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Re: Is there room for Community Paediatrics on the Ark?

Dear Editor,

Professor Stephenson’s perspective on the NHS Reforms (1) is a welcome stimulus for debate about the future of children’s health services in the UK. The article touches upon waiting lists for children, the tariff system and the ‘shifting care closer to home’ agenda.

If viewed dispassionately, the NHS reforms make perfect sense. Practice based commissioning (2) should allow primary care to use knowledge about the needs of their local population to commission appropriate specialist services. Patient choice is built into the process. Payment by results (3) was designed to incentivise providers to reduce their costs to the national tariff or below and so retain any surplus kept. Demand management was introduced to limit perverse incentives for increasing secondary care activity and hence income. The problems we see with these reforms are simply because healthcare is far more complex than any business model and market forces do not sit comfortably with clinicians who often value quality in isolation to efficiency and cost-effectiveness.

Where does all this leave children’s services?

Specialist inpatient services should be preserved at all costs and 69% top up to tariffs is the first positive step. Clinicians will have to take clinical coding more seriously to avoid underestimation of the service they provide. Primary care will increasingly demand ‘real time coding’ and prompt discharge summaries to trigger payments.

The Paediatric outpatient tariff is set at £217 for first attendance and £114 for follow-up attendance (4). This provides an opportunity for ‘shifting care closer to home’ without compromising emergency services for children and tertiary services. Strengthening of primary care for common childhood conditions would lead to some reduction in secondary care use over a period of time.

This leaves Community Child Health Services in the uncertainty of no- man’s land. There are no tariffs for community services, mental health, learning disability; so far so good. A complex Change for Children agenda conflicts with the principle of ‘integrated children’s service’. The Paediatric outpatient tariff, if strictly applied to Community children’s services hosted by secondary care would ensure its rapid demise. PCTs divesting themselves of provider services remains a real threat.

The waters of reform are rising. If our hospital based colleagues truly value the contribution of community child health services to the future of children, then they should not forget to help them find a place on the Ark.

References:

1.Stephenson T. How can the UK National Health Service be broke? Arch Dis Child 2007; 92: 189-190.

2.Practice based commissioning: A primary care led NHS. NHS Alliance July 2006.

3.Payment by Results: HSJ Briefing. www.hsj.co.uk.

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Re: Status of NHS in Some Trusts

Dear Editor,

The article by Stephenson on the status of the NHS is based on three measures, that more money is spent on the NHS, more salaries are given to workers and that waiting time is reduced. These outcome measures give an erroneous evaluation of the status of the NHS. Although there is some improvements in the delivery system of health care, it is in no way matches the increase in expenditure which then highlighted the inefficiencies of many Trust boards who suddenly found themselves in charge of hundreds of millions of public funds. It is almost like giving donation to third world countries and the money disappear into thin air and the place has not moved except for few. To illustrate the point you need to study cases, where misuse of systems has resulted in reduced quality of care to children. We know that the reduction of waiting lists may be genuin in some Trusts but in others is only a reflection of manipulations where patients are not listed unless they are going to be seen within the target. The status of Child Health is far from expectations. The senior management reached to the point that children are denied access to services that is existing to reduce cost. If you raise concerns, you are accused of possible fraud ( this is the new buz word), allegations are made against you by the senior trust board members to get you out. Misuse of disciplinary policies is now a common place. You now work for a chief executive and medical director who are accountable to nothing. Basically, they believe that they are the company owners. Other roles of the NHS is education and research. We are no longer allowed to take on fellows for education, research is almost dead by narrow sighted directors. When you get such type of people in driving seats you can not change them without being hurt and your career is on the line. It is interesting that you view the private sector role as a positive one, unfortunately this is not the case here. It appears that the NHS Trust is raising the barrier to the point that a child waited for almost a year to get a blood test. It appears that while the nation is trying to make patient, and in our case the child, the focus of care, in some Trusts, the centre is the senior management. We would like to be proud of our NHS but we can not, we are not allowed.

References:

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Re: Training on the NHS is also broke

Dear Editor,

We read T Stephenson's excellent perspective on the state of the NHS with interest (1). This is a very comprehensive account of the NHS budget, NHS reform and implications for children’s services. We would like to add a few points specific to the impact of the new NHS on the care of children both current and that in the future due its effect on the training of new paediatricians.

Towards the end of the article the important point is made that patient choice and plurality of providers may well not be the best solution for children with multiple coexisting long-term problems. We would like to add that there is also a real danger that the system by offering more patient choice may lead to delayed flagging up of child protection issues. One of the strengths of the old NHS was that it encouraged clinical networks and tertiary specialists were generally enthusiastic about giving informal telephone advice to generalist paediatricians. Many paediatricians will be worried that the Payment by Results scheme will demotivate the formation of such networks and financial implications may come in the way of professional relationships. Finally while it is important to ensure paediatric service are efficient and to emphasise the importance of discharging children back to primary care, it is arguable if measuring outcomes such as new to follow up ratios and dissuading consultant to consultant referrals are in the best interests of the child.

The NHS has always been about both service provision and medical training. The patient has been put in the centre of the equation but what about the trainee ? We believe that financially motivated changes in the way we work without understanding the way this will impact on training are shortsighted. Many changes have revolved around providing the most activity with minimum staff and ensuring that service needs are met without doctors working over the number of hours allowed by European Work Time Directives. This has meant that trainees are often stretched by service commitments, demoralised and demotivated so that they do not derive full benefit from the many learning opportunities that clinical care offers.

While educational supervision and regular appraisal of trainees do take place, we believe it is common for juniors and consultants to feel there is little room for tailoring each doctor's work experience to suit their training needs. For example, in most hospitals, junior doctors who are GPVTS trainees have the same service commitments as career grade paediatricians even though their training needs are likely to be very dissimilar. Similarly while the training needs of different Specialist Registrars will be different service priorities usually mean that their needs cannot be catered for. This makes the process of supervision and setting targets for learning less meaningful and can lead to low morale and lack of enthusiasm for such activities. Many juniors feel anxious about how well they would be prepared by their training and what jobs await them at the end of it. This anxiety can translate to less happiness and goodwill when they are working and increase in leave due to sickness.

The government and the politicians are likely to be less aware of the training needs of doctors and will tend to concentrate on using the current trained doctors to best advantage to run the NHS. The Royal Colleges and Deaneries must take it upon themselves to remind the powers of the dual role of the NHS so that the doctors of tomorrow are well trained and competent to serve tomorrow’s Britain.

Reference:

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Re: How can the UK National Health Service be broke?

Dear Editor,

Professor Stephenson raises many important issues with his rhetorical question, ‘is the NHS still something to be proud of ?’(1), pointing out that children are among a number of vulnerable groups likely to find specialist services increasingly difficult to come by. Payment by results seems poised to bankrupt children’s hospitals, and in my own Trust, from having been a net ‘earner’ the paediatric department is now likely to produce a £16 million annual deficit. Needless to say plans for the long awaited Children’s Hospital for Leeds have (once again) been shelved. The popular view fostered by New Labour politicians, parliamentary committees and much of the media is that greedy doctors (large pay rises) and poor financial management go a long way to explaining why record investment seems to have achieved so little. As Professor Stephenson shows, this is not the whole story. The fact that the NHS is being quite deliberately dismantled through the process of ‘patchwork privatisation’, eloquently argued by Alex Nunn for the ‘Keep our NHS Public’ campaign (www.keepournhspublic.com), is seldom mentioned. The prospect of a health service opened up to private companies beholden only to their shareholders is not what inspired many of us to become paediatricians. We can look forwards to a wasteful American style system of healthcare for those who can afford to pay. A broad and popular movement in defence of the principles on which the NHS was founded is the only way we might yet avoid being left to reflect dismally on the days of a comprehensive and equitable service as a vanished golden age. As Nye Bevan said of the NHS, “it will last as long as there are folk left with the faith to fight for it.” Professor Stephenson has thrown down the gauntlet.

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