It's time that NHS management started earning those big bucks they get paid

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It's a couple of weeks before the latest 'comprehensive spending review' so we can all understand the explosion of shroud waving, sorry tales of budget cuts and screams of 'crisis, crisis'. Indeed I've indulged (I think rightly) in a little bit of this myself.

However, we need to think very carefully about what we mean by 'crisis' - as in 'the NHS is facing financial ruin':

By next year, hospitals’ deficits may have escalated to such a degree that the NHS could face widespread financial collapse.

Now it's true that hospitals (and the writer is Chief Executive of a hospital trust) are facing something of a problem. We saw recently that the total deficit has reached over £800m and that most of them report continuing pressures on delivery. But Christopher Smallwood, the writer here, is just scaremongering as part of a timely lobby.

The inference in these arguments is in two parts - first that hospitals are the NHS and second that the problem is a consequence of cuts to the NHS budget. Neither of these two suggestions are right - hospitals are responsible for just about half of NHS spending and expenditure on the NHS is programmed to rise (funnily enough by the £8 billion the NHS said it needed and the government promised).

The problem here is that while the Department of Health has a specific amount of cash allocated though the national budget, this doesn't apply to hospitals - NHS Providers in the jargon - which operate on a tariff system and mostly get paid according to how many operations (or whatever) they undertake. As one consultant put it to me - 'each time a new patient arrives in hospital for an elective procedure it's "kerching, kerching".

The problems with this system are many and varied but the most egregious is the widespread belief in hospital management that fewer patients means less money for the NHS. The managers (who really should know better) think that because their hospital gets less money this means that the whole system has less money. And this gives rise to one of the more pernicious criticisms of extending the choice of providers in the health system - 'cherry-picking':

Around half of all NHS-funded hospital care – about £40bn a year – is paid for through a national tariff, where hospitals are paid a set rate for each patient, depending on the treatment given. As private hospitals generally do not treat complex or emergency patients, critics claim private contractors can profit by “cherry picking” easier patients.

What you need to understand here is that we're being told (by those same people complaining of inadequate funding) that the NHS should commission more expensive provision through general hospitals because otherwise those hospitals, in some way, would be less viable. Instead of purchasing elective surgery from the lowest cost provider meeting the necessary high standards, we are commissioning from general hospitals on the false premise that the more cost-efficient approach would cost the NHS more money.

The central issue for the NHS - and one of the reasons it has failed to meet (or even tried to meet, in truth) its efficiency targets - is that the dominance of general hospitals over the system has made it nigh on impossible to develop a market of specialised providers or to shift low-risk procedures into primary care. The moment these systems start to reach the point where their impact on the system is positive (ie releases more money for other NHS activity) the result is NHS Trust deficits giving the impression that there is some sort of crisis. This may or may not be the case but so long as the hospitals' budgets assume utter market dominance, we will continue to fail in making any meaningful efficiencies in the NHS. And there'll be this gun pointed at the government's head:

The choice is stark: more money every year or a sustained decline in the standards of healthcare and a financial collapse. How much more money? Even if the efficiency gains achieved in the next five years matched those of the past five, the government would need to increase annual budgets by £2bn-£3bn a year between now and 2020 to preserve standards. But since the NHS cannot continue to raise productivity at this rate, at least £4bn a year extra will be necessary, starting in April.

When I look at what local government - for all its faults and failings - has delivered over the past five or six years, I am forced to assume that these same opportunities exist in the NHS. But I - like the government and the public - would like the management of the NHS to make those changes without the blunt instrument of actual cash budget cuts. So far that management has avoided anything that requires structural changes and have resisted - to cries of "no privatisation" - any substantial attempts to use the private sector to help develop a significant and innovative delivery of high quality elective surgery and treatments.

I'm prepared to defend the high salaries of NHS management but that, I think, gives me the right to tell them that they need to up their game. If we're going to pay NHS Trust bosses £200,000 or more then those bosses need to start showing the creativity, innovation and invention those big bucks are paid to secure. And the message to people like Christopher Smallwood is to stop waving shrouds and start to make the case for a dynamic, flexible and responsive system - even if it means there are fewer huge general hospitals and more small, specialised and independent providers.

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The sleepers awake. How the left controls NHS leadership.

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Back in the 1980s the Conservative government did that very conservative thing - it decided that the way to improve the operational effectiveness of public services like the NHS was to get better leadership and management. It's very hard to argue with this principle, indeed it seems like common sense. So the government replaced local councillor led area authorities with a mish-mash of boards and panels each with people recruited to bring 'business' experience of one sort or another.

Spin forward a few years and we arrive at 1997 and the election of a Labour government. Now some on the left wanted to return to the old, pre-reform NHS where the organisation was centrally directed with no pseudo-market and no boards of 'business' people. But Blair and Brown decided otherwise - they realised that the boards in the NHS presented the opportunity to fill the organisation with people sympathetic to New Labour's aims (I'm talking about the NHS here but the same applied right across the public sector).

Once the key appointments - chairs, chief executives and so forth - were in place, Labour could rely on those people to fill the boards with like-minded folk. And, by introducing (in typical New Labour style) a control mechanism - the Nolan Principles - this could be portrayed as removing political interference from the appointment process. The board may be filled with apologists for Labour (and indeed, as we find in Bradford, with actual Labour politicians) but these supposed 'principles' allow that party to claim it has nothing to do with the appointment - the best person got the job.

When Labour left government some assumed (and to see the spat over just one appointment, Labour absolutely believed) that the Conservatives would apply exactly the same approach - chairs and directors would be chosen for their Conservative sympathies. But this simply hasn't happened because of that view, a deeply conservative view, that it's effective administration that matters - as I wrote a while back:

...Cameron’s “conservatism as effective administration” requires attachment to and confidence in institutions – the National Health Service, the Civil Service, Royal Colleges, Universities. Government should concern itself with ensuring these institutions are well administered rather than with the outcomes of the institutions work. Put the right leaderships in place and trust in their judgement is what government must do – and then act to implement and enforce the plans those leaders create.

So the urbane, professorial sorts who lead publiuc institutions remained in place despite their preference - even support - for the Labour Party. The result of this is that - especially in the NHS - the administration actively seeks to undermine the priorities and direction of government policy. And with the 'privatisation' debate the Labour-supporting men and women filling NHS boards have been activated in the manner of sleepers:

Party activists sat on board that slashed funds, doctor who is would-be Labour MP helped shape critical report and lead inspector was opponent of privatisation 

We are reminded again how the Labour Party and its supporters in trade unions like the BMA will always put the interests of power and self-interest ahead of the interests or the public and the patient. And this revelation reminds us that the biggest failure in the current government's administration of the NHS hasn't been the reforms or funding issues but has been keeping a huge fifth column of Labour supporters in place right across the system. Indeed, to allow those supporters to continue appointing their own to positions of power and influence in the NHS.

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Food heroes of the day - Ninewells Hospital, Dundee...

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Assorted health fascists and nannying fussbuckets are frothing at the wonderful dish served up at Dundee's Ninewells Hospital:

The pie is crammed with sausage, bacon, black pudding and beans and is topped with a fried egg. It is available from a takeaway counter at the Dundee hospital.

This is a hospital, people are gloomy, ill, depressed and in need of some decent nosh - hence such a fantastic pie. But the nannies  hate it:

Professor Mike Lean, a former government advisor and chair of human nutrition at Glasgow University said it was a "shocking" example of a meal.

"It should never be anywhere near a hospital," he said. "It is laden with fat, salt and without a vegetable in sight. There should be strict guidelines for all food sold in hospitals."

And Tam Fry, the self-appointed obesity expert shouts:

"What we have here is a heart attack on a plate. It should be absolute obligatory for the NHS to have wholesome food whether it is from a takeaway shop within hospitals or on menus."

I don't get it at all - what could be more wholesome that a fry-up in a pie. At least it's not deep fried (yet).

A good view of the pie (and a fine sight it is, if not for the faint-hearted) can be seen here.
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Sorry but fortysomething drinking isn't that big a problem, it really isn't

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Dr Foster has published some not entirely helpful (indeed a tad ingenuous) statistics about drinking and our friends at the Guardian are all over them:

A total of 533,302 people in England have been admitted to hospital as an emergency since 2010 with serious health problems related to their consumption of alcohol or illicit substances. The vast majority were admissions for conditions specifically related to alcohol abuse, such as liver problems. Of those, 60,738 were aged 40 to 44 and another 60,083 were 45 to 49 – together, more than a fifth of the total. Some were admitted a number of times between 2010 and 2013.

The headlines tell us that one-in-five admissions for fortysomethings are related to booze or drugs. This is a little over 120,000 across three years. The figures don't tell us whether this number is rising or falling, nor do they look at trends in overall hospital admissions. As I said, not especially helpful.

There are around 5 million emergency admissions per year (5.3 million in 2012/13), a figure that has risen by about 50% over the last 15 years. So those 120,000 admissions of drunk or drugged fortysomethings  represent just 0.8% of emergencies. What the figures actually tell us is just how few people in their 40s are admitted to hospital - just 4% of total admissions.

What this evidence actually tells us is that alcohol really isn't the big pressure on the NHS that the New Puritans claim - it represents 9% of admissions (even on the generous definition of 'alcohol-related' used in today's NHS) and this number is set to fall in line with the long-term decline in consumption. Even this particular assessment the cost of this problem to the NHS is set at £607m - a figure that should be set against the £15,000m and more raised in alcohol taxes.

What this information really tells us is that, if anything, alcoholics, street drinkers and the most excessive consumers of booze (and Dr Fosters note that 36% of the admissions were from the poorest neighbourhoods) begin to present with crippling emergency problems in their 40s. And there's a comment from Turning Point, the drugs charity, on the Dr Fosters website that is telling:

Over 20% of admissions due to people with a drug or alcohol problem do not have a recorded GP.

These are society's drop outs not those 'mddle class' drinkers the New Puritans keep speaking of - indeed the admissions seem inversely related to social class. The poorer you are the more likely to be a fortysomething admitted with a booze problem.

It's clear to me that our response should be about better targeting of resources, focusing on those relatively few people who get into a serious problem with alcohol. Partly this is about GPs doing their job but mostly it's about us taking the resources we currently waste on nannying people without a problem and spending them instead on talking to those - especially those who have multiple admissions that relate to alcohol.

Sadly, the doctors are still proposing something that we know won't work and which merely penalises less well off responsible drinkers:

The BMA urged ministers to embrace "a comprehensive system of minimum unit pricing for alcohol, that has already been taken forward in Scotland, and improved labelling on alcohol products so that consumers understand the damage that might result from excessive consumption", as well as a crackdown on "irresponsible marketing practices".

These people really should be let anywhere near public policy-making. They really shouldn't.

There are between nine and ten million fortysomethings in the UK - 120,000 is around 1.5% of them. Let's get some focus please!

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...and they still want to save the NHS!

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Defeats me why:

According to figures released by the Office for National Statistics following a Freedom of Information request, for every patient who dies from malnutrition, four more have dehydration mentioned on their death certificate. 

We really do have a problem, it isn't about management, it isn't about doctoring - it's the system. It just doesn't work well enough.

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Sacking the boss won't make our hospitals better...

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Although getting rid of the egregious Sir David Nicholson - boss of the NHS - will make us fell better and is probably the right thing to do, it won't sort out the problem.

The problem isn't money.

The problem isn't training.

The problem isn't management.

The problem is that the NHS system requires - even urges - otherwise caring people to ignore suffering and do the paperwork.

Sadly all we've done is set on a lawyer to look at the problem. And he's done what lawyers always do, propose new regulations, new systems and more paperwork. It is inevitable that a future government will set on another lawyer to look at the same problem. That lawyer will propose new regulations, new systems and more paperwork.

Sir David is a sympton of the problem - an arrogant, self-serving symptom who had he an ounce of decency would have walked - but still a symptom. Until we end the Stalinist structure of the NHS that Sir David's role typifies, it will carry on killing people.

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The real scandal of today isn't about horses...

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Think for a minute of the hours dedicated to picking over the carcass of the horseburger scandal. Look at how every politician - left, right, loony and sane - has had a say on the matter. The worst example being the ghastly metroliberal love in between Mary Creagh and Nicky Campbell on Five Live yesterday morning - a veritable festival of bias, platitude and ill-informed judgement.

Don't get me wrong. It's a major failing of our food safety system (wait for the evidence of corruption - there's some of that involved) and the responsibility lies with retailers to ensure that they're supplying what they say they're supplying. However, no-one has died or been made ill and, since horse protein has the same nutritional value as beef protein, no-one is likely to die. It needs sorting and, so long as government's doesn't get involved (especially the EU with its corrupt entourage of special pleading and corporate interest), it will be sorted. Those big, rich retailers won't want to be caught out again.

However, while thousands of hours are spent about horses cropping up in the beef lasagne, there isn't the same attention to this:

The public inquiry was ordered after a separate report revealed that between 400 and 1,200 more people died than expected at Stafford Hospital over a four year period between 2005 and 2009.

Patients were left for hours sitting in their own faeces, food and drink was left out of reach and hygiene was so poor that relatives had to clean toilets themselves.

Where are the special Newsnight reports, the queue of politicians calling for heads on poles, the in-depth Guardian reportsand the calls for "something to be done"? Why aren't the politicians responsible for this system dragged kicking and screaming into the studio to account for how they managed to create a system so useless that it resulted in over a thousand deaths at one hospital and untold numbers at dozens of other hospitals?

Why is no-one - no think tank chap or academic - popping up on the telly or the radio saying that the NHS has failed and continues to fail ordinary folk? And why is no-one asking whether there's a better system - one that doesn't kill thousands of people with bureaucracy?

And finally, no-one asks how those "caring" nurses and doctors walked past patients starving, thirsty and lying in their own waste - and did nothing.

Forget about the horsemeat - this is the real scandal.

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A crack in the anti-smoking edifice?

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Only a small one:

Health bosses have announced they are planning to install controversial smoking shelters at the James Paget Hospital despite it being a smoke free site for more than seven years.

There are predictable exclamations of outrage from the normal culprits plus, a new entrant to the nannying fussbucket ranks, Unison:
 

And Unison, which represents thousands of NHS workers, thought health bosses had more opportunity to address the problem rather than just installing shelters.

Jeff Keighley, Unison regional director, said: “Three quarters of smokers want to quit when asked and I would expect this to be higher in health professionals and hospital workers. 

So much for looking after the workers!

There's a poll on the idea with the article too.

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No we don't, we need to give them a glass of water...

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Baroness Greengross, who used to run Age Concern, says:

The government should introduce a nationwide policy to ensure elderly patients in hospitals do not get dehydrated, a former head of Age Concern has said.

I am led to believe that there are people called "nurses" in hospitals whose job is to look after patients who are there for treatment, operations or convalescence. Might I suggest that, if those nurses are doing their job properly they will give elderly patients a drink - a glass of water, maybe a cup of tea?

However the response from Baroness Thornton, Labour's health spokesman is priceless:

Baroness Thornton accused the government of “washing its hands of a hydration policy” and called for ministers to provide “leadership”.

You couldn't make this stuff up, could you? What next, a national strategy for making beds?

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Lower than vermin - a Tory muses on "Our NHS"

A while ago I celebrated 35 years of being Tory Scum, of knowing that the ease with which Labour tribalists and, indeed, the left in general reaches for insults demonstrates the complete absence of any rational arguments in support of their contentions.

Today the passing of the Health Bill through the House of Commons has brought out another version of that insult - a version introduced by the original bigoted Welsh windbag:

No amount of cajolery, and no attempts at ethical or social seduction, can eradicate from my heart a deep burning hatred for the Tory Party. So far as I am concerned they are lower than vermin.

Well down here with the rats, life is good. At long last we are seeing the great monoliths of British socialism - a sclerotic health system, a school system that fails the poor and a planning system that favours the rich - gradually moved aside in favour of the patient, the parent and the worker.

You see Nye Bevan was wrong. Comprehensively wrong about almost everything. But this did not matter as this man could wallow in ignorance and bigotry, could opt for the insult above the evidence and could paint his opponents as evil. And his Party loved him for it. Loved him for his insults, for his uncompromising hatred of not just the Conservative Party but of Conservatives.

Men like Bevan set the tone for the manner in which Socialists debate - not just the 'lower then vermin' gibe but the genesis for "Tory scum, here we come". All this ferocious insult mixed in with hyperbolic predictions of gloom and despondency - or what the layman might term "outright lies".

The Health Bill is taking a small step - putting the tiniest of tippy-toes into the waters of freedom. Moving us a small way - not enough but a start - towards a public health service that actually serves the public well. A service that isn't hung up on the financial interests of doctors, that doesn't prosecute a New Puritan 'nanny knows best' approach and which focuses on the basic care and medical support that the public want.

And, yes, that might mean some competition. It might mean that GPs no longer had a local monopoly but must compete a little with eachother. It might mean that some treatments, operations and interventions are provided by the private sector (as an aside it seems odd that the left are so supportive of private sector abortions while steadfastly opposing private sector hernia operations). And it might mean that the numbing, duplicating, obsessive and incompetent bureaucracy that is the dominant feature of "Our NHS" begins to go. Replaced, I hope, with some customer service and maybe, just maybe, a smile or two.

I sat in a meeting at which the health reforms were discussed. Not one person there mentioned how to improve the patient experience - instead it was the same old discussion about who was chair of this and chief executive of that, how to manage and organise the process so as to sustain the same old faces round the same old tables. I came away profoundly depressed - this is the NHS that the Labour Party (and the truly awful Dr Evan Harris) want to "save". A place of favours and fixes, of discussions in closed rooms and of make-believe boards with no real power that discuss matters of no real moment.

If I'm 'lower than vermin' for wanting a public health service that responds quickly to patient needs, that presents choice where choice is right, that is accessible and flexible and that stretches the value from that inevitably limited public purse as far as it will go, then so be it. I'll get down with the rats and make sure ordinary people stand a fighting chance of getting an accountable, efficient and effective NHS.

The changes that might be coming - there's a while to go yet before they're law - aren't enough. But they are a welcome start. And I hope we will start now calling for it really to be "Our NHS" not an NHS owned and controlled by the bureaucrats and the medical mafia (including their big pals in the drugs industry).

Lower than vermin I might be. But it's good down here where real people live real lives and want a decent health service from the government they pay so richly from their meagre earnings.

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Should we 'denormalise' sport?

We’re told – rightly so I believe – that taking part in sport and exercise is good for us. However, in the spirit of understanding and, with a wry couch potato smile, I thought I’d have a look at the problems with exercise.

Back in 2005 a survey was done for “Spaces for Sports” looking at the incidence of sports injury.

New research by Barclays Spaces for Sports has revealed that just under a third (30 per cent) of the nation pick up 22 million sporting injuries per year.  The major causes of these injuries are over-exertion, lack of preparation and general clumsiness, with third party involvement and slippery surfaces also blamed. On average a person regularly participating in sport will pick up 1.65 injuries every year and will take up to five days off work or college due to incapacity and/or treatment.

Stop for a second and calculate the cost to business of all those sprained ankles, broken collar bones and ruptured Achilles tendons. Consider, if you will, the burden these selfish people are placing on our National Health Service – over a quarter of a million emergency admissions every year. Our accident and emergency departments are, quite literally, clogged with sports men and women and their injuries.

Yet we never read of the dreadful burden all this indulgence brings upon society, there are no campaigns to ban rugby or football, to stop people doing lasting damage to knees and hips by running on hard roads. Indeed we praise those super-fit individuals for their dedication, their healthy lifestyle and their sporting prowess.

Contrast this with the new assault on the couch potato – following on from attacking smoking, drinking and the humble burger, we must now condemn TV:

Dr Lennert Veerman, from the School of Population Health at the University of Queensland in Brisbane, and colleagues report their findings today in the British Journal of Sports Medicine.

"If our estimates are correct, then TV viewing is in the same league as smoking and obesity," he said.

Last year, another Australian study by Professor David Dunstan and colleagues from the Baker IDI Heart and Diabetes Institute in Melbourne found an hour of TV viewing a day led to an 8 per cent increase in the risk of premature death.

Oh dear. Not that I believe a word of this – seems like an exercise in conflating all sorts of behavioural traits and then adding a cute bit of arithmetic to get an ace headline.  TV is bad – is killing us.

The point here is that the argument – or one of them – for introducing bans, pricing controls and other nannying nudges is that these sinful behaviours cost society loads of money. We’re forever being regaled with the cost of drinking or smoking or obesity. Yet it seems to me that, for all its goodness, sport and exercise is a huge cost to society in lost work time, in treating injury and in caring for the long-term consequence of sporting injury and strain.

Maybe, for the sake of consistency, we should tax, ban or nudge sport as well – starting with the really dangerous sports such as riding horses or playing rugby and then moving to protect people playing football. More padding, less physical contact, short game time, a smaller pitch and a softer ball – these things will protect those playing and will reduce the cost to society of sports injury.

Just a thought!

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How health reform prompts innovation....

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A striking initiative from Christies:

Specialist cancer hospital The Christie Foundation Trust is considering plans which could see it open branded treatment and diagnostic centres across England, in partnership with a private sector provider.


If the proposal goes ahead, the Manchester-based hospital could become the first in a wave of high profile FTs to use joint ventures with the private sector to develop national “chains” of providers.

Chief executive Caroline Shaw said the NHS reforms offered the Christie the opportunity to use its joint venture with private hospitals group HCA International to expand beyond its regional boundaries.

And probably good news too!

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The British Medical Association talking rubbish about drinking again!

I’m going to say it because it is a self-confirming piece of research* – the BMA are at it again:

Dr Alan McDevitt, deputy chairman of the BMA's Scottish General Practitioners Committee, said: "Those who suffer from alcohol related health problems are not just alcoholics or heavy binge drinkers. By regularly drinking over and above recommended limits, a significant proportion of the adult population is at risk of experiencing health problems that are linked to the alcohol they consume whether it is high blood pressure, breast cancer or even domestic abuse.

"In just one day, nurses and doctors working in general practices across Scotland saw more than 5500 patients where alcohol had contributed to their ill health. But the patients seen in general practice are just the tip of the iceberg. The impact of alcohol misuse across the rest of the NHS, in hospitals and in our communities is far greater."

What we need to understand is that these dreadful statistics are collected by doctors and nurses. And they are rising because those doctors and nurses are told to ask, again and again, about patients’ drinking.

When my son was mugged in Bradford City centre – hit on the head with a hammer – he was taken to Bradford Royal Infirmary. And, dear reader, do you know what the first question asked of him by the nurse was (once he came round enough to answer) – you’ve guessed it: “have you been drinking.”

And, when a doctor finally got around to seeing him – and bear in mind he had a serious head injury – what was the first question that doctor asked? You’re right, it was “have you been drinking.” You see a pattern emerging here don’t you. A pattern reinforced by a huge image of a glass of wine plastered on the wall.

My son needed a specialist face doctor. And – if it wasn’t so crazy, you’d laugh – the first thing that doctor asked was “have you been drinking.”

And, since my son had been drinking – he’d been into town to a pub quiz with his mates – I’m pretty sure that him being hit on the head by a nasty thug has gone down in the books at ‘partly alcohol related’. That is why, despite alcohol consumption falling significantly over the past 10 years, we have this terrible, awful rise in ‘alcohol-related’ ill-health. It is a self-fulfilling activity – the more you require doctors and nurses to ask patients whether they drink (mostly for no good medical reason), the more you identify ‘alcohol-related’ ill-health.

And it’s not a problem for the young either – the fall in consumption has been greatest among the 16-24 age group whether you look at exceeding “recommended” limits or “heavy” drinking.

On the average weekly measure, heavy drinking is defined as consuming more than 50 units a week for men and consuming more than 35 units a week for women. In the 16 to 24 age group there were significant falls, between 2000 and 2006, in the proportion of men and women drinking heavily (from 14 per cent to 7 per cent for men and from 9 per cent to 5 per cent for women).

And the fall has continued since 2006 - even under a new methodology for measuring alcohol consumption. So perhaps one of these clever doctors could explain why it is that, with heavy drinking falling so rapidly, there is an increase in ‘alcohol-related’ ill-health. It makes no sense and I simply don’t believe a word of what the BMA are saying, not one word.

*The "study" collected and added up raw figures from just 31 GP practices - no consistent methodology, no back check, no patient data. Pretty poor really.

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