Following some excellent posts by the medical blogosphere’s resident Pest Control Officer, Dr No has been learning two new words. Both get flagged as misspelt by his spelling checker, and only one has so far made it into the OED. The one that has made it into the OED is ‘commodification’, and the dictionary defines it thus:
“The action of turning something into, or treating something as, a (mere) commodity; commercialization of an activity, etc., that is not by nature commercial [emphasis added].”
At a stroke, Dr No has stumbled on the word that perfectly describes the core malevolence at the heart of Tory’s proposed healthcare reforms. And on this they have form.
It was of course the Grocer from Grantham (and here the epithet could not be more apposite) who introduced the idea that healthcare was in fact no different to apples and oranges. Her and her BATman Kenneth Clarke’s transformation of the health service into the health industry ushered in the internal market where hernias were treated as apples, and hip replacements as oranges, to be bought and sold along with other groceries. The present lot are merely travelling further and faster down that same misguided road.
Of itself, this is bad enough, for it reduces a noble art and science to mere commerce. But it is in fact malevolence squared. For, in addition to commodifying – indeed precisely because it has commodified – medical activity, it opens the door to another arguably even more sinister malevolence: that of greed, and the means of greed, manifested through the second new word: financialization.
Dr No’s trusty OED failed him on financialization. And when the OED fails, Dr No does as everyone else does, and goes to google.
Wikipedia is a bit dense on the matter. Others – perhaps unsurprisingly, because we are in economic territory here, and economic jargon has all the clarity of peanut butter, are equally opaque. But after a bit of reading around, Dr No began to get the gist of it. The essence of financialization is the transformation of just about anything into financial instruments that can be traded, as if they were stock options on the financial markets.
And where there be financial markets, there be gamblers. By now, Dr no was beginning to get a proper sense of déjà vu. Packaging up assets into ever more complicated parcels, and then gambling on the outcomes, sounds familiar, as indeed it is, for it is precisely the process that the bankers used to precipitate the recession. It was the financialization of the housing market, and the unchecked exercise of gambling and greed that lead directly to the credit crunch, the bailing out of busted banks and the recession.
Readers may feel Dr No is exaggerating the alarm. He is not. David Bennett, the new boss of the healthcare economic regulator Monitor, already talks of ‘commodity level [health] services’. The creep to commodification has already happened. And as the Witch Doctor’s black cat would no doubt observe, creep once started rarely stops. We are within a cat’s whisker of the financialization of health – and if it should come to pass, then it will only be a matter of time before the NHS the goes the way of the banks.
Ah, but the regulator – Monitor – will prevent such a catastrophe, the Tories will say. To which Dr No says: sure – just as the financial regulator spotted and stopped the banks going pop.
Monitor’s boss, Bennett, has already bought into commodification. The building blocks of financialization are already in place. All that is needed is for some bright City sparks to weave their dark magic. Only, when that happens to the health service, it wont be just a few thousand bankers who loose their jobs. We will all wake up one morning to find we have lost our NHS.
I appreciate that I can be a bit chippy about it, but I don’t like people using “commerce” or “industry” as insults. It is commerce that built this country, and industry. Napoleon called us a nation of shopkeepers, but it was our nation that put him on St Helena and brought about the Pax Brittanica in Europe.
There is nothing wrong in treating health care as a commodity, and nothing new either. The NHS has had public health doctors deciding on health care benefit and planning accordingly from the earliest days of the NHS.
I think that these reforms will turn out to be a damp squib, and a distraction from the two items that really will impact on British health care: revalidation and MMC. When revalidation comes in there will be a large number of early retirements. It will be the final straw to many who can’t be arsed to tick boxes, and insulted that they are expected to do so.
At this point the real failure of MMC will become manifest, with the sheild of Senior cover trained under the old system becoming ever more battered. It’s then that we will see some real scandals.
It matters little whether I am paid by Borsetshire Trust or Virgin Borsetshire compared to the prospect of a completely MMC trained workforce in a few years. In particular I hope that I do not go mad. The RCPsych has been unable to fill it’s posts this year, even with weak candidates. As our colleague Dr Rant might say: we will all be in the shitter then.
Dr Phil
Dr Phil,
I suspect most doctors will agree with you that it is commerce, industry, and shopkeepers that built this country. In fact I would have no problem having my body treated as a commodity if that is what I choose to do!. No, I’m not really referring to the oldest profession, rather botox, gastric banding, cosmetic surgery and a miscellany of procedures which might be considered “Lifestyle” health choices. I have no problem with competition either in this area.
However, if I’m lying on the floor unconscious from a brain haemorrhage, I have excruciating chest pain, or need urgent surgery or chemotherapy to keep me alive, then there is not much choice and I’m damned sure I don’t want the medical profession and their masters to regarded me as a kind of complicated lump of coal, or a crate of oranges! In fact I find the whole concept of commerce and competition in these circumstances obscene. I definitely don’t want to have the worry of remortgaging my home or filling in numerous insurance claims after grappling with the small print that I am too ill to understand.
It seems to me healthcare nowadays divides, to use todays jargon, into two pathways. The illness pathway and the wellness pathway. The latter is in danger of being encouraged at the expense of the former for commercial reasons.
My worry is nothing to do with commercialisation or capitalism per se. It is simply that healthcare or more accurately the prevention, diagnosis and treatment of illness should not be part of it.
Furthermore, the idea of doctors advertising and marketing themselves sticks in my gullet. Commerce does not seem to be able to exist without this nowadays. As a doctor, just be the best you can possibly be and whether you are practising in the pubic or private sector, the patients will find you.
The clients will find you too, but as a medical practitioner, they are not my concern.
I’m sure I can feel the earth move as Cezenne turns in his grave!
“I’m sure I can feel the earth move as Cezanne turns in his grave!” – So too does Dr No. The point about apples and oranges is that they are on different playing fields. As are commerce and the professions.
“However, if I’m lying on the floor unconscious from a brain haemorrhage, I have excruciating chest pain, or need urgent surgery or chemotherapy to keep me alive, then there is not much choice and I’m damned sure I don’t want the medical profession and their masters to regarded me as a kind of complicated lump of coal, or a crate of oranges! In fact I find the whole concept of commerce and competition in these circumstances obscene. I definitely don’t want to have the worry of remortgaging my home or filling in numerous insurance claims after grappling with the small print that I am too ill to understand.”
Spot on Witch doc, I too feel the same about ‘real’ need, however, why not advertise and market your expertise while sticking to this principal? Not everybody knows where to go or can find the most suitable Dr at this time of real need. By you advertising your services, this search is made easier, and that can only be a good thing to help inform?
Posted a link on my Monitor post:
NHS & Monitor: Eggs & Enron.
The Gp consortia in Borsetshire are coterminous with the old Pct’s so I am not expecting a lot of change. In the short term there are no alternative providers, so in the short term I expect no change to services. In the longer term there may well be some competition on elective services, but as long as this competition is not soley on price I have no problem with this. Genuine competition on quality and productivity is a good thing.
The threat to a collapsed witch comes from having inadequately trained and poorly supervised doctors managing her collapse or chemotherapy. This is more of an issue to do withrevalidation and the failure of MMC. There will be closures of accident and emergency services because they cannot be staffed rather than cannot be paid for, if there is one thing that GPs want to commision it is good acute care.
Boots – “I appreciate that I can be a bit chippy about it, but I don’t like people using “commerce” or “industry” as insults. It is commerce that built this country, and industry. Napoleon called us a nation of shopkeepers, but it was our nation that put him on St Helena and brought about the Pax Brittanica in Europe.” – Dr No, like the WD, has no trouble with decent commerce in the right place, and he further entirely accepts that it was commerce (including perhaps some not so decent) that built this great country (and indeed its Empire).
However, it wasn’t shopkeepers that did for Napoleon, it was Nelson and his Navy (with the Duke of Wellington delivering the coup de grâce a few years later). “England expects” doesn’t appeal to commerce – it appeals (quite literally) to duty, and service. Sure there was prize money to be had, to gee-up the officers and other ranks, but prize money is hardly commerce in the ordinary meaning of the word.
By calling us a nation of shopkeepers, Napoleon gravely underestimated our abilities in the line of duty, and in service, and his mistake cost him dear. Governments when they attempt to turn medicine into a game of shopkeeping risk making a similar mistake, only this time it wont be Napoleon destroyed, it will be the NHS – much of which runs on the invisible fuel of duty and service – that will be destroyed.
Most contemporary public health johnnies are Excel nerds, and the only thing they manage to change in real life are the contents of the cells in their spreadsheets.
Where we do agree, however, is on the viscous threats posed by revalidation and MMC; and I suspect the reason we agree on this is because deep down we both know medicine is a profession, in the true sense of the word, not a pool of civil servants to be Monitored and managed, nor – Heaven forbid – a collection of shopkeepers ripe for commodification and financialization.
WD – a very astute observation on the divergence into illness care and wellness care. Dr No hopes your black cat will find time to explore this further.
Sam – the problem with advertising is that it very quickly creeps into spin and manipulation, and genuine information – as in ‘the truth’ – is the first casualty. Patients will find and attend not the best doctor, but the one that has the best advertising/biggest advertising budget.
And Boots again – “as this competition is not soley on price I have no problem with this. Genuine competition on quality and productivity is a good thing” – it is impossible to compete on productivity without involving price, for they are both part of the same equation. You might ask providers how many hips they can do for £100,000 – but their variable answers can also be re-expressed as cost per hip – and some will turn out to be pricier than others…
Sam,
In addition to agreeing entirely with Dr No’s reasons above, my aversion to advertising in medicine is very deep rooted. When I qualified, advertising was forbidden and a doctor caught doing this would have been subject to disciplinary action. I suppose I subconsioulsy still see it as a type of malpractice although over the years the GMC has crept considerably on this issue and it will creep even more, now that it is a government quango, to the extent that doctors’ selling their wares will soon become the norm.
In my neck of the wood, within the NHS, there would generally be no need to advertise anyway, each doctor generally has more patients than they can normally cope with given the constaints of clinic, bed availability and other factors. ….hence the problem with waiting lists etc. In the private sector this is not usually the case and so private hospitals are very eager to market their consultants. However, there are a limited number of consultants available in each specialty, each with their own expertise within that specialty so there is not much point in advertising.
I am generally suspicious, perhaps unreasonably, when I see a doctor advertising. It is not the norm in this country and I would ask myself why he/she feels the need to tout for business. So, for me, advertising has the opposite affect – avoid that doctor like the plague! Same for dentists. If my dentist decided to advertise his prowess in the art of botox I would promptly look elsewhere for dental treatment.
Anyway it is just as well witches don’t do advertising because we would just cast a powerful spell over all and sundry that would turn us into money-making honeypots by attracting all the patients and clients in our vicinity!
No-one else would stand a chance.
I don’t want to divert to the Napoleonic wars too much, but the strength of the Royal Navy was because of the large population of able seamen who could be pressed from our 20,000 ship strong merchant fleet, established by our shopkeepers. Wellington’s army was predominantly European. There were 220 000 British men in the 1815 Army, but our subsidies to Austria, Russia, Spain and Portugal paid for another 450 000 continental troops to fight the French, and they were equipped with British small arms from our emerging industries. The Napoleonic Continental system, and the consequent British Orders in Council of 1807, built British trade and destroyed French commerce. Napoleon’s disastrous 1812 invasion of Russia was an attempt to end Anglo-Russian trade in violation of Napoleon’s Continental system
The British introduction of paper money into Europe, leaving the Gold standard, issuing of war bonds, and invention of Income tax meant that by 1813 we were spending 4 times what the French were. The Napoleonic wars were won by our shopkeepers, and financiers (such as the Rothschilds). We could not have maintained our Navy or Army without them. That is why Napoleon hated our shopkeepers.
Similarly our NHS is dependent on funds raised from our shopkeepers, industrialists and financiers. We should be grateful that we have them.
You seem to see professionalism as in opposition to commercialisation, but American, Canadian, Swiss, German, French, Greek, South African, Indian and Japanese Doctors are all substantially employed in the private sector. Are we really any more professional than them? It would seem a little insulting to our overseas colleagues to suggest that they are our social inferiors.
On the subject of productivity I could write an essay (and may do so on my blog). I agree that productivity cannot be divorced completely from price, but who is against high productivity? Nothing is more expensive than complications, and nothing slows down an intervention list down more. If you want high productivity you need good quality work. The same goes for medical units, if you want to shorten inpatient stays then you need committed and co-ordinated Nursing, OT, Physio and Social service teams, as well as support from other specialities and good links with GPs and community support services. Good productivity is Good Medicine.
An ISTC clinic set up in Felpersham,invited by the PCT, in direct competition with my NHS clinic. They lasted barely six months before the PCT asked me to take over all their patients on a waiting list initiative basis. They couldn’t compete on quality, productivity or consumer service. Victory was sweet, but sending them packing with their tails between their legs was done by a fair fight, and the competition made me up my own game.
Dr Phil
I didn’t mean adertise as you would a movie! … and advertising is not allowed in Egypt, for example, apart from a sign to state your specialty and professional status placed on a doc’s private practice only, meaning you only depend on word of mouth and that can be misleading.
I meant maybe just a register or a database online to list specialists and their qualifications, sucess rate in surgery for example, or something simple like that, or maybe there is one already but I do not know. It is not easy to find a doctor, say, if you are asked by relatives intending to come to England for treatment and want to see a capable doctor and not neccessarily be admitted to hospital straight away, or at all. I would also like to know how good is my doc before I sign this consent paper should I need to.
Regards to black cat 🙂
Sam,
Some information should already be available on all hospital and university websites and indeed the the information is usually very factual and worded in a way it does not “sell” the individual concerned, so it isn’t really advertising and it can be helpful. University websites often give more information than NHS sites usually focusing on research publications. For example if you suffered from very severe asthma, you might be able to identify a clinician who has a particular interest in asthma research and also sees a lot of patients. You can be pretty sure he/she will be competent and up to date. But so also might an NHS consultant with no university contract but it would be more difficult obtain detailed information.
Success rate in surgery is difficult to collect and interpret accurately but is available for several procedures. I’m not sure how much it would help a patient decide the best doctor or surgeon. It might well indicate who to avoid though. I have been involved in the collection of some information in the past and it was faulty ie only taking into account patients during the hospital stay rather than complications detected after discharge. This will be improving now but it is difficult and expensive to do accurately.
Normally, I would obtain information by word of mouth from medical colleagues. It usually works.
PS My Black Cat sends her regards too and recommends Iwantgreatcare for all your needs 🙂
“University websites”
never thought of this one before! Good idea!
“Iwantgreatcare”
Although I think any good professional will not care of where his/her name is going to appear, tell wise black cat that I do not trust anonymous comments on professionals in general, nor am I interested in ‘contacting’ a dead doc … but, I do look at anything if I’m stuck, since it is an available source where sources are scarce
… and give the feline one a cuddle from me 🙂
Boots – Trafalgar wasn’t fought on commercial principles. It was fought – and won – on something equally if not more powerful, but quite quite different – the Nelson Touch.
Dr No quite agrees that wealth generated by commerce funds the NHS, as it did Nelson’s Navy – indeed, Dr No has even read a seminal book on the subject, Paul Kennedy’s Rise and Fall of British Naval Mastery – and Wellington’s army. Etc etc. On this we can agree.
But just because wealth from commerce funds something, it doesn’t mean to say that something should itself be run commercially. It may even be that the commerce introduces new elements that are in the end self-defeating (transaction costs outweigh potential savings), goal displacing (more lolly for the shareholders rather than better care for patients) and down-right risky (avaricious greed, fraud etc etc as the corporate sharks come out to play).
Sam – as WD says, there is already a lot of ‘information’ already on the web (eg this at the top of a google search for ENT surgeons). The trouble with ‘info/adformation’ is that it is almost impossible in practice to do it validly (as in the results are a true reflection of reality). We have seen how difficult it is to even rate hospitals (Dr Foster), let alone individual surgeons/doctors (and the less said about iwantgreatbacon the better). And even if we could, the figures would suffer small number variability (and it may be that statistical methods will never get round that problem), not to mention gaming. Dr No the surgeon can so easily better his figures by only operating on safe patients, while Dr Yes down the road – who may be the better surgeon – has worse figures because she accepts all those hard cases that Dr No rejects. Sure, case-mix weighting is supposed to fix these distortions – but case-mix is very easy to get wrong and/or game.
Other ‘games’ are discharging people too early (a neat way of doubling throughput when the patient is readmitted; and a great way of reducing in-patient complication rates – the wound that breaks down at home doesn’t show up on the in-patient statistics) – the list is limited only by the crooked doctor’s imagination – and, as the WD notes, it is very difficult and expensive to detect such things accurately, if indeed it is ever possible.
The best way was of course the old way – the WD’s word of mouth from medical colleagues. For non-medical people, this was done through their GP, for GPs knew their local consultants, and so could direct patients to the consultant best suited to that patient’s needs. Even Boots might agree with that!
“the less said about iwantgreatbacon the better”
I have never really understood why the vement opposition to this particular site Dr No, apart from it allowing for anonymous comments which can be anyone with a grudge, or an undeserved compliment, as well as a genuine patient with a genuine praise/complaint, this uncertainty causes patients to doubt it’s validity I think. Surely, if that vague bit is addressed, then why not? Especially if a doctor is doing his/her job right most of the time since docs are not superhuman, then whats the difference between googling an ENT specialist or looking them up on such site? In our information age, I don’t think anyone can remain hidden anymore. Then again, what expertise you have should be celebrated [modestly] and not hidden.
It’s me Dr No, Anonymouse is my alter persona 🙂
Samymouse – you have answered the question yourself – iwantgreatbacon is wide open to being a completely unrepresentative sample. It is ‘8 out of 10 cats’ cubed. It is utterly unreliable – and hence shame on the airheads who dreamt it up – and hence the vehement opposition to it.
At least if Dr No puts up a website saying his frontal lobotomy results are better than anybody else’s you know (a) it is Dr No saying it (and so may be spun in favour of Dr No) and (b) you can inspect the figures he bases his claims on. If the figures don’t stack up – or he fails to produce them – then you can dismiss his claims.
Well, let’s put it this way Dr No, When patients need information, they will use word of mouth first and if that’s not available, then google or anything else including Iwantgreatcare is all they have and they will use it. I am no different.
Soon will come the time when my own children will be on that database too, they are not worried, and I am not too. And with the expertise you describe about yourself, I don’t think you should be worried either.
We have an Arabic saying that goes, ‘walk straight, and baffle your enemy’ …
As you probably know, My Black Cat, lurks around iwantgreatcare and from what she sees, there is a certain “Pyjama Man” who has more positive feedback than any other doctor in the land.
MBC therefore has come to the conclusion that every patient in the UK should exert “The Choice” that the government has endowed upon them and demand that they are referred to Pyjama Man, bypassing all the Referral Centres (which are the antithesis of “Choice”). This is because she has concluded that PJM seems to excel himself by working harder, being extra “nice’ to patients, as well as having the best feedback in the land.
I tell MBC not to be stupid, that there will be many more consultants within this specialty that are as good as or better than Pyjama Man. I tell her the only measurable skill Pyjama Man has from this website is in touting for positive feedback. He is probably the best doctor in the land in the “give me good feedback specialty”
If doctoring became part of the commercial world, then touting for positive feedback would put money in Pyjama Man’s own pocket. I don’t know whether this is already hapening since I don’t know if Pyjama Man has a private practice in addition to his NHS work. Maybe My Black Cat should be finding out.
The WD’s name appeared on iwantgreatcare shortly after it opened. She looked out of curiosity, not out of worry. She has no idea whether her name is still there or whether there is any feedback positive or negative. She doesn’t really care much about it one way or another although she should really keep an eye on it because if a patient reported she did not “trust” her and displayed that publically on this website she might well contemplate taking them to court if she thought it worth raiding the bank to do so. She would do it to put a nail in the coffin of this stupid unprofessional website.
It is likely that most doctors don’t fear iwantgreatcare, they just despise the stupidiy of our medical “colleagues” who thought it up, invested in it and will profit from it. Other doctors may even feel, as The Witch Doctor does, that their former medical colleagues have fallen from a profession into the gutter and are heading for the sewers! They are definitely not WDs medical colleagues any more.
Sam,
‘walk straight, and baffle your enemy’
MBC and me definitely approve of these wise words!
“if a patient reported she did not “trust” her and displayed that publically on this website she might well contemplate taking them to court if she thought it worth raiding the bank to do so.”
Hence one is allowed to post anonymously. Thank you for the explanation Witchdoc, I can see the logic now.
Only, given that patients are usually grateful for the ‘good’ care they recieve and therefore, that special bond that forms as a result between doctor and patient, if I were you, and knowing how you are re your patients, I wouldn’t worry about that above senario happening at all regardless of where your name gets listed.
“Other doctors may even feel, as The Witch Doctor does, that their former medical colleagues have fallen from a profession into the gutter and are heading for the sewers! They are definitely not WDs medical colleagues any more.”
You see, it is that ‘severence’ bit that I sometimes do not understand re the relashionship between doctor and doctor. It’s like ‘If you befriend my enemy, then you are my enemy too!’ This kind of ideology would make the job of a diplomat obsolete as it always drives people apart with no chance of reconciliation. All just for having differing points of view that may be valid on both sides. In this case, I believe it is.
What’s the point of debate if we are all in agreement? Is that good?