Sunday, 22 June 2014

Of course the NHS is out-of-control. It has been out-of-control for decades...


Of course the NHS is out of control. We really shouldn't be surprised to hear this from a minister - indeed it's perhaps the first honest thing we've heard about the NHS in my lifetime. Except, of course, that's not really what the minister meant - what she meant was that the service was out of her control.

A Tory health minister was at the centre of controversy after she was secretly recorded saying that the government could no longer exert much day-to-day control over the increasingly stretched NHS.

Read that carefully - the words used are "day-to-day control". In other words, the reforms to the system introduced under this government have finally (or at least in front of 'private' party meetings) ended the pretence that government ministers and officials in Whitehall "run" the NHS. As the defensive response from a government spokesman put it - doctors are in charge of the NHS.

Now I've a little insight into the NHS as a member of a health and wellbeing board. This doesn't make me an expert (partly because the NHS uses a language that is, to paraphrase Douglas Adams, 'almost, but not quite, entirely unlike English') merely that I have a little knowledge. The reality out there is that there is no effective 'control' anywhere in the NHS - at least not in the management sense of control. My amazement is that an endless search for strategy has replaced any sense of actually doing stuff.

Now health and wellbeing boards are that very thing - 'high level', 'strategic', 'focused on partnership' - that frustrates us normal folk when confronted with public sector management. The NHS likes to call this 'leadership', presumably invoking some sort of sympathetic magic that says if you call something 'leadership' often enough it will become leadership. The reality is that this high level strategic partnership approach to NHS leadership is more akin to a nebulous, ill-focused exercise in projecting managerial self-interest as strategy (and this is without commenting on the use of misleading statistics on public health and health inequality as the basis for planning - mostly because they fit the ideology of NHS management).

At the mish-mash of meetings where we consider vast swathes of documentation all written in that almost comprehensible NHS language, we have been told about a thing called 'the funding gap'. This is a chthonic darkness looming over health services in Bradford - the £364 million bogieman of the care economy. And we discuss this 'gap' as if it is real rather than constructed from a combination of speculation, guesswork and spatulamancy.

So because everyone present knows that the bogieman is probably a little old man from Kansas rather than Godzilla, the aim is to direct any changes away from each person's particular interest. The truth about that 'funding gap' is that it is almost entirely founded on the idea that healthcare cost inflation will exceed general inflation, that demand will rise and that the NHS will not improve its productivity or efficiency. This is pathologised by the setting off of pseudo-panic - 'if nothing is done now then the NHS will be in crisis' or 'the funding gap presents the biggest leadership challenge since the foundation of the NHS'.

Really? Over the life time of the NHS its inflation rate has always exceeded the general inflation rate, demand has always risen and any advances in efficiency have been resisted by unions or swamped by managerial mission creep. The current crisis is the same crisis as before except for one thing - we're assuming that the magic money tree won't provide meaning that the service really does have to think about its productivity. And faced with this fact the 'leadership' is like the proverbial bunny facing the pick-up truck, completely frozen, unable to act.

This inability to act is because the NHS is uncontrollable - even out-of-control. Take the review of hospital provision in London and consider how Labour used it to run a series of egregious campaigns during an election. Why would any politician do anything but resist any change at all to health services knowing that proposing - or even agreeing to consider - such changes will result in an unpleasant, personal attack from the other side. We talk about putting doctors in charge, huge investment in 'leadership development' is made and the chairs are reorganised into a nice new pattern.

But we're not going to make the changes needed to get a more efficient health service because too many people inside the service are banking on political pressure working. These people - at the front of the crowd are the trade unions but there are others like the risible 'National Health Action Party' lined up alongside - see defending the health system's inefficiency as some sort of holy mission. And because these campaigners can press that 'Our NHS' button, get people to say 'the NHS saved my life and nothing should change', the result is sclerosis - the arteries of the system are clogged with years of indulgence.

The NHS is out-of-control because - so far as I can see - it has no leadership brave enough or strong enough (indeed with the authority needed) to face down the vested interests of unions, assorted medical colleges and NHS management. So the service will sputter on - most of the time, in most places doing an OK job and certainly saving lives every day.  And the funding gap will get lost in the running of internal deficits, in salami slicing of non-essential activity and in skimping on investment.

So yes, the NHS is out-of-control.


1 comment:

Anonymous said...

Hoorah. You have put into words everything that I believe about the NHS.
When I worked in an administrative role in the NHS after having worked in private and industrial settings for most my life, I encountered all the problems that you list.
Group-think, I feel, is particularly prevalent and starts a training level. NHS accountants are trained to think like NHS accountants. Doctors trained to think and behave like NHS doctors. Nurses trained to think and act like NHS nurses. Supplies, ordering and administrative procedures have just expanded on systems set up in the 1940's. Newcomers, with ideas on efficiencies are sidelined with reasons why they cannot be implemented, mainly because modern efficiencies are not the NHS way, are frozen out with the particular language used within the NHS. In hospital settings patient files are still predominately paper based and computer tracking non-existent (Fed-ex could teach hospitals a thing or two). Meetings upon meeting are held that do not accomplish anything. Online diary co-ordination barely used at all. Appointment systems are 20 years behind times, as are most administrative tasks. Computers are used as glorified typewriters. (IBM could teach them a thing or two). Even surgeons have to attend mandatory training on lifting and carrying!
In my opinion, it is because taxpayers are the cash cow for the NHS that the NHS has not had to modernise and become leaner and meaner like other industries.
The NHS is the equivalent of 'Open all Hours' compared to modern supermarkets.