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Hospital: no place for doctors

 

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Friday, 11 February 2011

Hospital: no place for doctors

There are lots of myths about hospital doctors. Most of them are played out every week in television dramas like Casualty.

Consultants are egotistical, good-looking, oversexed, arrogant, flawed, temperamental, brilliant mavericks whose humanity, skill and dedication make them all the more loathsome. Only their personal battles with drugs, alcohol and gambling, their dysfunctional relationships, their conflicts with ruthless managers, their health problems and their brave struggle against implausible story lines stop us from hating them.

The view from primary care is that hospitals are monsters that suck patients and resources out of the system. Aided and abetted by Payment by Results, which rarely appears in a sentence that does not also contain the words perverse and incentive, consultants and the acute trusts that employ them grow steadily richer and greedier.

In a recent clinical leaders’ meeting, a GP declared that the description of his local hospital as a Hoover was inaccurate. “It’s far more efficient than that,” he said. “More like a Dyson.”

So much for the myths.

For GP commissioning to succeed the adversarial relationships between primary and secondary care need to be replaced by something much more grown up and responsible that puts the interests of the patient before vested interest and professional posturing.

It is true that some hospitals and some consultants will block any attempt to move treatment into other settings. It is also true that some GPs are far too quick to refer. Just as true is that there is more uniting primary and secondary care clinicians than dividing them, and that when you put them in the same room they are quick to set aside their differences.

The problem is not the rapacious appetite of consultants – though it’s true that some don’t want to let go – nor is it the tariff. PbR covers a minority of hospital activity and in any case there are plenty of options for primary and secondary care clinicians prepared to do deals on the price of local services.

If GP commissioners are not prepared to renegotiate secondary care contracts, nothing will change. You can redesign care pathways until you’re NHS blue in the face, but unless you decommission the old services to pay for the new ones, the improvement will not be affordable.

The answer to the question about how people get the best possible care at the best possible price to the taxpayer usually involves moving patients. The real answer is to move doctors.

Consultants are tied to hospitals financially as well as geographically. What if these connections were to be broken, if consultants were no longer employed by trusts but worked like lawyers in clinical chambers?

Taking doctors off the books and off the premises could be the first step to creating a more authentic and enduring form of hospital drama.

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