Discussion
4567231 said:
And what happens when all / most of the hospitals go into the red? Yes... wait for it... nothing (or they get fined, ironically meaning they are further in debt). Our trust fell into the red within 1 month of the new financial year, it is simply inevitable.
What happens if we don't have financial constraints?sidicks said:
What happens if we don't have financial constraints?
I don't know, but most of my colleagues (especially the junior, junior doctors) have little concept of this. It is improving, one of the trusts I worked in use to plaster on the intranet homepage We are in debt by... Our waiting list is behind by... etc.We do have regular clinical governance meeting about how much each department is in debt / profit by, and I'm glad to say our department is usually in the black. But that doesn't negate the massive debts run up by other departments.
4567231 said:
I don't know, but most of my colleagues (especially the junior, junior doctors) have little concept of this. It is improving, one of the trusts I worked in use to plaster on the intranet homepage We are in debt by... Our waiting list is behind by... etc.
We do have regular clinical governance meeting about how much each department is in debt / profit by, and I'm glad to say our department is usually in the black. But that doesn't negate the massive debts run up by other departments.
So you seem to be agreeing with me that we need constraints on the cost of the NHS and hence a cost-benefit analysis of treatment only gets you so far?We do have regular clinical governance meeting about how much each department is in debt / profit by, and I'm glad to say our department is usually in the black. But that doesn't negate the massive debts run up by other departments.
sidicks said:
So you seem to be agreeing with me that we need constraints on the cost of the NHS and hence a cost-benefit analysis of treatment only gets you so far?
No, I am only listing what happened as facts. I am not in charge of the overall costings of the NHS and I have no interest in being in charge (I wouldn't be very good at it, for a start!)My personal position is that we are already using the most cost-effective investigations and management. New drugs or interventional techniques, just because they are expensive, are not necessarily not cost-effective. If they can prevent admissions / complications in the long run then they are more than worth it.
And when there is an urgent / emergency case in front of us, the last thing we think about is the budget / cost of cannulas / etc. We only aim to do what's best for the patient at the end of the day.
I have already said this a few pages before, doctors "should" not really care that the NHS exists or not. If the NHS comes crashing down, we will not be retraining or be on the dole(!) Chances are with competition we will be earning more too. The only reason we care, is because we actually care about our patients.
eccles said:
sawman said:
All the posters in this thread are clearly thinking about the issues in the NHS, whichever viewpoint they take. Unfortunately, people who spend much effort mulling over these problems are very much in the minority. The vast majority of the population just expect it to be there and to be free. They have no regard for how they live their life, use services and what impact that has.
I have numerous people every week who fail to attend appointments, when questioned why they didnt turn up or cancel ahead of time just shrug. They dont care that there is a cost to a failed appointment.
Someone did cancel an appointment 5 minutes before it was due, explaining that he couldnt attend, as he had been out on the lash the night before and his girlfriend was so drunk he was in an ambulance with her heading to the already overburdened a&e dept.
Maybe if people had a better understanding of how much it all costs they may be more responsibility attached to their usage
I'd be in favour of something like a fine for missed appointments or something like three strikes and you're off the books.I have numerous people every week who fail to attend appointments, when questioned why they didnt turn up or cancel ahead of time just shrug. They dont care that there is a cost to a failed appointment.
Someone did cancel an appointment 5 minutes before it was due, explaining that he couldnt attend, as he had been out on the lash the night before and his girlfriend was so drunk he was in an ambulance with her heading to the already overburdened a&e dept.
Maybe if people had a better understanding of how much it all costs they may be more responsibility attached to their usage
On the rare occasion I visit my local GP's surgery, they have a poster up with the daily and weekly number of appointments missed, and the numbers seem huge to me.
Unfortunately, fines are not possible, neither (I am told) is striking non-attendees off practice lists, in any case, they'd just do the same at another practice.
4567231 said:
No, I am only listing what happened as facts. I am not in charge of the overall costings of the NHS and I have no interest in being in charge (I wouldn't be very good at it, for a start!)
My personal position is that we are already using the most cost-effective investigations and management. New drugs or interventional techniques, just because they are expensive, are not necessarily not cost-effective. If they can prevent admissions / complications in the long run then they are more than worth it.
In the long run we are all dead. Sometimes it is possible to take action that has short term costs but longer term benefits, however that doesn't mean that short term costs can be ignored.My personal position is that we are already using the most cost-effective investigations and management. New drugs or interventional techniques, just because they are expensive, are not necessarily not cost-effective. If they can prevent admissions / complications in the long run then they are more than worth it.
4567231 said:
And when there is an urgent / emergency case in front of us, the last thing we think about is the budget / cost of cannulas / etc. We only aim to do what's best for the patient at the end of the day.
I have already said this a few pages before, doctors "should" not really care that the NHS exists or not. If the NHS comes crashing down, we will not be retraining or be on the dole(!) Chances are with competition we will be earning more too. The only reason we care, is because we actually care about our patients.
Some might be earning more, some would not!I have already said this a few pages before, doctors "should" not really care that the NHS exists or not. If the NHS comes crashing down, we will not be retraining or be on the dole(!) Chances are with competition we will be earning more too. The only reason we care, is because we actually care about our patients.
Care is free, but NHS care is not!
Edited by sidicks on Saturday 13th January 14:22
sidicks said:
In the long run we are all dead. Sometimes it is possible to take action that has short term costs but longer term benefits, however that doesn't mean that short term costs can be ignored.
Yes, why bother anyway?Anyway of course we shouldn't ignore the short term, if a drug can prevent (for example) 1 admission which would cost £2000, but costs £200,000 per year then it's clearly not worth it. But if it's only £10 vs £100 (i.e. £90 per month) then it would be. That's why QALYs were invented to arbitarily introduce a funding ceiling. Lots of doctors do not agree with it, but it is what exists.
sidicks said:
Some might be earning more, some would not!
Care is free, but NHSn care is not!
Care isn't free either Care is free, but NHSn care is not!
We only make it cheaper (i.e. staying behind for free, doing paperwork for free etc. etc.) because we love the system. And I know the argument's going to be "but people in the private section stay behind too" etc. etc. but they stay behind to oil the corporate machine, whereas we stay behind because if we don't, patients deteriorate / die (there simply aren't enough staff around to handover).4567231 said:
sidicks said:
In the long run we are all dead. Sometimes it is possible to take action that has short term costs but longer term benefits, however that doesn't mean that short term costs can be ignored.
Yes, why bother anyway?Anyway of course we shouldn't ignore the short term, if a drug can prevent (for example) 1 admission which would cost £2000, but costs £200,000 per year then it's clearly not worth it. But if it's only £10 vs £100 (i.e. £90 per month) then it would be. That's why QALYs were invented to arbitarily introduce a funding ceiling. Lots of doctors do not agree with it, but it is what exists.
sidicks said:
Some might be earning more, some would not!
Care is free, but NHSn care is not!
Care isn't free either Care is free, but NHSn care is not!
We only make it cheaper (i.e. staying behind for free, doing paperwork for free etc. etc.) because we love the system. And I know the argument's going to be "but people in the private section stay behind too" etc. etc. but they stay behind to oil the corporate machine, whereas we stay behind because if we don't, patients deteriorate / die (there simply aren't enough staff around to handover).4567231 said:
I don't know, but most of my colleagues (especially the junior, junior doctors) have little concept of this. It is improving, one of the trusts I worked in use to plaster on the intranet homepage We are in debt by... Our waiting list is behind by... etc.
I think you might be surprised how many of us juniors have a concept of how bad the economic situation in trusts is. Our department has gone from being in the black to in the red purely due to the deflation in the tariffs. Our waiting lists are appalling and we are losing money because we aren't doing enough work but our theatres are at capacity, our clinics are running at 100% overbooked (commonly having 130 patients in a 50 patient clinic) and we have no more rooms to see people. We physically can't do anymore and are still losing money. There is some waste but its easily compensated by the huge number of extra outpatient appointments. A new hospital is being built but they don't even know how many clinic rooms there will be (they are currently building the first floor). Its an extremely demoralising position to work in. To be in an overloaded system which is obviously not going to get better any time soon is horrible.
We need an honest discussion about how the service is funded and what the capacity is. The countable care services which are being set up will hopeful make things a bit better
Lynx516 said:
I think you might be surprised how many of us juniors have a concept of how bad the economic situation in trusts is.
Ok? I teach FY1, FY2 and CTs and these doctors generally have no clue. They are rotating in/out 4-6 months so why should they?For the record, I am also a junior doctor but I am a senior junior and from that you said it sounds like you are one too.
Lynx516 said:
Our department has gone from being in the black to in the red purely due to the deflation in the tariffs.
Now I somehow doubt a 23 year old FY1 knows what tariffs even are?Lynx516 said:
Our waiting lists are appalling and we are losing money because we aren't doing enough work but our theatres are at capacity, our clinics are running at 100% overbooked (commonly having 130 patients in a 50 patient clinic) and we have no more rooms to see people.
All agreed - but junior doctors just do not get involved in this. They probably don't even know what theatre capacity is. I have CTs who are just looking for a few hours spare to come down to clinics to sign off their ePortfolios. Now I really doubt they'd care how overbooked the clinics are.I would, because I have my own list (and it sounds like so do you).
Lynx516 said:
We physically can't do anymore and are still losing money. There is some waste but its easily compensated by the huge number of extra outpatient appointments. A new hospital is being built but they don't even know how many clinic rooms there will be (they are currently building the first floor).
Its an extremely demoralising position to work in. To be in an overloaded system which is obviously not going to get better any time soon is horrible.
We need an honest discussion about how the service is funded and what the capacity is. The countable care services which are being set up will hopeful make things a bit better
Trust me when I said that most junior junior doctors do not know this, or at least they don't get involved. So you are either an extremely keen FY / CT or you are already an ST!Its an extremely demoralising position to work in. To be in an overloaded system which is obviously not going to get better any time soon is horrible.
We need an honest discussion about how the service is funded and what the capacity is. The countable care services which are being set up will hopeful make things a bit better
By the way, I absolutely agree absolutely with everything you said otherwise. I go into work with a heavy heart because it is as if the hospital is constantly in black alert etc.
Edited by 4567231 on Saturday 13th January 19:50
sawman said:
Maybe if people had a better understanding of how much it all costs they may be more responsibility attached to their usage
This would certainly be helpful, (as part of a range of changes, not sure of impact if standalone).Perhaps a simple receipt when the service is used to show the cost, everything from Gp appointments & prescriptions, to major surgery.
For the feckless it'd simply become a badge of honour of course, but it could help some if the more 'normal' members of society who just dont think about where its all being funded from gain an appreciation of the economic aspects.
@Lynx,
When you say the Theatres are at capacity, what do you mean? Do they operate outside 9-5?
Equally, a lot of the bed blocking issue caused by New Year is because many operations stop over Bank Holidays so a backlog is created.
This isn’t a criticism of you and your colleagues, I thank you for your wonderful service, but it is fair to say that when I had a Colonoscopy a couple of months ago at 5pm on a Friday in a new NHS hospital, my clinic was the only one working at that time.
Do we not have the ability to improve things by being more flexible in how the NHS operates and utilising the fixed assets more intensively?
4567231 said:
Trust me when I said that most junior junior doctors do not know this, or at least they don't get involved. So you are either an extremely keen FY / CT or you are already an ST!
By the way, I absolutely agree absolutely with everything you said otherwise. I go into work with a heavy heart because it is as if the hospital is constantly in black alert etc.
I'm an academic surgical ST2 so have my NTN but not that senior. I have previously done service design for CCGs so understand more than most. What I was trying and obviously failing to say was the impact of the current situation is felt all the way down, especially on the surgical side. By the way, I absolutely agree absolutely with everything you said otherwise. I go into work with a heavy heart because it is as if the hospital is constantly in black alert etc.
Edited by 4567231 on Saturday 13th January 19:50
I wish I had my own clinic list because I might be able to make enough noise to get something done about 130 patients per list. What happens instead is I get pulled out of theatre to "help" with the clinic. I haven't been in theatre long enough to do/learn anything since the start of December.
Currently dreading going to work everyday.
Lynx516 said:
I'm an academic surgical ST2 so have my NTN but not that senior. I have previously done service design for CCGs so understand more than most. What I was trying and obviously failing to say was the impact of the current situation is felt all the way down, especially on the surgical side.
I wish I had my own clinic list because I might be able to make enough noise to get something done about 130 patients per list. What happens instead is I get pulled out of theatre to "help" with the clinic. I haven't been in theatre long enough to do/learn anything since the start of December.
Currently dreading going to work everyday.
I wish I had my own clinic list because I might be able to make enough noise to get something done about 130 patients per list. What happens instead is I get pulled out of theatre to "help" with the clinic. I haven't been in theatre long enough to do/learn anything since the start of December.
Currently dreading going to work everyday.
Well done for having a grasp of the political side of things so early on in your training. And soon enough you will have your own clinic list.As for other posters - creating a list of charges is doable but will be another costing, who is going to be responsible for this "service"? At present in our hospital the treatment room has a price on all the equipment - e.g. cannulas 84p, syringe 41p (made up figures). But obviously this is much easier since it is fixed on the trolleys and not individualised. On all our clinic letters it is said when patients miss their appointments it cost the trust £150 or something (I do not know how they come up with this figure). We do discharge our DNA patients - obviously GPs do not have this luxury.
Second point - we have ridiculous clinic DNA rates (out of working hours), imagine if we open up elective endoscopy lists for weekday nights / weekend days. I cannot imagine how much more we will lose out. I once ran a weekend clinic and it was a complete waste - around 30% of patients didn't turn up. BUT we had to pay extra for the nurses, receptionists and cleaners. If we wanted to request bloods, ECGs, X-rays - well it's not available because it's out of hours. Unless we suddenly open all departments of the hospital out of hours, there's no point just opening one department. And finally as I have already said - where are the doctors going to come from to staff out of hours? That would mean spreading an already thin workforce even thinner!
Edited by 4567231 on Saturday 13th January 20:37
It depends where the pinch points are.
If it is physical, ie full operating theatres, then you can increase capacity by starting at earlier and finishing later. I am not saying that is what happens, I am simply illustrating the issues.
In a factory, fixed assets are the buildings and machines, and are utilised as much as possible. The principle that it should be the same in the public sector shouldn’t be controversial.
Your point about not enough doctors being there is more crucial and difficult to solve.
Equally, the bed blocking caused by a lack of transitional and social care accommodation is causing real issues.
There are no magic bullets, but equally there are ways in which the system can improve.
loafer123 said:
It depends where the pinch points are.
If it is physical, ie full operating theatres, then you can increase capacity by starting at earlier and finishing later. I am not saying that is what happens, I am simply illustrating the issues....
It is very hard under current rota systems to extend elective work. Those working in a hospital would know: the hospital simply runs on a reduced capacity out of hours.If it is physical, ie full operating theatres, then you can increase capacity by starting at earlier and finishing later. I am not saying that is what happens, I am simply illustrating the issues....
For example - let's illustrate by saying a district general hospital with 20 wards. Usually each ward has 2 junior doctors covering 9-5 (or 8-4 in surgery), but after hours (5-9pm) there may be 1 doctor covery 4-5 wards, and later after hours (9pm-9am) there may be 2 doctors covering 20 wards with 1 medical registrar covering everyone. Let's say the (elective, because emergency already runs 24 hours) operating theatres now go until 9pm, what happens if there is an emergency? Then it will take vital staff away from covering.
It is not as simple a matter as a factory, where more people can be employed in a flash to operate the machinery or rota'ed to cover more hours. Because we already have not enough doctors / nurses during working hours, there is no way it will be safe getting 2 doctors off during the week to cover weekends. It's simple enough paying consultants to cover weekends, and many already do, but routine 7 day care is unlikely to be implemented in the short-medium term without severe compromises in the rota.
Edited by 4567231 on Saturday 13th January 21:05
Previous said:
sawman said:
Maybe if people had a better understanding of how much it all costs they may be more responsibility attached to their usage
This would certainly be helpful, (as part of a range of changes, not sure of impact if standalone).Perhaps a simple receipt when the service is used to show the cost, everything from Gp appointments & prescriptions, to major surgery.
For the feckless it'd simply become a badge of honour of course, but it could help some if the more 'normal' members of society who just dont think about where its all being funded from gain an appreciation of the economic aspects.
Gassing Station | News, Politics & Economics | Top of Page | What's New | My Stuff