tag:blogger.com,1999:blog-68267804133660152912024-03-05T06:31:28.946-08:00The Red DolphinHard-hitting scrutiny on the politics of healthBernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.comBlogger40125tag:blogger.com,1999:blog-6826780413366015291.post-788390898216076312011-03-21T06:57:00.000-07:002011-03-21T23:46:22.159-07:00Understanding averagesPROPOSAL FOR EFFICIENCY SAVINGS BASED ON PERFORMANCE MANGEMENT<br /><br />Over the last few years the ability to collect information from the regional centres has increased exponentially so that we can now reliably assess multiple aspects of their work from locally and nationally gathered minimum data-sets. Using these it is possible to assess performance based on indices such as profit, turnover and safety. This last area has been of especial focus recently due to a few well-documented cases in the media indicating short-comings in the processes followed by the staff.<br /><br />An analysis of accident rates across all 10 UK regions show that safety is consistently high at over 95% but there is a variation from 95 to 99% - the average being 97%. Further details as to specifics of accidents in the under-performing regions is beyond the scope of this document but also considered unnecessary.<br /><br />In line with modern statisitical thinking the proposal is to close the under-performing five centres so that only an above average service remains. The resulting cost savings need hardly be elaborated upon here.<br /><br />The programme has been reviewed at senior management level and been assigned the title of: Consideration of Assessed Regional Departments: Insufficiently Average = Closed .Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-15127171940945786332011-02-17T16:47:00.000-08:002011-03-21T07:33:15.033-07:00The Point of Care?<span class="Apple-style-span" style="COLOR: rgb(72,72,72); LINE-HEIGHT: 17pxfont-size:12;" ><div><span style="font-family:georgia;"><span class="Apple-style-span" style="COLOR: rgb(72,72,72); LINE-HEIGHT: 17pxfont-size:12;" >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). </span>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.</span></div><br /><span style="font-family:georgia;">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.<br /><br />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.</span></span>Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-79357076996270493022011-02-16T15:17:00.000-08:002011-02-16T23:29:54.827-08:00What would the AV mean for your health?<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJfWY1tqSaOkNuskr7stg2ygTwV89n1hYuCqoKvObdAQquuJnrw96p53VYx0NKrV4uVqrxykqlOvx8HnLijEemV4nm5dLzegKh3jyy2uGo2anyM19e41tVPYeLPWeiMR1YAujA4iyFCk81/s1600/Voting.jpg"><blockquote></blockquote><blockquote></blockquote><img style="float:right; margin:0 0 10px 10px;cursor:pointer; cursor:hand;width: 320px; height: 252px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJfWY1tqSaOkNuskr7stg2ygTwV89n1hYuCqoKvObdAQquuJnrw96p53VYx0NKrV4uVqrxykqlOvx8HnLijEemV4nm5dLzegKh3jyy2uGo2anyM19e41tVPYeLPWeiMR1YAujA4iyFCk81/s320/Voting.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5574552823483795106" /></a><br /><div style="text-align: left;">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?"</div><br />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.<div><br /></div><div>Would the <span class="blsp-spelling-error" id="SPELLING_ERROR_0">NHS</span>, by then possibly with an independent <span class="blsp-spelling-error" id="SPELLING_ERROR_1">NHS</span> Board ostensibly outside direct political control, be much affected by changes in a government that had to <span class="blsp-spelling-corrected" id="SPELLING_ERROR_2">accommodate</span> 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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /><blockquote></blockquote><br /><br /><br /><br /></div>Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-90807154737899485812011-02-16T12:51:00.000-08:002011-02-17T16:47:20.518-08:00Paul helps set up a new serviceDespite 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.<br /><br />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.<br /><br />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."<br /><br />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.<br /><br />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".<br /><br />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.<br /><br />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.<br /><br />"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?"<br /><br />"You need a code," objected Mabel tartly.<br /><br />"And how do we get one of those?"<br /><br />"You need to fill out this form," she replied triumphantly, handing over a thick wad of papers.<br /><br />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.<br /><br />"Can you get a code now and start booking?" they asked hopefully.<br /><br />"Codes are issued by the Vehicle Bookings Manager," she replied. "She's on a Communications Course but will be back next week."<br /><br />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.<br /><br /><br />If you think this tale is far fetched, just try setting up a clinic for a new colleague in today's NHS.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-15237484112101742892011-02-07T22:51:00.001-08:002011-02-08T03:57:28.037-08:00Paul makes sense of economicsIt 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.<br />"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."<br />"Sure thing Jack," replied Billy. And they set to work.<br />Paul was incensed.<br />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.<br />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.<br /><br />"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.<br />"Work is being performed by personnel outside of their usual occupation, which will have downstream knock-on effects on productivity."<br /><br />The staff looked mystified.<br /><br />"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."<br /><br />The staff looked mystified.<br /><br />"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."<br /><br />"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."<br /><br />"Surely this just adds to the expense, Paul? These extra layers of bureaucracy won't make us work any better."<br /><br />"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."<br /><br />"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."<br /><br />"Other companies can now tender for providing these services more cheaply. Once you see you are saving money you'll change your minds."<br /><br />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."<br /><br />"Wait and see," said Paul, and got up and left.<br /><br />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.<br /><br />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.<br /><br />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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-47370641897487494572011-02-06T23:03:00.000-08:002011-02-07T00:01:23.650-08:00Big Society? No - Big ResponsibilityWell, 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.<br />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.<br />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.<br />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.<br />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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-11973058855827360382011-02-01T23:02:00.000-08:002011-02-02T12:46:37.160-08:00Red 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?<br />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.<br />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...<br />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.<br />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.<br />So who guards the guards?<br />No one who might know anything useful.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-89557354157265500672011-01-31T23:26:00.000-08:002011-01-31T23:27:25.793-08:00Red Dolphin's response to the Health Reforms (1)<span style="font-style:italic;">Posted on the King's Fund website:</span><br /><br />"The new reforms have missed an opportunity and the elephant in the room remains. The entirely artificial division of 'providers' (largely meaning secondary care) and 'commissioners' (also of course providers in primary care) serves no one and simply fosters the old antagonisms.<br />Patients of course are not concerned with these politically driven boundaries when it comes to rapid, effective and joined up treatment. They simply want to see the correct health care professional with minimum wait. Applying free market principles in a closed market has not worked but the ideology continues to be pressed.<br />Whilst we welcome the abolition of SHAs and PCTs as mountains of needless bureaucracy we are concerned that, at least the latter, will be replaced by something very similar under a different name.<br />The much needed simplification of the administration of the Health Service is still a long way off."Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-52792042986974070112011-01-26T14:27:00.000-08:002011-01-26T23:51:49.953-08:00Paul takes charge of trainingThey were busy times for the company. The drivers could barely keep up with the number of requests for their services. Most of their assignments passed off satisfactorily but sometimes they wished they had different vehicles for certain jobs. Even more than this they wished they could learn to drive their current ones in new and different ways in order to achieve more. But these extra expenses were hard to come by as there was a recession and there was little money for career advancement and the acquisition of new skills. The drivers found this sad but got on with their work, complaining but little.<br /><br />Paul too had been thinking about training. He had been on a management study day and saw that many coloured bar charts could be produced analysing the number of course modules employees had attended. These in turn curried favour with the executives who liked to feel that they were providing a good learning environment as this in turn ticked many legal regulatory boxes.<br /><br />Thus it was that he sat down and thought of the many areas that could be addressed by such a training programme. After several days of chewing his pen he came up with an extensive list. He composed a memo to all the drivers informing them of this splendid new opportunity to advance their knowledge and advised them that once they had attended all these modules they would only need to update their knowledge once a year. Topics included 'Keeping Fuel in Your Vehicle', 'Opening and Shutting Car Doors - the Risks and Benefits', 'Car Washing', 'The Importance of Servicing', 'Vehicle Identification', 'What to do in a Breakdown', ' Talking to your Passengers', 'Tyre Care', and many more.<br /><br /> "But Paul," cried the drivers as if with one voice when they saw this catalogue. "Apart from the 'What to do in a Breakdown' one, these are all useless. We know this stuff anyway and it is very patronising of you to think that we need to go on a course to learn how to shut a door. What we wanted was the chance to go on courses to learn how to drive in the snow, or change a fan-belt on the road, or how to load a removals van correctly. Not how to wash a car, which we do every week anyway."<br /><br />Paul looked annoyed. All his efforts on their behalf were being spurned.<br /><br /> "And another thing, Paul," they said. "Doing all these learning exercises will take lots of time - time that we could otherwise be working. We are barely keeping up with customer demand as it is."<br /><br />Paul looked annoyed. He needed those bar charts.<br /><br /> "It's not negotiable," he retorted. "It is a part of company policy that you do these and your annual increase in wages depends on their successful completion. We will lay on days when all work is cancelled and you can attend these lectures."<br /><br /> "But Paul, that will increase delays for our customers even more though," cried the drivers.<br /><br />Paul looked annoyed. He hadn't thought of that.<br /><br /> "We will also pay you extra to do some weekend and evening work to clear any backlog," he replied, pleased at this idea. How generous he was!<br /><br />The drivers shook their heads sadly. "But Paul. That's a huge extra cost to the company. If you let us go on the courses we wanted to go on, instead of these, we would do it in our own time. Some of this extra money could be spent on the course fees instead. That way you wouldn't lose any work and we would all get better at our jobs."<br /><br />But Paul simply looked annoyed. "It's compulsory," he said. And walked off.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-28990818463988134072011-01-24T03:16:00.000-08:002011-01-25T03:00:12.503-08:00Listen to those who knowOne morning Paul walked into the office through the car park where the majority the company's fleet of vehicles was kept. He looked at all the different models and types but was most taken by the row of red Ferraris. It was a picture of this row that appeared on the company's advertisements as they were the top of the range.<br /> 'We need to get more of these,' he thought to himself as he passed the other rows of less photogenic vans, estate cars and fuel-efficient Smart cars. And he called his managers together in his office.<br /><br />None of them had ever driven a Ferrari, nor indeed any of the other cars that the company owned, and rarely met the drivers who did. Nonetheless they made plans for changing the make-up of the fleet and energetically wrote business cases to this effect.<br /><br />On his way to another such planning meeting Paul bumped into one of the drivers in the corridor and casually mentioned this plan to him. The driver was aghast.<br /><br /> 'But Paul,' he said. 'The Ferraris are only hired by young executives for weekend jaunts. They don't make up a very large part of the business. Most of what we do is long-distance driving of both people and goods. A Ferrari wouldn't be much use there. The biggest growth area we are seeing is people wanting to hire cars to tow caravans.'<br /><br />Paul remained obstinate.<br /><br /> 'They are our top of the range. We need to get as many people as possible to use them as quickly as possible. We can only do this by having more of them.'<br /><br />The driver looked incredulous. 'But Paul. The Ferraris are the most expensive vehicle for the firm to run. They cost more to buy, to maintain and to fuel. Why use them for anything other than their specific tasks?'<br /><br />Paul remained obstinate.<br /><br /> 'It is good publicity if people know that we are associated with high profile, high performance vehicles like these'.<br /><br /> 'But Paul,' the driver persisted. 'Getting a Ferrari to pull a caravan is not only inefficient practice but it will damage the car if it goes on for any length of time. Not only is there no need to use such a car but it can be positively damaging.'<br /><br />Paul remained obstinate. He had had an idea and he was determined to see it through, evidence notwithstanding. 'We'll call it the initiative SPECIAL International Superior Transport Service - or SPECIAL-ISTS for short.'<br /><br />The driver shook his head sadly and wondered why his opinion counted for so little.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-870011170472051192011-01-12T23:06:00.000-08:002011-01-30T13:33:15.796-08:00A tale for our timesOnce upon a time there was a man named Paul. He ran a company that hired out vehicles with drivers for a whole variety of different tasks. On the whole the outfit worked well with all the drivers working very hard at their assignments, which were many and varied. But Paul, who had never driven a vehicle, began to feel as if he was being cheated by the drivers and started to think of ways to monitor them. The drivers, who were an honest bunch, were unaware of this and in any case often met up to see how they could do better as they liked their work and were seen by most outsiders as being good at it.<br /><br />However Paul's suspicions grew and grew until finally he decided to perform checks on the performance of his staff. Sadly, not understanding the work they did, he was unsure what to measure or how to interpret what he did measure or even whether the methods he used to measure things were at all valid. Undeterred however, he set up a complex system that he hoped would calculate the number of miles each driver with his vehicle had driven each month. He argued that as all the vehicles would have to fill up with petrol frequently, monitoring this would be useful and so he managed to put some very expensive sensors in place in the surrounding petrol stations. These would then send him data every time one of his vehicles filled up. He realised that the amount of petrol used depended on a number of variables including the engine size, the type of journey, the condition of the vehicle and the way it was driven so he calculated complicated formulae to factor this in. From these equations he derived his estimates as to how far each vehicle had gone in the last month.<br /><br />He was shocked. There was a huge variation. Some drivers seemed to be working far harder than others; some appeared to be doing next to nothing and must surely be losing him money. Still he did not ask the drivers as to why this might be but went to lots of meetings with other managers in the company and between them they made even more complex formulae to interpret the data by aportioning it in different ways. Finally though, they decided to meet with the drivers to explain the system to them.<br /><br />"But Paul!" they said. "If you wanted to know how far we drive why didn't you just look at the milometer instead of setting up this complex arrangement? We do it ourselves every month anyway so we could have just given you the data."<br />Paul looked a little embarrassed but said nothing.<br />"Sometimes," they continued "we fill up in far away petrol stations that don't have your monitoring systems so you aren't even capturing all the data."<br /><br />But Paul wasn't listening.<br /><br />"And Paul," they said. "Not all our vehicles are the same. Many of them do other tasks as well as simply going from A to B. Just measuring the distance they have driven won't tell you much about what we do."<br /><br />But Paul wasn't listening.<br /><br />"Look at Vehicle number Seven," he said, pointing at the spreadsheet. "Last month it only drove three miles, whereas Vehicle Number Two managed over two thousand kilometers."<br /><br />Ignoring the disparity in units the drivers replied: "But Paul! Vehicle Number Seven is a bulldozer. It can't go very far and in any case its main task is to flatten out the route between the depot and the main road every day. That track is in such bad repair that if the bulldozer didn't flatten it out every day none of the other vehicles could even leave base, never mind do all their work."<br /><br />But Paul wasn't listening.<br /><br />"And Vehicle Number Two is a removal van. Of course it clocks up long distances. What you should be measuring is how successful it is at transporting furniture and how much it breaks, or how happy the customers are with the service."<br /><br />But Paul wasn't listening.<br /><br />He was dreaming of rolling out his system to all the other branches of the company. He would call it Paul's Longitudinal Investigative Car Survey. Or PLICS for short.<br /><br />It made no sense but might make his name in the management world.<br /><br />And the drivers wondered how much all this had cost and whether that money could have been better spent on improving their vehicles or the road, and they wept to see such ineptness all around them but carried on doing what they did very well anyway, much as they had done before.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-51006815951545593422010-08-16T23:02:00.001-07:002010-08-18T23:17:41.772-07:00Losing itWell, it didn't last long, did it?<br />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.<br />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.<br />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.<br />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.<br />And fines? Words fail me. The internal market redistributing scarce monies doubtless to more middle managers to create more unhelpful rules.<br />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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-46787073542533223992010-07-12T13:13:00.000-07:002010-07-13T23:17:48.048-07:00Half rightSo 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.<br />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.<br />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?<br />So, the report so far? Nothing wrong, Mr Lansley, but only half right.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-72085105190759731602010-06-26T12:23:00.000-07:002010-06-26T12:32:31.711-07:00More4Less: The public sector spending challengeIn 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.<br /><br />Dear Mr Cameron, Mr Clegg and Mr Lansley,<br /><br />"<span style="font-weight:bold;">More for Less": Ideas for cost savings and efficiency improvements in the NHS</span><br /><br />1. The European Working Time Directive<br /><br />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.<br /><br /><br />2. Study Leave Budgets<br /><br /> 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.<br /><br /><br />3. Clinical Excellence Awards<br /><br />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.<br /><br /><br />4. Middle management<br /><br />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.<br />Remember the adage that "not everything that can be counted counts, and not everything that counts can be counted."<br /><br /><br />5. Reduce generic working<br /><br />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.<br /><br /><br />6. Budgets within the Internal Market<br /><br />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.<br /><br /><br />7. Strategic Health Authorities<br /><br />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.<br /><br /><br />8. Postgraduate education<br /><br />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.<br /><br /><br />9. Cancer networks<br /><br />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. <br /><br /><br />10. GP commissioning<br /><br />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.<br /><br /><br />Yours faithfully,<br /><br />The Red DolphinBernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-57296956621175293702010-06-21T15:20:00.000-07:002010-06-22T01:32:36.746-07:00Common sense... 1 Theorists... 0The 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.<br />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. <br />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.<br />Move over theorists, common sense has arrived.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-46775711246815879192010-06-07T01:02:00.000-07:002010-06-07T12:17:44.692-07:00Take a 180 degree look aroundOn 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.<br />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.<br />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.<br />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.<br />"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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-57157165266874807652010-06-06T11:00:00.000-07:002010-06-06T13:56:07.513-07:00The past is a foreign countryMy 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.<br /><br />Miss Polly had a dolly that was sick, sick, sick<br />So she called for the doctor to come quick, quick, quick<br />The doctor came with his bag and his hat<br />And he knocked on the door with a rat-a-tat-tat.<br />He looked at the dolly and he shook his head<br />And he said "Miss Polly, put her straight to bed."<br />He wrote on a paper for a pill, pill, pill<br />"I'll be back in the morning - yes I will, will, will.<br /><br />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.<br />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.<br />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.<br /><br />Miss Polly had a dolly that was sick, sick, sick<br />So she called the approved emergency number for out of hours consultations<br />A locum said: "Can you come to the local walk-in centre?"<br />Where he sat with his arms bare below the elbow and no tie.<br />He entered the dolly's vital signs into his computer and said:<br />"She doesn't fulfil the criteria for antibiotics so give her Calpol instead",<br />"I'll arrange for one of the nurses to ring you up in the morning to see if she is any better."<br /><br />Not all change is progress.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-28071203934203445502010-05-31T02:21:00.000-07:002010-05-31T02:40:03.040-07:00Sense with SensibiltyThe 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.<br />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.<br />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.<br />Or in the modern tongue: #bringbacklaws.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-64256976880563628092010-05-28T02:02:00.001-07:002010-05-28T13:26:01.360-07:00It's the people, stupidWell, 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.<br />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. <br />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.<br />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.<br />The new NHS must not just be a slimmed down version of today's but there must be a <br />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'.<br />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.<br />But first they need to remember: it's not principally about the economy. It's the people, stupid.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-39848129137612720862010-05-20T13:40:00.000-07:002010-05-20T16:17:20.384-07:00Opportunity 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.<br /><br />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.<br /><br />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.<br /><br />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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-86267335559791990992010-05-16T23:00:00.000-07:002010-06-01T00:54:01.542-07:00Lucky 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.<br />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.<br />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.<br />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.<br />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.<br />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.<br />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.<br />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.<br />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.<br /><br />£6 billion pounds in cuts in the first year? Mr Lansley could do it all alone. Lucky number seven.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-39439647440366064562010-05-11T23:05:00.001-07:002010-05-11T23:35:31.767-07:00A 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.<br />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.<br />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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-77219986667990814322010-05-09T00:38:00.000-07:002010-05-09T02:57:35.773-07:00The curious incident of the word in the weekendSo 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.<br />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.<br />"Do a deal with Nick", should be the mantra in Whitehall. And not to form a Coalition of Losers either. Will it happen? Maybe.<br />But chin up though. At the current rate we'll be voting again in the autumn.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-51703392625190224372010-05-06T23:31:00.000-07:002010-05-17T15:50:32.855-07:00They think it's all over - it's notSo 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).<br />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.<br />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".Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0tag:blogger.com,1999:blog-6826780413366015291.post-73594433582376923912010-04-19T22:57:00.000-07:002010-04-20T03:04:52.986-07:00You couldn't make it upAs 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.<br />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 <span style="font-style:italic;">each</span> party a million pounds.<br />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.<br />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.<br />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.Bernard Staceyhttp://www.blogger.com/profile/10656417212995626945noreply@blogger.com0