Monday, 12 December 2011

Dear Santa

Today I attended a really interesting meeting organised by the directorate I work in, designed to engage with clinicians about how we can meet the financial challenges up ahead.

The only problem was that there weren't many clinicians there. There were some consultants, who are involved in this kind of work on a daily basis, but below that level there was just me and one SHO.

Chatting afterwards to the SHO, she expressed some dismay that there weren't more doctors present, and it was a shame, as we had a really interesting meeting with some managers really keen to hear what we had to say. The question she and I mulled over together was whether this was the fault of doctors for not getting involved, or the fault of the people who organised the meeting for not enticing them.

The issue of how to meet the financial challenges facing hospital trusts is not one that can be met realistically without the heavy involvement of clinical staff. There are two main reasons for this: two thirds of healthcare costs go on salaries, and doctors are the individuals responsible for the majority of spending within the service. Therefore, the inevitability of trying to save 7% a year seems to inevitably involve a combination of reduced staff costs, and reduced spending in the provision of services, given that extra revenue streams are currently very difficult to find: the money available for paying for health services is already being spent, and except for some modest alterations in who provides which services for whom, the money that we currently have is all the money we are going to get.

It can feel as if we have been on an austerity drive for years already, but this has mainly focused on improving pathways, and efficiency; the real pain of reducing costs by the dramatic margins required has not yet begun in earnest.

How many doctors you know have a good feel for this? I sometimes feels as if I somehow ride above the fray on this issue - that the problem of how to streamline the service is someone else's problem, but then I remember that the challenge is to provide excellent patient care with less money, and this is something that I need to care about: without the right kind of clinical input, managers will be forced to guess how best to cut services without the clinical input required to know how the services should be altered.

One of the issues we discussed today was the difficulty we have in redesigning services that look the way they do because of historical quirks and happenchance. None of the services we were talking about would look the way they do if we started from scratch and built them from the ground up, but working out how to approximate this ideal from the position we find ourselves in now is a really difficult thought experiment.

My argument for the need for doctors to get stuck in to the discussion is not borne out of a desire to see doctors retain their influence, but rather to see doctors roll up their sleeves as part of the team and carry their share of the burden.

I am firmly of the mind that virtually every process in healthcare could be improved, and some of them can be removed entirely. It is crucial that we honestly assess what happens where and why, and what could be done differently, and what can be done away with entirely.

Too often, the efforts of managers to engage with clinicians in reducing costs are undone by the steadfast and unerring belief of the senior doctors involved that the process in operation is already as good as it can be, and that there is nothing that can be done. But if you ask the junior doctors who work for these consultants how the system could be tightened up, you will usually come away with some good ideas.

How then can we improve a system if the people who know what is wrong are not actually at the table?

There are two things that I would like for Christmas - I would like to see doctors in general take seriously their responsibility to get involved in the discussions about how to meet the financial challenges ahead of us, and I would to see junior doctors really believe that their opinion really counts in this process. That would fill a whole in my life that no iPad ever could.

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