The NHS: What is to be done?

Dr Rant has been thinking. He’s taken a holiday and thought about some of the comments made by various “anonym users” and feels he needs to respond positively to one of them. This blog is mostly run on reactive criticism, and there’s no shortage of rubbish against which to react e.g. Patsy on choice in delivery suites and the Mail’s misleading report here . But he’s looking beyond such rubbish today.

As anonymous has said eventually you have to stop criticising and suggest positive alternatives. So in this piece I want to do just this.

(And I do wish anonym users would at least number themselves off so I know if there were one or more voices on the blog! I’m more mellow now though as the olanzapine works very well, thank you, and Dr Rant has at least 11 voices in his head!)

Now any argument is usually made in two parts, namely what is wrong with what has gone before and what is right about what is to come. Philosophers (and bloggers) are much stronger at criticism of what is wrong than they are at saying why what is right is so.

To get the NHS right we first need to stop several things. These have been discussed on here before and it is sufficient here to say that,

The NHS needs to stop:-

-Patsy Hewitt
-Tony Blair
-Gordon Brown
-Andy Burnham
-Liam Bryne
-Lord Hunt
-Sir Liam Donaldson
-Spin doctors being preferred to medical doctors.
-Wasting money on PFI
-Wasting money on management consultants
-Wasting money on managers
-Wasting money on redisorganisations
-Wasting money on computer projects
-Wasting money on useless wheezes such as walk in centres, "">independent sector treatment centres
-Wasting money on stillborn administrative idiocies
such as practice based commissioning and payment by results (which are arcane concepts, even to their authors.)
-Wasting money on useless ideas such as “choice” and “choose and book”
-Wasting money on NHS direct
-Wasting money pandering to the “worried well” rather than those who are sick
-Wasting money on clinical governance
-Wasting money on arm’s length QUANGOS such as NICE and NPSA and the modernisation agency
-Wasting money on unused and unwanted “guidelines”
-Wasting money paying out negligence claims
-Wasting money and peoples’ lives in useless schemes such as MMC and MTAS
-Wasting money training midwives and physiotherapists for no jobs at the end of their courses
-Wasting money on non jobs such as “five a day eating co-ordinators”
-Wasting time on meetings that reduce hours to minutes, and their participants to tears.
-Listening to people who pretend to know something about healthcare but actually don't
-specifically Alan Maynard, Julian Le Grande, Paul Corrigan, Simon Stevens, Alan Milburn, Lord Warner, and the false expertise of spinmeister management consultants.
-Stop pretending that it can deliver all healthcare to all people
-Stop pretending that patients can have whatever they want
-Stop pretending that the NHS is in any way “patient centred” or “patient focused” (It isn’t, never will be, and never should be for reasons I’ll demonstrate in a future rant)
-Stop dealing with well people.

I predict that if we stop squandering money on the useless activities listed above we might find we have some spare money to use on developing a functional NHS.

The tragedy of the current NHS is that all the activities listed above and all the people employed in them could be sacked immediately and the organisation would get better, rather than worse.

There is much deadwood in senior NHS thinking and we’d be healthier as patients, as doctors, as taxpayers, and as a country without them. The tragedy of seeing all the billions of pounds in the NHS being wasted on the crap listed above breaks Dr Rant’s and the RCN's heart.

A map of what a functional NHS would look like:-

Dr Rant is a keen hill walker with over 200 Munros to his credit. He loves the detail of maps and knows well how to read them. He also knows Korzybski’s great statement, “The map is not the territory, it is a representation of the territory and useful in so far as it corresponds to the territory.” Dr Rant has stravaiged across many miles of NHS territory and knows well both the clarity of the sunlit uplands and the mess of the boggy valley bottoms in which most NHS work is actually done. Too many of the people who presume to advise on how to run the NHS work only from the sunlit uplands and have never had to deal with the messy mixed social and medical lives of real patients, hindered by late communications, inadequate information, shortage of time and resource that combine to make the average day spent treating patients harder than it need be.

There is no current map of what a functional NHS would look like. I now need to draw one and from this move to propositions for what the NHS needs to do to move towards becoming a functional co-ordinated healthcare provider.

1. I think we need to be realistic about rationing. The NHS is a great system as far as it goes. However at root it is a £1500 per person per year compulsory insurance scheme. This will buy a certain amount of healthcare, but will not buy everything. No insurance can cover everything or buy everything, and all policies have exclusions. To pretend the NHS can do otherwise is misleading and logically futile. The NHS has sloughed off most dentistry, most chiropody, most long term geriatric care and most infertility treatment into the private sector. The promise of “Cradle to Grave care” begins to look ever threadbare, and the mendacity that goes into maintaining the fig leaves of cover intact is a waste of energy when the truth could set us free. We here includes patients, health professionals, taxpayers and politicians.

2. I think we need to realise that market mechanisms are anathema to any health service, and increase transaction costs rather than health gain. Julian Tudor-Hart has shown this by his life and work summarised here and here

The Dr Rant Foundation contains various shades of political opinion but even the bluest of them retain great respect for Dr Tudor-Hart’s vision of the NHS. Conservatism is often presented as favouring accumulation of personal capital (think “loads a money” pastiches from Harry Enfield, but then think Goldman-Sachs $16 billion bonuses under Labour!)

However Conservatism must of necessity value social capital as well, and although personal wealth is nice private affluence and public squalor is an unappetising combination. Health is one of the pillars of social capital, and extremes of income inequality such as those seen within USA and UK are actually very bad for health, both for the rich and the poor. Michael Marmot summarises the relationship well in Status Syndrome. Any health scheme must deal fairly and equitably with all members of society. It must do this on the basis of pooled risks.
To do other is a denial of justice

And the Biblical injunction is very clear, both in Old and New Testaments:-

“He hath shewed thee, O man, what is good; and what doth the LORD require of thee, but to do justly, and to love mercy, and to walk humbly with thy God?” (Micah 6:8)

And

“Heal the sick, cleanse the lepers, raise the dead, cast out devils: freely ye have received, freely give.” (Mat 10:8)

Providing a just health service is a deeply held moral imperative, derived from Judeo-Christian tradition, but few humanists would demur from this ideal. The current NHS reforms take us further than ever away from this ideal.

3. We need to distinguish between remedial treatment of disease from health generation and promotion (Salutogenesis) We should have a government ministry for salutogenesis, but the Department of Health should not be it. Doctors are experts on disease causation, diagnosis and treatment, and are rarely expert on health. The medical enterprise is devoted to remedial treatment of illness and disease, and this does not usually generate health, it simply returns a patient to the status quo ante, (at its best) and stops the progress of disease (sometimes) The NHS and the medical profession should focus on treating genuine illness and should resist attempts to increase its remit beyond this aim. There’s enough in this remit to keep doctors and patients busy. The current NHS is really not even achieving this core role adequately yet as some of the links above demonstrate.

The creeping medicalisation of all life is a form of madness that we will live to regret.Petr Skrabanek sounded the alarm, and I will sound it again now.

4.The NHS needs to work better across its interfaces. This might seem basic, but it is so basic that management consultants recommend sacking hospital secretaries and hospital executives are stupid enough to follow the advice. As Mayur Lakhani says, “interfaces of care are dangerous places for patients” and in the NHS the casually poor communication between primary care, secondary care and psychiatric sectors is a major failing in our care of patients. Simply getting these people to talk more to each other would vastly improve the running of the NHS. It would be good for both doctors and patients, making life easier, safer, and more enjoyable. I can write this piece and post it edited properly within 24 hours. You can read it anywhere in the world straight after. Meanwhile Dr X is writing to me today in my local hospital 3 miles away and the letter won’t arrive at my surgery until about 2-3 weeks later.

5. Access needs to be better. The current pattern of opening hours and clinic scheduling is about as modern as Jurassic Park and the graphics are less good. This doesn’t mean the same doctors working longer hours; it means the same doctors working rescheduled hours. An inaccessible service might as well not exist as far as its patients are concerned

6. Referral pathways need to work well both to get necessary referrals dealt with quickly and just as importantly stop unnecessary referrals from being made.

7. The importance of primary care needs to be appreciated. Barbara Starfield shows just why this is so. (Full essay on her contribution to come) The key thing to say here is that the patient’s care must be continuous through time, and through healthcare sectors. Systems that have well focused primary care with long term continuous supportive relationships between doctor and patient working as co-creators of the relationship will achieve better results than those which simply provide episodic reactive care (e.g. multiple visits to the emergency room) In the UK GPs are the last doctors who see the patient as a whole, in their life context. The acute hospital sector (at organisational level…some specialists are all too sharply aware of the idiocy they are working under) has largely given up thinking about longitudinal care for patients instead thinking in terms of “completed consultant episodes” and “procedures reimburse under the payment by results tariff.” Consultants are now encouraged to discharge everyone they can……which then results in the patient being referred back by the GP at a later date. (New patients are paid at a higher rate under payment by results than follow ups so this works to hospital’s advantage. That’s a great result of this system isn’t it?)

8. Everyone is entitled to good care. However the articulate middle classes always do better. No system will ever get round this inbuilt advantage that proactive people who can think, plan and act will always maintain over those who drift, react and panic.

9. Disadvantage accumulates with one problem leading to ever more social and medical problems. It’s called “Co-Morbidity” Doctors dealing with these harder cases need more time and resources. How a society deals with its weaker members, “the widow, the orphan and the resident alien” is a touchstone for its moral development. Currently there is much bleating about the topic, but no real shift of resources to help deal with it. And before Gordon Brown thinks it, making the rich get poorer through higher taxes simply makes beggars of us all!

10. If you want more than the NHS basics you will have to pay for it.


So what would the NHS spend its money on if it was a functional system?

1.Well qualified and trained professionals-
Nothing is as empowering for patients as an accurate diagnosis and speedy treatment. Good professionals will help achieve this.
As Red Adair puts it “if you think professionals are expensive you should see what an amateur costs!”

2. Communication
At all levels between doctors, patients, and relevant others. Hospital secretaries would rule the world and managers would be roasting in the Devil’s kitchen

3. Ensure continuity of care to provide better care to patients and to avoid unnecessary referrals (and their expense)

4. Speed of access to diagnosis and treatment.

5. Minimal management to achieve 1-3 above. Alexander the Great once asked the Cynic Philosopher Diogenes what he could do to help him. Diogenes replied with the classic, “Please get out of my light” The medical profession is asking the managers to do just this.

6. Right patient, right treatment, right time
Doing the job right first time would be simpler and safer than trying to sort out mistakes later. Treat patients well and put lawyers out of business.

7. If 5 fails get a reliable complaints system in place. No scape goating. No blame displacement. No management involvement.

8. Contracts in place to ensure the viability of long term patient-doctor relationships.
(The new GP contract signally fails to do this)

9. Prevent fragmentation of care. Fragmented care is less good, and more expensive.

Nothing I am asking for here is unachievable within present NHS spending. However the current political will is to squander the NHS resource on useless and expensive projects, rather than to understand or value the detail of individual doctor-patient relationships and see what is needed to allow those to work more effectively.

Until the NHS focuses its attention on the doctor-patient relationship and creating the context within which it can work better there will be no progress in developing the NHS.

Change and modernisation is not always for the best. The current unfocused blizzard of initiatives is utterly useless for managers, doctors and patients, and meanwhile basic simple improvements go unmade. What a total waste.