Monday, 16 August 2010

Losing it

Well, it didn't last long, did it?
The first flush of goodwill and decent policies, devolving power to the clinicians, no more top down management, etc. But now, just three months into the job Mr Lansley drops his first clanger and shows us what may be his true colours. Fines for hospitals that don't have 100% compliance with single sex accommodation by the end of this year.
Leaving aside this policy was first mooted in 1996 and that successive governments have been promulgating it so that he is jumping on the end of a long bandwagon and claiming it as his own, we are now - at a stroke - back to central control. Never mind that the fines would penalize those least able to afford them; never mind that this would in turn impact on patient care and staff morale. No, we need an ego boost for Mr Lansley and his increasingly shabby looking administration and this makes good headlines.
Don't get me wrong: single sex accommodation is absolutely the right thing for which to strive and I doubt anyone would disagree with him on this. But it doesn't just happen at the click of a finger. It needs the real estate and the staff to man it and neither of these occur overnight. And lastly, it does not need punitive measures from on high.
If a hospital has one ward for a particular speciality it will need two but these need to be built and then there needs to be more nursing staff as the male to female ratio is never exactly 50-50. Doubtless there will be fudges where a screen is built but the rest of the ward remains the same and this will constitute compliance - for in recent years clinicians and managers have become adept at circumventing daft rules by creative accounting - a skill that New Labour leaves as one of its many unwanted legacies but one that the new government seems intent on continuing. And this will be worse than useless for the problem will be perceived by the bean-counters to have been solved whereas it remains, and no further work will be done.
And fines? Words fail me. The internal market redistributing scarce monies doubtless to more middle managers to create more unhelpful rules.
Three months in and he's already losing it. I would say roll on May 2015 but we all know that it makes no difference: they are indeed all exactly the same.

Monday, 12 July 2010

Half right

So the new NHS vision has been released. GPs will be responsible for a huge amount of money, deciding in which services to invest, what services to buy from local providers, how to create maximum competition between other NHS providers and the private sector. Over 150 Primary Care Trusts will go, as will ten Strategic Health Authorities along with the legions of ineffective middle management that staff these organisations.
All this is to be largely applauded. Whilst allowing GPs so much freedom with so much money is inevitably a risk it is a better system than the current one - as long as the same people who run things now are not reemployed by GPs to do the same in a different setting.
But the government has missed a large and important trick. Secondary Care should also be commissioning services. GPs do not, and cannot be expected to understand the requirements of each and every disease state - especially those with chronic disease. It is hospital specialists who are best placed to advise on the intricacies of the needs of patients in these groups, not GPs. Furthermore, giving all the purchasing powers to Primary Care reinforces the sad message of the internal market that GPs are little more than conduits for channelling patients towards those who can actually treat them; little more than a shop front for the 'real' medicine that lies further into the service. This is of course not the case as GPs have a vast array of services that the provide and herein lies a further problem: is there not a massive conflict of interest here with publicly funded businesses paying themselves for as much as they like?
So, the report so far? Nothing wrong, Mr Lansley, but only half right.

Saturday, 26 June 2010

More4Less: The public sector spending challenge

In response to the Department of Health's call for ideas from public servants on how to cut costs and improve efficiency within the various public services, Red Dolphin has submitted a blueprint of 10 ideas, the implementation of which would unquestionably save money, improve efficiency and raise staff morale. It remains to be seen whether the government is courageous enough to implement it.

Dear Mr Cameron, Mr Clegg and Mr Lansley,

"More for Less": Ideas for cost savings and efficiency improvements in the NHS

1. The European Working Time Directive

Whilst no one would wish to see a return to the 'bad old days' of the 100-hour week and the tiredness-induced mistakes that this bore, the pendulum has swung too far the other way and opting out of the EWTD would allow junior doctors achieve decent amounts of training during their time whilst still capping the hours worked for safety reasons. After all, consultants are not subject to this constraint and for them it is currently entirely possible for one to be on call from Thursday morning until Monday afternoon these days and this is not illegal. Whilst that is not tolerable as a junior doctor we are currently in a situation where good specialist registrars deliberately fail their final year assessments in order to get a further year of training: more doctors does not equate to better doctors. A better training experience (the apprentice style is still the best) creates a higher quality of doctor. The New Labour tactic of throwing money at the problem was in fact counter-productive. So: train fewer doctors but train them more intensively thus saving salaries.

2. Study Leave Budgets

As in the airline industry it should be the responsibility of doctors to arrange and fund their own Continuing Professional Development, whether it be courses, meetings or sabbaticals. The £700 a year or so that is potentially spent on every doctor in the country could be withdrawn. With revalidation due to come on line in 2012 this is a good opportunity for the profession to demonstrate it's own professionalism and no longer rely on the public purse to pay for updating it.

3. Clinical Excellence Awards

Bonuses in the public sector should be all but unnecessary and this divisive set of awards should be dramatically pared down to reward only the most deserving. One criteria should be that the recipient does no private practice work. The negative effect that CEAs have on the profession far outweighs any incentivisation that they induce as the majority of consultants who do plenty of 'extra' work receive no points and feels doubly aggrieved when not awarded one in any given year. The exaggerated and even bogus claims that are made in the application rounds should make these an early target for cuts and, as they are pensionable, will make for significant savings. A national, independent panel including members from outside the profession should judge the very few remaining cases against stringent standards of merit and achievement.

4. Middle management

Partly, but not entirely borne of the era of New Labour targets, there are too many people engaged in meaningless exercises of counting what does not need to be counted - and furthermore not even understanding what it is they have counted due to a lack of understanding of the system. Great swathes can be cut through the reaches of 'assistant project managers' and similar to save millions at a stroke. Allowing clinicians more freedom to govern themselves - and this might include some more education in the history and running of the Health Service at medical school - will end their disenfranchisement of recent years and end the 'counting culture' that currently abounds.
Remember the adage that "not everything that can be counted counts, and not everything that counts can be counted."

5. Reduce generic working

Whilst the introduction of generic working - that is for work of a general nature to be performed by anyone within a particular department rather than a named individual - is useful for the reduction of waiting lists, the principle when applied too rigidly can be obstructive. Clinicians value the personal link and the ability of an individual consultant-secretary combination to prioritise and manage appointments is immeasurably valuable and more efficient than a rigid adherence to the generic principle. This would increase efficiency by reducing waste both in terms of unnecessary appointments being issued and the small 'team' understanding the particular abilities and limitations of any given service.

6. Budgets within the Internal Market

Whilst the concept of the internal market appears set to stay for now it must be recognised that the myriad of small, notional micro-budgets held within every department and managed almost in isolation creates a cottage industry of accountants and administrators who merely hamper the smooth running of a hospital or primary care facility. Internal 'purchasing' of services within a large hospital, for example, is meaningless as the is no competition (the idea behind the internal market) to drive any change. Meanwhile non-clinical managers push spreadsheets of inaccurate figures around the organisation, basing decisions on these data that affect clinical care. Whilst disciplined spending of an annual budget in any department is of course mandatory, clinicians should have more involvement in the process, it needs to be greatly simplified and far fewer people need to be involved in it's management.

7. Strategic Health Authorities

These leviathan organisations offer very little value for money. The majority of their budget is spent on education and this 70-80% could be devolved directly to the Deaneries, thus saving the 'middle man'. Whilst the role for Public Health is of course vital this should become a stand-alone speciality, especially as the SHAs add little or no strategic thinking to the process. The cut in personnel and sale of the resultant plush real estate currently given over to them would result in huge financial and efficiency gains for the NHS as a whole.

8. Postgraduate education

This aspect of medical life has become needlessly bloated over the last decade with courses existing for multiple unnecessary topics. As discussed in point 2 the profession needs to take responsibility for it's own clinical and non-clinical updating. The release of Trusts from the fear that every action needs accountability to the n-th degree would make unnecessary the many "compulsory" courses that are now the norm prior to undertaking any extra work. If indemnity from consequences could be assured in many areas then these box-ticking exercises could be usefully abolished with the consequent saving of salaries and gains in clinician productivity.

9. Cancer networks

Whilst the cancer multiple-disciplinary team (MDT) are an essential and irreversible innovation the bureaucracy to which they are currently answerable should be significantly slimmed down. The cancer networks as they currently exist are yet more circular middle management jobs the output of which serves more to obstruct than to help the frontline staff.

10. GP commissioning

Currently this is a highly complex process involving yet more accountants and middle managers and it need not be so. GPs are well placed to inform secondary care Trusts what services they need but again, infinitely dividing their notional budgets simply creates more administrative work rather than helping the process. Broad quotas and plans for when these are significantly exceeded or unreached, agreed by the relevant clinicians, are all that is necessary to avoid the current 'death by spreadsheet' system that obfuscates rather than clarifies the need for any given service.

Yours faithfully,

The Red Dolphin

Monday, 21 June 2010

Common sense... 1 Theorists... 0

The announcement today of changes to the NHS Operating Framework including the scrapping or softening of many targets has breathed new hope into the clinical body, an organism that has been sorely tried by the last decade of over-management. Told time and again that we were not trusted to deliver a fair and efficient service by the then government such that we needed the yoke of these targets in order to perform, the resentment has grown and grown. As much time was given to ways of circumventing the more ridiculous diktats as was given over to useful innovation with the public purse the inevitable loser. Clinicians were left to battle with the unforeseen consequences of the targets and then blamed for them too.
Whilst the patients' views are clearly valuable to any health planning exercise they lack both the knowledge and the detachment to be able to offer the final say, whereas the clinicians that work day in, day out at the medical coalface understand the issues, the strengths and limitations of the service and - contrary to New Labour's rhetoric - care deeply about the people they serve. There are rotten apples in any basket, but not many in this one.
So now, rather than introducing a headline-grabbing target of 4-hour A&E waiting time and not know, care or worry about the patients who were unnecessarily moved onto an inappropriate ward to avoid breaching the target, now we can concentrate on making parameters that are meaningful, achievable yet challenging and above all, practical.
Move over theorists, common sense has arrived.

Monday, 7 June 2010

Take a 180 degree look around

On my way to London on the train this morning I was momentarily confused by a double illusion of motion and stasis. To explain - the train was stationary at a platform alongside another when this second one moved off giving the familiar sensation that my own train was pulling off. However, this was not mirrored by the expected simultaneous sensation movement that ought to come with this and for a few moments I was disorientated, not to say actually quite dizzy. Only when I looked through the opposite window to see a branch of a well known coffee shop reassuringly static On the platform did my equilibrium return as my brain was able to make sense of the conflicting messages that had previously been passed to it.
And this got me thinking as we all relentlessly plunge into the daily routine, having and giving little time for reflection on even the most major issues that affect us in the longer term. The reason I was on the train in the first place was to attend a conference at The King's Fund on the implications of the election result on the NHS. Speakers from both the Fund and outside outlined their views on the times ahead - but in truth of course nobody knew anything for sure. There was a fair degree of consensus that the pledge to cut administration would be enforced somehow but, understandably, there was anxiety in the air in this management heavy audience. Many views on how to improve efficiency and the same for achieving quality in commissioning but surprisingly nothing about the proposed independent board. Much food for thought but little to aid the digestion, one might say.
And so I thought about my train analogy: perhaps we need to look in completely the opposite direction to achieve some clarity of thought. Rather than try and modify the system we currently have we should rethink it root and branch. The internal market, in place for nearly two decades, has not brought about the revolutionary change that was expected by the introduction of free market principles into a closed market. It should not feature as a part of our future. Rather, let us focus on the patient's journey along disease paths and fund these accordingly using well validated incidence and cost data and thus end the artificial division between primary and secondary care, surgeon and physician, acute and chronic care. Like it or not, the next generation of doctors and nurses will need to be well versed in the nuts and bolts of how the service is run and funded. This is not unique and applies in other countries so we should not be afraid of a slimmer, more accountable and transparent service that has patients at it's heart and healthcare workers as the drivers for change. Those who work within the service are best placed to advise on the way to change it for the better. This way we can achieve more agreement on what constitutes best practice and how to roll it out across the country. And the management infrastructure that has manifestly not succeeded in this to date can hence be drastically slimmed down.
If we miss this opportunity to revolutionize the way the NHS functions we may not have the chance again as then either the service will fail due to lack (or waste) of funding, or survive in some fiscally healthier future climate that allows this wastage to go unchecked again. We should not put ourselves in the position of seeing the train of opportunity leave without us being on it.
"The train now leaving ...." are not words we want to hear from the platform; rather we should seek to shout: "The old stations are behind us" as we travel down a new track.

Sunday, 6 June 2010

The past is a foreign country

My daughter came home from nursery a couple of weeks ago singing a new song that she had learnt that day. After the initial parental pride and pleasure at discovering that she had memorized it so quickly it made me think of the healthcare that she might expect in her dotage. The lyrics are worth repeating here - you will see why.

Miss Polly had a dolly that was sick, sick, sick
So she called for the doctor to come quick, quick, quick
The doctor came with his bag and his hat
And he knocked on the door with a rat-a-tat-tat.
He looked at the dolly and he shook his head
And he said "Miss Polly, put her straight to bed."
He wrote on a paper for a pill, pill, pill
"I'll be back in the morning - yes I will, will, will.

Doubtless you can already see where this is going. The utopian vision presented to the children here is of a rapid resonse personal service to the home - note the use of the definite article 'the' doctor: not any old doctor - her own family doctor. The traditional Victorian image of the frock coated physician persists as does the diminishing skill of clinical acumen - the ability to recognise sick patients is now no longer an assumed, not to say real part of the modern doctor that juniors are sent on compulsory courses to learn this vital art.
The part about treatment at home fits in well with the modern notions of healthcare so that is one area of which the old DoH doyens would approve but a paper prescription? Hardly the Connecting for Health ePrescribing on an electronic patient record, is it? As for the idea of continuity and follow up that is very rare these days. Shift patterns and the diminishing professionalism borne of clock-watching have seen to that.
So whilst we still wait to see what plans the coalition government has for our future and hope against hope that the top-down micromanagement goes with the legions of unnecessary administrators, I propose a modern version of the same song.

Miss Polly had a dolly that was sick, sick, sick
So she called the approved emergency number for out of hours consultations
A locum said: "Can you come to the local walk-in centre?"
Where he sat with his arms bare below the elbow and no tie.
He entered the dolly's vital signs into his computer and said:
"She doesn't fulfil the criteria for antibiotics so give her Calpol instead",
"I'll arrange for one of the nurses to ring you up in the morning to see if she is any better."

Not all change is progress.

Monday, 31 May 2010

Sense with Sensibilty

The departure of David Laws this weekend is more than a sadness for the coalition and a blow to the Treasury. As the man responsible for the cuts that we shall all have to endure the NHS looked to him to ensure equity and fairness. Acutely aware of the promise to increase real-time funding over the lifetime of this parliament we recognise the need to spend wisely what we have and the privileged position that we hold in public service life. Giving us this gift during a time of financial crisis requires delicate and sound judgement in the management of all other areas of the economy.
All the more important therefore that the man overseeing these spending rearrangements is of the very highest quality and seeing David Laws disappear into the political shadowlands in the precise opposite of what is necessary. The exposure of a claim that may or may not be at the limits of the definition of the word 'partner' coupled with the Daily Telegraph's shameful homophobia does not begin to justify this ousting.
The Red Dolphin therefore calls upon the British public to demand the reinstatement of the man 'put on this earth to sort out the economy' (and preferably simultaneously shun the DT). In this 'new politics' era where we, the populace, have a voice let us call as one for both national benefit and common sense.
Or in the modern tongue: #bringbacklaws.

Friday, 28 May 2010

It's the people, stupid

Well, the noises coming from the Department of Health are encouraging. Increases in real time NHS funding, cutting administrative waste, reducing manager numbers, devolving power to local levels to stop the top-down micromanagement culture so prevalent these past years. Not much detail has emerged yet to put the flesh on these ostensibly attractive bones but it is early days.
The potentially most exciting announcement is the creation of an independent NHS board outside political control. How exactly this might work will be the cause of much discussion, debate and disagreement in the weeks to come but the priciple is sound and has long been advocated by this author. The difficulties lie in ensuring non-political appointments, equitable distribution of power between it and government - an impotent board would be mere window dressing but an entirely unaccountable one would soon become corrupt - and above all, the sticky question of 'Who guards the guards?'. Many will be left unhappy at the end of this process but I believe it could be a large step in the right direction.
My hope is that the new board will have the power, foresight and gumption to tackle the very way that money flows through the NHS. The internal market, created in 1991, revamped in 2002 and seemingly beloved of both Labour and the Conservatives before them is inherently flawed. Applying free market business principles to an essentially closed market does not make sense. At no time was this better highlighted than Labour's disastrous attempt to introduce Independent Sector Treatment Centres (ISTCs) into the equation to generate competition with the NHS. As they cashed in on non-performance related start-up and subsequent payments, generous tariffs and the ability to cherry-pick the easiest, low risk cases with no responsibility for any ensuing complications the rest of the medical world gazed in wonder as to how this could possibly have ever been thought to be a good idea. Sure enough, the impact on quality was minimal, the effect on morale devastating and there is now good evidence, to take one area at random, that their introduction continues to jeopardise training as junior doctors see the 'easy' cases where they traditionally learnt their craft, vanish to the private sector.
But the biggest reason that the internal market failed is the human factor. In a truly free market organisations are free to choose the best people for the job and can replace them if they fail. Whilst this holds true for the medical and nursing staff of the NHS, it most manifestly does not for the managerial cadre as the best of them naturally gravitate to the private sector with its higher pay and bonuses and the choice for the public sector is akin to picking the wheezy fat boy for one's sports team at school when all the athletic types have already been chosen. Of course there are exceptions and there is a cohort of managers who both have talent and value service above personal gain but those with this laubable combination of skills and views are the distinct minority.
The new NHS must not just be a slimmed down version of today's but there must be a
sea-change in the approach to staff recruitment and retention. Even the name - 'Human Resources' - suggests a depersonalisation of the subject since the happier days of 'Medical Staffing'.
It is the people that make the organisation and the knowledge and skill-base that exists within the NHS is unparalleled and should be allowed far more freedom to provide the service. Management teams drawn far more from the ranks of clinical staff will be able to run a much more efficient service as they understand the issues rather better than a 'professional health service management trainee'. And they will know that the artifical constraints imposed by the internal market, the arbitrary division of primary and secondary care, makes no sense. Given this power to change I predict that the service will transform out of all recognition leaving the politicians little more to do than claim the credit for it.
But first they need to remember: it's not principally about the economy. It's the people, stupid.

Thursday, 20 May 2010

Opportunity Lost or Paradise Postponed?

The Coalition's much vaunted Programme for Government has arrived and the direction of our next five years is fixed. I suppose the rumours were always too good to be true. The idea that centrally imposed government targets would cease and that Strategic Health Authorities would be abolished clearly sounded good on paper but in the cold light of day did not survive the political process. What has been announced is certainly a change - much of it for good - but is diluted compared with the promised land.

The guarantee of real term increases in NHS spending is of course welcome but, if we have learnt one thing from the last 13 years, it is that spending without proper guidance is shackling. Cutting administration and quangos is also to be encouraged; giving frontline staff more control of their working environment sounds good but many of the statements are somewhat vague - some might say suitably vague at this early stage - and the devil may yet emerge with the details. But overall the document does provide some grounds for cheer and so one can only hope that it heralds bolder and more liberating reforms further down the line. Great oaks from little acorns grow.

I grow tired of hearing that 'the public voted for a coalition' as though the public is one large sentient being. Some people may have cast their vote in the hope of electing one or other party; others may have voted tacically to keep out their least favourite; others may have indeed voted in the hope that a hung parliament would result. We shall never know. But one thing is for certain and that is that we, the public, did not have a pre-election mass huddle to determine who would vote for whom and where. The result is a statistical one borne of millions of votes and, whilst the numbers may vary, is precisely what would happen if we adopt PR. Coalitions would be the norm. So the fact that this document represents much watering down and postponement of the tough decisions pending 'commissions' should not be too much of a surprise. If we reform our voting process it will be a template for future similar publications - every five years. Our duty for now is to try and make it work.

Therefore we should not lose heart entirely but remain optimistic about the intentions of our new coalition - or rather not the intentions but their (to use government's own term) ability to deliver. Bold moves inevitably lead to polarised responses from the media and public alike and in the current vacuum of political certainty that accompanies the first coalition since the war, no one can accurately predict which way the mood pendulum will swing. Better then to introduce measures piecemeal and buffer any negative reactions than to risk it all on the first hand. This is not a Miltonesque tour de force that was published today. But let us hope that it heralds a paradise to be regained.

Sunday, 16 May 2010

Lucky seven?

Over the past 13 years, six people have held the post of Secretary of State for Health - their tenures varying from 11 to 44 months. Now, with the new coalition, we see the seventh, Mr Lansley, with a chance for a fresh start and a chance to make radical reforms within this most important public service keeping service improvement rather than political gain as the ultimate goal. Will he grasp the opportunity? Indeed - can he grasp it? Many would argue that his hands are rather tied by the financial constraints within which we now all need to abide for the next few years but I would contest this and furthermore suggest that, as the old military adage has it: there are never problems, only opportunities.
So can I offer Mr Lansley some pointers as to how to turn the apparent checkmate position of years of over- and mis-management plus a financial crisis to his (and the nation's) advantage? Certainly.
1. The already announced cut in manager bonuses is good, but does not go far enough. There is no earthly reason for there to be bonuses in any public service at all. Fine in the private sector where profits are all driving (except where the profits are made by the gambling of our money, of course) but the ethos in the public sector should be so different and be aimed at service, not profit. As such, the last people one wants to attract into this sector are those who are driven principally by the desire for wealth. The argument that the highest quality people would then not join is not valid for two reasons: one is the security of pubic sector jobs (with their still relatively generous pension plans); the other is that the public sector accounts for such a large proportion of the UK workforce - 1 in 5 - that it is impossible for everyone to 'migrate out' into the the private equivalent.
2. Manager numbers have doubled in the last decade. The reason for many of these was to monitor centrally set government targets. Abolish the targets to allow local hospitals and GPs to create services best suited to their own region - and at one stroke one can radically reduce manager numbers. The tail should stop wagging the dog.
3. Abolish Strategic Health Authorities. Even now they are often referred to as "The Health" (as they have neither strategic vision nor wield any genuinely respected authority), these bodies are a bar to progress that add nothing to the health of the nation. Three quarters of what they spend is on education - itself an area where an entire cottage industry of needless courses has sprung up - and this could be both cut and locally administered. This limb of bureaucracy could be safely cut with few to mourn its passing.
4. Following on from the above point the need to have a certificate for every activity thus creating the industry of educators can be drastically pruned. From the inability of ward staff to make a patient some toast because they lack the 'proper training' to the annual online self-assessment health & safety and equality awareness training that is a waste of everyone's time, education should be overhauled to include only the valuable for knowledge consolidation and to encourage innovation.
5. Scrap Clinical Excellence Awards for consultants who do private practice. This outdated system is much abused and is simply another method of distributing bonuses - and these bonuses are annual and pensionable. Given the high salary differential already present within the NHS this would help even out the terrain.
6. Along with the abolition of SHAs there should be a severe slimming down of the National Programme for IT (NPfIT), responsibility for which has rested with the SHAs for over three years now without any significant progress having been made. It is a costly utopia that we cannot currently afford and the idea of an integrated electronic patient record is still a long way off. Whilst laudable as an ultimate goal it is not achievable in the current NHS where stand-alone IT systems rub shoulders with commercial off-the-shelf ones and the whole, on the frontline, is still very much underpinned by pen and paper.
7. Cancel the ISTC contracts as soon as possible. The Independent Sector Treatment Centres are a financial drain on the NHS and do not provide the competition that they were misguidedly introduced to do. The cherry-picking of 'low-risk, high-volumes' cases, the upfront guaranteed payments irrespective of performance and the lack of accountability in standards all driven purely by the need to make a profit is hardly a recipe for healthcare success.

£6 billion pounds in cuts in the first year? Mr Lansley could do it all alone. Lucky number seven.

Tuesday, 11 May 2010

A new dawn?

Man, as John Le Carre famously wrote in his novel The Russia House, is not equal to his rhetoric. Let us hope that this is not true as we embark upon a new era of politics and, with it, healthcare policy. The last 13 years have been morale-sappingly bad for the NHS - any new funding notwithstanding - and the two opposition parties, now wedded in coalition, have consistently damned the architects of this demise with strong words and lengthy speeches. But it is one thing to oppose, quite another to dismantle. Just like the higher earners who watched their tax-free allowance silently vanish in the last Budget and who will doubtless not see it reappear even though the measure was opposed by Her Majesty's then Opposition, so we now wonder whether the new administration has the courage, energy and drive to dismantle the rotten, creaking structure of the Health Service and replace it with a slimmer, healthier organism.
Not just the culture of targets and the cottage industry of clipboard carriers that surrounds it; not just the glut of managers with little to do and even less idea of what they are supposed to be running; not the plethora of needless quangos that wield disproportionate power over situations their members are not qualified to understand - and in these I include the Strategic Health Authorities that act only as non-visionary bars to progress and should be closed forthwith; not even just the appalling culture of 'counting hours' that has reduced the profession to clocking in and out of an ever more monitored workplace. No - even the utterly wasteful internal market itself, the mechanism that sets doctor against doctor, speciality against speciality and wastes the money that we are told is so very precious right now: a new way to govern the NHS must be found, perhaps even one that puts it, in part, outside the whims of the government of the day. Health, unlike government now, is not a fixed term event and should not be solely run by those who are shackled by this constraint.
Mr Lansley has apparently secured himself a Cabinet post within the new coalition. Let us hope that he and his colleagues in the Department of Health - itself in need of a reform diet - can live up to the many election promises of the two parties (and go further) to treat this once bejeweled public service to the lifestyle change it so desperately needs.

Sunday, 9 May 2010

The curious incident of the word in the weekend

So 48 hours into the trading and bargaining that will eventually result in our new government there is a word that has, to my intense dismay, not even been mentioned. Health.
What plans do our political masters have for the service? It seems that it is but a secondary issue. Never mind that it is the country's largest employer with 1.3 million people, nor that the waste within it would in these financially constrained times account for massive savings if properly managed, nor even that access to it it is a key measure of social equality. The talk is of economic cuts (watch out there!), divisions over Europe and voting reform as the main areas of dispute between the parties. The current crippling bureaucracy of targets and stifling paperwork, quangos and internal market financial squabbling will remain untouched to eat away at the morale and quality of a service that should be the best in the world in both ideals and quality. Granted, the two parties currently in discussion have not too dissimilar views on making administrative cuts but the magnificent over-riding pledge to abolish Strategic Health Authorities - those costly, non-visionary, paper-pushing, interfering nuisances - belongs to only one. Without swathing cuts like that the rest will be mere window dressing and so the outcomes of these negotiations is crucial to our immediate future within the NHS.
"Do a deal with Nick", should be the mantra in Whitehall. And not to form a Coalition of Losers either. Will it happen? Maybe.
But chin up though. At the current rate we'll be voting again in the autumn.

Thursday, 6 May 2010

They think it's all over - it's not

So it looks like a hung parliament. Vote something, get... what exactly? No one really knows. The current options are a minority government, a coalition between the Tories and the LibDems or some regional parties or, unbelievably still, a Labour plus something alliance. (Surely this last cannot happen: how much of a 'no' does it take for these people to hear? If they had a shred of decency then they - ah... I've answered my own question).
The losers could include the NHS. Little will change if all the energies are directed at shoring up power and fighting for each and every vote for every debate. Targets misguidedly set by Labour would then be here for some time yet as there would be no one to wash them away. Health service funding would fall in real terms and natural wastage will be the surrogate for job cuts. Services might slim down a little but essentially they would reduce. Unless a strong government is formed to mitigate this potential disaster.
A hung parliament. Health service rationing. Get used to it now. Would electoral reform help? Again, no one knows but we might have a chance to find out rather sooner then 2015 as the uneasy alliances fragment. What should today's political slogan be? For the sake of the health of the nation: "Do a deal with Nick".

Monday, 19 April 2010

You couldn't make it up

As if the tale of the bizarre 'them and us' way that health service funding is run could not get any more convoluted and bureaucratized there is another player on the block. This week we were told that the result of the annual negotiations that are held between Primary and Secondary Care Trusts to thrash out how much the former will pay the latter for work done above and beyond the contract had a new result. Usually the sum arrived at is somewhere between the true figure of over-performance and zero and both parties retreat, grumbling, into their respective corners to work out an equally inaccurate contract for the next year.
This year however the leviathan that is the Strategic Health Authority - a body whose function is to set the overall plan for the way in which health services are run within the region - stepped in and fined each party a million pounds.
Yes - you did read that correctly. Each Trust, instead of either earning money for work done or paying for services received, did neither and had to pay this huge sum to an unelected third party where it will be frittered away on more needless administration. The result of course is that both Trusts now have even less to spend on healthcare and for the first time in my career I have heard the word 'rationing' as applied to the NHS. Not the very expensive cancer drugs or the post-code lottery of access that occasionally pops up in the news but real, sweeping rationing where 'need' and 'want' are distinguished and patients may have to pay for non-essential services: the example given to us was varicose vein surgery - as this can be thought of as cosmetic.
And here, during an election campaign, the government is not going to want this to come out for general debate - however wrong it might seem.
Strap in, folks: the US passes a healthcare reform bill to, at long last, start giving its people some decent healthcare; we however are dismantling and killing our system. Start saving now for this will only get worse.

Wednesday, 7 April 2010

Five a day? Try ten.

So eating five portions of fruit and vegetables a day only reduces your risk of cancer by 2.5%. Not worth doing then, clearly, as our no effort, instant gratification society will see this as reason to eat even fewer a day.

In truth the reduction is less than expected because five a day is not even close to what we were atavistically designed to eat in the centuries before the high fat, shrink wrapped, sterile, tasteless convenience garbage that passes for food all too often these days. Ten a day might come closer but even this needs to be seen as a part of a wholesale dietary change rather than the current perception that eating these portions as well as the usual junk will suffice.

But when we are still at a stage where supposedly intelligent newsreaders ask what exactly a portion is then we still have a long way to travel. Our ancestors on the forest floor knew a thing or two.

Tuesday, 6 April 2010

And they're off

So the phoney war is over and we are now due to endure four weeks of wall-to-wall unverifiable promises by the men in grey, who appear every four or five years to pretend that they understand and care what really goes on outside Westminster.
The health service should of course be a central pawn in this battle and numerous suits will promise that 'the NHS is safe with us'.
In reality none will dare to meddle too much with this jewel in the British crown but will nevertheless be unable to resist detrimental fiddling when the winner(s) is/are announced. But they will all ignore the elephant in the room - or perhaps they are genuinely so wrapped up in their own inflated rhetoric that they actually do not know. The service is managed and bureaucratised to distraction and the doubling of the number of managers over the last ten years appears not to have been noticed by those who seek cuts. Regulation has stifled innovation and progress and the army that drives this inertia-creating industry will be in no danger from the eventual winners.
And there lies the lost opportunity for vast savings and increases in efficiency and morale that cutting a swathe through these pen-pushers would create.
So vote for change, fairness, both or neither. It all adds up to more grey.

Friday, 19 March 2010

Told you so

"So how do we save money in this Alice in Wonderland pseudo-economy?" And answer came there none.
"Do more work; see more patients?" Er, no.
"See fewer patients?" No.
"See different patients by changing efficiencies?" Still no.
"Do work for free?" Sorry - still won't work.
All because the organisation that 'buys' from us doesn't have the money to pay the bills for what we do. So it doesn't. But it still expects the same level of work to be done and of course it will be done as no sane doctor will turn away a sick patient.
And there you have the internal market in an unpalatable, zany nutshell. Business principles in the ultimate non-business environment.

I was talking to my mother-in-law the other evening and she was reminiscing about the birth of her daughter, my wife, as parents tend to do on the occasion of their offspring's birthdays. She fondly remembered being in a large single room for a week - yes you read that right: a week - after the delivery, being pampered by the nurses and able to recover in peace. These days, after an uncomplicated delivery she would be sent home inside eight hours. Of course we no longer have the resources to do the former but it does not necessarily make the latter better.
Not everything that can be counted counts. And not everything that counts can be counted. Information is not knowledge.

Monday, 8 March 2010

Here comes the rain....

So after months of dyspeptic rumblings the machine that is the NHS is now due to vomit forth its response to the global economic recession. Healthcare spending will remain static so in real terms it will fall and something needs to give. Because of the ludicrous system of 'them and us' for primary and secondary care described below hospital Trusts are victim to not being paid or work already done and work still to come. One cannot turn a sick patient away from the door (not in this country anyway) so this situation will continue. Regardless of the amount of work commissioned the actual amount done will inevitably exceed it and, in contrast to virtually any other business model, the more we do the more we lose. Crazy?
Never mind that by cutting a swathe through the countless layers of ineffective middle management saving huge sums and improving efficiency. Never mind that the sums involved bear no resemblance to the market price for services in the private sector anyway. Never mind that cuts now will not only not help the current situation but bear grave dividends in the future. No - my major gripe is that when we meet with the bean counters next week to try and thrash out a plan their only agenda will be to cut salaries, lay off clinical staff and close wards.
I shall ask them only one question: "How do we save money in this Alice in Wonderland economy?" And you know what: they won't have a clue because they have no idea what is being counted anyway.

Monday, 22 February 2010

You get what you pay for

Time was, not everything was counted, catalogued and ticked. In the era before management consultancy and targets professionals were left to run their profession with minimal meddling. After all, they did know the most about it. And it worked well. A few bad apples made the headlines and the stifling, corporate, faceless culture moved in to transform a once beautiful vocation into a parcel of 'Programmed Activities'. And there is unlikely to be a way back.
Seven years ago the New Contract was introduced/imposed (delete as per personal view) on the hospital consultant body. Initially representing a basic pay rise along with the threat of no pay advancement for those that did not sign up, it was embraced by the majority. But now those carefully monitored and counted chickens are coming to roost. The working week was painstakingly divided into fractions with each Programmed Activity representing fours hours a week of work. There was initial managerial surprise at the amount of previously unpaid work that went on but after the usual acrimonious 'smoke and mirror' accounting (see below) the answer was usually 'ten'. Some managed eleven or twelve but the allocating depended more on negotiating capabilities than real work done.
Now, with the recession in full swing, there is a desire to cut these 'PAs'. But the expectation is that the previously done work will remain. In days gone by the consultant body would have tightened their belts and weighed in with a collective effort in the interests of professionalism but now, the goodwill having been long since eroded, there is the liklihood that it will take the attitude that - as with any other paid job - if one pays less one gets less work back from the employee. And services will suffer.
That's what comes from having one's cake and eating it. Ultimately they will regret destroying what had been and some lessons are hard to learn but necessary.
Oh woe, my beautiful profession.

Wednesday, 17 February 2010

Smoke and mirrors

I previously expressed the idea that the finances of the NHS, whilst obviously originating from a central government source, are then split, divided, hidden and generally massaged to distraction leaving no semblance of reason in the resultant mire.
Take this example - not at all unusual I'm sad to say. Consider a business case is written within a particular speciality for four new specialist services - A, B, C and D. All are proven technologies, some newer, some not so new but the team is agreed that to further the department these are essential steps. They collaborate to make the case to the Board to but into these advances. Technology A is a real money-spinner and would, within two years, not only pay for itself but also for the initially otherwise loss-making B, C and D (provided that the Primary Care Trust can fund it - see 'Divide and Conquer' below). The sums work out. The document gets passed through the legions of paper-pushers that inhabit the halls of administration but eventually the answer comes back: 'yes'.
So far so good. Arrangements are made to part-fund technology B from charitable sources and this is forthcoming. B, C and D all start up as they are more easily acquired and the services start later that year. There is small delay with Technology A as competitor quotes are evaluated but soon a decision is reached and the clinicians are happy and keen to proceed.
But, but, but.
Suddenly the message percolates down from on high that the purchasing of this Technology A must wait until the new financial year as there is not enough money to invest in this during the current financial year. Meanwhile B, C, and D carry on regardless - providing a service but allegedly losing money. Money that was to have been covered by the income generated by A...
Could any private sector company run its business like this? Of course not. And there one sees the problem of an internal private market within a state funded system.
These are just numbers on someone's irrelevant spreadsheet but they carry more weight than clinical concerns.
If only it was as simple as looking through smoke and mirrors. Sadly it is the highest imaginable degree of obfuscation, the running of which costs as much as the service that it purports to underpin.
I would weep were I not so angry.

Monday, 15 February 2010

So what's in a name?

It has bothered me for a long while now - so long that I cannot remember exactly when the 'Personnel' department became 'Human Resources'.
Just stop and think about it for a moment. Human resources. How cold is that? But a very accurate reflection of how the system is designed to treat the employees. There is very little compassion to be gleaned out of those two words and it is not a coincidence that over these last years staffgeneral disgruntlement is on the up.
Doubtless a legion of management consultants was drafted in to think up this title - and paid handsomely - but ask yourself whether you would go to a store that was billed as an 'Essential Nutrient Vendor' or see a film called 'Mobile Images and Sound'. And if you were working in that store or making that film how long before you became disenchanted with your core business and gave off less than your best?
I'm betting not so long.

Snail mail? Fail mail

Although it is a large organisation and everyone is aspiring towards a paperless office the reality is that much paper correspondence still goes on these days. From GP referral letters to clinical queries to cheques that are sent in as payment for one thing or another. It is this latter that has been occupying me this last week although the frequent going astray of post relating to important clinical issues is arguably more important and certainly can have more of a serious consequence for the patient - as always unwittingly caught up in this calamity.
Whilst no paper system is perfect (well, no system of any sort is perfect but that's another matter) the error rate of post going astray is extraordinary. No private sector organisation would tolerate it - it could not sustain such a poor public image. Here, in the shielded environment of the state sector, the onus appears to be on the recipient to ensure his mail arrives and the slovenly internal mail system trundles along in its own inimitable, blundering way with no ability for retribution.
It is one of those instances that makes for, on the face of it, a powerful argument for private sector solutions and in this instance - an entirely non-clinical service - that might be the better solution. But the mistake is to try and recreate that solution across the board. The filthy lucre mars good medical practice - look States-side for proof, if you doubt this. Look at our own Independent Sector Treatment Centres.
The genius of the inception of the NHS in 1948 was to remove the two systems (the money and the care) from each other to the benfit of each side. Now the gap is shrinking to the detriment of both although the politicians try to make us believe that this is all 'progress'.
A system of checks ('performance management' is, I think the jargon) is of course necessary but this depends on good motivation. The simpler the system the more likely it is to work and sadly the middle management that runs thie infra-structure is bloated, out-of-touch and ineffctive. 'Performance management' does not seem to apply to them. Their number has doubled in the last decade yet their output has become more and more impotent.
Were the clinical staff to run the various services that underpin the smooth running of the organisation there would be no room for the slovenliness that loses post as regularly as happens now. It is because they are motivated by a vocation. There is no vocation for management.
'Delivering' services, targets and deadlines are a part of the management-speak culture that pervades the country. That the only things that can really be delivered are the post and the milk does not cross their buzz-word polluted minds. Doubtless there lie in a drawer somewhere voluminous files on the departmental structure of the mailroom and flow-charts outlining the 'process'. Employee appraisals may well figure in this file too and probably countless standing orders and records of staff updates.
But can they deliver my mail? Can they hell.

Wednesday, 10 February 2010

Open letter to the President

Dear Mr Obama,

I've been following your efforts to introduce healthcare legislation into the United States with interest. It is of course high time for an aspiring first world country to have this but I realise that several of your predecessors have tried and failed. I wish you better luck.
Being fortunate enough to live in a country where the ABC of resuscitation is not 'American Express, Barclaycard, Chargecard' you may suppose that I am about to be smug. Not at all. Indeed it is precisely because I am a cog for the third largest employer in the world that I know the system's strengths and flaws. I can appreciate how incredible is this National Health Service of ours but also I can see its shortcomings and write to urge you, if successful in your initial efforts, not to make these mistakes on your side of the pond.
Currently healthcare in your country is a huge business like any other private sector venture. The sea-change that you have to make is that a state sector service no longer follows the same business principles and that the more it tries to do so the more ineffectual it becomes. Let your traditional managers run the show and you will probably be worse off than now for not only will the system fail but it will not provide the niches of excellence that you currently do have.
Here is an area where all the key personnel by definition have started on the shop floor and worked their way up. Consultants (attending physicians to you) and senior nursing staff were not born, but made. These people know more about the nuts and bolts of what is required than any health service manager fresh from grad school.
Whilst you will of course need some checks and balances to ensure equity and fair play, please try and keep the system structure simple. The more convoluted layers of management and regulation you put in place the more clogged the whole becomes.
And don't, whatever you do, try and recreate a mini-economy within your health service: the internal market is a distraction and a failure here with no easy way out.
For both good and bad: look over here and watch, and learn.
Best of luck!
Yours sincerely.

Tuesday, 9 February 2010

Still dividing, still ruling

An operating list, nominally for one type of procedure but staffed nonetheless each week. No reason why a very similar procedure should not occasionally take place on this list as well to the benefit of patients. No reason at all. Is there?
And so it goes. The divisions that set primary care against secondary care both in terms of vying for intellectual supremacy and for funding is mirrored in microcosm in the tensions within and between individual teams. Scant resources are jealously guarded - not for the benefit of the hapless patient but to boost the egos of the self-appointed movers and shakers within the management structure.
Whilst charity might begin at home it certainly does not make it across the threshold of the hospital. Internal politics dictate that the alpha males must cry loudest when their own pet projects are threatened. Facts are twisted and statistics hastily invented to justify unsanctioned changes in policy.
All of which sounds like a normal day at the office - until one remembers that this is the state sector. No real money changes hands here. The figures are on an internal spreadsheet. There is no profit. There are no private sector bonuses or forfeits. The ideal stated that these petty differences should not operate here. But Man is a weak creature and seeks power all too often. Never mind the patient.

Friday, 5 February 2010

Man is not equal to his rhetoric

There's a line towards the end of the movie 'Die Hard 4.0' of which I was forcibly reminded today. In the film, Bruce Willis and a nervous young sidekick have entered the building where all the bad guys are - also holding his daughter hostage.
"What's the plan?" asks the junior.
"Save Lucy and kill everyone else," comes the instant reply.
"Sure, yes - but any idea how?"
No reply.

That's healthcare management in a nutshell. A missive this morning reminded us all of how the recession will hit healthcare spending. Fair enough - an important issue. But then follwed a list of approaches to coping with this lack of funding growth. Phrases like "Maximising our assets", "Integrating patient care" and "Leaner investments" were amongst the more inscrutable. But there was not a glimmer of a hint as to how this should be done.
Most clinicians are not particularly resistant to change - often they initiate it. However, the cumbersome, clunky, bloated administrative structure that currently underpins the NHS makes change well nigh impossible when not driven by a higher government target. As clinical staff are outnumbered by over two to one by the management and have less and less control over their destiny, I am not optimistic for rapid and effective change here.

Monday, 1 February 2010

The 'Hot-Air-ometer' is set on 'High'

The verbal diarrhoea that eminates from the corridors of management is sometimes simply astounding. Just this week we have been informed over the organisation's e-mail updates that someone 'only' achieved 97.3% of their target and that that 'listening clinics' have been set up. I also cringe when I hear of the poor souls who frequent this place being referred to as 'customers'. They are not here by choice.

Targets are the unrealistic and non-clinically driven attempts by people far removed from the coalface to assess what we do. Usually they create a cottage industry of other people measuring those targets and a raft of new measures to help a department achieve them. None of which ever helps the patient. Usually these arbitrary figures look at a single parameter without taking into account the multiple factors that govern them. The result of these targets can be clinically damaging. Consider a patient being moved out of the Emergency Department at the 3:59 hour cut-off to avoid 'failing the 4-hour wait' target. If the only bed available for them is on a ward of an entirely different speciality then that is where the patient will go. No matter if an appropriate bed is scheduled to become available in half and hour. Or even ten minutes. How can this help patient care?

And what on earth is a 'listening clinic'? What do we do all day in the outpatient department and in the surgeries if not listen? But no - this is a great buzz phrase that will generate managerial slaps on the back all round. The mandarins love it.

An organisation that truly succeeds is one where the bosses had to work their way through the shop floor and so know every twist and turn, not one that can boast more MBAs in the upper echelons. This used to be the case for the NHS as senior doctors and nurses would manage the majority of what went on and, by definition, they came from the grass roots. These days the corridors of administration are peopled with business graduates and youths who have been trained in nothing other than 'Healthcare Management' with consequently no understanding of what it is they are supposed to be running.

There are sad times. The only solution is to take the NHS out of direct government control but that of course opens a whole new can of worms as to accountability. More of that soon.

Thursday, 28 January 2010

Divide and conquer

When it comes down to it this is the part about the way the NHS is run that irritates me the most. The idea that dividing primary (GP) from secondary (hospital) care is remotely useful. It created an 'us and them' mentality with the two factions warring over spending - and using up vital funds in the process. As if the poor patient wanting treatment gives a moment's thought to which particular link in the chain is paying for something. The internal market was and remains a disaster for patient care.
Worse, the energies (considerable) wasted in inventing methods of cost cutting with respect to the other party are enormous and could so much better be spent on actual work.
The latest incarnation of this crazy system is CQUIN- or Commissioning for Quality and Innovation - a Department of Health initiative (if that is the word) to force a certain standard out of hospitals before their services can be bought. That in itself seems all well and good but the realities of the process involve countless man-hours of paperwork collecting meaningless data that is then interpreted by those who cannot possibly understand it and on this the decisions are made.
During the last decade the number of NHS managers has doubled but the number of frontline staff has risen by only 30%. When you go to your local hospital you are more likely to bump into a manager than a clinician.
Is this 'rage against the machine'? Well, yes and no. It is rage at the fact that a system that is in many parts so utterly wonderful, an idea so envied but never reproduced around the world, so altruistic in its conception can be degraded into a political football.
About the number of Americans as there are people in Britain have no health insurance and they would kill for what we have. As it is they are more likely to die for what they have. And yet we treat our national treasure as a management consultancy training exercise.

Wednesday, 27 January 2010

What is Red Dolphin all about?

It is altruistic, voluntary and aims to inject some simplicity into the increasingly complex world of modern medicine. It's aim is to raise awareness of one of the largest health issue facing us in the coming years: namely heartburn and the dismal potential consequence of oesophageal cancer.
Written by a 'serving officer' in the army of healthcare who is well aware of both the advantages and the shortcomings of the system the aim is also to provide insightful commentary into the issues of the day. No punches are pulled.

Want to know more?

Visit our homepage to find out.

The Pride of Britain

It seems that some people cannot recognise a good thing when it stares them in the face. I speak of course about the current denigration of the NHS by the Republican right over the pond in our erstwhile colony. When in 1948 the service was created it represented the single most humane and important development of government activity since the abolition of slavery and it has come on in leaps and bounds since then.

In any vast organisation employing over a million people (it is the world's third largest employer) one will find stories of things that went wrong but these are dwarfed by its successes. The vitriol directed at it from it opponents is borne out of fear of losing lucrative contracts rather than from any shred of sustained truth.