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NHS: The Health Files

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Jon ManelReporter: Jon Manel
Read some of your responses to Jon Manel's NHS reports.


The NHS Cake.
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HM Treasury - Spending  on NHS

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The King's Fund

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Almost all the money supposedly 'invested' in the NHS has been spent, not invested, on wages. No wonder there is virtually nothing to show for the vast extra spending. As the Jerry Robinson efforts showed it is a stultified organisation. The penalty of state ownership, no responsibility to the customer. Rather like the BBC!

Payrounds are a constant theme in today's health service. There are however some myths perpetuated by senior PCT executives, namely GP pay. GPs are well paied, but they are also extremely very good value for money and have a proven ability to manage high workload, and manage risk effectively. Nurse on the other hand have seen significant pay increases, yet accept less and less responsibility. As such we find the situation common in many hospitals where basic hygiene procedures are not followed because many nurse feel it is not their job and "an inappropriate use of their clinical skills". Being critical of nurses is a taboo subject. We must be critical in order to get to the root of the problem. The NHS is traditionally secretive and very politically motivated. the document 'shifting the balance of power',has had the effect of demoralising the GP community whilst lining the pockets of poorly performing PCT Managers.

The structure of the new NHS consultant contract makes it clear that the DoH believed that under the old contract most consultants were underproductive and not giving value for money. By introducing a contract in which you are paid for the work you do rather than for providing/running a notional 'service', the sharp thinkers at the Department obviously convinced themselves that this would lead inevitably to a more productive consultant workforce. However, with what can only be described as a spectacular lack of judgement, they had utterly failed to perceive that most consultants were actually doing far more work than their salary reflected and were not as perhaps suspected, spending countless NHS hours on the golf course or at the local private hospital. Hence the introduction of this contact resulted in a significant salary rise for most consultants with no additional work being done (in some cases less). Declaration of interest - I am a consultant working exclusively for the NHS.

GPs have received huge pay rises over the last few years due to the implementation of the new GP contract. At the same time their level of work has reduced - they are no longer required to provide an out of hours service and thus typically work normal office hours. GPs now typically earn more from the NHS than hospital consultants despite having a significantly shorter training period and arguably less technical expertise. The main reason for the dramatic increase in primary care expenditure over the last few years has been the increased pay of Gps. Trainee doctors have also seen large pay rises coupled with reduced work levels - they are no longer required to work 100 hours a week. Nurses pay has risen significantly in real terms since 1997, though not at the same rate as GPs. Board level pay has also risen dramatically since 1997, it is not uncommon for a Chief exec of a PCT or acute Trust to be on more than £150k and for a Director to be on £110k+. Professions allied to medicine (physios, occupational therapists, speech therapists etc) have also experienced large pay rises, at least as much as nurses with some groups such as speech therapists receiving much more.

I am a full time GP. Good things about the GP contract for the public; Before the nGMS contract our practice received 80-90% of it's income whatever we did. With the new GP contract 2/3 of our income depends on performance- quality points standards set by the Government and providing services like minor surgery.The quality points system we have in the NHS is the envy of thw world and I believe has helped us focus on improving health outcomes through preventative work and better disease management. We obtained almost all the points in the first year and 100% in the second year through a lot of hard work. We were driven by pride rather than money in this. We wanted to be seen as providing the highest quality care. We have had a significant increase in income in these two years but this has been balanced by a freeze for the last two years in our 1/3 core funding ( the global Sum which covers 70% of staff pay costs)and the need to employ more staff. Our staff hours increases and pay rises have been funded out of the performance related pay. We know the government will manage to claw back what it sees as an excessive pay rise over the next few years. With regards to investment and the "taking excessive profits out of GP businesses" allegation and future profit drawings caps it seems the the Government has forgotten we are small businesses and have been so since the start of the NHS. As with all businesses you cannot invest straight away. Fortunately enough for us the start of a £40,000 surgery refit in our practice coincided with media being full of fat cat GP allegations. The planning process to get this project done started a year ago. I am working harder now than I did in the old contract when I had the out of hours commitment. Bad things about the nGMS contract: The government pricing the 24 hour commitment at £6000. I was paying that to be in a co-operative. I was not unhappy to be doing out of hours in a GP co-operative- I did not want that change in the contract. I wish we could go back to out of hours organised by GP's in non profit making co-operatives- patients got better care. The private sectors bottom line is to make a profit and this can be at the expense of quality and safety of care. I and many of the GP's I know do not do out of hours because of concerns about exposure to the risk of adverse events while on call working in the private sector because of too many demands on the GP on duty. The majority of GP's derive their feeling of self worth and happiness from the relationships they have with their patients and their teams not their pay packets. I did not become a doctor to get rich. I have been very lucky with job security and the priviledge my knowledge and skills give me in being involved in people's lives and trying to make a difference. My satisfaction on achieving 100% quality points was in the fact that our patients would see that we really had provided collectively a high standard of care externally validated in the NHS. What matters most to me and the team I work with is the good opinion of the community we serve. I think the government in it's response to attacks on it's competence in managing the NHS has gone a long way to undermining that good opinion and it saddens me.

As a hospital consultant I was surprised to hear your interviewee from the Kings Fund describe the average consultants salary as about £110 - 112,000. Where did this figure come from ? The starting salary of a consultant is ~£72k, and after 30 years it rises to ~£94K (just before retiring). Given that there are far more young consultants than old ones (there has been a constant increase in consultant numbers), the average *must* be £80-90K. Can you ask your interviewee to explain this 30% discrepancy?

Oh good, so my husband is now working normal office hours and earning £100,000 a year. That's news to me. Since the change in the contract, he starts work at 8am and all too often works through until 6.30pm with often just 20 mins for an interrupted lunch ("Dr, could you just sign this, could you just phone a so & so etc.") and maybe a lucky cuppa. No more 1/2 day once a week to make up for the night work. He comes home shredded, cross and depressed. And the extra pay? Well, at the moment it's going towards the rise in staff pay and national insurance costs and trying to improve the premises for better patient access and comfort (not something hospital consultants have to spend their money on!). And less we forget, every 'high earner' supports society with 40% of their pay going back to the government to prop up the state!

I more than tired of this debate. The present average earnings of doctors, £100K or so, isn't such a big deal. Even only moderately senior executives of large corporations have base salaries of £100k or so plus many fringe benefits and have had that for many years past. The reality is, doctors in the NHS have been underpaid for years and this is no more than catching up with their market value. I am not a medical doctor, am more than satisfied with the performance of my own GP, am a retiree of 5 years and was indeed a corporate executive. People in UK need to get used to the idea of international market value of professionals or lose them, and not just doctors either.

It was refreshing to see some realistic data concerning consultant salaries. Unfortunately the media competition for listeners and viewers is such that the mundane reality for the vast majority of the profession is disregarded for spinning the public with sensational data concerning the minority. I have no vested interest in this issue, being a semi retired physics lecturer.

Just a note to remind people that there are approximately 12000 doctors who work in the NHS and ARE YET TO RECEIVE ANY PAY INCREASE.The SAS grade is paying the price for the supposed "largesse" of the government towards GPs, consultants, trainees, nurses.The recent SAS pay negotiations have been a fiasco and any apparent increase in pay is less than sufficient to cover additional working time. I ask myself whether the demographics and ethnic belonging of this SAS group are responsible for their plight.

I have been bedridden for many years suffering an incurable condition for which pain relieving medication is my only requirement. Prior to the "new initiatives" I saw a GP roughly once every 2-3 years. In the last year, he has visited twice - once about every six months. Why? Is it because I need more "care"? No, it is because he is now paid for these visits. Are his visits useful? Emphatically, NO. I have a medical background and am well able to manage my own condition. It would be generous to say that his contributions over the years have been minimal, in fact, they have been NIL. I am certain he has learnt much more from me. How can I stop him wasting NHS funds in this way? Not only does his visit "cost", but he suggests that a blood test might be useful - adding further to the cost and also, to the work load of the pathology lab. His visits will be considered "improved performance", but in reality, they are comparable to the factory employee who wanders around a manufacturing plant carrying a spanner - sufficient evidence that he is working.

I have been a fan of the Radio 4 Today programme for many years but was amazed by the biased, aggressive interviewing of a GP spokesman regarding pay for GPs. My husband is a GP who has worked himself into the ground and sometimes ill health in order to care for his patients. Our children hardly saw him when they were growing up and we were so 'rich' that I had to work full time all my working life to make ends meet. When he worked in the hospital during his training as a GP he worked a 126 hours a week on a 1 in 2 on-call rota. Only hours over 70hrs a week were classed as overtime for which he received 1/3 of the normal rate. His working day as a GP was 6AM to 7PM and then until the new contract he would often have walked through the door only to be called out. He has met all the governments targets and was only one of two practices in his area to have achieved maximum points for the first two years of the contract. In fact he had reached the maximum points this year prior to his retirement at the end of December 2006. But does he get any gratitude - on the contrary - he, along with other GPs, has to put up with this constant carping about being overpaid. Why are GPs constantly the target of government who know better and people like, I'm sad to say, your interviewer who have not bothered to do their homework. How dare he say GPs are being bribed to work longer hours? Shouldn't any one be paid for the hours that they work? It is expensive to keep a surgery open for extra hours as all the staff have to be present and be paid for their extra hours too. Why do consultants come in for so little criticism? My husband used to spend hours doing work that they should have done - chasing up discharge letters, prescriptions and outpatient letters when patients were sent home without them. They get all their expenses paid whereas GPs have to pay for all the costs of running their surgeries - staff wages, utilities etc. Why this animosity towards GPs? Doctors go into medicine to help people. Yes it is a vocation, but why should they not be rewarded like comparable professions. Lawyers are never targeted but then most of the Cabinet are lawyers! Doesn't everyone know there is a shortage of GPs? So what do we do - insult them and try to renege on legally binding contracts. Do we really want privateers ( I use the word advisedly ) coming in to run general practice and skimming off another layer of money for profits and shareholders? No, BBC, you have let us down this time. We have come to expect a higher standard of interviewing from you.

The introduction of a time based contract for consultants stemmed from Alan Milburn and the DoH erroneously believing that we spent all of our hours golfing and doing private practice. But at no point did any one from the government actually ask us what our work patterns were. The BMA told them that most of us worked hard and beyond our contracted hours but they chose not to pay any notice of this warning. That is shocking mismanagement and it underpins why the government underestimated the cost of this new contract so badly. Since becoming a consultant in nearly 15 years ago I have always worked approximately 50 to 52 hours per week. I used to be paid for only 38.5 hours but now receive remuneration for 48 hours. That is a reasonably fair arrangement-although I would stress that this additional work (beyond the standard 40 hour contract) is not paid at a premium rate, not pensionable and is subject to annual review. In effect it is not secure income. Politicians now state that the new contract has proved to be poor value for the taxpayer. Are they really incapable (or indeed unwilling) to understand that roughly the same volume of work is being done now as before. The difference is that work previously done free gratis is now remunerated. The main value of the new contract is that it enabales us to hand back this work if the additional funding is withdrawn. To do so would pretty much spanner the entire NHS consultant service. My basic salary is around £78000. Considering my training (four university degrees including a doctorate) and a fiendish fellowship exam that I sat in my early thirties, this amount is hardly earth shattering. Any half decent plumber probably makes more and most accountants, lawyers and anyone in the square mile would likely treat this as pocket money. And like most consultants, I love the job. This new contract now effectively has to be negotiated every year, whereas the old contract was negotiated once at the start of your consultant post. The manpower and time involved in this annual appraisal and job planning is immense and in itself must cost a fortune. One very important point that you must try and clarify is whether doctors who are being recruited to work in independent treatment centres are subject to the same rigorous regulations as those of us already working in the UK. I am subject to various controls ranging from continuing professional development, participation in external quality assurance schemes, annual appraisal and now the spectre of revalidation with the GMC is rearing it's ugly head again. These activities all eat into our time and efficiency. Is the playing field a level one for all doctors or is it the case that excessive regulation only really applies to those of us trapped in the NHS.


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