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As I write, word comes that the new National Health Service contract for consultants, negotiated by the BMA, has been rejected by large majorities in England and Wales, though accepted in Scotland and Northern Ireland. The Government's efforts to increase efficiency, and the hopes of the nation for an adequate NHS, have suffered a blow.
Some of the papers in this month's JRSM relate to efficiency in the Service, and I looked again at a BMJ paper that generated much agitation last January. Feachem and co-workers1 compared the costs and performance of the NHS with those of a health maintenance organization in California, the Kaiser Permanente, which has been running for about the same time. Their conclusion—shocking for those who believed that the NHS was generally efficient even though underfunded—was that the costs of the two systems were similar but Kaiser members were better served, with superior primary care and faster access to specialist care and hospitals. The reasons for the better performance of Kaiser, they suggested, were real integration, through partnership between physicians and administration; treatment of patients at the most cost-effective levels of care (hospital stays for Kaiser patients were much shorter); competition and choice (consumerism) in a population with high expectations; and good information technology. The data required ingenious statistical adjustments for population and other differences, and many commentators simply rejected the authors' interpretation that the troubles of the NHS are due more to inefficiency than to underfunding. But the message about inefficiency stuck.
Let's turn to the papers in this issue. On p. 580 Dr Gibson and Dr Frank take up the theme of rehabilitation, a neglected discipline in the NHS2,3. Their subject, multiple sclerosis, typifies conditions resulting in static as well as progressive disability; and the article spells out the great benefits to be achieved when health and rehabilitation professionals work closely with the voluntary sector—in other words, integration. (In a recent Lancet, Bent et al.4 conclude that, in young people with physical disabilities, multidisciplinary teams promote greater participation in society than does the usual ad hoc approach, at no greater cost.) Next, the paper on p. 604 by Mr Patel and his colleagues neatly illustrates the inefficiencies that result from missing data in outpatient clinics: over the past thirteen years, though the time allocated to each patient has lengthened, time spent with the patient has actually shortened. As they say, an obvious remedy is information technology. After this, try the robust Book of the Month review (p. 623) by Dr Julian Tudor Hart. Here you will find no support for the consumerism/competition component of the Kaiser-Permanente regime: instead he calls for ‘an NHS pursuing rational goals set by public health, with patients developing themselves as informed and responsible citizens with our professional assistance’; in Wales at least, he thinks, a socialized NHS could survive. Finally, there is the intriguing report by Mr Ramchandani and colleagues (p. 598), who sought the views of consultant ophthalmologists, general practitioners and patients on pooling of waiting lists for cataract surgery. The consultants were 2 to 1 against (partly because they valued the continuing doctor—patient relationship), whereas the GPs and patients were at least 4 to 1 in favour. So, here at least, the views of consultants seem contrary to the mood out in the community.
Why was the new consultant contract rejected? According to the Chairman of the Central Consultants and Specialists Committee it offered rich prizes—a time-limited contract, recognition of emergency work, payment for being on-call, extra payments for working beyond 40 hours a week, protected time for teaching, research and audit, and big increases in pay and pensionable salary. Managers would not have gained any extra powers but would have been able to work more efficiently by obtaining greater control over deployment of the labour force. The rejection came down largely to a lack of faith. According to a BMA statement, the referendum revealed relations between NHS managers and doctors to be deeply unhappy. Doctors feared that they would come under unreasonable pressure to meet performance targets and that they would be forced into working unsocial hours as a routine. So, no respite from existing stresses, and the vision of a well-managed (Kaiser-Permanente-style) NHS retreats a little further. Cui, as the late Sir Douglas Black put it, bono?5 To what good purpose?