Partnerships in paediatrics: renegotiating the contract Richard Smith Editor, BMJ .

Partnerships in paediatrics: renegotiating the contract

Richard SmithEditor, BMJ

www.bmj.com/talks

What I want to discuss

• The unhappiness of doctors• Why might they be unhappy?• Renegotiating the contracts

between doctors and government and doctors and patients

• 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 digestion.” Jean Jaques Rousseau

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

Anthony Trollope on happiness

•“It is the grind that makes the happiness.”


• “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.”


• “The happiest man is he, who being above the troubles which money brings, has his hands the fullest of work.”

• “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 doctors?

• 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

work.”• "I feel dissatisfied in my current post." • Most days I am enthusiastic about my work”• "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 satisfaction

Job satisfaction of senior doctors

Specialty group ScoreA and E 18.8Obs and gynae 19.6GPs 19.1Private medicine 22.8Medicine abroad 21.6Paediatrics 20.8

GPs intending to quit patient care in the next five years

Age % intendingto quit 1998

% intendingto quit 2001

41-45 9 1151-55 27 4556-60 64 87All 14 22

League of unhappinessCountry Very

unhappyUnhappy 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 unhappy?


• 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


• Underpaid• Doctors have lagged behind some comparable

professionals--for example, barristers• 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, solicitors


• 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 politicians


• 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)


• They are exhausted by too much change

• Doctors are not alone in this• There will probably be more change in the

next 10 years than in the past 10


• 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


• They are increasingly accountable

• They are, but they were probably insufficiently accountable before

• The NHS now runs on Hobbesian rather than Lockeian lines

Thomas Hobbe’s philosophy

• People are essentially bad

• If you don’t control them carefully then they will do wrong

John Locke’s philosphy

• People are essentially good

• Give them enough space and support and pay them well and they will do wonderful things


• 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 education


• 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


• Close contact with patients are disrupted

• Little support for this explanation• This remains much of the joy of the

job


• The health service is falling apart

• Many doctors in Britain seem to feel this• The BMA begins to look at alternatives

to the NHS • Mind you, the BMA maybe falling apart

as well


• Patients are too demanding• Politicians are stoking patients’

expectations• 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 problems

• You, the doctor, can see inside me and know what's wrong

• You know everything it's necessary to know • You can solve my problems, even my social

problems • So we give you high status and a good salary

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 • Doctors should be open about their

limitations • Politicians should refrain from

extravagant promises and concentrate on reality

Spin offs from the “new contract”

• 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 together

• You and your children need to be willing to participate in experiments

Spin offs from the “new contract”

• 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 it• For every problem there is a

simple solution. Unfortunately it’s wrong

The old contract

• What doctors give

• Sacrifice early earnings and study hard

• See patients• Provide god care as

doctors define it

• What doctors get

• Reasonable pay• Reasonable work/life

balance• Autonomy• Job security• Deference and

respect

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 working

Creating new contracts: doctors and the NHS

• Doctors get• The opportunity to shape the goals of the organisation• 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 standards• 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, relationship.”

Renewal: Dutch style in the 16th century

T H White on learning

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.”

Partnerships in paediatrics: renegotiating the contract Richard Smith Editor, BMJ .

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Transcript of Partnerships in paediatrics: renegotiating the contract Richard Smith Editor, BMJ .