NO, NO, NO to current NHS reforms

There seems to be a widespread view that the NHS needs reform and that all the current NHS reforms are good, and that only antediluvian “vested producer interests” of doctors, nurses and other unions are holding them back.

To these commentators who all seem to be politicians, health economists or management consultant types reform is a great good in its own right, and all who stand in its way are some combination of:

Lazy
Overpaid
Overprotected
Anti-competition
Anti-choice
Non patient-centred
Slow
Backward
Scared
Self serving
Vested producer interest
Knaves

As Richard Vize, the HSJ editor, puts it, “In the struggle to improve health services the only easy part is finding someone to say 'no'.” Well we’re certainly happy to oblige him with this piece.

Actually I have got news for them. We are none of the above. We think that the current NHS reforms are just WRONG, both IN PRINCIPLE and IN PRACTICE. New Labour has been a total disaster in its running of the NHS and relations are worsening again.

There is a real feeling of us versus them and for all the talk of “clinical engagement” most doctors are ever less involved in service design.

Let’s look at Labour’s record on health:

A fortune has been spent on the NHS.

However, it has not gone on anything sensible such as extra GPs, longer consultations, better access to investigations, speeding up discharge summaries, improved primary-secondary care communications. In short patients still encounter a system working under resource and severe time pressure at every point they meet it. Patients, doctors and other health service staff are run ragged and frazzled, and somehow still keeping a smile on and a service running despite management hindrance and interference. Clinics run late, and get overbooked. Notes are lost, letters get mislaid, or never typed. The doctor-patient consultation is still only a few minutes in an experience that may have taken several hours of travel and waiting. The patients still don’t fully understand what the hospital doctor says and go to the GP only to find that the consultant’s letter is not yet there…4 weeks later.

Admission wards overflow, and back up back into A+E departments. Winter pressures could easily overwhelm most local hospitals. Bed occupancy in UK is appallingly high, and MRSA, and clostridium difficile are rife. Wards are easily closed when there is an outbreak of norovirus. NHS long term care for older or young disabled people has been destroyed and NHS dentistry is becoming rarer, and harder to access. GP premises have been run down, and cost rent scheme stopped.

And the NHS is such a “world class service” that only Cuba has anything like it. But what would Johny Foreigner know?


Where has the money gone?

-On a grandiose computer system- imposed top down, with no regard for confidentiality, or for what would help doctors manage patients better.
-On choose and book- needless, slow, offering the wrong choice at the wrong time
-On reorganisations and structural changes- same old face, nice new desks, nice new titles, bugger all done.
-On management consultants Know alls who know nothing, who have never met a patient and would faint with dread if they did.
-On NHS Direct and NHS 24 Stand apart facilities, drawing money and staff away from other areas. Same money could have been spent on giving GPs more practice nurses and improved phone access to GP surgeries. Nurses could then have worked alongside GPs and used a shared database and so had some background on patients they were speaking too. Would have improved the GP service, made patients lives easier and been safer for patients too.

-On Payment by results (which should really be known as payment per activity) a national tariff system that does not really allow for complexity and case mix.
-On practice based commissioning introduced too late and too timidly to be useful. More slippage announced this week. Likely to be scrapped or renamed soon.
-On appraisal- a system that takes doctors away from front line practice to “reflect”
-On ISTCs ministerial vanity to destabilise local hospitals
-On Mergers- ever larger hospitals- The DGH is now seen as an enemy to be destroyed
-On PCTs the most useless organisations ever invented
-On Walk in centres Useless, and money would have better been spent on improving local GP services or negotiating a deal for commuters to be seen by GPs near their workplace.
-On new contracts that deliver what neither doctors nor patients really want or need.
-On sacking medical secretaries and outsourcing the typing to agencies in India
-On management pet projects rather than locally needed projects
-On competition in what is fundamentally a co-operative and collaborative venture
-On PFI and 'LIFT' projects- the true cost of which was dragged out of a civil servant this week

The key flaw in all the reforms suggested for the NHS over the last 20 years has been the notion of an “Internal Market” It’s a totally flawed analogy, that does not, and never has, matched NHS reality. Any solution based on it is wrong de novo, and the NHS’s record on implementation of anything is a dire warning to other organisations.

So when people say “It’s easy to find people who say NO to reform” Dr Rant shouts back, “Yes, here we are, and we have something valid to say. And we start by saying “NO” to what’s going on now.”