Friday, 20 February 2015

NHS: price and non-price rationing

The NHS is free at point of use, so they have to impose two types of rationing:

1. Some services are simply not provided because they are deemed too expensive or not medically necessary.

NICE explain this concept ("it is not worth keeping you alive") as diplomatically as they can here.

2. Waiting times. If waiting lists are long enough, then some people simply don't bother going for NHS treatment; either they go private, live with it, die with it, or it goes away by itself.

As we well know, most GP's are taking the piss. Besides charging for non-existent patients, taking bungs from medical rep's and doing little other than referring you to a specialist, prescribing antibiotics/painkillers or telling you to go away, they are underworked, overpaid and you have to wait days for an appointment. If you miss your slot by a few minutes they give you another appointment in a few days' time.

Faced with this intransigence, many patients with something acute go to Accident & Emergency (even if strictly speaking it was neither accident nor emergency) and take their chances. Even if they have to wait more than four hours, at least it gets dealt with on the same day at a time of their choosing.

So we end up with headlines like this:

A&E waits worsen across England

NHS England says A&Es have faced increased pressure this week partly due to a rise in attendances. Some 420,000 patients turned up at emergency departments, up from 407,000 the previous week.

I've Googled it, and there appear to be around 40,000 GPs in the UK. So a simple solution suggests itself:

Terminate all GP contracts and offer them proper jobs in A&E Departments instead.



paul said...

problem is ideally you need continuity of care, so in my case I found a GP who mostly I don't have to tell a long long story to (my notes are very fragmented) trade of is I can only see this GP on Thursday or Tuesday mornings about a month from now, makes planning very difficult but saves me time trying to explain whats going on in a very short appointment.

For many acute complaints your suggestion is ideal but for any chronic condition it needs the same person looking so they can spot trends, understand the individual circumstances and not restart gold standard NICE pathways which without realising that these landed the patient in hospital. Unfortunately we are not all machines and don't all react the same

Physiocrat said...

The Swedish GP system seems to work better. Presenting patients are triaged by a nurse - urgent, and you see the GP the same day, non-urgent and you see the doctor within 4 weeks, or no further action required.

You pay about a tenner to see the GP, up to a total of £100 within 12 successive months.

Mark Wadsworth said...

P, if you have to wait a month then that is a sign that something is seriously wrong with the system.

But, assuming we went with the all-in-one scheme (see below), and you know that your guy will be there at certain times of the week, then that's when you go.

"Unfortunately we are not all machines and don't all react the same"

Well yes and no. Faced with a large enough population, people are surprisingly predictable.

Phys, that is half way there to an all-in-one GP-A&E-drop in centre.

Healthcare is about specialistion, so what you need is a huge great hospital where you are only one form away from being treated by the right person (or told to clear off and stop worrying, as appropriate).

The Stigler said...

Exactly - It's not so much that they're underworked, it's how unproductive they are. You want to get people to a specialist as fast as possible. It's not just about putting GPs in A&E - it's more about not creating GPs, but getting medical schools to create more specialists.

If someone's got an ear problem, you get them to someone who spends all day on ear problems, because that person has probably seen your problem before. If someone is looking at ears, toenails, hair, throat infections, mental health and STDs, they're not going to be as good at ears as someone who does only ears. They're going to have to either pass it on, or take a shot at the diagnosis, which means yet more labour applied to the problem.

I recently had a medical problem and I knew that my GP would look at it, say it was probably nothing to worry about, but it would need tests. So, why couldn't I just go to the place where the tests happen myself? It's not like the GP was any cheaper than the people doing the tests. If I'd turned up and wasted their time it would have cost less than turning up to my GP and wasting his.

And in all sorts of areas, we already do this. If you think you've got the clap, you go to the STD clinic. Eyesight seems a bit off, you go to the optician. Teeth, dentist. You don't turn up to your GP and he refers you to a dentist. You know your teeth hurt, you go to a dentist. Why does that not apply to ears?

Physiocrat said...

The month's waits have been for long-standing problems -- old aches and pains from injuries, which needed looking at - there were obviously not urgent but needed checking nevertheless.

When you eventually do get to see the doctor, you get 30 minute appointments so they are an opportunity to have a sort of general check on other stuff as well. The doctor arranges all the tests which need to be done once or twice a year. There is room for improvement but there is not the sense that the doctor is rushing to get you away to hold to his timetable.

Mark Wadsworth said...

TS, exactly. That's sort of the German system. it works fine.

Phys, that also sounds sensible.

Anonymous said...

Just wondering why, if GP's are obviously 'underworked' and 'overpaid' there are less and less applications for GP training places. 6% down on 2013 which was in turn 9% down on 2012. Despite extra efforts to recruit new trainees 12% of training posts remained unfilled in 2014.

Mark Wadsworth said...

PC, give us a source for that and tell me why you think this is.

Mark Wadsworth said...

Ah… here we go...

"However, GP leaders said the biggest concern was the vast differences between regions, with the popular regions filling all places, but areas where workforce recruitment problems are at their most acute, such as the East Midlands, the Northern region and Merseyside, have fill rates of 62%, 71% and 72% respectively"

Fred Harrison explained this in one of his books, GPs effectively get their mortgages paid on top of salary, so if you can choose between having half a million mortgage paid off or a hundred thousand, what do you choose?

Anonymous said...

I don't know about GP's getting their mortgages paid on top of salaries. I can't find any source for the claim. Fred Harrison?

Mark Wadsworth said...

PC, it's not as blatant as "paying for their mortgages".

GPs can claim from the NHS for the notional rent if they own their premises (on top of their handsome package).

That's is why it is more attractive being a GP in a high-price area. Unless you can prove otherwise, I believe Fred. he has seldom been proved wrong.

PJH said...

"As we well know, most GP's are taking the piss. Besides charging..."

...£160 for two signatures so someone can be cremated.

Bayard said...

"It's not so much that they're underworked, it's how unproductive they are."

Probably because they spend far too much time dealing with timewasters: the "worried well", pensioners with nothing better to do and NHS bureaucrats.

The Stigler said...


But you can't do much about those things. They're going to happen. What you can do is to get diagnosis right with less attempts.

I'd also say that there's a problem with the cost of support staff in GP surgeries, typically a couple of receptionists for 2 or 3 GPs. And you need at least 2 to make sure the desk is manned. But it's generally pretty relaxed in a GP reception, and there's no bottleneck. Patient will spend 10 minutes with a GP and 1 minute in reception. The whole Oxford Eye Hospital with dozens of specialists looking at eyes has 3 receptionists.

Mark Wadsworth said...

PJH, nice one, thanks.

TS, at my GP you spent half an hour in reception and ten minutes with a GP.

Bayard said...

"But you can't do much about those things."

Yes you can. You can get someone who isn't a GP in to deal with timewasting "patients" and allow the GPs to tell the bureaucrats to take their box-ticking exercises to the proctology department.

The Stigler said...


And that's going to be? A GP? A nurse? If you've got a GP practice with say 3 GPs, you've then got a triage nurse for the odd time waster. That works when you've got a large number of people, which is why scale works.

Bayard said...

"And that's going to be? A GP?"

Well obviously not. You and I would be able to argue about this more effectively if one of us knew what percentage of patients, on average, could be classed as timewasters.