Comments on Dr Rant: Delay, Diminish, Deny and Blame: What the NHS can ...

The problem is recognising what we have and how we...

2007-11-04T12:55:00.000Z

The problem is recognising what we have and how we got there.

Hell, the NHS nearly ended up with the state-insurance, private provision concept in the first place. Nationalising the hospitals was one option in the original plans/reports.

GPs are semi-private providers of health care. I note that most of their complaints against the system are that they are constrained from doing the right thing by the system. That is, they want complete control of their work - be fully independent..... fully private :-)

The "US is the only alternative" mantra is a smokescreen to defend the current comedy. Almost no-one else has their system. Bit like the popularity of the NHS method.

In the real world, people who can, choose. When my daughter gets sick, I don't phone NHS direct etc. because if I do, we get sent to the causality dept. of a filthy, falling apart hospital, full of fighting drunks to wait several hours before we can join the queue in the paediatric clinic (no space for lots of children). This is because we are in the catchment area.... Instead, being a middle class scummer, I taxi her to the wrong hospital. The one with space, beds and medical staff who appear to have had an opportunity to sleep in the last week. Did I mention that the crap hospital sends you to the decent one, after getting to see a doctor?

A few years ago, by brother looked as if he would need an operation. A chum of his who was a senior chap at a certain famous hospital gave him a list of who he should trust to operate and who he should refuse to be in the same building as. All verbal. This was back when measuring such things was being ranted about (John Major was PM)...

We use BUPA when we can. AXA and similar schemes are becoming a standard part of good jobs in this country. It *saves* the company money. Bit like paying for flu shots. Now you getting competition on the lines of "Our scheme gives you better coverage". We are already in the land of mixed funding. Just for the well off and those who know.

Don't wish away all management. Without management and financial control an organisation will collapse very rapidly. I have seen this personally. What is wrong with the NHS is centralisation. This means many, many layers of management. In the private sector we know this cannot work.

In addition they are attempting to reduce all the jobs in the NHS to tick boxing. This was a management idea tried and abandoned in the 20s - reducing people to numbed robots doesn't make things better. Does this sound familiar.

The problem is control. There is a religious belief that one more target, one more directive can change things. "You can't just let people spend public money..."

Control of other people is an illusion. It is imperative that the system lets go. There needs to be management. Good management. Smaller, better paid - with more power. Yes, I know. But motivated differently. A real manager is an enabler, not a troll in a basement who whacks you with a club. No, I am not a manager. But I have worked for good and bad ones.

What we need is a loss of control. For the Sec of State to have no power to tell a hospital administrator *how* to run a hospital.

The NHS IT thing is a perfect example of this. I went to a seminar run by Craig Larman - one of the top guys out there on project management. He asked me why the NHS contracts were being run on a waterfall basis - first you gather the basic data, then you write the prefect design... etc. He was puzzled because the waterfall concept was discovered to be utterly useless for large projects in the 1960s - no-one has *ever* made a multi-million dollar project a success with that method, let alone....

It comes back to control. To run such a large project successfully means *not* centralising, not having a vast staff to control it, not having a huge pile of paper to prove that all the paper clips are aligned correctly... all an anathema to those who run things....

The NHS is dying. Those who can are leaving. The NHS is killing itself. More money will kill it faster - I have seen this happen when a failing organisation is given more money to fix things up. Without reform the problem get worse, faster

"I see a future with the ill-informed blowing all ...

2007-10-25T22:43:00.000+01:00

"I see a future with the ill-informed blowing all their personal cheque on pointless preventative treatments, like Dr Ray's whole body scans"
X-ray Ted,
Can I make it clear that I don't carry out preventative whole body scans even though I am often asked. I do offer screening ultrasound for aortic aneurysms in elderly male smokers as the NHS does not provide this even though there is unanimous expert opinion that it is worth doing. The £50 I charge for a once in a lifetime scan is hardly profiteering

yep i do want any treatment that a consultant tell...

2007-10-23T18:24:00.000+01:00

yep i do want any treatment that a consultant tells me would be a good idea

yep id dont see why any of us need to wait for 3 months, 6 months or longer in practise

yep i want to choose the hospital

happy to pay a fair market price, which are easy to gauge from current private rates and costs abroad, im sure these providers are financially viable

yep whats wrong with weekend appointments, sounds fine to me, probably some of the workers at the providers would appreciate the extra cash and would enjoy it too, seems to work fine outside the nhs

i would prefer to keep some element of state backed system to act as a safety net yes, but id like the patients to still be able to choose which provider to go to

whats wrong with that?

if you dont like that just scrap the whole thing and let me keep all the tax i pay towards the nhs, ill be fine with that, cheers

Basically you want the ability to have any and all...

2007-10-23T16:03:00.000+01:00

Basically you want the ability to have any and all treatment that takes your fancy. Have it now and not wait for any time, at any location you choose for a modest fee (you have no clue about the cost involved in running a service) at a time that suits you (Sat or maybe Sun just after lunch) but not loose the state backed system that would then take over when you then couldn't afford the cost of more serious illness or acute event.

grumpy med,thats why id rather we had a state back...

2007-10-23T09:24:00.000+01:00

grumpy med,

thats why id rather we had a state backed insurance scheme replace the nhs, because its state backed it can take on high risk cases which a commercial company would struggle to, and can take on people who contribute too little

same people would pay into it as pay into the nhs now, only instead of the state running the medical providers, the state would only guarentee the insurance company, patients get a cheque from company, and take it anywhere they want

for what its worth access to diabetic nurses, consultants, foot clinic and so on is piss poor here in the nhs, probably for most of their life middle income earners would be better off paying their own way even if diabetic, if only they could get a tax reduction to compensate i am sure many would

Um Anon? Anon of the whinge-about-diabetic-servic...

2007-10-23T07:32:00.000+01:00

Um Anon? Anon of the whinge-about-diabetic-services Clan?

You do understand that if we went to a "take your cheque" system, or a pure insurance system, you would NOT BE COVERED don't you?
You and all people with chronic illness, particularly those with progressive problems like the risk of diabetic retinopathy, neuropathy, and nephropathy, are not a good risk.
Your cheque will barely cover insulin let alone a doctor.
Unless you are very very very wealthy prepare for minimal care that will not cover diabetic nurses, consultant input, or fancy stuff like foot clinic. And as for when your untended kidneys pack it in - oh boy I sure do hope you have a Sugar Daddy for your dialysis cos Insure and Go aren't going to cut it.

x-raythere are ways around thisyes i think the pub...

2007-10-23T04:31:00.000+01:00

x-ray

there are ways around this

yes i think the public can be a bit strupid at times, but the facts remain that competition and similar systems are the only ones that have ever worked in the consumer supply business

yes it will need regulation and probably an OFFHEALTH style organisation

but at least you CAN get car credit and choose from the pros and cons of multiple providers, you are not given a one size fits all solution, and forced to wait in dirt

probably an excess on early treatment would be good for some stuff, to force folk to think about why they are there, same for GP appointments, balanced by a reduction in taxation, open to ideas here

at least they would be able to get a hip replacement rather than tolerate the massive waits and problems from a PCT

and there would be a contractual relationship between the patient and the medical supplier, if they failed to provide treatment you would have the normal remedies of law, rather than no real remedy when a PCT fails to provide treatment

the beauty of the patients being able to make the ...

2007-10-22T22:11:00.000+01:00

the beauty of the patients being able to make the decisions is that they can overcome the bottleneck of the crap GP or the piss poor PCT etc.

This would be the same patients who spend hundreds of pounds calling premium phone lines. Who allow cowboy builders to tarmac their gardens. Who believe every crack therapy revealed in the press. Who beleive Andrew Wakefield. Who demand a CT scan for 'headache after heavy drinking' (sic). Who bought their car with 'Yes Car Credit' and who bought every single permutation of the Manchester United kit.

There maybe crap GPs. There may be piss poor PCTs but, for heavens sake don't leave the general public in the hands of the advertising executives and snake oil salesmen.
Everytime I cross the Atlantic I am astounded by the 'insist your physicial gives you X' or 'your life will be shit forever if you don't insist you get Y immediately from your doctor' ads that appear between every single program.

I see a future with the ill-informed blowing all their personal cheque on pointless preventative treatments, like Dr Ray's whole body scans then pitching up seriously ill at the end of the year, funds bled dry, with a critical illness. How far can you stretch a safety net?
Patient choice would expand considerably to include such choices as 'shall I pay for some food or for the gas bill?' will become 'do I have my hip fixed or should I have the glioma removed?'

no look back and read you abused me before i ever ...

2007-10-21T16:23:00.000+01:00

no look back and read

you abused me before i ever used the term funnny fucker

yea france isnt perfect either, but i know little of the sitation there so i wont spout on about medical treatment in a country i hardly visit like many do on here

no one

France had one of the best helth systems i have us...

2007-10-21T14:29:00.000+01:00

France had one of the best helth systems i have used.
The big thing would be the levels of ta in France. I had no problem with the part that was removed from my pay packet each month but lots of the ex-pats i worked with (esp the new ones) were always up in arms about how much more they had to pay than in the UK.

I think its dirty and seedy but we have to mention levels of taxes in relation to levels of public spending and funding the better public infrastructure.

Oh and no-one you started the abuse..unless funny fucker was a term of endearment (then i will give you a kiss and all is well again).

sounds like in france at least the patient can tak...

2007-10-21T08:54:00.000+01:00

sounds like in france at least the patient can take their health spend where they like, allowing at least some competition to keep the places clean and answering the phone etc

"You can be sure if we had a nationalised roof rep...

2007-10-20T18:23:00.000+01:00

"You can be sure if we had a nationalised roof repair service there would be a 12-month wait to get an appointment with a roofing guy."

You mean like trying to get a telephone line put in when BT was a state-run monopoly? You know, when you couldn't actually buy a phone -- only rent it...

DK

Perhaps the following might add some light on the ...

2007-10-20T12:37:00.000+01:00

Perhaps the following might add some light on the arguments over state v private: I have worked (up until my retirement) and lived in France for around 9 years. In a nutshell the health service in France is around 70% state funded with the balance being picked up by insurance (normally paid for by your employer), or if you are (1) broke (means tested) and/or (2) you’ve got something serious, the state pays.

When you visit your GP you pay (at today’s rate) 21€. Of which you can reclaim 70%. Until about two years ago you could chose any doctor licensed to practice medicine, have your consultation and claim your money. Now you are still free to consult who you chose but you can only reclaim your 70% through a doctor (which would normally be a GP) with whom you are registered. By why of an example if you were to seek a second opinion it would cost you 21€. If you are referred to a specialist you can chose your specialist and hospital, most people I know, like me, just go to the nearest hospital and see the specialist recommended by the GP.

I don’t know the official reason for this change but, (1) my GP and (2), a relation through marriage, who is a radiologist, both say it was because so many people peddled themselves around so many practitioners looking for a diagnosis that they liked the state had to stop it on the grounds of cost and the best interests of the patients.

I could go on…but I think that’s enough for now.

Dr Rant, yea the Canadian system is worth looking ...

2007-10-20T10:56:00.000+01:00

Dr Rant, yea the Canadian system is worth looking at, so are the systems in New Zealand and Australia, and indeed the Swiss one, doesn't think Europe is the only place to pick up good ideas from. However I don't think having a profit motive to attract investment and innovation is bad, I just think it needs real competition with the end consumers really choosing between providers to make it work.

Dr Ray, of course you are right to some degree. Some regulation is necessary in essential services and can help to some degree. But being a buyer and consumer is always harder than it looks. One of the reasons the NHS is so fucked up is it really has such screwed up ideas on how to buy and subcontract things. For an individual you can research roofing contractors, there are ways of improving your chances of getting a good provider. I think you are naive regarding the competence and service provided by the bottom rung of NHS doctors, especially in the inner cities and poorer areas. The reality remains you can have a new roof built with input into the design decisions, using materials and techniques you want, within the parameters of the labour available on the market, and both sides optimise the financial side. You can be sure if we had a nationalised roof repair service there would be a 12-month wait to get an appointment with a roofing guy. Yes health care outcomes for patients are difficult to assess to some degree, but consumer organisations will do surveys and monitoring and reports etc, which the public will be able to read. It not only the superficial (although some of this is important too) the public will notice, long time to access a diabetic consultant, inability to see a gynaecologist and being fobbed off with a nurse, failure to remove skin lesion because the nhs doesn't think the chances are high enough it maybe skin cancer, being able to avoid an obviously dirty hospital, these are all potentially life or death decisions, simples examples there are many more, and decisions that a public with buying power would be able to dramatically change the way they are treated, and almost certainly improve their outcomes.

"Most of the professionals who serve me profit fro...

2007-10-20T09:08:00.000+01:00

"Most of the professionals who serve me profit from it, doesnt bother me"
Anonymous-you must have more faith in human nature than I have. I live with broken teeth, a leaking roof and my money almost literally under the mattress because I have had my teeth drilled for money, been left with a worse roof than I started with by builders and been ripped off by Equitable Life. When I deal with anyone the first thing I as if whether the advice is for my benefit or theirs and sadly, people generally go into business (or politics) to help themselves.
NHS doctors will have different levels of ability and won't always get it right but there isn't the added complication that they are trying to rip you off. A few doctors are lazy or uncaring and I would not try to defend them but, from the ones I have met, I think this is rare. The correct advice from a doctor is not always going to be the most popular but many patients have unjustified expectations and then interpret this as uncaring or bad advice. For example, anonymous, if you had really bad neck pain would you expect to have x-rays and an MRI scan and be angry to be refused by the PCT?
I suspect you would, but in practice the radiology is almost always a waste of time but we still do it because it is what patients expect- making access faster or giving the patients the money to get it done privately is not going to help anyone.
I do in fact agree with you that the level of service would improve with your system- you would see more pretty smiling receptionists and better decor but health care outcomes are more difficult for the patients to assess and most patients do not have the ability and information to make a valid choice and will use proxy indicators such as whether the doctor was pleasant or the parking was easy.

"how about looking at Canada? In that system, the ...

2007-10-20T00:31:00.000+01:00

"how about looking at Canada? In that system, the state pays for the care (or as much as it does in the UK) but the provision, i.e. the hospitals, etc., is private."

For-profit providers are illegal in Canada.

Most hospitals are owned by the provincial health care systems, and any that are not are not-for-profit units.

oh and on the "topped up by private contributions"...

2007-10-19T23:36:00.000+01:00

oh and on the "topped up by private contributions" thing, one thing we can learn from the US is their family health funds, sort of like a UK personal pension or ISA account (so its got tax perks), but can be shared across many members of the same family (so the risk gets shared to some degree), and can be used to pay out for medical fees as and when the family choose. it allows ordinary familys to build up significant sums over time to pay for health, make their own decisions about which treatments are covered or not, and removes the nasty insurance companies from failing to deliver the cheque when you most need it. this can be supplemented by health insurance in variable ways.

I like this much more than straight private medical insurance. Granted it would only work for those lucky enough to have a good extended family, But to a lesser extent a similar scheme can work for individuals.

Of course I would advocate a better state saftey net insurance scheme underlying this than anything in the states.

One of the worst things about the UK system is being taxed so much for the NHS, then having to pay again out of taxed income because the NHS fails to deliver treatment.

Another approach would be to get anything you spent on your own health to be added to your tax allowance. You have after all saved the NHS or equivalent a lot of money by going private.

dr blue,good points, there is however a big differ...

2007-10-19T23:07:00.000+01:00

dr blue,

good points, there is however a big difference between "choice" and "patient centeredness" as spouted by the bullshit merchants running the nhs and what these words really mean.

jayann,

yea what needs topping up, and what doesnt, becomes up for debate. but at least then its up for public debate rather than decisions taken behind closed doors by PCTs with no accountability to the people. i would go for the simplest definitions possible.

dr ray,

the problem with your model is that it depends on having a half decent GP to guide you through the maze. for many of us this is not the reality. the other problem is that what treatment you get is dependant on the prejudices of the consultant and management team of the PCT etc, rather than on an agreed basis of what is covered and what is not. the beauty of the patients being able to make the decisions is that they can overcome the bottleneck of the crap GP or the piss poor PCT etc. Most of the professionals who serve me profit from it, doesnt bother me, but I can shop around, get different opinions etc.

glad this blog is moving away from the militant communist model for the nhs and starting to open its eyes to reality

"show me a patient with the cash to pay for an ope...

2007-10-19T22:06:00.000+01:00

"show me a patient with the cash to pay for an operation unable to get one where and when they want and ill start listening to alternates".
Yesterday a 52 year old non smoking female with no family history phoned me up to arrange a screening scan for aortic aneurysm privately. I told her it wasn't worth doing. This was because I have a background in the NHS and don't put profit before ethical practice. I also refuse to do private whole body CT screening CT scans though there are plenty of companies that do, especially in the US. How does this fit in with the market approach. If she had gone to her GP and asked for it on the NHS she might have thought she was being denied a scan due to rationing but the fact is that patients need an advocate to help them through the complexities of health care and, in the UK, the lack of financial incentive for doctors is a great strength.
Would you absolutely trust a doctor if you knew he might profit from his recommendations?

I have realised I need to know more about European...

2007-10-19T21:30:00.000+01:00

I have realised I need to know more about European models of funding and providing

?! you didn't look into that first?!

I can't help thinking that a basic state safety net topped up by private contributions for extras/ luxuries would be more sensible

I think we might have some problems defining 'luxuries'. Some might see IVF treatment as a luxury, some, cosmetic surgery. Some would continue and exacerbate the current system of covert rationing by age.

Britain is usually a sensible country and uses a mixed/compromise approach to many things

hence its mix of NHS and private medicine?

I think looking at other countries' solutions should be accompanied by an analysis of NHS spending.

But, start with Sweden

http://news.bbc.co.uk/1/hi/health/4460098.stm

Thanks for all the replies. I think the US experie...

2007-10-19T20:56:00.000+01:00

Thanks for all the replies.
I think the US experience illustrates the problems of insurance based schemes clearly. Anyone with any sort of pre-existing condition- "you sneezed once therefore you must be uninsurable" should be very afraid of US (and UK holiday insurance at times) insurance based medicine.

The UK experience illustrates the problems of single payer and single provider all too clearly. Tim Worstall is right about the sheer unwieldiness of an organisation of 1.3 million people. I think a good half of NHS employees hate the management, and the other half are the management.

I have realised I need to know more about European models of funding and providing. (Info greatfully received by us)

Britain is usually a sensible country and uses a mixed/compromise approach to many things. Its appproach to health puts us at one extreme of ways of funding health ranging from total private provision at one end to total state provision at the other. I can't help thinking that a basic state safety net topped up by private contributions for extras/ luxuries would be more sensible.

The great themes of "choice" and "booking" along with "commissioning" and "patient centeredness" that are so talked about by current NHS management are in urgent need of ridicule for the idiocy that they are.

jayann,of course its getting significantly worse n...

2007-10-19T19:58:00.000+01:00

jayann,

of course its getting significantly worse now, cos the nhs is forcing more and more diabetics to be cared for by GPs rather than consultants, and GPs "with an interest" are becoming in loco consultants, in fact GPs with no clue at all are replacing consultants, which "may" be OK in the most routine cases, in the more extreme difficult to control cases is just plane dangerous

to be fair some of the GPs will admit this, but without a history in that locale, it is impossible to bypass the system and go to the consultant or his team when the long term locals probably can, so you end up in a circa 4 month queue (officially) of course its much longer in practise (due to various techniques such as "you must ring this number to have a special blood test" but of course the number if permanently engaged for weeks on end)

if the Dr C and rant team actually saw a lot of this close up from the patient point of view they would probably become even more keen for something to be done!

this for diabetics is pretty essential, but takes ...

2007-10-19T19:20:00.000+01:00

this for diabetics is pretty essential, but takes at least 6 to 12 months to build up in a new area,

Yes.

Whatever you, Team Rant, might hope and pray for, ...

2007-10-19T18:48:00.001+01:00

Whatever you, Team Rant, might hope and pray for, as long as both the provision and payment of the health system is in the hands of politicians, you will never get the chnages that you want. Why will you not understand this?

If you don't like the solutions on the Continent or the US, how about looking at Canada? In that system, the state pays for the care (or as much as it does in the UK) but the provision, i.e. the hospitals, etc., is private.

Maybe if we tried even that modest adjustment, we would not have Canadians coming over here and asking why our hospitals are "crumbling" and "in such a state"?

DK

funny fuckeryoure just spouting constant abuse, il...

2007-10-19T18:48:00.000+01:00

funny fucker

youre just spouting constant abuse, ill not bother responding anymore, good luck

jayann,

yea but i have many friends/relatives spread allover the UK, and have a wide ranging view of how many of them experience the nhs, many different areas and demographics, none particularly good experience of the nhs

yea long term care does depend on close relationship with the local consultant, their specialist nurses, the other members of their team, to bypass the "system", and to have the "heres my mobile just ring it if youre in real trouble" informal access, this for diabetics is pretty essential, but takes at least 6 to 12 months to build up in a new area, so any diabetic who moves address frequently is let down big time by the nhs

etc etc