Hamster health care
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7276.1541 (Published 23 December 2000) Cite this as: BMJ 2000;321:1541All rapid responses
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Editor - Congratulations on an amazing article - as a tired GP and
PCG Board Member off with flu and quite exhausted I was very much
encouraged.Well done indeen to Ian
Morrisson too.Has he written widely before?
These are some of the most insightful comments about General Practice I
have ever read and so very much needed to be heard.
I'd like to be involved in this in any way I can because I've felt the
issues are so important - and I hear so many others who quietly do too.
Reduction in GP satisfaction
and sheer fatigue ('burn-out') are commonplace at all ages of
practitioners now especially the conscientious and keen ones who seem to
face it first- -for many like me
retirement is'nt an option yet but they wish it were; desperately sad but
true.
Health care workers in general and GP's in particular must be very hard to
manage well because they think ovewhelmingly in a reactive not a strategic
way and so just
work harder and harder in the face of new demand just because 'this is
what they do' .This goes on without serious requests for extra resources
until they cry 'crisis' and
feel they can't cope and start not to.This is hardly a style that lends
itself to strategic management and sustained patient satisfaction but it
does conveniently play into
the hands of 'stingy payers' .This unfortunate tendency in GP's only
compounds their problems and those of their patients in the long term as
we are all finding out. I do'nt
believe it needs to be like this for any of us and we owe it to ourselves,
our 'burnt out' colleagues and their dependants and all our patients to
sort it out.
Let's have more of this and please if I can be involved in any way
I'd be absolutely delighted. I will certainly be requesting the article is
discussed at PCG level locally
soon.This Hamster has certainly had enough of not addressing these issues.
Is there any electronic way I could have the follow up references etc
to this article in future sent to me please?
Thank-you so much for publishing this today.Significantly my non-
medical wife was completely impressed too and said 'yes' a lot.
Simon Andrews
Competing interests: No competing interests
To the editor,
Dear Sir,
Hamster health care
Morrison and Smith’s analysis of current problems with health care
provision (1) will ring true to many general practitioners working in the
British NHS. The issues of lack of time with patients, increasing
complexity of care, and the rising expectations of both patients and
funders of care, combine to make for unhappy patients and pressurised
doctors.
Redesigning health care, their suggestion for the way forward, is a
necessary but certainly not a sufficient solution. The roots of the
problem lie in the complex and confused relationships between medicine,
perceptions of health, and society, which are not addressed in the
editorial, and which tend to be ignored in medically based analyses of
these problems.
Hanson and Callahan (2) suggest that unless we (doctors, politicians,
media, society) start to look at the goals of medicine and not just the
technology and processes of care, we risk medicine becoming economically
unsustainable, clinically confusing, socially frustrating and lacking
coherent direction and purpose. The title and content of your editorial
suggests that this has already happened.
Perhaps the time is right for a theme issue of the BMJ on the biggest
issue that will face us and our children: What’s medicine for?
Yours
John CM Gillies,
general practitioner,
Selkirk Medical Centre, Selkirk TD7 4LL
j.gillies@rural-health.ac.uk
1. Morrison I, Smith R. Hamster health care.BMJ 2000;321:1541-2.
2. Hanson M, Callahan D. The Goals of Medicine; the forgotten issues in
health care reform. P12-13. Georgetown University Press, Washington DC
1999.
Competing interests: No competing interests
Society has effectively barred physician's requests of more or
"adequate funding" with the knee jerk but politically effective canard of
the doctor's greed.
In the United States, as the percentage of health care expenditures
rose in the 1980's above an arbitrarily set percentage of the gross
national product, those in government understood the need to break the
power of the physician to control health care expenditures. Thus they
created managed care to remove the doctor from his prime role as arbiter
and patient advocate. In addition, Medicare bureaucrats by fiat fixed and
devalued the prevailing fee schedule.
A parallel strategy was initiated to attack the profession's
integrity and label all attempts at asking for adequate funding as guided
by greed and self interest. Hence we have the reticience of our
organizations to call directly for more funding.
A more politically effective strategy has been to shield ourselves
from such attacks by enlisting the patient in our battle and pointing out
the loss of quality that hamster medicine has wrought.
So my fellow young hamsters (all old hamsters have jumped off the
wheel by now), don't compromise the quality of your medicine by running
faster, hope for a tax cut!
Competing interests: No competing interests
To the Editor:
One must endorse Morrison and Smith's (1) clear documentation of the
widespread problem of time pressure on doctors, with its adverse effects
on patient care and professional satisfaction and morale. My geriatrician
colleagues and I are especially plagued by time pressures: histories are
longer and more difficult to elicit and evaluate; examinations take more
time; polypharmacy prescribing requires more thought and greater care; and
advice to patient or caretaker must be given slowly and often
repetitively.
However, I cannot agree that "…organising medical practice in a
way…ill-suited to an information age and a world of sceptical, better
informed patients who…want the best care" are major underlying issues that
can or should be solved. In addition, it seems unlikely that doctors can
"…redesign their work to meet their patients' needs within the economic
constraints, just as…in…other service industries." Certainly, all time-
saving proposals should be explored, such as reduced and streamlined paper
work, easier access to results or consultation and various novel ways to
transmit information or to contact patients. But an irreducible time will
remain for provision of adequate
face-to-face patient contact, for reflection, planning and discussion and,
at times, for further exploration with family members or with a
consultant.
Morrison and Smith seem hesitant to press for an obvious but costly
solution: more physicians and increased time with patients. The etiology
of "hamster health care" is long exposure to austere health budgets. The
symptoms may be partially and temporarily ameliorated by various
interventions, but the prescription for cure is replacement therapy--
adequate funding.
Reference:
1. Morrison I, Smith R. Hamster health care.
BMJ 2000;321:1541-1542.
Sincerely,
Gerson T. Lesser, MD
Assistant Professor
Dept. of Geriatrics & Adult Development
Mount Sinai School of Medicine
Competing interests: No competing interests
A good analysis of the problems of state or institutionally funded
medicine; it accords all too well with my thirty years experience as a
full time fee for service G.P.
I am less sure about your solutions; a bit simplistic at the very
least. I do agree that a complete redesign of health care has to be the
starting point but my instincts tell me that only when the patient is
directly responsible to the doctor for the cost of a consultation will
both parties be satisfied. If such an arrangement can be worked into a
state funded system we may regain some of the professional satisfaction
that used to be ours.
Competing interests: No competing interests
Hamster Health Care
Dear Editor - In your recent editorial you mention the Canadian
health care system, suggesting that it suffered from shortcoming similar
to that of the NHS.
I work both in Canada and the UK, so am familiar with the two
systems.
I would point to significant differences.
Although now there is monetary penalty for a new graduate if he
wants to open an office in an overdoctored area, a physician in Canada
sets up his practice as and
where he wishes and is free to move about.
More importantly, in Canada a physician is free to work to whatever
pitch he/she wishes. Nobody forces patients on you, as happens here.
With fee-for-service, it is
perfectly possible to run a general practice at less than full power
whilst earning a very decent living. It is you who decides when your
practice is full and how much time
you wish to devote to your patients. Your patients, in turn, can decide
whether they are satisfied with your services or whether they wish to
attend another doctor. Under
this system physicians have a sense of control over their working
conditions which is unknown here. They are not burned out by the time they
reach their 60th birthday,
most do not think of retiring then, but remain productive members of the
community. Naturally, you are paid according to how hard you work.
You mention the limit on earnings, but you put no monetary figure to
it. The limit is a pretty respectable sum and to reach this you have to
work very hard indeed. Once
you reach this yearly total, to take off extra days of holiday on top of
what you had planned is not a bad alternative. It is clear that the
provincial governments in Canada are constantly trying to pare away
healthcare budgets but so far the system there still seems to work to the
benefit of patients and doctors.
I fully agree with you that the most important shortcoming of the
system in the UK is the absolute lack of control healthcare providers in
the NHS have over their future,
destiny and working conditions. To my mind lack of healthcare provider
satisfaction undermines morale here more than anything else. At the very
least, one should be
given the option to refuse additional work. Until, as a starter, that is
introduced I think we shall see this system continue to slide downhill.
You cannot expect people to
work well and happily when they are simply pawns in the hands of the
regulators, whether these are politicians or administrators.
Nicholas Koleszar MB BS.
Competing interests: No competing interests