Coffee House

Jeremy Hunt’s NHS Mandate will make the service even more cumbersome

14 November 2012

10:53 AM

14 November 2012

10:53 AM

Earlier this week my wife called to make a GP appointment for our daughter, who has been experiencing some worrying tummy pains.  Middle of next week she was told, earliest. ‘It’s a pity you didn’t call at 8 o’clock,’ the receptionist chided. ‘We had several slots then, but now they’ve all gone.’ Silly us for prioritising getting the children to school at that time of the morning.

I expect that Jeremy Hunt would say that it is precisely this kind of thing – not a scandal, not a crisis, but just one of a million similar tiny rebuffs people experience at the hands of the NHS every week – that has led him to demand that everybody should be able to book their doctors’ appointments online by 2015. A quick glance at the internet will tell you that this is not the first time the promise has been made, but it has been promised again as part of the new NHS “Mandate”, which Mr Hunt launched yesterday. If this pledge is to mean anything more than a fleeting mention in a Sun newspaper headline, it is to the Mandate that we must turn in order to try to understand its significance. This is where the going gets tricky.

The first point to be made is that some GP practices already take online bookings, and found their way there without having to be empowered to do so by the Secretary of State. If it were both easier to take one’s medical business elsewhere, and if the financial incentives were stronger for practices to attract patients, then we might have expected competition to have done already what Mr Hunt hopes his Mandate will achieve in the next three years. Alas, however, market forces here seem to be pulling in different directions, including the news recently that five GPs have become millionaires by selling on their out-of-hours service company to a bigger concern. Good for them maybe, but it says something about the skewed way in which we channel money to the NHS that there is not a stronger interest in organising something as basic as online booking. It also says something about the NHS’ endemic lack of consumer responsiveness, for all the years of ‘putting the patient first’.

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If we must rely on Whitehall’s writ for getting us our online bookings, how then will it will it? The bookings pledge is just one speck in a constellation of priorities and objectives gathered together under the Mandate, covering everything from stopping people dying before their time to giving the NHS a ‘broader role’ in society. Don’t worry though if your favourite isn’t there, because the Mandate is not in any case ‘exhaustive’. ‘Objectives’, we are told, are legal requirements on the NHS Commissioning Board and the ‘objective’ under which online booking appears is ‘to achieve a significant increase in the use of technology to help people manage their health and care.’ So what does that mean? If the surgery won’t let me book online by 2015 can I sue the pants off them? Or would I have to pursue my claim against Sir David Nicholson, chief executive of the Commissioning Board? Would I have a claim at all, since presumably still hanging on the phone at 8 o’clock in the morning wouldn’t constitute prima facie evidence of a failure by the NHS to increase significantly its use of new technology? I might just have to expire while waiting for the receptionist to pick up and get them under the premature death clause instead.

There are 26 pages of Mandate mandates, followed by a page and a bit that might loosely be said to be concerned with enforcement. This tells us that the Department of Health will hold the Board accountable for delivery and that every year it will publish an assessment of its performance. It stresses how, in the interests of fairness, it will ‘invite feedback’ from those it is assessing. What it doesn’t say is anything about what we, the punters, can do if the performance stinks.

The obvious answer might be that we can vote out Mr Hunt, except that the whole point of the Mandate is to take politicians away from these matters. Mr Hunt says that he wants to ‘loosen the reins’. Perhaps we should start electing the NHS Board itself – elected police commissioners will be such a success after all – in which case it would be fun to see if David Nicholson stood on behalf of his old outfit, the Communist Party.

The serious point is that the NHS is inundated with priorities, objectives, targets, guidance and Mandates. There is no space here to address the NHS Constitution, an entirely different set of rules apparently binding upon the Service, a refit of which was, in an amazing act of joined-up government, launched only a week ago by Mr Hunt’s deputy, Norman Lamb. I once asked a DH official which of the two contradictory sets of extant marching orders on diabetes the NHS was supposed to implement. I needn’t have waited the six weeks it took for the answer to come back, because I knew already: both. And they say that the BBC is too big to manage.

Richard Marsh is a former special adviser to two Conservative Secretaries of State for Health.


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Show comments
  • Rosa

    @vix. Well done for picking up on the ‘ tongue in cheek’, vix. The reality is that we do have to triage our requests or the system wouldn’t work. If patients do make it reasonably clear that they need to see someone today, then, usually, they do. But we are dependent on them making that clear, that is all I was saying.

  • Margo

    I’m not clear how booking on line will help. I can book on line at my GP’s but it does not make more slots available or earlier. Surely as Chris Mullins pointed out in the last volume of his autobiography the problem is that GPs are paid per patient on their books, not paid for actually seeing them.

  • Margo

    you were offered an appointment for next week. Lucky you! We are usually told 3 weeks. Surgery has a triage system but only an emergency can get through. What is an emergency? I’m planning on making use of A&E whenever we have a problem. Locally they seem to be very keen on drop in centres: I’m wondering what is the function of the local GP?

  • barbie

    Mr Hunt is the wrong man for the job, all will fall apart with him at the helm. Doctors will in the near future have their contracts reafirmed by the government, although the BMA don’t like the idea. It will happen, as will realignment of their pensions, they have far to much money. Labour gave them all this, and a bad thing is was for those who meet the bills, for a poorer service. My GP, whom I’ve just joined seems very nice, easy to book with, and once in the surgery well looked after. The last one was awful, the receptionists like little HItlers, and the service impossible to believe.
    I once asked of the previous doctor to change my BP pills and was told, NO I won’t, and she meant it. Even though the side effects were making me ill. I removed myself off them for my own safety. I tried her husband who was also a doctor, he refused and said what I was on was one of the cheapest and they needed to keep costs down. Needless to say I removed myself from this surgery.
    They treated my husband for arthiritis knees for five years, and it was found out he needed two hip replacements, even gave injections, on having them x-rayed we saw the mistake and the results. It seems if your hips have gone you can get pain in the knees so both should be photographed. Not all doctors are up to scratch, as this proves.

  • Rosa

    I am a GP too. Just phone back, explain it won’t wait til next week. Your practice WILL have a triage system, we all do – you just have to get the hang of how to use it.

    • 2trueblue

      And your tone says it all. And you might be dealing with someone who is not as forceful as you obviously are.

    • vix

      Sorry, Rosa. Did I understand that right? We, the sick, have to get the hang of the Gp’s bureaucracy? I am sure you meant that better than it sounded, but often the sick can’t express themselves to a peremptory medical receptionist or fight for an appointment.
      In fact the older generation apologize for needing to bother the doctor at all, I find. Some of them even believe that if they say ‘it won’t wait’ and make a ‘fuss’ that they will be blacklisted.

      • 2trueblue

        Absolutely so. But many GPs are not interested.

  • William Blakes Ghost

    This tells us that the Department of Health will hold the Board
    accountable for delivery and that every year it will publish an
    assessment of its performance. It stresses how, in the interests of
    fairness, it will ‘invite feedback’ from those it is assessing. What it
    doesn’t say is anything about what we, the punters, can do if the
    performance stinks.

    Government by the poltical and bureaucratic classes for the political and bureacratic classes.

  • HooksLaw

    The NHS mandate has been in the NHS reforms since inception. Its the mandate given to the commissioning board by the govt. Its then up to the commissioning board to deliver. The reforms otherwise take the government out of interfering with delivering the service. Responsibility is devolved down.
    Mr Marsh has previously supported these reforms so the point of his article now seems strange. Sadly we can’t all burst into print when we have had a medical appointment to sort out.

    • Salisbury

      Come on Hookie. You’re always bursting into print on anything and everything in these pages.

  • David

    First experience. Recently my daughter felt unwell on a
    Saturday with some symptom we thought serious enough to warrant seeing a doctor
    quickly. To cut a long story short we ended up at A and E as the out of hours
    cover was, to be polite, inadequate.

    Second experience. Family pet, a guinea pig., becomes ill on
    a Sunday. We’re a bit concerned so decide a visit to a vet is in order. Interrogate Google and get a couple of local
    vets who offer surgeries on Sunday. Not just for emergencies but just as part
    of the usual service. These vets are commercial operations. They need the
    business. They provide the service their customers want.

    My dental practice is non NHS. It provides a Saturday
    service. It offers what the customers want.

    My GP practice is a large one, yet only works during office
    hours and closes for lunch. You cannot even call over lunch as the phones are
    not manned. They arrange matters for their own convenience.

    • 2trueblue

      And for every £ you earn you and your employer pay NI which is now somewhere in the region of 23%. Makes you think……….

  • David

    First experience. Recently my daughter felt unwell on a
    Saturday with some symptom we thought serious enough to warrant seeing a doctor
    quickly. To cut a long story short we ended up at A and E as the out of hours
    cover was, to be polite, inadequate.

    Second experience. Family pet, a guinea pig., becomes ill on
    a Sunday. We’re a bit concerned so decide a visit to a vet is in order. Interrogate Google and get a couple of local
    vets who offer surgeries on Sunday. Not just for emergencies but just as part
    of the usual service. These vets are commercial operations. They need the
    business. They provide the service their customers want.

    My dental practice is non NHS. It provides a Saturday
    service. It offers what the customers want.

    My GP practice is a large one, yet only works during office
    hours and closes for lunch. You cannot even call over lunch as the phones are
    not manned. They arrange matters for their own convenience.

    • telemachus

      Dont tell Jem Hunt
      He remains pleased with himself
      Probably still living on the Murdoch payoff

    • 2trueblue

      Since GPs contracts were reorganised by Liebore the service has not improved. GPs are now overpaid.

      • telemachus

        Given the responsibility and accountability you are wrong

        • 2trueblue

          How?

        • 2trueblue

          An elderly patient recently after a visit to the GP asked why the doctor did not look at her, or converse with her, but watched his television.

          • telemachus

            As you well know he was consulting the computer for state of the art help on treating this chaps condition

            • 2trueblue

              Talking to the patient, looking at the patient……… oh for goodness sake. That and a packet of crisps will cure it all.

  • TomTom

    I hope the General Election and Euro Elections will ONLY list candidates online as with the Police Commissars because people without Internet Access should not be permitted to use public services or vote. It is vital that everyone buy a computer and Internet access to exist within The Matrix and thatose without such access be declared Outlaws

  • Magnolia

    My GP practice has changed to a ‘triage’ system for patient appointments.
    You can no longer ask for an appointment or speak to your own GP but the receptionist will take a message and a doctor will ring back, usually within hours.
    The advantages of this system are than you can usually get seen that day or get a routine appointment within days.
    The disadvantages are that you have lost the family doctor system and there is pressure to do telephone diagnosis which is unprofessional because it excludes examination.
    I suppose this is just part of the rationing of state health care that we must expect in a country that is so weighed down by debt.
    I always worried about Mr Landsley’s bill giving too much power to the GPs and them using it unwisely just to do their state employers bidding.
    I think I was right.
    I would imagine that some younger GPs will leave and go to the private sector which will grow as it becomes apparent that the NHS counterpart is not fit for purpose.

    • TomTom

      There is NO family doctor system and has not been for years since the NEW Contracts signed a few years back mean you are a Patient of the PCT not the GP Surgery. You really should check out the new arrangements whereby GPs are “Contractors” and the Secretary of State can transfer your records and Service Contract to other “Contractors” at his discretion

      • Mark

        Factually inaccurate. Patients are now registered with practices rather than individual doctors. GPs have been independent contractors since the earliest days of the NHS.

        • TomTom

          Not True. Read the GMS Contract 2004 and then try Health and Social Care Act (2001) and The General Medical Services (GMS), Personal Medical Services
          (PMS) and Alternative Provider Medical Services (APMS) Regulations and
          Directions 2004 –

          • Mark

            Read it (GMS). Signed it. You’ve memorised them all have you?

  • AlfieJ

    My GP surgery has online booking, the earliest available booking would be several days hence, suggesting it’s not for emergencies. Your experience suggests your GP has a triage service, which I think they all have – go back and insist someone sees your daughter today. I know someone who sat in the surgery until they were seen.

  • Mark

    I’m a GP with an IT system that doesn’t allow patients to book appointments online. I didn’t choose it. It was imposed on my practice by the PCT. Furthermore the software is no longer being developed. If/when we move to a new system it will be because the upgrade has been approved by and funds found by some central bureaucracy. Top-down management is indeed the problem here. You’d think the Tories would know better.

    • TomTom

      Why should the Tories know better ? It was Keith Joseph using McKinsey that created the chaos in the 1970s Heath Era…….politicians are simply puppets of some lobby group and give bucketloads of cash to McKinsey or Bain to keep 5-star hotels in the black

      • Mark

        Because Conservatives should on principle be opposed to statist top-down solutions. Not sure what your blather about hotels and lobby groups has to do with anything.

    • 2trueblue

      Are you sure that part was actually set up in this parliament? Don’t think so.

      The biggest cock up was made by Liebore in overpaying GPs and in allowing them to opt out of the ‘Out of hours’ service. They had no idea how much it was going yo cost, and should have said you can opt out if you get it covered from your funds.

      • Mark

        Which just goes to show how much they were getting for so little under the pre-2004 contract. The OOH opt-out was the main reason GPs voted for the 2004 contract (not me).

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