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".