Look On My Works And Despair

The overall cost of the NHS IT system is thought by insiders to be heading for £50bn making this the most expensive government grandiosity since the Pyramids. Except this one won't generate any tourism revenue (Wat Tyler)

The scandal of PFI - or Gordon's "stealth borrowing" as it is becoming known - is beginning to reach public consciousness largely due to the efforts of financial journalists such as Mike Denham. As we reported before, Mike was apprehended by the police when he tried to slip into Whitehall to film his exposé on PFI



The government is proud of the fact that it has poured money into the NHS. But it has gone in without proper planning, and often been devoted to doctrinally motivated projects which have not improved health care. Financial waste within the NHS has to be seen to be believed. Once again, Dr Crippen turns to Mike Denham:




The amount of money spent on PFI "initiatives" (sic) and malfunctioning IT projects dwarfs the money wasted on GPs, but it is the latter that is much in the news, because the government has found a scapegoat. The colossal waste of money is all the fault of the GPs. If only they had not been greedy and dishonest, this money would not have been wasted.

The British Family Doctor

Let us look at what really happened.

The new GP contract was introduced in 2004. The use of the word “contract” was a linguistic abuse for, as any lawyer will tell you, a “contract” is an agreement between two independent adults. Many doctors voted against the contract. Dr Crippen and his partners did. It was then imposed upon us. If we had not signed, we would have been closed down.

The government decided upon, and introduced, a system of health care targets, and awarded points to practices that hit the bull’s eye. They assumed that family doctors were lazy and it did not cross their mind that most practices would hit the bull’s eye. Well, we did. It was a lot of work, mostly a complete waste of time, and nothing to do with real health care. In particular, it was nothing to do with patient needs. But we did it.

The government is now accusing us of dishonesty. Hewitt and Warner have both said that we have had our hands in the till, and have lined our pockets with money that was meant for health care. It is not true.

GP finance and pay-structure is complex, and has grown over the years in an unplanned organic fashion. We are notionally self-employed independent contractors but, in reality, we work under the terms of a “contract” (sic) which is imposed upon us. Before 2004 the money we received was divided into two; our own pay was ring-fenced and separate from the money we received for expenses and staff salaries. From 2004 onwards we receive a global lump sum out of which we have to pay all our expenses and staff salaries and then can pay our selves with what is left. We did not want this. We resisted it. Yes, it has the advantages that the more efficient you are, the higher is your pay (and what is wrong with that?) but has the disadvantage that as staff salaries rise, and the lump sum stays static (and it will), our own pay goes down.

Inevitably, GPs reacted as any business would by keeping costs and expenses down as far as was reasonably possible.

The only icing on the cake was money to be earned from QoF data. From hitting those targets. That was additional money and, the better you did, the more you were paid.

At no time, and at no stage, was there any suggestion that QoF money was earmarked, or partially ear marked, for anything other than GP's pay. If the government had said that the money was not going to go to us, we would not have done the work, because it was of no value to patients. If British Rail told its employees it would give them a 20% pay rise for polishing railway lines, the railway lines would be polished. If it told them it would give the money not to the staff but to OXFAM the lines would not be polished.

Now the government is saying we have had a 30% pay rise over the last year. That is not true. If you have read NHS BLOG DOCTOR regularly you will know that I have always been open and honest about pay rates. We have had an increase of approximately 23% over two years. Not to be sniffed at, but nowhere near the figures that government has been bandying around.

The government burnt its financial fingers by assuming that GPs were idle and could not possibly do the work necessary to hit the targets. They made exactly the same mistake when they put the hospital doctors on a contract and insisted on paying them for the work they did.

The truth of the matter is simple.

The government have made yet another costly financial error. In trying to control GPs they have paid us far too much money to hit targets that have nothing to do with patient care. Hitting the targets involved a lot of work (much less for well-organised, computerised practices such as mine) which has impinged upon time that would have been better spent with patients.

It is has been a complete waste of money.

This government does not admit mistakes. Have they apologised for PFI? Have they apologised for the money wasted on a computer system that no one wants and that does not work? Have they apologised for paying GPs silly money to do silly work? No they have not.

They cannot find a scapegoat for the colossal PFI and IT financial disasters, but they can find one for GP finance. The GPs themselves.

So they have accused us not only of greed, but of financial dishonesty. We stand charged with lining our pockets with money we knew was earmarked for health care. We have been stealing calipers from cripples. It is upsetting and demoralising. I susect though that this time they will not win the media wars. Most GPs, indeed most doctors, are decent hard working professionals and I think most people know that. Or I hope they do.

Let us now try to be constructive. If the government really wanted to improve the services provided by GPs what should they have done? They should have asked the patients. I know what patients want from doctors. They want reasonable access to their doctor at at a reasonably convenient time, and they want to know that, during the night and at weekends, they can speak to and see a doctor. A doctor that is, not a dumbed down "health care professional" sitting on the end of a telephone reading from a protocol. (See, once again, the Welch Family Christmas). Of course, as a doctor, I know that patient demands cannot be met in their entirety because many of them are unrealistic and some are unreasonable. But we can go some way towards meeting them, and a lot further than we have gone at present.

What should the government do?

Scrap QoF and targets tomorrow. That will produce an immediate and huge saving. Use the money to offer a similar pay rise to all GPs who will :

• run surgeries on Saturday and Sunday, morning and afternoon
• run late evening “after-work” surgeries
• run early morning “before-work” surgeries
• run surgeries from 12.30 pm to 2.30 pm (i.e. covering other people’s lunch break)

It could be done and GPs would do it given a reasonable financial incentive.

And finally, the OOH work. Dr Crippen does not do OOH work any more and will never, under any circumstances, do it again. I did it for over 25 years, and it nearly broke me. (see "Out of hours - a personal view"). What I did do though was work with local colleagues to set up a system in which we joined together in a co-operative to share the OOH work. The system worked. It was not perfect, but it worked.

The government destroyed it.

Until 2004 the OOH service had been functioning reasonably due to these large well-organised co-operatives. Dr Crippen was involved in setting up his local co-operative which has now become one of the largest in the country. Dr Crippen remembers having meetings with the Chancellor of the Exchequer, Badger (“je ne regrette rien") Lamont, and the Secretary of State for Health, then the very lovely Virginia Bottomley (whose name always amused me because, before I let Bill Gates in my life, my cheap spell checker tried to persuade me to change her name to Vagina Bottomless...but I digress). The Conservative government was very keen. A genuinely no-cost option to solve the OOH problems.

After a few years, the co-operatives controlled the OOH service nationwide. They were independent non-profit making companies and they flourished. Dr Crippen was then a director of his cooperative. GPs still had a legal obligation to provide OOH cover 24/7 but the co-operatives made OOH work almost manageable and provided a good service for patients. For the first time in our lives GPs had found a way of coping with the 24/7 on-call commitment. The Labour government however saw the cooperatives as a threat. They were an independent professional power base and New Labour does not like things it cannot control. It wanted to take control of the co-operatives, but the doctors were not going to hand over something that had changed our working lives.

The government was so desperate to get hold of the co-operatives that it found the only way there was to make us let go. They offered to relieve us of our 24/7 responsibility. I can remember when the offer came in. We did not believe it. They could not possibly understand what they were taking on. But the chance of being relieved of being on call 24/7 was too good to miss. For the first time in our professional lives we were free from this onerous commitment. And the co-operatives? The government took them over, effectively nationalising them

It was a huge error.

An error that could have been avoided if the government had done some basic research into the work-load and labour costs of OOH work. They had missed one crucial factor. The co-operative had been such an improvement in the quality of GPs lives that, not only were we paying the administrative costs out of own pockets, but also we were working for the co-operatives virtually for free.

Now the government has the 24/7 OOH commitment. And they have the co-operatives. The only thing they do not have is the doctors. They cannot afford them. Enter dumbing down and NHS Direct. Just like “hospital at night” attempts to cover up for the lack of doctors in the hospitals, now we have “Direction of Travel for urgent care” to cover up for the lack of doctors in the community.

Doctors are intelligent professionals and are capable of dealing with problems. They set up co-operatives to deal with OOH work. The co-operatives were a private initiative, run as private non-profit making companies outside the control of the NHS. They cost the taxpayer nothing. No grants. No subsidies. No hand outs. And they ran well, because they were run by business men used to working in the private sector. The government should have let them get on with their work. Indeed, it could have fed and watered them with a little of the money that was wasted on QoF targets and we could have had the best OOH service in the world.

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I am grateful to Wat Tyler of Burning our Money for the economic data, and for lending me the title and graphics