There has been plenty of assertion / anecdotal evidence to suggest that continuity of care matters. Now there is more hard evidence to show that there is a benefit to patients seeing their own GP instead of walk-in centres & A&E departments. This is in addition to plenty of US research which shows the same.
After adjusting for measures of medical need, demographic characteristics and other covariates, we found that increased emergency department use by elderly patients was associated with lack of a primary physician, lower continuity of care with the primary physician, low overall use of primary care services and residence in a region with more general practitioners per 1000 population. Furthermore, lower continuity of care and low overall use of primary care services appeared to have a stronger effect on emergency department use among urban than among rural residents, whereas absence of a primary physician had a stronger effect among rural residents.
A much bigger & more robust study then than the British one.
Something to consider when commissioning services perhaps?
The verdict of the Better Government Initiative, contained in a series of reports to be released over the next few weeks, is damning.
Government departments have “serious deficiencies”; the combined output of Parliament and the executive contain “too many disappointments and failures”; and “emphasis on ‘management’ has led to more bureaucracy at the expense of substance” in the Foreign Office.
“Health, education and the armed services have had constant change, insufficiently discussed and thought through.
“We’ve had nine revolutions within 10 years in the NHS. We’ve gone away from markets, then back to markets. It’s just disruptive and demoralising.”
“What has really damaged the public’s trust in politics is the failure to live up to promises… Ordinary people want the money spent on the NHS to have brought about the improvements it should have done.”
“Teachers, nurses and doctors can see how much micro-management is going on, that makes their job harder and seems to treat them as unintelligent creatures.” There is a similar problem in Whitehall. “Civil servants are not expected to analyse problems and produce intelligible policy,” he says.
“Ministers come up with an idea and expect civil servants just to do it. You can’t just come down on civil servants if they don’t deliver when you haven’t been very precise about what you mean by delivery.”
“Constant change, often couched in impenetrable jargon has had a depressing effect on morale. People feel that they no longer feel they know whether they are coming or going, that they are unappreciated and ignored… This is not management in any real sense, it is certainly not leadership and it undermines the effectiveness of the organisation.”
Hmm, so where does it absolve the authors from responsibility for standing by while all this was happening? Not to mention the very many failures of years past? After all, it is not as if the civil service has clean hands in all this as can be seen below. But I will take allies wherever I can find them.
Sophia Christie in the HSJ punctures a few bubbles relating to the way in which policy seems to be populated by some remarkably persistent ideas that pop up every decade or so in search of believers.
Several weeks later, Lord Darzi announced polyclinics as the solution to primary care capacity in his interim report for Our NHS, Our Future (or the On/Off review).
The last time I remember polyclinics taking centre stage was the late 1980s when Margaret Thatcher sent teams of civil servants overseas to investigate alternative funding for the NHS. They came back from Germany with polyclinics, which at least diverted attention for a while from personal insurance as the answer.
However, the theme of finding community-based activities for hospital consultants is a recurring one. In his London review, Lord Darzi rightly identified a key principle as ‘localise where possible, centralise where necessary’. However in On/Off he also references US achievements in shifting outpatients to community settings. Given the lack of primary care in the US, much of this outpatient activity would have been seen by a GP in the UK anyway.
Meanwhile the many GP fundholding initiatives of inviting consultants to sit in GP surgeries and see a fraction of the patients they could have in a clinic should have been a lesson in both (in)efficiency and inequality.
At-least someone is paying attention & is willing to display a healthy cynicism. Now to help educate the rest of her colleagues.
More about accountability then & I am warming to my theme, what with well argued comments from a number of commentators.
How can you police the competence of a chronically incompetent organisation where the probability of discovery of any single error is very low? Answer: make the consequence of discovery very high. That way you provide the correct incentive to staff and ministers to be competent. They will multiply the probability by the consequence - knowing that it is unlikely that their mistakes will be unearthed, but that if they are unearthed they cannot expect the press and public to be all sweet reason.
I have to agree with this well reasoned opinion from Daniel Finkelstein as also I do with the following from Simon Jenkins.
Who bears responsibility for the deaths of hundreds of Britons from hospital infections, almost certainly the result of the privatisation of cleaning services? Should it be the Tory health ministers who instituted the policy or Labour ministers who failed to reverse it? When should “responsibility” mean resignation?
All we know is that not a week passes without something going wrong somewhere in the public sector and an almighty row ensuing over “whom to blame”. The reason is that the dinosaur’s head is too far from its foot.
The nearer a school, hospital or police force is to its client the easier it is to identify responsibility and thus allocate blame. In the private sector, blame attaches to whoever makes the mistake. The same applies in properly “tiered” democracies. In most cities abroad, a poorly performing school, a corrupt planning decision or a fiscal scandal is accounted to the elected mayor. If the relevant service is provincial, it is to the governor, if national to the minister. Accountability is clean. The franchise bites at each tier.
In Britain nothing bites but an occasional general election. Nobody down the ladder of public administration accepts blame since performance is dictated by Whitehall. The reason why so many police cars crash is that government offers more money the faster that 999 calls are answered. Hospitals are dirty because ministers want cash diverted to lower waiting times. Yet when these policies go awry, the centre pushes blame back down the line.
Continuing with the theme, a local GP has his say in the letters section of the Times.
As a GP representative for 20 years I have never before dealt with such an arrogant hospital management which treated its employees, including consultants, with contempt, some threats and a degree of bullying.
Management styles of the type we have experienced in Maidstone over the past four years should have no place in the NHS. We must never allow any trust in the UK to be run by such a publicly unaccountable and — and in the end — ineffective regime again. Other communities should be on their guard and “whistle-blowers” protected.
GPs who fail to provide out-of-hours services could be penalised if their patients seek treatment elsewhere, a leaked NHS document suggests.
According to the letter, “recharging” would mean surgeries on the General Medical Services (GMS) contract, which has allowed 90 per cent of doctors to opt out of providing out-of-hours care, would be charged if their patients are seen elsewhere.
Just as soon of course, as the GPs also have control of the various other services that would affect their patients health & precipitate an attendance at A&E. After all, they can’t be held responsible for things that are not totally under their control. And then we could disband the PCT & possibly the SHA which would really be an improvement.
To readers from far & wide:
The server logs make for interesting reading, telling me just who is visiting the site & the topics that interest you.
So can I invite you to participate in the discussion, by telling me why I am wrong if indeed I am so & generally shedding a little light on this brave new world we inhabit.
It is more fun that way, honestly!
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