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.

Red Dolphin's response to the Health Reforms (1)

Posted on the King's Fund website:

"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.
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.
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.
The much needed simplification of the administration of the Health Service is still a long way off."

Paul takes charge of training

They 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.

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.

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.

  "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."

Paul looked annoyed. All his efforts on their behalf were being spurned.

  "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."

Paul looked annoyed. He needed those bar charts.

  "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."

  "But Paul, that will increase delays for our customers even more though," cried the drivers.

Paul looked annoyed. He hadn't thought of that.

  "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!

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."

But Paul simply looked annoyed. "It's compulsory," he said. And walked off.

Listen to those who know

One 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.
'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.

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.

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.

'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.'

Paul remained obstinate.

'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.'

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?'

Paul remained obstinate.

'It is good publicity if people know that we are associated with high profile, high performance vehicles like these'.

'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.'

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.'

The driver shook his head sadly and wondered why his opinion counted for so little.

A tale for our times

Once 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.

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.

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.

"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."
Paul looked a little embarrassed but said nothing.
"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."

But Paul wasn't listening.

"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."

But Paul wasn't listening.

"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."

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."

But Paul wasn't listening.

"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."

But Paul wasn't listening.

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.

It made no sense but might make his name in the management world.

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.

Losing it

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