On payment by results and why it is wrong

I work in the NHS. Before becoming a medical secretary, I used to be a teacher. The hospital have asked us to “cluster” all our patients by the end of October. On googling ‘clustering’, I came up with the dreaded term “payment by results”, which will strike fear into the hearts of any teachers out there.

The problem with ‘payment by results’ is that, as the NUT put it in its fight against SATS (Standard Attainment Tests), teachers will be too busy ‘weighing the pig to feed it’, i.e. too busy measuring, assessing, marking, rather than getting on with doing your job which is supposed to be educating. The temptation also is to teach to the test, which is a process I shudder to remember from teaching Year 9 kids Romeo and Juliet.

One part of the play which was to be studied in the exam was Act 1 scene 5, where Romeo uses an elaborate extended metaphor to persuade Juliet to kiss him:

ROMEO: Have not saints lips, and holy palmers too?
JULIET: Ay, pilgrim, lips that they must use in prayer.
ROMEO : O, then, dear saint, let lips do what hands do;
They pray — grant thou, lest faith turn to despair.
JULIET: Saints do not move, though grant for prayers’ sake.
ROMEO: Then move not, while my prayer’s effect I take.
[Kisses her.]
Thus from my lips, by yours, my sin is purged.
JULIET: Then have my lips the sin that they have took.
ROMEO: Sin from thy lips? O trespass sweetly urged!
Give me my sin again.
[They kiss]

I particularly like Juliet’s reply after this embrace, “You kiss by th’ book”.

However, I was instructed that the teaching of the play was not to extend beyond teaching in minute detail every aspect of the selected extracts to be tested – other than a showing of the Baz Luhrman film.

Why can’t we teach the general principles of literary devices – extended metaphor, simile, dramatic tension, etc., allow the children to experiment with these forms, and then this can be applied to ANY text? Otherwise literature just becomes a stultifying, dry memory exercise. Any enjoyment of the piece, any appreciation of how literary effects are used is completely lost -enjoyment is gone. Isn’t that supposed to be the entire point of listening to a poem, reading a book or watching a play?

I might sound like an old fuddy-duddy here, but what is wrong with giving people a completely unseen passage of text and then allowing them to come up with their own interpretation? This would value creativity, imagination and test the intellect, rather than spoon-feeding children pat answers. This is a criminal waste of talent and potential.

Now SATS at key stage 3 have thankfully gone, we now need to get rid of KS2 stats as well. While we are at it – we need to get rid of league tables, make schools select a broad intake of pupils, get rid of the market in education completely and have a truly comprehensive education system.

A similar process is going on in the NHS. In order to be more ‘market-driven’ and ‘patient-centred’, we have been told that by October all our patients need to be “clustered” – classified into how much resources need to be used in order to treat them.

This is not for any clinical reason, but purely to allow the Trust to get the coveted Foundation Trust status – at the moment savage cuts are being made across the country to hospital’s budgets in order to balance the books, staff are being made to input meaningless data, rather than type up clinical letters, or actually treat patients. The result is more bureaucracy and less treatment. In other words, like the SATs, we are too busy weighing the pig to feed it. We will also have to record every patient contact of over 15 minutes, even a phone call. This is ridiculous, wasteful and completely pointless, not to mention a major step in privatising the NHS.

Just as ridiculous are the 21 pages of criteria corresponding to each cluster that doctors have to compare their patients against. Yet, it is a simple matter to automate this – I wrote a simple program in basic in an hour or so using a set of IF . . . THEN commands.

cl=0
IF c=1 AND v(6)2 AND v(8)>2 AND v(13)>2 THEN cl=6
IF c=1 AND v(7)>1 AND v(7)1 AND v(8)1 THEN cl=7
IF c=1 AND v(7)>2 AND v(8)>2 AND v(15)>2 THEN cl=8
IF c=2 AND v(6)>1 AND cl=9 AND f$=”Y” THEN cl=10
IF c=2 AND v(6)2 THEN cl=13
IF c=2 AND v(6)>2 AND v(12)>1 AND v(14)>1 THEN cl=14
IF c=2 AND v(6)>1 AND v(7)>2 THEN cl=15
IF c=2 AND v(6)>1 AND d$=”Y” THEN cl=16
IF c=2 AND v(6)>0 AND v(14)>2 AND v(12)>2 THEN cl=17
IF c=3 AND v(4)>0 AND v(4)<3 AND v(10)1 AND v(4)3 AND v(18)>2 THEN cl=20
IF c=3 AND v(4)>1 AND v(18)>2 AND v(12)>2 AND v(10)>2 AND v(5)>2 THEN cl=21
IF cl=0 THEN PRINT “Variance – cluster 0”
IF cl>0 AND cl<3 THEN PRINT “Cluster 1 or 2”
PRINT “Cluster “;cl

The clustering forms we are supposed to use, imposed from the top, are complete nonsense – you input the data in numbers, which is checked against a visual representation of each cluster, which needs to be printed in colour, due to colour coding, which necessitates expensive inkjets or travelling two miles to a different hospital with a colour photocopier. All this can be achieved in a few simple lines of code.

I would get rid of the NHS “internal market”, introduced by Thatcher in the 1980s. I would get rid of clustering and payment by results. I would get nationalise the pharmaceutical companies and kick out big business from the NHS completely. Profit should not be made from people’s illness. The great socialist Aneurin Bevan resigned immediately when the NHS’s ideal of free treatment for all was first compromised. It is only by fighting, protesting, taking strike action, that we can defend the principles of the NHS, just as the teachers’ unions eventually won part of the battle over SATs.

The party I am part of – the Socialist Party – is fighting for democratically controlled, completely nationalised public services, with no markets and less bureaucracy. This would be massively more sensible and efficient. We need more people to get involved, from the private and public sectors. We need to fight back.

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One Response to “On payment by results and why it is wrong”

  1. Andrew Brain Says:

    Thanks for that Drew – very interesting and clearly argued post.

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