The Point of Care?

The NHS has been in the news again with a stinging attack by the Health Service Ombudsman on the quality of care given to the elderly. However, this thinly veiled invective is based on only 10 cases (taken from 226 accepted for investigation). Ten cases, whilst each and every one deplorable, is not a sign of institutional failure in an organisation that employs 1.3m people. These are the 'bad apples' and the full weight of professional and federal law should be brought to bear on any involved in such neglect but it is the tiny minority. To tar the whole of the NHS with this brush is pure sensationalism and headline chasing.

That is not to say that standards have not slipped over the last 20 years with more emphasis on the pseudo-intellectualisation of nursing and the continued attempts to demean medicine from a profession to a job of work. The King's Fund's answer to this problem is to promote their "Point of Care" programme - designed to enable health professionals to reconnect with their patients despite the stresses of the modern workplace. Key amongst the initiatives is something called "Intentional rounding' (am I the only one who weeps in despair when he hears such meaningless patter?). Apparently this encourages nurses to go round the wards and visit their patients before they are called to help with something. This just used to be called 'nursing'. The very fact that a programme exists to encourage nurses to visit patients before they buzz for help is an indictment of their current training, not to say attitude.

Bad apples aside, most mistakes and cases of poor practice in the NHS are due to either laziness or the failure to carry out usually simple instructions. This in turn is a function of the deprofessionalisation of medicine and nursing caused by a loss of the values of the past in favour of the shallow ideals of today. To change this around requires a wholesale change in the education of student doctors and nurses from ground level up and a strong, respected leadership for them to aspire to. This cannot happen overnight an certainly requires more than an effete soundbite of a programme that amounts to an apologist for the lack of basic principles.

What would the AV mean for your health?

There has been much debate this week about the Alternate Vote system for future General Elections. The government will have a referendum on the matter where we all have our say. I do not wish to rehearse all the arguments for and against - these have been covered endlessly elsewhere - but simply to ask: "What effect, if any, would the introduction of AV have on our Health Service?"

Let us first consider the most basic fact. What would have happened to the make-up of parliament last May had alternate systems of voting been used? The above graph shows you the situation in all five of the proposed methods. A Coalition or minority government in each case with the Liberal Democrats (with possibly groups of minority/extremist parties in the case of full PR) as permanent kingmakers. Is this a good thing? Other European countries function perfectly well with successive coalitions and their health services have not necessarily suffered. The UK is however, in many respects, not Europe. Like it or not, policies that have encouraged us to emulate the Continent have not always worked - think 24-hour drinking/cafe culture.

Would the NHS, by then possibly with an independent NHS Board ostensibly outside direct political control, be much affected by changes in a government that had to accommodate more than one view? It is possible that future administrations might want to reverse this autonomy although it would be risky politically, given the degree of distrust that the public has for politicians tinkering with the service after the clumsy, shackling central target culture that characterised the Blair/Brown years. It is possible that future, more right wing governments might want to cut funding in favour of more involvement of the private sector (the seeds of this are starting right now). Having a centre-left balance might therefore not be a bad thing.

But overall, the NHS at 63 years of age, has a central place in the heart of the nation who will therefore not tolerate its dismantling and politicians do it at their peril. There will always be stories of mishaps - disasters even - as there will be in any health service in the world but underneath we know that we have it good. So good. As many people as live on these islands enjoying largely free and comprehensive healthcare remain uninsured in the USA.

So whilst the political landscape may change in other respects the NHS will remain relatively immune to changes in the voting system. So in the referendum, vote whichever way your conscience tells you. You'll still have a health service, free at the point of care.

Paul helps set up a new service

Despite the rumblings of discontent that the new methods of administration had brought, work continued apace. The Ferraris were driven out to executives for the weekend; the removals vans could barely keep up with demand; the estate cars towed caravans until their drivers nearly broke down with exhaustion; the bulldozer cleared the way for everyone to go to work each day.

Despite all this the drivers continued to think up new ways of improving the business. It was quite clear that demand for the caravan-towing arm of the operation was mushrooming and the current quota of drivers and vehicles could not really cope. They knew of a colleague who was just finishing a short-term contract with a rival company nearby and they wondered whether he could be persuaded to join them and help increase their capacity. They took the proposal to Paul.

Much to their surprise Paul was in favour of the idea and approved it without much hesitation. He authorized the new post. As to the work that he was to do, he merely had said: "Just get it up and running through the usual channels."

That was two months ago. Setting up this additional activity had not been as easy as they had initially hoped. Paul's 'usual channels' - ones he had created alongside all the other new initiatives - were not entirely straightforward. After the visit to his office the drivers had gone to see the Vehicle Bookings Clerk to arrange for bookings for the new driver to start. She was keen to help but explained that she needed to run the idea past her supervisor, who was away that week.

When this lady returned, she seemed quite amenable to the scheme but felt that it still needed approval form the Vehicle Bookings Manager. This person only worked on Thursdays and Fridays and no one could deputize for her but the Bookings Supervisor thought that time would not be wasted as she could "run the idea past the Section Service Transformation Lead".

This young man, Norbert, in turn thought long and hard about the plan and asked whether executive agreement had been sought for the post of the new driver. The other drivers were by now becoming a touch exasperated and replied that they would hardly be trying to set up more bookings if they hadn't secured this rather obvious first step to start with. Norbert thought he had better check with his Section Operations Manager, who in turn asked Paul. Paul remembered that he had acquiesced and sent a message to the head of the 'General Performance - Car Concern' group to chivvy things along as he was noticing the increase in delays from booking to delivery of the cars and this had led to some heated discussions with the head of the Sedan and Hatchback Agency.

When the Vehicle Bookings Manager returned she saw this correspondence and acted quickly. First she enquired whether this was an new service they were offering or the extension of an old one.

"For heavens sake, Mabel!" chorused the drivers. "You know it is the extension of the caravan-towing service. You come and pester us to take more of these bookings on almost every week because there are so many! Now can you please just set up the booking facility?"

"You need a code," objected Mabel tartly.

"And how do we get one of those?"

"You need to fill out this form," she replied triumphantly, handing over a thick wad of papers.

And so the drivers sat down to fill out the form, answering questions that had been sorted out at the very start of this process but trying nonetheless to keep their patience. Proudly they gave the completed result to Mabel later that day.

"Can you get a code now and start booking?" they asked hopefully.

"Codes are issued by the Vehicle Bookings Manager," she replied. "She's on a Communications Course but will be back next week."

And Paul looked on from his office on the top floor, and smiled, and felt a deep wave of satisfaction wash over him as he regarded his kingdom, where everything was proceeding like clockwork.


If you think this tale is far fetched, just try setting up a clinic for a new colleague in today's NHS.

Paul makes sense of economics

It was a fine summer's day. Paul sat by the open window and gazed at the activity outside. Presently he heard two of his workers - one driver and one of the fuel pump attendants - in conversation.
"Hey, Billy!" called the driver. "Can you give me a hand with this roof-rack. I need to remove it from the car before the next trip and it's a bit stuck."
"Sure thing Jack," replied Billy. And they set to work.
Paul was incensed.
How was Billy going to account for this time. He was not working on his designated tasks - he would doubtless be late for something. And Jack - he was being paid for work not all of which he would have done himself. It made him seethe with anger.
He got to work with pen and paper and by the evening he had come up with a plan. The very next day he called all the workers together for a meeting.

"It has come to my attention that tasks within the company are being performed by random personnel," he began. The drivers and washers and pump attendants and all the other workers looked nonplussed.
"Work is being performed by personnel outside of their usual occupation, which will have downstream knock-on effects on productivity."

The staff looked mystified.

"To combat this I am from today introducing a new system whereby individual groups can both sell their services to other groups and purchase others within the company. The drivers' grouping will be known as the 'General Performance - Car Concern'; the fuel pump attendants and washers will form the 'Forward Taskings' group; the management in this building who oversee and regulate all the work will be known as the 'Sedan and Hatchback Agency'. All will have budgets for which they will be accountable and from which they need to purchase services from other groups. They may of course attempt to turn a profit - either by also offering their services elsewhere, or by looking for services that are cheaper outside and thus saving money. This degree of competition will, I am sure, drive up the quality of what we do."

The staff looked mystified.

"How on earth is that going to make us more efficient, Paul?" they asked. "For a start it'll take half our day just to manage all this new paperwork."

"Ah!" countered Paul, pleased that he had an answer to this. "We will employ new people to do this for you. The 'Profitable Car Traders' will work with you to achieve maximum profits."

"Surely this just adds to the expense, Paul? These extra layers of bureaucracy won't make us work any better."

"Oh, I think they will." smiled Paul knowingly. "Once you have your individual budgets to safeguard you will understand the meaning of efficient, cost-effective and accountable work. Competition with the outside world is no bad thing."

"Maybe not," argued the workers. "But we have fuel pumps and washers here on site. Why would we go anywhere else? For a start it would take us miles out of our way and so increase the time spent on a job."

"Other companies can now tender for providing these services more cheaply. Once you see you are saving money you'll change your minds."

The staff looked mystified. "Saving what money, Paul? This all comes from the over-arching budget of the company. There's no real money behind this initiative - only numbers on a spreadsheet, accounted for in a different way."

"Wait and see," said Paul, and got up and left.

And so the drivers and washers and fuel-pump attendants all convened into their nominated groups and started to buy and sell services to each other, though did not notice much difference in the way they worked, other than there was a lot more paperwork.

The Profitable Car Traders closely monitored the number of interactions between the General Performance - Car Concern and the Forward Taskings groups and the Sedan and Hatchback Agency set targets for the maximum allowable number of these interactions. At the end of the year there was very little change in the number of journeys the drivers had undertaken or the way in which the company was perceived by the outside world but there was a large amount of data on how this had come about.

And the drivers noticed that as attentions were now so focussed on the flurry of paperwork that pervaded the buildings no one really gave much thought to the customers anymore.

Big Society? No - Big Responsibility

Well, it never really looked like living, did it? The last week has witnessed several pre-terminal gasps from Mr Cameron's Big Idea. Charities leaders are lambasting the public sector cuts that are severing the lifeline that should have fed the initiative and a flagship council withdraws from the programme citing, again, cuts.
The fundamental flaw with the Prime Minister's idea is that although the British public are by and large very keen and able volunteers there is a vast difference between helping to run something and running it. This he has failed to grasp. The financial, legal and moral implications of taking on ultimate responsibility for an enterprise, be it library, school or local swimming pool, is a world away from donating even large amounts of time to it. And so it is that the Big Society will die a rapid death, unmourned by most, leaving the Coalition's flagship ideological legacy in tatters.
What implications this will have for the Health Service remains to be seen. Whilst I am sure that not even in his wildest dreams did Mr Cameron envisage local people clubbing together to run a 'failing' hospital (I am crossing my fingers here) there may yet be knock-on effects with respect to GP commissioning. This other half-misguided policy leaves GPs holding much of the NHS budget to purchase care for the patients (purchasing care, you will notice, that is also given by themselves). Who gets a, for example, physiotherapy contract is no longer a given but groups could tender bids just as in the world of business. Whilst clearly these sort of bids are outside the general level of Big Society thinking it is not hard to shift the ideology up a level and expect suitably qualified groups of independent specialists in this field or that to make bids for fragments of contracts for a myriad of services.
The more fragmentation that goes on, the less smooth the patient's journey from one medical staging post to the next. Those with chronic diseases will be proportionally more affected as they need more 'fragments' of care.
The death of the Big Society, its own highly suitable acronym, might help limit the amount of this breaking up of our national treasure that can go on. Perhaps there is after all a silver lining.

Red Dolphin's response to the Health Reforms (2): Quis custodiet ipsos custodes?

The idea of de-politicising the NHS if of course attractive. Removing it from the short-termism of the past, with politicians creating sub-5-year milestones that enable them to massage the data into their re-electability is clearly not a sensible way to form strategy for a country's health service, where the term of a parliament is but the blink of an eye. Under the new reforms Monitor, the independent Foundation Trust regulator, will be given far more powers. It behoves us therefore to scrutinize this body closely and ask: is it able to perform this extraordinarily delicate and vital task, and also - who guards the guards?
Remember that this watchdog had the responsibility to ensure that all Trusts are able to stand firmly on their own financial feet but under the new Bill it receives a far wider mandate to include licensing providers, price setting, promoting competition and supporting service continuity. This is from it's own website.
But wait one moment. 'Promoting competition' and 'supporting service continuity'? Is it just me or is that a contradiction in terms. Let us just imagine for a moment...
Let us say that a hospital is offering a diagnostic service that is an integral part of a pathway for patients with a variety of conditions. The result is fed into the body of knowledge that is accumulating on the patient and reviewed in a specialist clinic or multi-disciplinary team meeting. Now consider that a private consortium - hospital, independent diagnostic centre or consortium of private providers - offers to undercut the tariff that the hospital charges for this test and wins a contract to perform a fixed number of these per year. However, being outside the organisation the results are not so easily available; they may not find their way to the patient record in time, or at all. The patient's treatment is delayed; the test might even need to be repeated. A pessimistic scenario? Not at all: a regular occurrence since the introduction of the Independent Sector Treatment Centres some years ago.
So how does one square the circle of promoting this competition yet supporting service continuity? Clearly having some experienced medical input into these decisions would help identify such retrograde steps. But one look at the Board and Senior Management Team of Monitor reveals a local government officer, three management consultants, a venture capitalist, two accountants, a lawyer, an HR professional and an administrator at the top table. Not a medic in sight.
So who guards the guards?
No one who might know anything useful.