My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Medical and resource decisions. Should GPs make them both?

Filed Under (Clinical Commissioning Groups, GP Commissioning, Primary Care Trusts) by Paul on 09-11-2011

(These new forms of media can be very difficult. Blog readers will probably know that I tweet to let people know there is a new post on the blog. But I am not sure whether blog readers follow me on Twitter. I assume that some of you just read the post and are not in the Twittersphere.

Yesterday I posted about the very difficult relationship between the autonomy of GPs in CCGs to make commissioning decisions for their locality, and the National Commissioning Boards central control of those decisions. Following that there was a fascinating flurry of activity about the problem – or not – of GPs making referral decisions about their patients and how those decisions will relate to the financial decisions they will have to make as commissioners.)

This question is not only at the heart of the current Government reforms but is also at the heart of the debate about the vision of professional responsibility within the NHS.

There is a position that says that GPs should only advocate for their individual patients. Their sole responsibility resides in that relationship and anything that cuts across that – like the limitations that exist in the resources of the NHS- is not their responsibility.

The argument goes that the patient expects the doctor to think about their needs in the context of the doctor-patient relationship – and not whether the country can afford it. Obviously if the GP is a part of a CCG group and feels a responsibility to it then they will know that there is a limited amount of money in their commissioning budget and will work to live within that budget. The CCG leader will look at referral patterns in their location and talk to their colleagues about the relationship between those referrals and the budget.

This is at the core of the debate about the professional’s relationship with society. Is it best for them to make professional decisions that do not take resources into account? Or should they play a role in relating individual decisions to resource limitations?

What is certain is that someone has to make the decisions about resources and their limitations. There is not enough money for everything (and there is likely to be less money in the future) so someone needs to make decisions about priorities.

One politics of the profession feels happy that professions don’t do this so that they are not sullied by making that decision. This gives the professions the opportunity to separate themselves from the implications of scarcity and attack those that are making those decisions.

But there is another politics of the profession that says that there is a professional responsibility to take the nation’s resources into account and that professionals themselves should play a role in the economics of scarcity. Some would say if they don’t do that they are not acting with the full meaning of responsibility.

So yesterday – in the Twittersphere – a really interesting argument raged, until somebody pointed out that this is a difficult argument to have when you are restricted to 140 characters. I agree with that – especially since it has taken 500 words for me to introduce the topic – but thought I would give my two penn’orth today.

First this seems different for other professionals. Architects rarely develop plans for private or public buildings without asking the question “How much have I got to spend?” Sometimes that amount is private and sometimes it is public, but it is always limited. Teachers know that the school budget is limited and if they spend it on one thing they will not be able to spend it on another. University lecturers have, over the last 30 years, become aware that if they don’t take charge of the departmental budget then managers will.

(I suppose barristers often seem to be working with little consideration of the cost of what they are doing for their clients and the economy – but I am not sure they are a good example to follow as a model of responsibility).

What is different for the doctor and patient in the NHS is that the whole system has failed to construct a recognition that resources are scarce. The promise that seems to have been made to the patient is “you give us a sum of money in taxation and we will give you everything”. As a promise, as medicine develops, that becomes less and less sustainable.

So organisations such as NICE are set up to help professionals to both make the decisions and to hide behind it as the main decision maker. Many professionals don’t like NICE because they seem to be making decisions that would be different from their own. But that would mean the professionals make the decisions – and if they do they will be rationing decisions.

So I am with those that say that given there are limited resources I would rather have professionals making the decisions rather than those who are abstracted from the medicine behind them.

It may be easier for professionals to attack the people who make the resource decisions but I don’t think it’s responsible.

But I have another problem with the idea that professionals can be abstracted from resources. I have written previously that the main activity that passes for clinical commissioning at the moment is based around ski slope graphs.  Ski slope graphs have, on the horizontal axis, the number of practices or GPs in the consortium – and on the vertical axis the extent to which the different practices or GPs refer patients for drugs – or for a certain procedure. The ski slope is formed by the very high number next to the vertical axis that swoops down to a very low number at the other end.

The GPs near the vertical axis are using their professional judgement to refer patients of a similar population 3 or 4 times more than their fellow GPs. Similarly those that at the other end of the graph are making only one third of the referrals of those next to the vertical axis. The interesting point is that there are spreads of between 3 and 5 times between those who refer the most, to those who refer the least on nearly everything.

This means that one GP makes his or her professional judgement, without thinking through the resources, and comes to a decision which – over a span of time – is very different from their colleague’s.

Therefore leaving professionals to make judgments in relation to patients – with no concerns about resources – has not led to anything that I would see as a set of judgments that relate to a profession. What we have is a set of judgments that are wholly taken by an individual with little evidence of a profession impinging on those variations.

If the profession had spent the last 60 years getting hold of this variation and doing something about it, then I might think that the lack of responsibility they showed towards resources might be worth it. But they haven’t.

The main activity that makes this happen across the profession through clinical commissioning has been the entry of resources into the peer-to-peer equation. The CCG’s leaders are worried about resources and are having hundreds of conversations about why there is such a set of variations between GP’s professional judgement.

In the past, when PCTs tried to do this, GPs would say that because they were not fellow professionals their contribution should not be heard. But now the conversation is taking place from professional to professional.

In this way taking responsibility for resources is leading GP leaders, as professionals, to tackle the extreme (and unprofessional) variations of practice.


3 Responses to “Medical and resource decisions. Should GPs make them both?”

  1. Agree that we need to challenge health professionals on what it means to be “professional” – this applies not just to taking account of resources, which should be a no brainer must-do – but to the way a culture of “non-care” has been allowed to develop in parts of the NHS in relation to eg care of the elderly. Phrases such as “learned helplessness” and “primitive fear” which have been used in the last fortnight to describe “professional” attitudes within the NHS. See also today’s report from the Patients Association. This, together with a cultural reluctance to challenge poor care, smack of a failure of professional ethos and nerve.

    In defence of barristers: I used to be one, but left 11 years ago. Back then, when advising whether Legal Aid should be awarded to a would-be litigant, I had a duty to advise on the merits or otherwise of the case and assess the prospects of success. This was a duty to the public purse as well as to the client. Understanding that was a straightfroward part of being a professional. Lawyers today continue to be asked to make the same judgments.

  2. Every time the “doctors don’t want/aren’t equipped to make resourcing decisions” gets rolled out, I also wonder about medical triage?

    Surely every medic must deal with limited resources – whether theatre time, number of ambulances, transplant organs – at some point? What’s the difference between telling a patient you can’t afford the treatment (or at least you have higher priorities for the money) and telling them that no ambulances are available because they have all been sent to other incidents? Neither is infinite and at some point the demand will exceed the available supply.

  3. There are a few things for me in this post.
    One, no one openly talks about variation or quality in GP practices. Sure, there is QOF but it is so weak, measuring inputs and activity rather than outcomes.

    Two, when money is tight GPs do make rationing decisions around their own practices including some short term ones (such as getting rid of salaried GPs so partner income can be maintained) so the argument about resources is interesting.

    Finally, until we get the nature of the psychological contract between the public and the NHS changed, this debate will carry on for the next 50 years. Each and every individual has to recognise that even if we wanted to, we could not afford to provide all things to all men, women, children and people most vulnerable. A good start would due to educate the public about what they get for their taxpayer pound, and what the level of expenditure is in the last 5 – 10 years of life. That’s where the focus needs to be. The public would also then become more vocal about quality of care and service – something that is desperately lacking at the moment.

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