gov­ern­ment per­sists in cit­ing our age­ing pop­u­la­tion as a stress fac­tor in health ser­vice de­liv­ery. If you live in a dis­ad­van­taged neigh­bour­hood you are far less likely to reach the stage where you can be in­cluded in “our age­ing pop­u­la­tion”. Per­haps it would be bet­ter to make the in­iq­ui­ties of health in­equal­ity in these ar­eas a pri­or­ity. De­spite some changes GPs will still largely be funded on the num­ber of pa­tients on their reg­is­ter, re­gard­less of what post­code they ser­vice. In healthy and af­flu­ent ar­eas there is less de­mand for GP ser­vices than in those where there are multi-faceted and com­plex pat­terns of ail­ments brought about by ex­treme poverty.

The sweet­en­ers and priv­i­leges em­bed­ded in GP con­tracts are a di­rect con­se­quence of a re­cruit­ment cri­sis. But are they a price worth pay­ing when there is a win­ter flu epi­demic or year­round pres­sure on hospi­tal beds and wait­ing times? One of the cen­tral aims of the new con­tract is to make part­ner­ship more at­trac­tive for younger GPs to help tackle the huge re­cruit­ment prob­lems. These have left one in four prac­tices with at least one GP va­cancy. One of the rea­sons for this is that, hav­ing trained in a vi­brant and de­mand­ing hospi­tal sys­tem, many young doc­tors don’t rel­ish the prospect – no mat­ter how well-paid – of work­ing in a couthier lo­cal surgery en­vi­ron­ment.

Yet, if they were salaried, full-time em­ploy­ees of the NHS this could be ad­dressed. We could bring GPs fully into the NHS and ro­tate their du­ties so that they also re­ceive some experience in the acute wards. It’s time to de­ploy their skills fully in re­duc­ing the pres­sures on our busiest hos­pi­tals.

Theresa May should iden­tify the per­son ne­go­ti­at­ing these con­tracts for GPs and parachute them into the Brexit ne­go­ti­at­ing team

‘GPs en­joy all the ben­e­fits of be­long­ing to the NHS, such as at­trac­tive pen­sion pro­vi­sion and IT sup­port, but they are not ac­tu­ally part of it. They are en­trepreneurs.’

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