Partnerships in paediatrics renegotiating the contract by tracy14


									 Partnerships in
renegotiating the

   Richard Smith
    Editor, BMJ
 What I want to discuss
• The unhappiness of doctors
• Why might they be unhappy?
• Renegotiating the contracts
  between doctors and
  government and doctors and
• What’s needed for success
  Are doctors unhappy?
• Unhappy is a crude word
• “We are never so happy nor so
  unhappy as we imagine”
 La Rochefoucauld

• “Happiness is the light on the
  water. The water is cold and
  dark and deep.”
 William Maxwell
  Are doctors unhappy?
• “Happiness: a good bank account,
  a good cook, and a good
 Jean Jaques Rousseau

• “Happiness is essentially a state
  of going somewhere,
  wholeheartedly, one directionally,
  without regret or reservation.”
 William H Sheldon
  Anthony Trollope on

• “It is the grind that
  makes the happiness.”
     Anthony Trollope on
• “It is the grind that makes the
  happiness. To feel that your hours are
  filled to overflowing, that you can barely
  steal minutes enough for sleep, that the
  welfare of many is entrusted to you, that
  the world looks on and approves, that
  some good is always done to others,--
  above all things some good to your
  country;--that is happiness. For myself I
  can conceive none other.”
   Anthony Trollope on
• “The happiest man is he, who being
  above the troubles which money
  brings, has his hands the fullest of
• “A broad back with a heavy weight
  upon it gives the best chance of
  happiness here below.”
• “There is no human bliss equal to
  twelve hours of work with only six
  hours in which to do it.”
     How unhappy are
• Do you need convincing?
• Friend who is an orthopaedic
  surgeon who has retired early.
  Every time he visits the
  hospital, colleagues ask him
  how can they retire early.
• Consultants contract
• BMJ Careers Fair
  Job satisfaction of senior
  doctors: a questionnaire
• "I find enjoyment in my current post.”
• "I am doing interesting and challenging
• "I feel dissatisfied in my current post."
• Most days I am enthusiastic about my
• "I am often bored with my work."
• Totalled the scores for all five statements: 5
  strongly agree; 1 strongly disagree
• 20 or more represented a high level of
  Job satisfaction of
    senior doctors
Specialty group    Score
A and E            18.8
Obs and gynae      19.6
GPs                19.1
Private medicine   22.8
Medicine abroad    21.6
Paediatrics        20.8
GPs intending to quit patient
 care in the next five years

Age   % intending    % intending
      to quit 1998   to quit 2001
41-45 9              11
51-55 27             45
56-60 64             87
All   14             22
     League of unhappiness
Country Very      Unhappy   Neutral   Happy Very happy

UK      23        43        17        14    2

US      14        45        10        19    11

NZ      8         25        30        25    11
Why might doctors be
    Why might doctors be
• Overwork
• Perhaps nothing new
• Doctors feel like hamsters in cages,
  but they actually have more time
  with patients--but there is more to do
  in that time
• Who isn’t overworked?
• If Trollope is right this is happiness
      Why might doctors be
• Underpaid
• Doctors have lagged behind some
  comparable professionals--for example,
• But still much better paid than most other
  public sector professionals--like teachers
• Many doctors have greatly supplemented
  incomes from private earnings
• Doctors have much less variability in
  earnings than other groups--for example,
   Why might doctors be
• Inadequately supported
• Most work in teams
• Some doctors seem to think that
  nurses have “lost their way”
• Singlehanded doctors are
  increasingly unusual, and even they
  have support staff
• Relationships with managers are
  sometimes fraught
• Many doctors feel unsupported by
   Why might doctors be
• Their status is falling
• Still much more valued than,
  say, social workers
• In Britain doctors are still the
  most trusted professionals
  (politicians and journalists are
  at the bottom)
    Why might doctors be

• They are exhausted by too much
• Doctors are not alone in this
• There will probably be more change in
  the next 10 years than in the past 10
   Why might doctors be
• They have declining control
  over their work
• Doctors, particularly GPs, have more
  control than many other groups
• Nevertheless, they have less
  “freedom” than before--revalidation,
  audit, CHI, NICE, guidelines
  Why might doctors be
• They are increasingly
• They are, but they were probably
  insufficiently accountable before
• The NHS now runs on Hobbesian
  rather than Lockeian lines
Thomas Hobbe’s
       • People are
       • If you don’t
         control them
         carefully then
         they will do
John Locke’s philosphy
           • People are
             essentially good
           • Give them
             enough space
             and support and
             pay them well
             and they will do
             wonderful things
   Why might doctors be
• Their job is not what they were
  trained for
• Most doctors practising now were
  not trained in management,
  leadership, improvement,
  communication, ethics, etc
• Some doctors may be “phobic” about
      Why might doctors be
• They have to pick up the pieces in a
  society unable to cope
• The NHS is almost the last of the
  “socialist” institutions
• Doctors do find themselves trying to help
  the marginal (poor, unemployed, homeless,
  addicts, prisoners, asylum seekers, etc)
  but with very limited ability to do much
• Life’s problems are increasingly being
  medicalised; doctors are now the victims
  not the perpetrators of medicalisation
   Why might doctors be
• Close contact with patients are
• Little support for this
• This remains much of the joy of
  the job
   Why might doctors be
• The health service is falling
• Many doctors in Britain seem to feel
• The BMA begins to look at
  alternatives to the NHS
• Mind you, the BMA maybe falling
  apart as well
   Why might doctors be

• Patients are too demanding
• Politicians are stoking patients’
• Modern medicine promises
  more than it delivers
   The bogus contract: the
        patient's view
• Modern medicine can do remarkable
  things: it can solve many of my
• You, the doctor, can see inside me and
  know what's wrong
• You know everything it's necessary to
• You can solve my problems, even my
  social problems
• So we give you high status and a good
   The bogus contract: the
        doctor's view
• Modern medicine has limited powers
• Worse, it's dangerous
• We can't begin to solve all problems,
  especially social ones
• I don't know everything, but I do
  know how difficult many things are
• The balance between doing good
  and harm is very fine
• I'd better keep quiet about all this so
  as not to disappoint my patients and
  lose my status
 The new contract: both
patients and doctors know

• Death, sickness, and pain are
  part of life
• Medicine has limited powers,
  particularly to solve social
  problems, and is risky
• Doctors don't know everything:
  they need decision making and
  psychological support
 The new contract: both
patients and doctors know
• We're in this together
• Patients can't leave problems to
• Doctors should be open about
  their limitations
• Politicians should refrain from
  extravagant promises and
  concentrate on reality
  Spin offs from the “new
• Because there is so much we don’t
  know and don’t do well we need
  continuing research
• We need to do this together, sharing
  uncertainty--but also planning
• You and your children need to be
  willing to participate in experiments
  Spin offs from the “new
• Much experimental research “fails”--
  because it’s experimental
• Risk can never be abolished
• We need information from you and
  specimens from you
• We must be clear what is
  acceptable, sometimes privacy may
  be compromised
  Would you like to join
 my new political party?
• It’s called “The life is tough we
  have no solutions” party
• Death is inevitable, prepare for
• For every problem there is a
  simple solution. Unfortunately
  it’s wrong
       The old contract
• What doctors           • What doctors
  give                     get
• Sacrifice early        • Reasonable pay
  earnings and study     • Reasonable
  hard                     work/life balance
• See patients           • Autonomy
• Provide god care       • Job security
  as doctors define it   • Deference and
      New imperatives
• Greater accountability
• Patient centred care
• Be more available to patients
• Work collectively with other staff to
  improve quality
• Evaluation by non-technical criteria
  and patients’ perceptions
• A growing blame culture
Creating new contracts:
 doctors and the NHS
• From doctors
• Work within guidelines
• Be accountable for key objectives and
  improving quality
• Actively support and contribute to
  achieving the goals of the organisation
• Work within resource constraints
• Engage in team and collaborative
   Creating new contracts:
    doctors and the NHS
• Doctors get
• The opportunity to shape the goals of the
• Participation in resource allocation and
  major decisions
• The resources to do the job expected
• Training and technical support
• Time to step off the "hamster wheel"
• High quality data
• A supportive culture that uses information
  for learning rather than judgment
• High quality appraisal and support for
  personal development
Creating new contracts:
doctors and government
• Doctors required to
• Follow nationally agreed standards
  and guidelines
• Work to improve quality
• Work within available resources
• Account for their work
Creating new contracts:
doctors and government
• Doctors get
• Participaton in developing the
• Realistic targets
• A manageable number of targets
• No micromanagement
    Building new contracts
•   Recognition that contracts exist
•   Mutual respect
•   Trust
•   Conversation
•   Encouragement of creativity,
    personal renewal, and learning
 Building new contracts
• Greater geographical and
  career mobility
• Chance to restart career paths,
  retrain, and diversify without
  attracting criticism
• Portfolio careers
• Greater flexibility
• Better career advice
     Can this be true?
• “Negative media coverage
  might represent the world's
  waking up to the limitations of
  doctors and medicine,
  andthough it's uncomfortable
  now it may lead to a much more
  honest, adult, and comfortable,
Renewal: Dutch style in
   the 16th century
T H White on learning
• “The best thing for being sad is to learn
  something. That is the only thing that never
  fails. You may grow old and trembling in your
  anatomies, you may lie awake at night
  listening to the disorder of your veins, you
  may miss your only love, you may see the
  world about you devastated by evil lunatics,
  or know your honour trampled in the sewers
  of baser minds. There is only one thing for it
  then - to learn. Learn why the world wags
  and what wags it. This is the only thing
  which the mind can never exhaust, never
  alienate, never be tortured by, never fear or
  distrust, and never dream of regretting.”

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