Tag Archives: health policy

Is it right to vilify homoeopathy? Sometimes. Often, perhaps. But not always.

In a brilliant article for the Guardian Tim Lott decried the intolerance of people on the left of politics. He complained that people, like him, who raised questions about gender discrimination, Islamism, feeling English or complaining about political correctness, risk unleashing intolerant invective from the “liberal” left.  He was speaking as a Labour loyalist – but I recognise the same issue in the Liberal Democrats. Now let me make my politically incorrect contribution to the genre. It’s about homoeopathy.

Homoeopathy is a branch of alternative medicine developed in the 19th Century. Its theoretical grounding might fairly be called mumbo-jumbo. But it has retained a degree of popularity, and has been available under Britain’s NHS, which supports placebo therapies in some circumstances. It is, however, a popular subject of ridicule, particularly from the liberal left. They condemn its availability on the NHS, and want it to be driven off the face of the earth. This article by Edzard Ernst in today’s Guardian is one of the more temperate ones. It follows some publicity from a recent Australian study showing that there was no scientific foundation for its claims.

Let’s clear the decks a bit. I have no doubt that homoeopathy provides cover for charlatans. And practising homoeopaths are their own worst enemies. They persist in using their outdated mumbo-jumbo explanations. According to Dr Ernst they also cite scientific evidence that is spurious. That goes for David Tredinnick, the Conservative MP who is a public supporter. People that suggest that homoeopathy is an equivalent discipline to modern conventional medicine deserve the ridicule that is heaped on them.

But there is another side to this story. Arguments over the discipline’s scientific basis miss a point that should be understood by everybody. Scientific evidence will only ever get our understanding of the world around us so far. Much knowledge is simply beyond its reach. Homoeopathy may not be an alternative to modern medicine, but it may enter space that modern medicine cannot go.

Conventional medicine it is bound up with the idea that people suffer a series of different ailments, and medicine’s job is to find and test therapies for each of these ailments in turn. These ailments are further described in turns of measurable chemical or biological imbalances. The therapies are likewise usually chemical or biological agents – though other therapies may be admitted so long as they are standardised and repeatable. This line of approach (which I like to call the “magic potion” method of medicine) is extremely powerful. It goes alongside a system of evidence gathering  that allows you to place a tick or cross against each therapy. The standard is whether or not the symptoms are alleviated against an alternative “placebo” treatment which uses chemically inert substances. Through this approach medicine has developed a formidable inventory of magic potions over two centuries and prolonged many, many lives.

But it will take you only so far. Now take two places where homoeopathy might help to provide patients with relief. The first is what might be called “mind over matter”. It has been demonstrated countless times that mental outlook can affect symptoms. This phenomenon accounts for the placebo effect.  Scientists do everything they can to eliminate its effects from their evidence. So if homoeopathy is an effective placebo, the scientific studies wouldn’t show it. This is something Dr Ernst’s article is quite careful to state (“no effect beyond placebo”).  Of course there is danger if a patient is persuaded to use a placebo when something else is more appropriate – but not to treat a patient with a placebo when this might be effective also poses an ethical problem. Or it should. Conventional doctors often use antibiotics to treat viral infections; this is surely a much more questionable practice.

The second way homoeopathy might work is holism. Homoeopathic practitioners should (even if many don’t) look at the patient’s complete circumstances – from  the complete range medical symptoms to anxieties and outlook on life, before selecting a therapy that is individual to that patient. This is another place that scientific method cannot go. It cannot produce the sort of repeatable results that science requires – because everybody is a bit different. That still leaves therapies depending on placebo effects, but it could give that effect extra oomph. One of the causes of disillusion with modern medicine is that patients are treated as disconnected symptoms parcelled out to different specialists, with  obvious things (like what the patient eats in hospital) often neglected. Puzzling symptoms are overlooked to focus on ones more within practitioners’ comfort zones. There is much talk of patient-centred medicine, but remarkably little practice. That may be because building up an appropriate evidence base is impossible.

To my mind that leaves space for an ethical homoeopathist who is no simply trying to peddle expensive but inert magic potions. Modern medicine can’t be beaten in the magic potion business. But when it comes to treating mind and body as part of the same human being and looking more widely on how to advance that human beings health and wellbeing – modern medicine does not look so hot.

 

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The NHS: how the accountants are hiding dubious policies

The NHS is quite high up the news agenda these days. From the media there seem to be two big issues: culture and privatisation. The mainly right-wing press say that much of the NHS lacks a caring culture and this often leads to a breakdown of service. Left-wingers, and NHS insiders, worry about the new commissioning rules, and whether unscrupulous private companies will bid their way into contracts that destroy what is good about the service. These are both valid concerns, but a third issue should be causing more controversy than it does: funding. Not so much the NHS’s overall budget, though that too is worthy of debate, but how it allocates what it has. Recently the Health Service Journal has highlighted no less than three quite distinct issues on the topic. Politicians should be paying attention.

The first was an opinion article on 14th February by Robert Royce, a visiting fellow at the King’s Fund, the health think tank. His subject was the Mid Staffordshire Foundation Trust: but not the Francis report, but the preceding report by Monitor, its regulator. This report questioned the trust’s financial viability, suggesting that the hospital lacked scale. Hospitals like Mid Staffs are funded mainly through something referred to as “the tariff”, and which used to be called by Orwellian name “Payment by Results”, which was put in place by the New Labour government. This puts a price on every service episode the hospital performs: payment by activity, rather than by results. This system is often portrayed as being a commercial, market type discipline, but the tariff looks like no market tariff that I have ever seen. It is massively complicated, requiring big information systems resources to work.

What the tariff does remind me of is a transfer pricing system to allocate costs internally between two fractious units of the same organisation, who hope that by referring the problem to management accountants they can find an objective resolution. As the accountants grapple with the complexity of the problem they add layer upon layer of detail, in a hopeless quest to replicate the infinite complexities of real life, resulting in something which is nearly useless for management purposes. The system is designed for a political rather than a commercial environment, with the aim of pretending that strategic value judgements are mere technical problems. In the NHS almost all commentators go along with this pretence.

Mr Royce points to one pernicious value judgement in the tariff. It is that emergency services are bad, and elective services are good. Mid Staffs is perfectly viable financially on its elective services, but is being dragged down by losses on its emergency services. What if the tariff were raised for emergency services and lowered for elective, to genuinely reflect the underlying costs? The the hospital’s viability might look altogether different.

The second article was in the magazine’s “Resource Centre” section on 14th March, and is entitled The real reason for “failing” hospitals. It is by Sheena Asthana and Alex Gibson from Plymouth University. This is dressed up a piece of academic data analysis, but it is politically pointed. The authors look at the funding formula for Primary Care Trusts (PCTs: the bodies that fund the hospitals, at least until 31 March), and tries to correlate troubled hospitals and underlying population characteristics. They find that there is a strong correlation between hospital stress and a high proportion of older people in their catchment area. Their claim is that the funding formula is diverting financial resources away from these areas of greater need towards areas that are less wealthy – and this is the fundamental reason why so many hospitals are failing.

The last government was obsessed with addressing “health inequalities”, an expression that I hate because it implies that the solution is making things worse for the better off, rather then improving the lot of the worse off. And if Ms Asthana’s and Mr Gibson’s study is to be taken at face value, that is exactly what is happening. The present government show no sign that they want to address this awkward issue, and, according to the authors, much the same allocation is being ported into the new system.

The third article was another opinion article, this time by accountant (sorry, independent consultant and former NHS finance director) Noel Plumridge on 21st March. This looks at something that has been bothering me. If the NHS budget is protected, and increasing at a rate faster than most people’s pay is rising (2.6% as against 1%), how come so many NHS organisations are under such financial pressure? He finds the figures for next year’s budget less than transparent but concludes that there are no plans to spend a large chunk of the money at all: they are destined for unspent surpluses or contingency funds to “mitigate risk”. These surpluses are a point of difficulty: the individual trusts that make a surplus are supposedly allowed to reinvest them in future years. But under Treasury rules the NHS as a whole must hand the funds back to the Treasury for good. Is this just a backhand way of breaching the promise to ringfence NHS funding?

I only subscribe to the HSJ because I forgot to cancel it after my attempt to find a job in the NHS ended in failure – now I find interesting articles nearly every week. What these three articles show is that there aren’t enough accountants in politics. NHS leaders are being allowed to get away with some highly contentious political policies by dressing them up in complicated accountancy.

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My heart attack

Last Monday, three days ago now, I lay, conscious, on an operating table at St George’s hospital, Tooting.  A tube had been inserted into my artery in the right arm at the wrist, through which dyes and then wires were inserted.  On my left wrist a drip had been inserted into vein so that drugs could be injected rapidly.  Two surgeons were doing their stuff around the area of my legs, looking up at two monitor screens.  A large cylindrical  device was being pointed at my chest at various angles.  I lay as still as possible, as the surgeons exchanged comments and gave occasional orders to technicians outside the room, who would respond over the intercom.  Some music was playing quietly in the background.

The surgeons were doing an angiogram.  They were pumping dye into my bloodstream to make the blood flows visible through an X-ray camera and spot any problems with the blood flow to my heart.  And they did find a problem.  “One of your arteries is completely blocked.  This almost certainly caused your heart attack,” one of the surgeons said to me, “We want to insert a piece of wire to clear it.”  I consented.  The surgeons then completed a procedure known as an angioplasty.  This involved using a piece of wire pushed through my arteries to insert an stent, a small length of tube, into the blocked bit to open it up, after first inflating a small balloon to create the space.

It was really only then that I fully realised what had happened – that I had indeed suffered a heart attack, and that as a result my life was in the hands of these two surgeons and their team.  Until then I had thought the problems might be some sort of viral attack (as my elder brother had suffered a few years before) with few longer-term implications.  The previous evening, my family visitors remarked on how well I was looking – though the medically literate among them could spot the abnormal trace on the heart monitor that I was wired into.  This is a shock.  I had no indication until then that I was at risk.  I take regular exercise; I’m not overweight; I have never smoked; I eat my five a day; I even make sure I have a couple or more portions of oily fish a week; my blood pressure has always been normal; no tests that had been run on me had shown me with anything other than a very healthy heart.  It really can happen to anybody.

The problem seems to have started over two weeks beforehand, while we were on an organised tour of Sicily.  One night, after dinner, and a day when I had felt slight constrictions to the chest area, I started to suffer acute chest pains.  I couldn’t sleep.  Eventually, at about 3 or 4 a.m I took some aspirin, and the pain subsided and I got some sleep.  I was puzzled at what had caused this episode.  The chest pains pointed to a heart attack, but none of the other symptoms did.  I wasn’t breathless, I could carry out normal physical activity.  As the pain subsided, the idea that it was severe indigestion took hold.  Gavascon seemed to help with the contuining mild episodes of pain.  The local diet can be pretty acid.  The day after the attack I had no trouble in climbing to the top of a stone tower to get a wonderful view of the western Sicilian coast.  The next day, though, I  felt lethargic and a bit feverish, collapsing into my hotel bed for an afternoon; but a couple of days after that things seemed to return to normal.  We continued with the tour, returning home at the end of the week.

The episode has was scary enough for me to go to my GP in the week after we returned.  I probably wouldn’t have done this had my wife not insisted on it, though I had noted that my fitness at the cardio-vacular exercises in the gym had fallen rather sharply.  My GP tended to agree with my diagnosis of acute indigestion, as he would have expected that a real heart attack would have had more of an impact.  But he did recommend that I did some blood tests.  This I did last Friday morning, at 8.30 a.m.  By midday my GP had rung me to say that one of these tests had revealed a high troponin level, indicative of heart problems.  He recommended that I go to St George’s A & E to get an ECG (electro cardiogram – where they put a dozen electrodes on your skin and get traces of your pulse).  This I did straight after lunch, expecting to be home for tea.  But the ECG showed an abnormal trace.  I was admitted to hospital, hanging around in A & E while a bed was cleared.  The next step was the angiogram – but that couldn’t be run until Monday.  Meanwhile I was kept under observation, with a cocktail of drugs administered by tablet and injection.

Now I am at home in rehab, recovering from the damage to my heart from the blocked artery, and the operation itself – but the prospects for a full recovery are good.  But I’ll be on pills for a long time, probably for the rest of my days.  At the moment there are six different sorts of pill, but it should come down to less than that after a year.  My fitness regime will have to be adjusted downwards so as not to place too much strain on the heart.  I am quite lucky though, first that the original attack did not do more damage, and second that the problem was picked up before the blockage to my artery caused more damage to the heart and maybe a more serious attack.

Why me?  I don’t hit any of the main risk factors – except that I was not avoiding cholesterol in my diet.  In fact I was a heavy cheese eater, and relished meat fat and chicken skin.  That will now change.  But some peple are just more at risk than others.  My physical fitness may have helped reduce the effect – though a bit too well if it had meant that I had avoided having it checked out.

It is customary at this point to praise Britain’s NHS and scorn its critics.  I will try and be a bit more objective, after my close observation of the service at work.  But it doesn’t come out badly.

Firstly I am immensely grateful to all those many professionals that helped me through the episode.  I always felt that they had my interests at heart and they did their best to help me.  Nurses, doctors, technicians, pharmacists and surgeons – I can’t fault any of them.  I now have very benign feelings towards St George’s hospital, which happens to be my local one – from being a rather anonymous presence beforehand.

Second I cannot fault the overall effectiveness of what the NHS acheived.  From the point of that blood test a system was quickly kicked into action that was appropriate at every step, acheived the right outcome, while managing the risks properly.  And at points the service was better than good.  The surgery was world class; the briefing from the cardiac rehab nurse afterwards was also deeply impressive.  The speed with which my blood sample was analysed and acted on was very impressive too.

Effective, yes, but how efficient?  Here I was left with a few question marks.  I ran into an awful lot of different professionals in my journey, having to repeat my story to up to ten different doctors.  This is a warning sign from a process management standpoint – though the need for specialists, 24 hour cover and risk management does not make the matter easy.  And there was an awful lot of paper records and documents.  It isn’t surprising that there were communication breakdowns; I’m still waiting for my discharge papers.  And the whole thing about the service going on hold for the weekend does not feel right either.  At least one, and probably two nights of my four night stay were clinically unnecessary.  Room for improvement, I would say – and that matters in a tax funded system where overall resources are subject to arbitrary limits.

It is clear though that I was much better off under the NHS system than I would have been under the US one, especially before Obamacre kicks in.  I would not have qualified under any of the government funded schemes, and neither would I have been covered by an employer plan.  I would either have to to have bought my own insurance plan, which would suddenly have become a lot more expensive.  Or I would have to have winged it without insurance, which would have landed me in serious trouble.

But then very few people outside the US think that their system is in any way sensible.  A universal insurance scheme, like most advanced countries run, would have caused a little more bureaucracy at the start of my hospital visit, but nothing very burdensome.  And I don’t believe that health professionals would be any less caring or professional if they were not working for a state provider.  Neither do I beleive that the vagaries of private sector management are any worse than the arbitrary resource management of a nationalised, tax-funded system.

But the NHS did do the job it was supposed to do.  And for that I am thoroughly thankful.

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Why healthcare may grow to 50% of GDP and still be affordable

I can’t over-emphasise how important the concepts in this article in last week’s Economist are: An incurable disease, and I would urge my readers to try and get to grips with it.  If you want to understand how our economy is changing, and the implications for public services, the idea it describes is critical.  It ranks alongside Ricardo’s law of comparative advantage (gains from trade) and Keynes’s multiplier (fiscal policy) as a counter-inituitive idea that explains so much.

What it describes is something usually referred to as “Baumol’s cost disease”, and reviews a book by the eponymous William Baumol, “The Cost Disease: Why Computers Get Cheaper and Health Care Doesn’t”.  It stems from the observation that productivity grows in some parts of the economy faster than in others.  The paradox is that the more productivity in a sector advances, the smaller its share in the the economy at large.  Thus agriculture used to dominate the economies of the current developed world – but as agriculture became more productive, it needed less people and so shrank to a negligible propertion of GDP – while generating ever larger larger quantities of agricultural produce.  The same effect is clearly visible in manufacturing industry – producing more goods than ever, but from a shrinking workforce.  The more these areas advance, the bigger less productive sectors bulk in the economy as a whole.  It is, misleadingly, referred to as a “disease” because these less productive sectors, within the service economy, then act as a drag on economic growth as a whole.  It is not in fact a disease, but a symptom of success.  The failure of economists to understand the difference between creating wealth and realising it (i.e. turning that wealth into something that actually benefits humankind) is one the biggest failures of the dismal science, and it is a shame that Mr Baumol perpetuates it in the title of his book.

The most important of these unproductive services are healthcare and education.  Personal contact go the very heart of what these services are: to succeed these services must accept that people are individuals, and that a solution which works for one person may well not work for her superficially similar neighbour.  But, while productivity grows only slowly, if at all, costs, i.e. rates of pay, must reflect the increased productivity of the economy as a whole.  So costs advance faster than productivity.  Sound familiar?  But this only happens because we can afford it.

The eye-catching claim in the book is that on current treads healthcare will take up 60% of the US economy in 100 years, and 50% of the UK one.  But this is all paid for by the fact that other parts of the economy have become more efficient – and in fact it only takes up such a large part of the economy because these parts of the economy have become more efficient.  Actually this projection is a bit silly.  I think the advance of conventionally measured productivity will slow, as technological change now affects quality rather than quantity.  Also other sectors of the economy will reverse productivity as people value personal content more (think of the return to craft food production).  But it is rather a good way to make the point.

Which means that the challenge with healthcare and education is not that growing costs are unaffordable, as various right-wing types claim, but something much more subtle.  There are three issues in particular:

  1. A lot of healthcare is indeed inefficient, both in the UK and the US, and political pressure must be brought ot bear to address this.  But don’t expect it to halt or reverse the share of health costs in the economy in the long run.  The NHS “Nicholson challenge” in the UK may therefore be a valid policy goal, but it will not solve the long-term funding needs of the health service.
  2. The larger the share of the economy healthcare takes up, the more difficult it will be to fund it entirely from tax.  In the UK this either means that a parallel private sector will flourish and undermine the NHS (as has already happened in dentistry), or that the NHS will need to be a lot less squeamish about co-payments.
  3. There is a temptation for the owners and workers in the highly productive parts of the economy to keep the rewards to themselves, creating inequality and undermining public the public sector.  And yet we still want productivity to advance so that we can all afford a higher standard of service.  Higher taxes are part of the solution, but only part.  Again this points to the fact that a higher proportion of healthcare (and education) services will have to be delivered and paid for privately – allowing the remainder of the public services to pay decent wage rates.

I hope that provides food for thought!

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Affording the NHS

The British government has been talking darkly about the exploding demands on the National Health Service, which will rapidly make it unaffordable if it is not reformed.  This has recently been challenged by Professor John Appleby, at the health think tank King’s Fund.  This was in a recent article in the British Medical Journal, behind a paywall, but summarised by the BBC here.  This question goes to the heart of health policy in the UK, but politicians dare not discuss it – because it puts the very principles of the sacred NHS in question.  But the problem will not go away.

According to some figures on Wikipedia Britian spent an unremarkable 8% of its national income on health, compared to over 16% in the US, before the financial crisis struck.  Those figures will be higher now, since our income has shrunk, but the relativities will be much the same.  The comparison between the two countries is usually held up to show how ineffective US health spending is, since health outcomes look generally pretty poor there.  But the comparison can be looked at the other way.  The US can afford to spend more than 16% of its national income on health and still remain one of the most prosperous countries on the planet.  There is nothing mysterious about this.  Developed countries are long past the level where basic human needs of food and shelter are met; how we choose to spend the surplus is up to us, and there is no reason why we can’t choose health care over cars, designer clothes or big holidays.  It’s not as if it requires massive imports to sustain it.

You can take this line of reasoning further.  The basic proposition of health care is to reduce pain and prolong life; these are consumer propositions to, well, die for.  Suppose we lived in the economist’s free market utopia, where health spending was a matter of individual choice in a perfectly competitive free market with no information asymmetries.   There is no reason to think that health expenditure would not be higher than the 8% or so we currently spend in Britain, or indeed as high the US figure.  We can perfectly easily afford it.

That’s not the problem.  The problem is paying for it almost entirely through unspecific taxes, the core design principle of the NHS.  And here the government is on much stronger ground.  There is an upper limit to how much tax we can raise for health care.  Up to a certain point, of course, the NHS model works perfectly well.  Look on the taxes as an insurance premium and it helps spread risk in a way that people like.  But the more you spend, the more the weaknesses of the model are exposed.

  • There is no direct line of sight between what you pay and what you get.  How on earth are you supposed to decide whether you are getting value for money?
  • You have no choice in the level of service you get.  One size fits all.
  • People who are better off may feel that they are paying too much relative to what they get.  This may not be quite as strong an argument as it first appears, since the less well off pay a lot of tax through cigarettes, alcohol, petrol and VAT – but the perception is still a problem.
  • Taxes create a drag on the rest of the economy, reducing incentives to work and therefore shrinking the resources available.

America is able to get away with much higher levels of health expenditure because so much of it comes from private insurance premiums and direct private payments for treatment.  But even there a battle royal is developing over how to balance taxes and government support.

Of course, to some putting up taxes is the right way to go.  France and Sweden get away with higher tax burdens than the UK after all.  But this is very fraught.  Some think you can go after big companies and very rich people and leave everybody else.  This is not as easy as it sounds though, since this wealth is very mobile.  Property is not mobile, of course, but raising taxes on property is probably as politically toxic in Britain as taxing fuel is in the US.  There is also a problem if too much tax revenue comes from the very rich or corporations – these start to acquire more political weight.  Which leaves the not-so-rich.  But these people are under pressure and feel over-taxed – Ed Miliband’s “squeezed middle”.

So I think the government is right.  We have hit the limit of what the country can afford for tax-funded free-at-the-point-of-use health system.  But we have not hit the limit of what people are prepared to spend if it’s their own money and for their own benefit.  The risk to the NHS is that the more affluent middle classes start to opt out of NHS services, depriving them of critical mass and undermining the principle of social solidarity.  This has already happened to NHS dentistry.

Nasty.  In the last years of the previous government the issue of co-payments was quite high up the political agenda: the possibility of NHS patients topping up their treatments with their own money to get things not on the basic menu.  This had become politically charged because of the costs of some rather questionable cancer treatments which the NHS were denying but which people were prepared to pay for.  The Conservatives clearly considered the topic politically toxic, since they have fudged the issue of cancer treatments with a bit of extra funding.  Labour and the Lib Dems were inching towards accepting co-payments, though I expect both parties are now bouncing back.

But in my view co-payments is the best way to relieve the pressure.  The NHS should define a basic menu of treatments that everybody is entitled to, but accept payments for anything outside this.  This undermines one of the sacred founding ideas of the NHS, that everybody gets the same, no matter how wealthy.  But it is better than the alternatives.  It’s the debate we should be having.

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Why are NHS managers so unpopular?

Health Service Journal (HSJ) was on its high horse last week.  Its front cover says “The Big Lie exposed: the truth about NHS management”.  The proximate cause is a report by the King’s Fund called The Future of Leadership and Management in the NHS.  This report suggests that the NHS doesn’t have too many managers, and that, if anything the service is under-managed.  The HSJ is directed at NHS managers, and it is easy to see why they are so fed up.  But the HSJ coverage has a blind spot.  It doesn’t ask how the NHS got itself into this situation, and why NHS managers have become politically toxic.  It’s no use waving around King’s Fund reports; if NHS managers don’t understand of this, they will struggle to reverse it.

But let’s clear the decks first.  The idea that the NHS has too many managers as opposed to those “front line” staff is silly, and the political target to reduce their number is at best unhelpful and at worst positively damaging.  In order to deploy those front-line resources most effectively, they need to be properly managed.  Huge strides have been made by the NHS through more and better management over the last couple of decades.  Furthermore, my impression of the quality of NHS management is that it is easily up to the same quality as the private sector.  That, of course, is not as much comfort as it might be, given that crass management is pretty rampant in the private sector.  So a lot of the political comments made about NHS management are unjust, unfair and often just plain untrue.

So what’s gone wrong?  Well a clue comes in the frequent use of the word “bureaucrat” by politicians.  This is a word thick with negative connotations, of insensitivity to people’s real needs and of the arbitrary exercise of power.  Many of the public’s interactions with NHS management have left just this sort of impression.

The NHS is a hierarchical organisation, with pretty much all accountability through a single man at the top, the Secretary of State.  To most people this is no accountability at all.  One man can’t possibly grasp the intricacies of any particular local situation.  So local NHS officials have huge amounts of effectively arbitrary power.  And they rub our noses in it.

When the local NHS where I live executed a 180 degree turn and decided to close a local hospital rather than develop it, they rode roughshod over local feeling.  A local official just told us the area was too posh to have a hospital.  After a kerfuffle involving the local Labour (at the time) MP, more facilities were promised nearby in an appropriately less posh place – but of course these were soon cut, even before last year’s election.

The problem for most NHS managers is, I think, that they don’t remotely get what the problem here is.  Tough decisions have to be made.  If we followed local opinion all the time the NHS would go bust in days; if we kept consulting nothing would get done.  We have clear mission and we execute it.  NHS managers seem to bristle at the idea of genuine local accountability.  HSJ itself opposed the Lib Dem proposal of directly elected health boards.  Chaos.  Postcode lotteries.  Working for people that don’t understand.  And so on.  NHS managers are all too happy with their hierarchies, allowing them to pass the blame upwards the whole time.

But the local NHS is taking political decisions all the time.  For example, reducing health inequalities, a key local NHS objective, is loaded with political judgements.  A key political objective is to maintain middle class consent for the service; without middle class users the NHS would collapse (and we already have the example of NHS dentistry to show that).  So treating them like muck because they are on the wrong side of the equality equation should be a no-no.  Politicians can see that easily; bureaucrats can’t – it’s just not their problem.

And once you are perceived as an insensitive bureaucrat, the rest follows pretty quickly.  An organisation as large as the NHS will always throw up examples of crass management, which will be gleefully reported by patients and clinical staff alike.  And if managers are overstretched, they are bound to drop some balls too.  Episodes such as the Mid-Staffs fiasco add grist to the mill (and incidentally I did not sense much outrage from other NHS managers in the HSJ coverage of that sorry affair).  Throw in the management consultant blather dropped on the NHS (World Class Commissioning and such), and you have a massive stock of ammunition.

So NHS managers need a lot more political sensitivity, and should welcome more genuine political accountability instead of resisting it.  The NHS reforms are meant to help this, though whether do, of course, is another matter.

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NHS reform: we’ve started so we’ll finish

The NHS, probably rightly, is one of the main controversies in current British, or rather English, politics.  The Coalition government has put it there after Labour, by dint of a massive increase in spending, had managed to take most of the heat out of the debate, bar a few controversial hospital closures.  Personally I am a bit perplexed.  From one side I am being constantly lobbied by the Social Liberal Forum, a Lib Dem pressure group, to express disapproval of what looks like almost the entire reform process.  On the other side is 18 years experience as a business services manager, reinforced by my regular reading of the Health Service Journal (HSJ), the weekly magazine aimed at NHS managers.  This takes the need for reform pretty much as read, almost on a continuous basis – and gives me an inbuilt suspicion of people who resist change.  Partly because I have been trying to get a management job there, I am better informed than most on the NHS; but I have found it very difficult to make up my mind.  Will writing a blog post help me?

First, let’s understand that there is something of a crisis in the NHS.  The figure of £20 billion of savings required by 2015 is widely accepted as a fact.  This is quite interesting.  The figure first emerged a couple of years ago from a leaked McKinsey report, which the government tried to deny.  But it is a now central theme of NHS Chief Executive Sir David Nicholson’s management.  But the NHS’s budget isn’t being cut: the Coalition is protecting it in real terms.  In response we get some rather airy stuff about the increased demands on the NHS from an ageing population, medical inflation and suchlike.  But if we are cutting £20bn, we must be adding the same sum back somewhere – but we aren’t being told where.  I have a dark suspicion that a lot of it is about large PFI rents coming back to haunt us from all the capital investment of the last decade, though I’m not sure if that quite adds up either.  I find it strange that so little is being said about this.  It has the signs of a manufactured crisis to inject a sense of urgency across the organisation.

If so, then I don’t particularly disapprove.  There is a massive inertia about the organisation, with almost any change proposal meeting outraged resistance.  When I reflect on my career as a manager in the private sector, we were in an almost continuous state of crisis.  As a result we pushed through change after change, so that after 18 years the business had been transformed out of recognition both in efficiency and business model.  This was the result of simple competitive pressure.  Such competitive pressure is largely absent from the NHS, so Sir David’s success in stoking up a comparable level of crisis is to be commended.  It is clearly helping him deal with the resisters and rally supporters of change.

There seem to be two main challenges to the government’s reform strategy.  First is along the lines of “we don’t need this” – it will disrupt the process of making the £20bn worth of savings.  The second is that the reforms themselves are wrong, because they will “privatise” the NHS.  The answer to the first depends to a great extent on how convinced you are that the previous government’s infrastructure was up to the job.  This rested on three levels of organisation to commission services from a series of notionally independent providers, in turn answerable to various parts of the bureaucracy.  It is easy to think that this was over-complicated, but the three levels (national, regional and district) have a resilience about them; the NHS seems to revert back to such a structure every time people try to cut a layer out.  A more valid criticism is that the system is accountable only upwards, to the Secretary of State, meaning that managers spend too much time managing their chain of command, and not enough on the patients.  Another criticism, which may follow from this, is the sheer volume of management blather that the system generated.  Heaps of guidance, toolkits, methodologies, procedures, silly names, acronyms, and such.  The commissioning framework was called “World Class Commissioning” and involved developing eleven competences, progress on which had to be reported up the system.  This sort of thing is a charter for mediocre management.  People who manufacture millions of words that somehow don’t get to the point.  A particular worry is the lack of management with any clinical experience, and a failure to integrate clinicians into management generally.

To many this management structure was incapable of driving through the change needed, except in a few lucky pockets.  The blather merchants would succeed in populating scorecards with green spots and burying their peers and seniors in verbiage, but be unable to deal effectively with entrenched resistance from clinicians, and politicians nervous about reactions to reconfigurations.  To these critics it was essential to tear this structure up, while trying to salvage some of the best bits.  I wasn’t so sure.  I would have opted for keeping most of the infrastructure intact but bringing local political accountability into the picture, while trying to cut back on some of the thickets of blather.

But it’s too late now.  Many managers have lost their jobs; many more face the prospect of their job disappearing an uncertain future.  The damage has been done.  Far reaching reform may not have been the best idea, but we must capitalise on the current fluid situation to create something that works better than the previous version.  This may well slow down the march towards the £20bn savings in the short term – but maybe these savings aren’t quite as urgent as it suits many to claim.

But are the reforms going in the right direction?  I’m nearly up to 1,000 words already.  this is a topic for another day.

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