PbR: bugs, buts and bull riding

Windows gets better with each upgrade, but what of HRG4? (If you are a smug Apple user, I sympathise - I understand what it is to be a visible minority).

Here's an interesting PbR bug. It is more financially profitable for some units to have children on haemodialysis than to have them transplanted.

If I were running a business, as opposed to a clinical service, then it would be wiser not to structure my service to deliver pre-emptive transplantation as a primary objective, not be innovative with the biology of transplantation, to offer haemodialysis as the preferred modality, delay transplantation and maintain a minimum number on dialysis to ensure that the service is kept at break-even point, at the very least.

So, the choices are: haemodialysis = financial survival; transplant = financial loss. This is not a choice. I am an ethical creature and everything I do with my team is aimed at achieving the highest live related, pre-emptive transplantation rate with the best transplant to dialysis ratio in England - not a great business outcome but a fantastic every other measure outcome for the child and family.

But here's the rub - conversations with managers, clinical and non-clinical, now only ever about activity/income, will acknowledge the quality outcome (when reminded), but that achievement feels very swiftly dismissed by the 'but' that inevitably follows.

We will continue to serve our patients to their best advantage, leading through and past managerialist policies and behaviours - but we still have to expend enormous energies to justify our financial value to local managers as a consequence of an immature, error prone financial instrument devised, adapted, 'matured' and implemented by Department of Health managers and policy wonks even more removed from the reality of clinical service delivery.

Perhaps the Department of Health can buy the services of extremely bright economists and mathematicians from the City to have a go at fixing HRG4 and what surely must be less complicated than constructing magic mortgages and dodgy debt derivative contracts; I gather it's a buyer's market. I will take a bet that they will run screaming out of our old public sector and back to the 'new public sector' that is now 'Our City'.

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