Tuesday, October 23, 2007

Dirty Hospitals Are a Result of False Priorities

Following the Maidstone & Tunbridge Wells NHS Trust debacle last week, it seems there is a bad situation developing in Wales, according to THIS BBC report. People need to be careful not to tar all hospitals with the same brush, but one thing is becoming clear, and that's that NHS management is failing. If managers are not able to implement proper cleaning procedures it is only right to ask what else they are getting wrong. The NHS is one of the world's largest employers - second only to the Indian army, I read somewhere. Reforming it is like turning round an oil tanker. Successive governments have tried and failed, partly because few politicians have the courage to admit what we all know - that it's a 1940s national structure, trying and failing to meet the demands of twenty first century healthcare. It seems to me that there should be national centres for some treatments, but apart from that, the NHS needs to be broken down into much smaller units. You cannot run an organisation employing more than a million people centrally. At the moment you have the worst of all worlds, with national, regional and local administrations burdening people at the coalface with daily demands, targets and bureaucracy.

The other reason the NHS creaks is because no one will own up to the fact that it cannot meet every demand placed on it. When it was created it was meant to provide a comprehensive system of healthcare. No one envisioned to the medical advances that would be made. No one predicted that we would need a body like NICE to ration the provision of drugs. Certainly no one would ever have predicted that the NHS would take up around a sixth of government expenditure.

But it's this expenditure that has proved to be the essence of many of the NHS's problems. Since 1997 expenditure on the NHS has more than doubled, yet the outcomes are nowhere near what one might have predicted with such a rise in funding. Ok, much of it was spent in salary rises for nurses and doctors, but one might have expected at least a 25% increase in productivity. Instead, what we have seen is a target culture which has led to a huge increase in false prioritisation within the NHS. Everything is about patient throughput, rather than patient care. And, I am afraid this brings us back to where we started. Dirty hospitals are a direct result of these false priorities.

52 comments:

john said...

Spot on.

Madasafish said...

I am a fan of the NHS. But I also know that you do not pump money into failing businesses. You reform them (hard work), or close them and replace them.

Frankly I do not see it's rocket science.

I personally would not want to go into hospital. The chances of being satisfied are 95%. The chances of catching MRSA/Cdiff are about 0.5% in the worst ones.

These are not good odds as if things go wrong, they are either terminal or your subsequent quality of life is carp due to complications.

If the rest of Europe can solve the problem, so can we.

Frankly I can see in 2-3 years time, Labour in despair for they have thrown oodles of cash and people at it, screwed it up..., reduced waiting times.. and it still will not be right.

I'd set some simple criteria. No cosmetic surgery. Want IVF? Pay for it. Cut out all the "nice to have but not essentail " stuff.
Politically unequal? Yes.. (but see Scotland )


As it is, health campaigns are being plundered financially to keep the treatment side going. So obesity/STDs etc will just get worse.

And I do applaud policies of smoke and you will not get served..Smoking is curable (if you want to be cured) same as obesity. It's not easy but... (and you can be helped .see Weightwatchers. If you don't accept help, you are on your own.

These nasty choices will become harder as money runs out... The State cannot do everything include hold people's hands...

Vicky Ford said...

If you read the report into Maidstone you find its not only the "cleaning" to blame but also ...

1. Too many beds too close together - isolating patients is key to prevention of C-Dif. This is one of the reasons why medical staff are so cross about bed closures and

2. Staff numbers - Maidstone had some of the lowest staff ratios in the country and was relying a lot on agency staff. If a patient has C-Dif they need alot of extra nursing. If there aren't enough staff in the first place then ....

There's more too.... not having decent infection control responsiblity, too many of the wrong anti-biotics etc. Some of this should admittedly have been picked up by management but..

This is much more than just "dirty hospitals" it is all about whether the right resources were available in the right place at the time they were needed.

Whether the NHS is one big organisation or many small ones the final responsiblity for getting the resourses to the right place must lie with the Government. They collect stat after stat in our hospitals. They could have easily questioned the low staff ratios. They have been warned again and again about the possible side effects of staff and bed cuts - I firmly lay this blame at the feet of the government.

Rant over

judith said...

If I were Andrew Lansley, I'd ask Waitrose, Tesco, Balfour Beatty, BUPA and M&S how they would supply medical care across the country (hospitals are high-profile but do only something like 10% of actual care).

And before Gary Elsby and Chris Paul get their respective knickers in a twist, no I am not thinking about making a profit out of the NHS, I am talking about good management practice.

The DoH has been incompetent for decades, and builds incompetence into the system as a whole. I have just read an internal leaflet produced by the NHS about lean management - when I'd finished laughing at its ineptitude, I started crying at the thought that I'm paying for all this.

Johnny Norfolk said...

Iain

If you remember when the Labour party was in opposition it faught every proposed Tory reform to the NHS tooth and nail, for political purposes. They came into power and stopped all the Tory reforms. i totaly blame Labour both in power and oposition for the problems the NHS has todays. They should have co-operated with the Tories 20 years ago to reform the NHS.I think now it has to be broken down into smaller managable pieces to try and sort it out. thanks Labour.

Anonymous said...

<< Everything is about patient throughput, rather than patient care. >>

Rather like the voting problem in Scotland?

verity said...

1. Break up this greedy, sloppy, unproductive monster and sell it off privately.

2. Continue to deduct money from salaries, but the person whose paycheque it is gets to say which private insurance company the money should go to. (Also, they get to determine the amount to be deducted, as private will always be cheaper than supporting the public sector.)

3. People on "benefit", aka as non-productive scroungers to have insurance payments deducted from their charity payments at source. There could be government/private partnership hospitals for these people to go to. But they have to contribute.

4. No foreigner admitted to Britain without proof of health insurance. End of story.

5. Hospitals licensed and inspected annually and liable to lose their licences.

Once the whole set-up is privatised, the insurance companies, doctors and hospitals will compete and capitalism will work its magic.

The NHS is grotesque, and that it is still in business after killing hundreds of people who should have got better and gone home is mind-boggling.

Dump it.

There should be a slimline regulatory agency with the power to inspect and take away licenses, and that would be the end of the government's involvement.

Anonymous said...

the french education system have around 10 million staff i believe!

Anonymous said...

Eee-yayn

Are you pissed from lunch with Trayzaa?

Thomas Gordon said...

Iain

A very nice post

But isn't it time to think 'the unthinkable' and introduce private health insurance and abolish the NI system?

Wouldn't it be better to allow people to choose their own health package based on individual or family need with real choice on whom, how and where you would like to be treated? Wouldn't it be better to match cost to need? The idea of a 'universal' health system where clients are individuals seems to be a socialist oxymoron.

Of course they will be many who say that every hospital should be clean-that goes without saying-and that every person should have access to decent healthcare.

But the basic minimum requirement can be met through legislation (obligatory basic healthcare) and some additional payment through general taxation for those who truly are in need. Everybody else should make choices and pay for that service-it can still be 'free at the point of use' but instead of paying the state, pay the health providers direct.

I lived in the Netherlands for six years-I had clean, properly equipped and staffed hospitals to go to, a GP I could see within 12 hours, treatment that was tailored to my needs with a short period of waiting time, affordable dental treatment, state of the art medical techniques, proper mental health provision, and access to state of the art medication. My treatment was also directly linked to my employment and was done in a holistic manner so getting back into work was also part of my treatment.

There was never the shrill Government propaganda machine (which in itself costs Billions) telling people what to eat, drink, and smoke or what lifestyle they should live. People are allowed to live and die by the sword.

It also reduce those who would normal go and see a doctor on minor aliments that clog up the health system in this country.

Here I shudder every time I go to my GP-dirty, overstaffed with management, a five day waiting list for an appointment, expensive dental treatment, poor after care service and endless chasing for follow-ups. That’s when the overpaid doctors can be bothered to see you and refer you to the appropriate department in the allotted time. Cheap ‘care in the community treatment’ and ‘phone in centres’ for the mentally ill. Cost cutting drugs and backward medical thinking. Giant bureaucracies like the NHS and DWP that don’t know what the left hand is doing while the right hand carry’s on its lonely furrow.

It’s a Third rate system better suited for a Third world country. Isn’t it time the UK makes a choice, a decent healthcare system that you pay for or a massive bloated system that treats everybody like cattle?

Justin said...

...much of it was spent in salary rises for nurses and doctors, but one might have expected at least a 25% increase in productivity.

Where did you get the 25% figure from? And if you blame targets for creating the NHS's current culture, how would you propose to measure any future increase in productivity?

Anonymous said...

An excellent piece.

The pedant in me is screaming to point out that it's the Chinese, rather than the Indian, army but I've managed to keep him quiet.

How was lunch?

Ted said...

Now there are 4 NHS's there could be alternative models or approaches to see what works best. Shame than none of the four though has radically changed from the old UK NHS model.

drwho said...

It's the Indian railway ... not the army.

The health of the nation (or the national health if you like) sees its biggest improvements through reductions in poverty, improved nutrition, improved public sanitation, vaccination, and drugs (in particular antibiotics and antivirals).

The NHS is spending more and more money on surgical interventions and emergency services, which are great for the outcomes of particular individuals, but do little to improve the health of the nation.

Roger Thornhill said...

I suspect had nothing changed (demands, technology, population, diseases etc) I still think the NHS would be in a similar mess after 60 years of operation as a Statist monopoly.

barry monk said...

Well done, Iain, but still politicians fail to face up to what a shocking scenario the C diff story is. People have died (and died in significant numbers) because of the headlong drive to achieve "access targets" in hospitals.

Hospitals are designed for about 75% bed occupancy rates; if you go over 85% infection rates rise significantly, and if you run constantly at close to (or over) 100% this is a simple recipe for disaster.

So whose fault is it; put plainly and simply Patricia Hewitt and Sir Liam Donaldson, the latter because he failed to explain to his political masters how dangerous their actions were likely to be.

There is a police enquiry on the Maidstone and Tonbridge situation (300+ deaths) but the C diff death rate was higher in TWENTY other NHS hospitals.

It is time to see some of the senior politicians, and especially Hewitt, in the dock

Brownbadger said...

There's a lot of effort going into keeping c.dif down at the moment. Effort that is taking staff away from other issues. It is unsustainable and cannot last. Either we will get a endemic c.dif problem or there will be an outbreak of some other nasty hiding under the bedclothes(and I don't mean Gordon).

verity said...

I almost wrote "Good thinking!" to Judith, and then she said hospitals shouldn't make a profit. Whyever not?

Thomas Gordon writes: "Wouldn't it be better to allow people to choose their own health package based on individual or family need with real choice". Yes, but coverage and payment should be compulsory, which is why the premium for the private insurance plan that YOU have selected should be deducted at source, as the NI is now. Except it would be private and go to your nominated provider.

But coverage must be absolutely compulsory for everyone except pensioners. That includes compulsory deduction from "benefits" from welfare recipients.

"... some additional payment through general taxation for those who truly are in need."

No. Your health is nothing to do with the taxpayer.

Also, one's desire to have a child is nothing to do with the taxpayer and IVF should be available only privately. So should cosmetic surgery,including "sex change" operations and other personal fantasies.

The only people entitled to treatment paid for by the taxpayer should be OAPs and our military.

verity said...

Those machines that sell travel insurance at airports could be situated pre-Immigration and, should the Immigration officer's computer reveal that actually, the foriegn visitor's health insurance expired two years ago, or never existed, he could be directed to one of these machines to make a purchase.

cpr said...

Whys is it a "false priority" to have a target that A&E attendees are discharged, treated or admitted within four hours? Personally I think it is a good idea - certainly better than waiting 12 or more hours, with patients stacked up in ambulances outside. And why is it a "false priority" that one can be referred to a hospital consultant and be treated within 18 weeks? Was it just fine when some people waited years for treatment? And some dies before they were seen?

What is your suggestion for increasing "productivity" in the NHS over and above just handing over the cash and seeing what it deigns to give us in return?

Finally, you say that the NHS should be broken up into smaller units, and imply that these units would be free of "daily demands, targets and bureaucracy". Fine, as long as you are prepared to accept a huge increase in the "postcode lottery" and repeated scandals as small numbers of these small units go badly wrong (because of poor management) - which won't be detected early because there is no tracking or auditing of what they do. In practice no Government can accept that - not least because the media and blogs like this will castigate them for every failure in every far flung corner of the NHS.

Fixing the NHS - such that is gives the people that pay for it the service they want and deserve whilst preserving and respecting the professional ethos of the doctors and nurses that work in it - is one of the trickiest problems we face in this country, and glib posts like this are a step backwards in the debate.

verity said...

cpr - You're fiddling while Rome burns. Fidgeting around tweaking here, making a little tuck there ... the NHS is no good! It kills patients who were perfectly capable of getting well and going off home.

It is overburdened with management and has a bad attitude. It should never have been introduced, but whatever purpose it served after WWII, its time is gone. It's an unproductive dinosaur run for the benefit of its million+ employees and the thousands people in the government/local government charged with overseeing it.

Time to dump it and move on.

Anonymous said...

My mother, who was around at the time, said when the Health Service was created it was sold on the basis it would actually save money because everyone would be healthier.

Madasafish said...

cpr said "Fixing the NHS -- is one of the trickiest problems we face in this country,..."

I'm sorry but that statement is complete and utter balderdash (substituted for another B word).

The NHS problems are those caused by a giant organisation with central control and little real accountability.

If there was more local accountability.. ie. peopel get fired without pay and with loss of pension for gross misconduct as in the case of Maidstone
AND
there were far fewre centralised targets..
there would be incentives for local managers to MANAGE.

At present, it is all too easy to think the Dept of Health is the customer rather than the patient.

The Dept of Health should be a facilitator, buying medicines cheaply, giving medical guidlines, doing audits and allocating money...

Instead it tries to run the day to day medical life.

As I said before, this is not rocket science: it's basic management techniques devised by Sloane in the 1920s when he formed Gneral Motors... and used around the world since then.

A decent Management team at the top would solve the problem in under 4 years. there would be some firing and re-allocation of resources...

Sinc ethere is NO effective management at all in the Dept of Health (not visibly so), the problem is not going to be solved.
NEVER .
EVER.
Full stop.

Until they bring new management in.
Which is not planned.
So it is not going to happen.

And the Chief Medical Officer is NOT a manager of the type needed.

Anonymous said...

gMany suggest private healthcare is the answer but it's not. BUPA's great if you need a nose job or a hernia fixed but they won't touch you if you've got a 'chronic' ailment.

Get alzheimers in your 50s and you'll need decades of nursing care but you won't get it from BUPA. Many of their hospitals don't have a doctor on site so if you get a post operative infection, they'll send you to emergency ward MRSA at the local NHS hospital.

My local hospital recently failed its NHS hygiene inspection. It's filthy. New born babies who have never left the maternity department die of MRSA. The kitchens were inspected by the council's environmental health department. They were found to be squalid and infested by vermin.

The hospital runs a private ward that competes with the local BUPA hospital for private patients and their lovely insurance payouts. The private ward is a gleaming island of serility amid the squallor of the NHS wards.

Cleaining hospitals isn't rocket science. Dirty wards are a result of cleaners and managers not doing their jobs properly because there's no incentive for them to do so.

We need the NHS to provide the services we pay for in clean and well managed hospitals.

Anonymous said...

cpr
Well said!
The last thing we need is a u-turn, a "dumping" or a glib replacement for the NHS.

The salient question (leaving aside the silly "privatise it" suggestion that only about 2 people want) is how to mange the process of treating patients in the most cost-effective way.

The major problems are to do with a rapid expansion of "target-meeting", where the pressure to achieve results has compromised attetion to the basics (and the distance between beds is as basic as it gets!). This suggests that NHS managers are not managing effectively enough the expectations of the taxpayer. If an extra £1bn is alloocated, it's up to the managers to justify the expenditure, not the tables, or any of the statistics.

My suggestion is simple - empower decent managers to face the DofH officials with proper reports, and to blazes with the festering statistics. If a civil servant wants to know why x hospital is only seeing 75% of the norm, let him lose sleep over it, not the patients. Decent managers inspire and lead their teams, and should be trusted to do so.

NHS Doctor said...

The Hospitals are Dirty because no body has the guts to say that the Doctors and Nurses are not working.
If they all got their bloody sleeves rolled up and got on their knees and scrubbed for a day, the hospitals would be clean.
Visit any Hospital and you will not fail to see STAFF of all qualifications stood gassing, drinking tea or Knitting.
They think they are working but the evidence is there that they are not- cancellations to appointments, golf trips, meetings, away days. On top of that the Doctors are a Law unto their own.
I know I work in the environment- Has someone got the guts!

verity said...

Anonymous 8:20 - who cares what BUPA does? You are provincial, so restricted in your vision and your imagination. Perhaps the time for BUPA is gone, too.

Study the big private hospitals in India that are so good and so effective that American Blue Cross and Blue Shield actually pay out on them.

The NHS is a horrible idea and the whole organisation is staggering around lost, too clumsy to change, too set in its ways to even contemplate change. Kill it off! It was always a terrible idea. With today's mediccal advances, it's a bloody awful idea.

Why are you all so attached to this? You're all like a cowed dog, frightened of its master, but afraid to be left behind by him.

Dump it.

Anonymous said...

verity - Glad to see you have taken money from Michael Moore to be part of the 'spoof advertising' campaign for his wonderful new film 'Sicko' highlighting what a disaster the US 'healthcare' system is in, and how even ours in the UK is ten times better...

You are doing your work - SPLENDIDLY!

http://www.michaelmoore.com/sicko/trailer/

Michael said...

NHS DOCTOR -
Smacks of poor management to me.

Verity, no-one in this country has the desire for an abandonment of the NHS in favour of a private USA style system. "Free at the point of need" is the mantrea, and the public doesn't seem to mind the cost; we expect proper management and value for money, that's all.

Thomas Gordon said...

Verity

"The only people entitled to treatment paid for by the taxpayer should be OAPs and our military."

I was thinking of people people with serious conditions like Spina Bifida or other serious long term needs and conditions who will never be able to work.

The military would have their own health insurence system provided by the MoD.

That is what I mean 'basic healthcare legislation' and funded from general taxation-not for the 'workshy' who would have it deducted from benefit payment,but for those who will never be able to work due to their medical conditions.

The rest as you say in your post "coverage must be absolutely compulsory" is bang on the money.

But why exempt pensioners?I accept low income pensioners would need help (possibly from deductions from the state pension system)but why for the retired couple who have done well and have the means financially to do it?

Shouldn't the health system be able to provide a 'cradle to the grave' provision as well? Couldn't that be included in a package for the option for carehome treatment for OAP's or mental rest home for provision like the Netherlands?

Why burden the working age group with increased premiums when we have an older population who are just as much of a 'burden' (in fiscal terms) as any 'work shy scrounger'?

Total private insurence for all except the very needy-not just exemption for those of a certian demographic group.

Thomas Gordon said...

Anon @ 10:24 PM

Good to see that you are advertising an overwieght American who is about as correct in facts as found in Pravda.

And as far as I am aware I've yet to find any hospital that has killed ninty odd people in the United States,unlike the NHS.

No doubt he will be increasing his carbon footprint to fly over an tell us how 'evil' America is.

verity said...

Anonymous 8:59: "My suggestion is simple - empower decent managers to face the DofH officials with proper reports ...". Oh, that would do it, would it?

"Empower" managers, as they have "empowered" nurses to the point where caring for sick and frightened people is beneath them? Anyway, I thought managers were already "empowered". Isn't that what a manager is?

You're fiddling while Rome burns. Every day more people who should have recovered and gone off to be tucked up in their own home with their family caring for them are never going home. How can you be so sanguine contemplating this unmanageable hydra?

The government has no business in the health care industry (or any other industry, come to that). That an ignorant, pretentious lout like Patricia Hewitt should have been in charge of the nation's health is an obscenity.

Let private hospitals and hospital management companies set up. If Tesco's wants to try its hand at hospital management - why not?

Let the owners of some of the big private hospitals in India buy some hospitals in England. Why not? They have a tremendous success rate - .04% better than the US for open heart surgery, for example. And you get a decent curry.

Compare and contrast.

This idea is dead and gone and the Sovietesque concept should never have been implemented in capitalistic Britain. They slipped it in after the War.

Why are you clinging onto it?

(They're not even putting our wounded servicemen in private hospitals/wards. They're in open wards where suicidal islamic nutjobs posing as visitors can finish them off while they're helpless. This is beyond disgraceful. A country that doesn't even have hospitals for the military!)

yozza hughes said...

"They should have co-operated with the Tories 20 years ago to reform the NHS"

results suggest they were right to oppose the privatisation of hospital cleaning and are wrong not to reverse it.Even Howard admitted it was a Tory mistake when put on the spot during the 2005 general election, not that he had much choice mind...

I am not a number said...

The government had a choice spend the money making the NHS run like a dream for the public, so becoming instantly redundant. Then lose the next election.

Or tax and spend and borrow and get on the never never as much extra staff with extra wages as humanly possible.

Thus inflating the economy and getting a large amount of the 'investment' back in Tax and NI contributions. With the all important bonus of hundreds of thousands of, happy for a while at least to vote Labour, brainwashed public slaves in marginal constituencies.

Then just simply tell the BBC to tell everyone it would be EVEN worse if the Blue Nasties were running things. Then win the next election.

I wonder which one they went for?

Anonymous said...

Verity

Very last Century I'm afraid. No-one agrees with you! Forget it. You are fantasising!You can get a decent curry in our system - it's a good one which lacks enough top management techniques that's all.

Get over it.

verity said...

Thomas Gordon -
Yes, but I thought it was over 300 old people who had contracted the disease and died in Maidenhead and one other hospital alone? And now more examples of mass deaths from this filthy infection in other hospitals are coming to light?

Any American hospital that had one-tenth of that record would have been shut down - STAT! - and its administrators charged with manslaughter.

You write: "I was thinking of people people with serious conditions like Spina Bifida or other serious long term needs and conditions who will never be able to work."

Sorry, as we appear to be batting for the same side, but this comes down, in my opinion, to private charity. Kindly charities used to work before the socialists took over their role and made it compulsory. Although I do think most private hospitals have - or we could even legislate it - a requirement that they put aside a certain tiny percentage of their profits, to treat such cases as a condition of their licence.

These are things that can be worked out.

I can agree that the military should have their own health care under some MoD deal or other. Our fighting men should not be lying in filthy public wards where a suicidal nutjob could come in and harm them while they are helpless. God! What a way to thank those who are protecting us! (It's part of the socialist agenda to downgrade the military of our country, though.)

I take your point about pensioners. I think those who are struggling to live on their stipends should be given a break, but you are right. Many are financially sound, due to their own good judgement and partly due to the luck of the market, and they should pay their way through insurance.

"Shouldn't the health system be able to provide a 'cradle to the grave' provision as well?"

I don't know. It would depend what each private insurer was offering. But no: it shouldn't be legislated. If there's a gap, count on private companies to elbow each other out of the way to fill it. It's nothing to do with governments.

Michael 10:31 writes: "Verity, no-one in this country has the desire for an abandonment of the NHS in favour of a private USA style system." Really? Can I see the figures of your nationwide survey, please?

Second, did I suggest USA-style system? Hello? How about a Singapore-style system?

Why do you want the clenched fist of the government around your throats Are you mad?

verity said...

Anonymous 11:54 who thought he had a killer putdown: "Very last Century I'm afraid. No-one agrees with you! Forget it. You are fantasising!"

No. You are.

You don't think British hospitals are going to be managed by the Indians within the next 25 years?

Glad you can get a curry in an NHS hospital. Made with halal-slaughtered meat, I'm sure. Just like school lunches given to normal British children whose parents contribute to animal charities.

Don't you understand this socialist government has taken over your lives?

Devil's Kitchen said...

"The NHS is one of the world's largest employers - second only to the Indian army, I read somewhere."

Nah. The NHS is the world's second biggest civilian employer, second only to the Indian Railways.

DK

Anonymous said...

Verity
You really are a spoof Michael Moore advert, aren't you? when I said "last century", I should have said 19th Century.

Simply batting away the NHS isn't going to work; suggesting your idea has support anywhere in the UK is nuts. Which political party has that as a policy? None of them does! Why? Because they klow people want a health service which is "free at the point of need".

re your ridiculous question :

"Why do you want the clenched fist of the government around your throats Are you mad?"

Stop being silly.

Thomas Gordon said...

verity

The problem we face on this argument is that it has been hammered into them that the NHS's 'unique' funding is the only way to go when wanting decent schools and hospitals.

That is in the same way as the BBC's 'unique' funding makes it a rubbish broadcaster.

They love the NHS until they go to Spain,France,the Netherlands,Australia,New Zealand,Singapore or the US and get health treatment that is.

The NHS has NEVER been fit for task-people rave over it because they don't know any better.

This isn'tto say that the doctors and nurses arn't doing their best-its just the whole concept of healthcare in the UK is woeful.

Steve_Roberts said...

Anon 8:59
After 60 years of twists and turns to make the NHS work, if the key was as simple as 'empowering decent managers' , this would have been implemented long ago. When problems are so persistent across the decades and different governments, ministers and civil servants, the roots of the problems are systemic, in the nature of the organisation itself. The special characteristics of the NHS are: 1) It is a state monopoly with control over all physical and human resources. 2) Its income is derived entirely from taxation. 3) It offers services free of charge to everyone.

It is obvious that an open offer of free services leads to overutilisation and excessive costs. It is quite clear that the absolute separation between income and service provision prevents the system from improving itself. We all know now that state monopolies are a very bad way for any industry to be run - not least because their true purpose is diverted towards being the means by which politicans (and their bureaucratic hangers-on) develop and advance their careers.

The way ahead should involve four insights: a) routine care to be paid for routinely by pay as you go or subscription b) disaster care to be paid for by insurance c) charitable funding to take care of those genuinely unable to pay for or insure themselves d) taking ownership and operation of services and facilities out of the hands of the state.

Please note that this is not a proposal that we emulate the US. The US system has evolved differently and has in the process has acquired different problems which we do not need to import.

Michael said...

The Singapore Health system is funded by the tax-payer, similar to ours, and with a similar private sector.

The Indian hospitals to which you refer represent a tiny part of the Indian Healthcare system. Presumably "health tourism" is what you were advocating.

The public health service in India receives 0.9 of 1 percent of India GDP. Malaria and TB are rife.

The US system of funding is rife with unfairness - Insurance companies offer a range of products which get less and less affordable the more comprehenive they are.

And the US government claims your assets upon death if the cost of your long-term medical care exceeds
the amount of your cover.

Anonymous said...

Steve Roberts

The policy of reviving the role of Matrons was precisely what I was referring to when I suggested the empowerment of decent managers. People who face both ways, and can as easily tell their political masters where to get off as tell their staff to accompany a patient to the toilet.

It was implemented long ago, and only revently have they attempted to bring it back.

Relying on charity to cover costs will only work if the charities receive enough donations to cover costs! Of course they would not, and it would be the most vulnerable people who will suffer most.

Dr Fiona Kemp said...

I am devoted to the NHS, it trained me and I am proud of the work I do. Quite simply I save lives because of it. Now lets stop squabbling about how we got into this unholy mess and lets start to do something about it.

Here we go... back to first principles....

Firstly;

Lets accept the NHS is ingrained in our psyche and as much as the business minded of you want to fracture it or abolish/privatise it this is is not an option, we have to redesign it sensibly and not politically because health services should be run by people who understand ill health and how it needs to be treated in a cost effective way.

Secondly:

Forget at your peril that primary care, ie your average GP, sees 91% of all health consultations in the UK and the gatekeeping role between primary and secondary care needs to be preserved at all costs. If you fracture this delicate ecosystem a wave of demand will hit hospitals the likes of which have never been seen before.Fracturing will come through privatisation because the best asset we have in the NHS is continuity of care and this makes us far more efficient and in the long run privatisation will cost more.

Thirdly:

Let health provision decisions be made by clinical staff at a county level using a set budget fairly distributed throughout the country.

Fourthly:

Focal local and allow innovation to thrive. We find administrative obstruction a nightmare, let us get on with running local services.
Get the politicians out of the service, make long term practical and not political decisions. Cut the clipboard staff, we dont need them they just create hassle.

Etc etc

I could moan on about all the daft managerial decisions I have seen in my lifetime and they would fill a book. But we have to be positive and move on. We own the NHS it is ours.We pay for it and have the right to say what we want. I have set up a Campaign for a Better NHS because I believe we the public, who are all consumers of this service, need to wake up, take some responsibility and get our voices heard.

We cant go on leaving it to politicians and 'other people' any more.

Steve_Roberts said...

Dr Kemp

I do wish you well, but I think you are mistaken in some key points.


1. The NHS is not an end in itself, it is a means towards the end of wide availability of high quality healthcare. As an institution, it has to earn its keep by being effective, indeed more effective than any alternative.

2. Is reform - "we have to redesign it sensibly and not politically / Get the politicians out of the service" - possible ?

When Gerry Robinson was interviewed after his 'Can Gerry Save the NHS ?' TV show he told the NHS CEO that the politicians' involvement was at the heart of the problems he could not solve. The reply was that politicians were rightly and necessarily involved because it was money raised by taxes that funded the NHS. I conclude that as long as the NHS is tax-funded, the politicians will stay in charge. Obviously, as long as the politicians stay in charge, the NHS will fail in its purpose.

If I'm wrong, you would think that at some point in the last 60 years the politicians and bureaucrats would have come up with a way to make things work effectively; enough of them have tried, they have good intentions, and success would further everyone's career.

3. Primary care is indeed hugely important, but the assumption that continuity of care requires a State monopoly is incorrect. In most of continental Europe healthcare provision is a mixture of independent practices and partnerships, private and public companies, charitable trusts, mutual societies, trade unions, universities, etc. This does not prevent practitioners from ensuring continuity of care.

4. "Let health provision decisions be made by clinical staff at a county level using a set budget fairly distributed throughout the country."
This was actually the starting point in 1947 with the local health boards, the weaknesses soon became clear - How is the budget to be set ? Who has the last word on 'fairness' ? What is included and what is excluded ?. Those issues were crucial in the development of the bureaucracy we have today

5. " Focal local and allow innovation to thrive. "
Innovation thrives when there is free trade in capital goods - in other words when an innovative hospital (or GP) can generate enough capital and buy out other, less effective players. When all the players are state-owned, this is impossible. When there is no connection between performance and income, this is impossible. (Playing let's-pretend internal markets is no substitute.)

cpr said...

Madasafish: you denounce targets, yet call for "audit". What would the auditors do when they found a trust that takes two years to carry out a hip replacement when the average across the NHS is one year or less? Do they say - no problem, it is not up to us to do anything about it - in which case what is the point of the audit? Or do they say to the trust in question that it needs to improve. In which case they have created a de facto target. The idea that you can measure something, audit it, but then not set targets is bonkers. Either you measure nothing, and everyone does what they want, or you measure stuff and act on the results - which means having targets.
Dr Fiona: You have a lot of good points but then say "health provision decisions be made by clinical staff". Many years ago that is what happened. But many years ago was an age of class, of deference, of accepting what we ordinary folk were given by the professionals. This can never work today, simply because in a modern deomcracy the people that pay (£90bn this year) are not going to accept having no say in what they get for their money. Politicians reflect this reality. The challenge is therefore for preofessionals in the NHS (and in other services such as education) to come to terms with consumerism (for want of a better word), accept it can't be rolled back, and find ways to meet the demands of modern taxpayers whilst retaining a degree of professional autonomy. This is hard, but the alternative - of harking back to a golden age when doctors ruled and politicians kenw their place - is a dead end.

Anonymous said...

cpr
"find ways to meet the demands of modern taxpayers whilst retaining a degree of professional autonomy."

Couldn't agree more.

These ways can include absolving NHS managers from form-filling and from relentless exhortations to hit targets. Changes can also allow professionals in successful hospitals to be relieved more, say, than those in "basket case" hospitals, where more attention to detail is required.

One of the main areas of frustration is the "one target fits all" approach, and the false "given2 that every pund of taxpayers money needs to be scrutinised by a committee. I have no glib answers, apart from "don't hand it over to private companies", because when their efforts fail, it'll be impossible to regain it.

verity said...

Steve Roberts- Thanks for your excellent post. Actually, if you read through the whole thread, you would see that I had already emphasized these particular points you make: The way ahead should involve four insights: a) routine care to be paid for routinely by pay as you go or subscription b) disaster care to be paid for by insurance c) charitable funding to take care of those genuinely unable to pay for or insure themselves d) taking ownership and operation of services and facilities out of the hands of the state. But it doesn't hurt to emphasize them again and again for the very naive British.

Leading me to Thomas Gordon's strong point that the British love the NHS until they go overseas and experience modern - not 1930s Soviet - health care. It shakes them, rather, as they've always been told that their filthy, creaking, incompetent, sloppy, trashy system is "the envy of the world". Those who experience health care overseas come home chastened.

Michael - Give me strength. The Indian hospitals to which you refer represent a tiny part of the Indian Healthcare system. Presumably "health tourism" is what you were advocating.

Look. Short sentences, simple words. No one said the health system of India was advanced over the NHS. They are probably on a level. I said that their PRIVATE - this means "not state-owned" hospitals are the way forward in service and talent and patient service. They are so good that flinty-eyed American insurance companies pay out for treatment. Give me strength. There are people on this thread who are so protective of the NHS they lose their tiny reading comprehension abilities, presuming they have a few to see them through their daily life.

Yes, I know how the Singapore Health System works, thanks, having been a grateful recipient of it. Both public and private sectors are spotlessly clean and its employees are dedicated health care professionals. Nurses are nurses who want to care for the sick and recovering. If any hospital in Singapore had even two or three deaths due to filthiness lazy employees, that person would not only have resigned with terrible of face for himself and his entire family, but he would probably have to emigrate because he would never get a job - any job - in Singapore again.

Also, if I recall correctly, the trades unions pay for membership for their members. (I can't remember for sure.)

I was not making a case for the American system, but as the envious, viperish British can't see beyond the United States and how much they hate it, you bash it anyway. Just for the hell of it.

And the US government claims your assets upon death if the cost of your long-term medical care exceeds
the amount of your cover.
Why is this a bad idea? Why would the taxpayer be intersted in open-ended funding for healthcare for people he's never heard of?

Anonymous 10:12 writes Relying on charity to cover costs will only work if the charities receive enough donations to cover costs! Of course they would not ..."
You know this, do you? The Victorians gave very generously to help the less fortunate. It was the imposition of the dead hand of socialism that dried up a lot of the private charitable foundations that throve in Britain previously. These days, how much money do people donate to save the dolphins or the polka-dotted water vole? The charitable instinct has not dried up.

Dr Fiona Kemp says we should accept that the NHS is ingrained in our psyche.

No. Nothing imposed by socialists is ingrained in my psyche. This is a communist construct and communism is dead.

Fiddling around with a dead system is never going to be productive.

Dump it and make insurance compulsory and insurance payments to the insurance company nominated by the wage-earner to be deducted at source, as is NI just now. The difference is, the payments would go to private companies chosen by the earner.

As mentioned before, people on welfare would also have healthcare payment deducted from their welfare cheques at source whether they liked it or not. I guarantee you that some enterprising insurance companies will set up healthcare schemes for non-productive wards of the state. And they'll be more efficient at dealing even with this end of the market than the NHS.

Yes, the French health service is extremely well-managed - the French are bloody good at grands projets - but it's still socialism and, in the way of all socialism, it is failing. People keep forgetting to mention this: The French system is going bankrupt and they are madly trying to shore up the dykes. But it won't work. There is no more money.

Anonymous said...

Verity

Utter rot from beginning to end.

Ugh.

Where's your evidence that this Victorian approach is evere going to catch on?

We're not enslaved to socialism, or if we are, then so is David Cameron and the entirity of the sensible wing of his party.

Dr Blue said...

http://www.drrant.net/2007/03/management-spaceship.html

The NHS would work better without its managers.

Dr Blue said...
This comment has been removed by the author.
Anonymous said...

Interesting Video on Common Purpose which includes references to the Widescale corruption withion the NHS syphoning off the Nations wealth.

http://video.google.com/videoplay?docid=3664960863576873594&hl=en-GB