4 Hours is a limit not a target!
During the first weeks of 2017, it is clear that the NHS is having problems coping and the blame is being laid at patients themselves, at the growth in demand due to the changing population, at NHS Managers for not managing or being afraid to manage. But in simple terms why should a patient need to wait 6 hours to see a doctor in an A & E Department with no apparent offer of triage on entry into the Department. Answer – No one.
Constant Change Does Not Improve the NHS
Based on my own research and experience, I believe that the problems have been caused by political change and a constant reorganisation of the NHS which just has not worked. In 2004 General Practitioners were given even more independence to run their own practices with an allocated budget from the NHS. A quality driven payments system was added into the melting pot which allowed practices to earn significantly extra amounts. The responsibility for deciding how many doctors worked in a practice and how many sessions and days they worked was devolved to the practices themselves. Previously medical manpower was indirectly managed by the Medical Practices Committee who approved entry to the medical list in a specific location and the PCTs who might approve part time working. But as a consequence more and more GPs decided to work part time so that now a very small percent work a 5 day, 9 session week.
Part time working should be Approved not a right
The change in the commitment of GPs to working part time rather than full time is attributed to amongst other things the workload created by growing elderly population, and growing ethnic communities. The result is a lack of immediate GP appointments, and more and more GPS want to work part time whether they are approaching retirement or not. The growing number of female doctors taking maternity leave and wishing to work a shorter working week is also cited. Whilst NHS Hospital Trusts can manage employed doctors in a hospital environment it is not so easy to manage self-employed GPs working in general practice. Where singlehanded doctors work in small practices maybe with the help of locums the future of such practices is in doubt. Even where practices with a handful of GPs work unless the doctors are flexible with their sessions and days of work it is becoming almost impossible to manage smaller and even larger practices.
Reintroduce Management Controls
In my view controls need to be introduced to manage the approval of part time working and added to that the employment of locums needs to be controlled. Locums are an expensive draw on the funds of a GP Practice to such an extent that in reality they are unaffordable. Perhaps if a practice is in real difficulties caused by maternity leave or sickness the local CCG or the NHS Area Team could both give approval to the employment of a locum and ‘funding’ within reason. My major concern, for general practice, however, is that the advent of Care Quality Commission inspections has probably contributed to the demise of smaller less efficient practices, where no doubt good doctors have been in practice, but their management and organisational skills have been lacking. I think it is also true to say that practices managed by local health organisations who employ salaried GPs also seem to fail. There are practices that have closed due to lack of funds i.e bankruptcy. This is not a way to run a health service. There must be essential small practices that should receive additional funding to survive.
Start to Ring Fence New Funds
My main concern though about offering any extra funding to so-called independent general practice is that the recipients of extra funds don’t regard the money as their profit or their pay rise. Any extra funds given to resolve real problems in practices that deserve help must be ring-fenced and only spent on resolving the problem. I feel the same about practice staff pay. There are those that argue that the independent nature of general practices gives practices the right to pay their staff whatever they want. What an attitude. Practices too continue to find ways of reducing toe cost of GPs by employing cheaper nurses, nurse practitioners and health care assistants. In their defence I have to say that some posts should be funded by the NHS and generally have not been. This includes phlebotomists. In my view an essential practice based service.
So to me the solutions to an ailing NHS lie in directing funding at real problems to deserving practices and regaining management control of the number of GPs working in general practice along with managing their days and hours of work. Lets stop this practise of deciding to work a four day week or less, and to employ other types of staff to replace GPs without good reason.