Do we pay our doctors too much?
From Mmc
Do we pay our doctors too much?
By Victoria Lambert Last Updated: 2:23am BST 19/05/2007
Where did it all go wrong, the spin doctors and civil servants were asking each other wearily, as the midnight oil burnt late at the Department of Health yet again. Billions of extra pounds invested in the NHS; more doctors, nurses, physios; local hospitals closed down, spanking new walk-in medical centres, help lines and even lessons in salsa dancing to get the nation fit. Why isn't the country singing our praises and demanding Hewitt for PM?
Junior doctors protest against the application system: Do we pay our doctors too much? Junior doctors stage a protest march in London
"I blame the doctors," said one.
"Too right," said another. "If we could only shut them up and run the whole thing from here. No more protest marches, no more interference or damaging headlines, just targets met, nice neat balance sheets and OBEs all round. And no more bloody British Medical Association."
"Listen, I've got an idea," said one spinmeister. "What if we were to pay doctors as much as they keep asking for, or even more? Then tell them they don't have to put up with those long hours - European law, human rights, any old rubbish - and that we want them to be more like the French; take more lunches, have weekends off. Then, all we have to do is sit back while the doctors start enjoying themselves."
"You mean give them enough rope..."
"Well, would you be happy to learn that your GP earned more than a hundred grand for working nine to five? What if you read in your paper that they were refusing to do call outs at night or weekends, that they're only working a couple of days a week, or that we had to fly in German doctors at great expense to cover out-of-hours? And don't forget the hospital consultants. A 25 per cent rise in salary but more time for private practice. If we crack the public's confidence in doctors, I don't think we'll have quite so much trouble cracking the doctors."
Now, if you think that sounds too Machiavellian, even for this government, you are probably right. But there is no question that doctors are dramatically better off following the introduction of the new GP and Consultant contracts in 2003/2004. The profession received substantially more money for what appeared to be very little extra effort.
It is also true that doctors are under attack as never before; this week, Prime Minister-elect Gordon Brown, joined the mob baying for their blood when he announced that the NHS would be one of his priorities and that he wanted to see GPs providing out-of-hours cover again.
For a profession accustomed to respect, this bout of "GP bashing" has come as a rude shock. The medics' tough contract negotiations may have represented a triumph in the short term but, in retrospect, seem to have been a rare own goal, paving the way to accusations of greed by the public, politicians and sections of the press. So, are we paying doctors too much? Or could it be that the profession has at last been outwitted by Westminster?
The BMA - the doctors' trade union and a contender for most ruthless and efficient representative body in existence - has been the scourge of successive governments. NHS historian Charles Webster has written that the Association "possesses an unenviable record for assaults against the government of the day on matters great and small" and is capable of "menacing demonstrations of force".
Aneurin Bevan, the founder of the NHS, accused the BMA of attempting to sabotage the Act that brought it into being in 1948. It kept Barbara Castle at the negotiating table from 4pm to 7am, while discussing pay in 1975; and saw off Kenneth Clarke, who alienated the entire profession in 1989 with his remark that he wished "doctors would stop feeling for their wallets whenever I mentioned the word 'reform'."
Behind the BMA stand the Royal Colleges, the gatekeepers of modern medical practice and guardians of standards and tradition, quietly run by some of the most intelligent, eminent and well-connected men and women in the country. Where the BMA fights government change head on, the Royal Colleges apply discreet pressure, like a tourniquet.
Both organisations have the same secret weapon, however: their members. For who among us has not been grateful to a doctor at least once in our lives? No other profession possesses such a high cachet of trust and integrity. In the eyes of the public, on a sliding scale of honour, doctors are at the top - and politicians are close to the bottom. When it comes to negotiations, the Department of Health has always been between a rock and a hard place - until now. Their low incompetence at the bargaining table seems to have been rewarded with the moral high ground.
From the BMA to Westminster, the consensus is that the crux of the problem facing doctors has its roots in the Government's failure to negotiate from an informed position. Both sides agreed that decent pay rises were appropriate. The figure of 15 per cent for consultants (whose pay had drifted downwards over many years) plus approximately 10 per cent to cover inflation over the following three years, was reached painlessly. In return, ministers expected consultants to work harder, be more accountable and have less autonomy.
The fundamental error they made was in failing to realise how hard doctors were working already. Far from strolling around hospitals dispensing pearls of wisdom in the manner of Sir Lancelot Spratt before heading off for a fat lunch, they were already working 60 hours a week or more, seeing and operating on tens of thousands of patients, performing surgery, developing and implementing new procedures and training junior staff.
When the negotiators told them firmly that the new contract meant there would be less time for the golf course or the "cake shop" (private practice), who could blame consultants for a wry smile or two? They were already fulfilling the Government's demands. Meanwhile, at the GPs' negotiating table, doctors were having to suppress their incredulity when some hapless Department of Health mandarin suggested they could opt out of all out-of-hours cover by taking a £6,000 pay cut. Few GPs would object to getting out of bed for a genuine emergency, or giving up a Sunday afternoon to see a terminally ill patient whom they have known for years - many still do. But the majority were fed up of being called out at 2am because "I've got a headache" or "We've run out of Calpol".
Out-of-hours care was repeatedly cited as a reason fewer medics were choosing to go into general practice or opting for early retirement. Certainly, it was discouraging women who make up more than 50 per cent of medical school intake. The result was a crisis of care, particularly in inner cities.
Making the job of a GP more attractive was a key plank in the Government's thinking. However, once again the DoH had underestimated the sheer volume of work GPs were already doing. So when they brought in their trusty New Labour targets - the Quality and Outcomes Framework, which offers performance-related pay for tackling chronic problems such as obesity, diabetes and asthma - they didn't realise they were paying GPs more for work they were doing already.
Earlier this year, as the NHS teetered on the brink of one of its periodic crises - two thirds of NHS trusts in deficit, 37,000 jobs threatened and GPs owed in excess of £200 million - the Government decided to act. Enter the Health Secretary, Patricia Hewitt, saying that, in hindsight, there should have been a cap on the money that GPs could make from the new contract. Miss Hewitt told the BBC in January: "I think if we anticipated GPs taking a higher share of income in profits we would have wanted to do something to try to ensure that the ratio of profits to the total income stayed the same."
It was the first salvo in the PR war against doctors. In March, Miss Hewitt announced that GPs would get a nought per cent rise this year because she considered them well-rewarded. Consultants, whose salaries were a factor in trust deficits, would get a flat rise of £1,000 a year, with trainee doctors picking up just £650.
The media took its lead from Miss Hewitt; headlines proclaimed "Gloating GPs delighted with lucrative pay deal", "GP earnings soar by 23%", "Massive rise in GPs' salaries worsens NHS cash crisis", "Docs get pay rise for less work" and "The £100,000 GP". In April, the National Audit Office weighed in, with its head, Sir John Bourn, saying: "The new contract was introduced to benefit not only consultants, but patients and the health service in general."
And now Gordon Brown is ploughing in, too. He wants to see GPs justify their pay when he takes over as prime minister. Given the negative publicity surrounding "greedy doctors" he seems to have picked the right target.
However, there has been a major hiccup in the doctor-bashing campaign: the Modernising Medical Careers debacle, exposed by The Daily Telegraph. It means thousands of young doctors face unemployment from August because there are not enough jobs. The online MMC application system was not only a disaster, it was insecure and repeatedly hacked into, allowing confidential personal information to be accessed.
Many brilliant junior doctors weren't even given interviews for jobs, leading to fears of an exodus of the next generation of Britain's doctors abroad. It was difficult to understand why such a ludicrous system was set up in the first place, although the suspicion that it was an attempt at social engineering was hard to ignore. A chance, perhaps, to "slot more people called Dave and Pete and Mandy into the sort of top-notch jobs that were previously filled by people called Charles and Jeremy and Harry", as Telegraph columnist Vicki Woods argued recently. In reality, medicine is one of the most meritocratic of professions, the bedrock of which is women and ethnic groups. The furore grew, the consultants threatened to strike in sympathy and junior doctors marched on the House of Commons.
Once again, the public sided with its favourite profession, prompting the resignations of those responsible for the MMC and the scrapping of the scheme for this year. It must have filled the DoH with dread as it realised the upcoming generation of juniors were even more bolshie than their predecessors.
So, the momentum is now back with the medics, but for how long? Will Brown persist in pushing the line that our doctors are over-paid and over-bearing? Professor Alan Maynard, of York University, one of the country's leading health economists, has some sympathy with the Government.He argues that the public deserves proof of value for money - that a good bedside manner does not good value prove. "The new contracts have cost billions - shouldn't there be some sort of quid pro quo for all that money?" he asks. "We don't begrudge doctors decent pay, but it would be nice to see some data to measure their work, as exists in every other profession. And there isn't any.
The NAO says consultants' productivity is declining. The consultants say cases are more difficult and time-consuming. I say, 'Show us the data'. The GPs justify their increase, saying the Quality and Outcomes Framework (QOF) shows they are working harder than ever. But, as no baseline data was collected before the QOF was introduced, we have no idea if that's true."
However, Mark Porter, a consultant anaesthetist from Coventry and lead negotiator for the BMA's consultants' committee, says that the new contract may look generous on paper - but the reality is different.
"Both sides agreed we used to be massively under-paid - so more than half of our increase was a 'catch-up' payment," he says. "The rest covered inflation for the next three years and meant we could concentrate on what we do best, not waste time in annual pay round bargaining."
He is keen to stress that the consultants didn't want the new contract just for its monetary value: "Our role has changed so much. We're in the hospital 24/7 and that's what the public want - to be treated by the best in the profession at the time they need that expertise most. We also develop procedures, teach younger doctors and monitor standards - our job description has become much wider and our pay needed to reflect that."
GPs, meanwhile, were astonished to hear themselves described as greedy. They say that their new contract was not just about money but about changing the way general practice worked to attract more women and to encourage doctors from ethnic minorities, who are the mainstays of challenging inner city practices.
Dr Prit Buttar, a GP from Abingdon, Oxfordshire, concedes that, on paper, he has enjoyed a substantial rise in the past two years, earning more than £100,000 a year but says that this year, in real terms, he has made a loss.
"My practice will receive no increase in income this year from the NHS - but my costs, such as utility bills and salaries still go up. I believe that my staff are my greatest asset. So even though I won't be getting a pay rise, I will still be giving the people who work for me an increase," he says.
"Per patient, per year, I am paid approximately £50, regardless of how many times I see them. That's a year's unlimited cover. The cheapest policy I could find for pet insurance - for a hamster - was £65 a year, plus £50 excess. So your health care costs less than your pet rodent's. GPs are excellent value for money."
Put in those terms, who would disagree? The reality is that the multi-faceted nature of medical practice - the physical and emotional consequences of illness and its impact on the lives of others - and the qualities of those who choose this demanding but well-rewarded profession is what makes ministerial demands for productivity data a nonsense. It's bad enough that doctors must now waste so much time on paperwork and form filling for targets and initiatives. Do we want to turn them into a profession of clock-watchers as well?
Soon we will discover if Gordon Brown has decided to be man or mouse with the BMA. But if the public can accept that doctors deserve to be properly renumerated, then however many spin doctors he employs, the real ones will ultimately triumph.
