An NHS business manager once told me, quite seriously, that the NHS should be run strictly along business lines. Given that this was slap bang in the middle of the 2008 banking crisis it seemed to me that she had not thought through this statement thoroughly. I briefly considered asking her which business model she had in mind, did she, for example, admire the way the Lehman brothers had managed their trade? What did she think of Taylorism? Fordism? A cottage industry model? How did she feel about the Peter Principle? What did she mean by ‘business model’? Was she linking this with capitalism? What did she think of Adam Smith’s theories on the division of labour? Thinking more widely, did she follow Herbert Spencer’s idea of the survival of the fittest and if so how did that fit in with the ideals of the NHS? However, at the time I was temping for £6.50 an hour whilst she was probably on about £35k per annum so it seemed more sensible to keep quiet and keep data inputting, even though looking at the data I was inputting I could think of at least 6 ways to save the NHS money, starting by sacking whoever had designed the inept survey from which the data had been drawn.
Let’s think for a moment about a type of business with which we are all familiar – supermarkets. Leave aside for now the vexed question of the ways in which many of them treat their suppliers. Since MPs of various hues often say that they want the NHS to be patient-centred, if we are going to use a business analogy, let’s examine this from the customer’s viewpoint. Towards the end of the month when my salary goes into my bank account, I might take a trip into Marks & Spencer’s or Waitrose. Feeling a bit flush, I’ll probably opt for something in the Finest/ Bestest/ Poshest/ Middle-class pretentious range. Give it a couple of days and I will have calmed down enough to head for Sainsbury’s. I’ll probably shop in there for most of the month, although whereas I’ll start with the Posh range I’ll end up grubbing around on the supermarket floor trying to wrench the last packet of 35 pence basics shortcakes from the back of the lowest shelf, because that’s the kind of woman I am. In the days just before the next pay packet I’ll be in the Co-op at around 7:45 pm, in the 15 minute gap between them bringing out the knockdown-price yellow stickers, and hungry hordes of underemployed, pissed off bargain hunters running away with all the reduced price bread rolls. In the midst of all of this there might be a trip or two to a large German discount supermarket to stock up on olive oil; loo roll; tins of tomatoes; cheap pasta and whatever cleaning products I suddenly think I need, whilst I try to avoid the middle section with all the shiny trinkets; illuminated house numbers; saucepan sets; lava lamps; gardening gloves; bird food; diving equipment and dehumidifiers because I don’t need that stuff and buying it will defeat the object of going into a cheap store in the first place.
Is this the business model I want for the NHS? No. In so many, many ways, no. Businesses which are badly run and which fail are allowed to go to the wall and I do not want parts of the NHS going to the wall. Neither do I want this kind of choice. I just want good quality treatment. I don’t want to think that somebody else is getting much better quality because they can afford it, whilst another person is getting an inferior product because that is all they can afford. Neither do I want more popular parts being given more funding for R&D whilst those less under the pressure of consumer demand are allowed to wither on the vine. So is there a way of reconciling a business model which depends on offering choice and variation, with the NHS which was built on the idea that it should be free at the point of access and equally available to all?
In announcing the reforms to the NHS this week, Cameron went to great pains to point out that he was not driven by ideology but instead was concerned only with saving lives. In essence the Tories (or perhaps the coalition, who can tell anymore?) want to streamline the NHS and give power back to the clinicians but I’m not sure that they have thought this through any more than my business manager had thought through her remark. Looking at this from the perspective of someone who has worked in a non-clinical capacity in primary care and is trained in the history of medicine, I would say that those who are unaware of their history are doomed to repeat it. And the Tories seem deliberately unaware of the NHS’s history. They plan to abolish the Primary Care Trusts and Strategic Health Authorities, placing the majority of decisions in the hands of GPs. But I think if you are going to do this you need to ask yourself where did the PCTs come from and what is it really like dealing with the NHS on a day-to-day basis?
The 1997 paper The New NHS set out the aims for Primary Care Groups. These were to bring ‘together GPs and community nurses in each area to work together to improve the health of local people’ and they would ‘be subject to clear accountability arrangements and performance standards’. They were to commission services and monitor performance. One paragraph is worth quoting in full:
5.18 For the first time in the history of the NHS all the primary care professionals, who do the majority of prescribing, treating and referring, will have control over how resources are best used to benefit patients. By cutting through the artificial barriers that have been erected between drug budgets, hospital referral budgets and emergency admission budgets the Government will give real choices about how GPs and community nurses deploy their cash. In this way Primary Care Groups will extend to all patients the benefits, but not the disadvantages, of fundholding. By virtue of their size and financial leverage, they will have far greater ability to shape local services around patients’ needs.
PCGs became PCTs as attempts were made to place power back in the hands of the clinicians. So how did they end up growing so rapidly and why did they employ so many non-clinical staff, including business managers? There are many reasons and this would repay a full study, comparing the different PCTs with each other, analysing their growth, asking why smaller PCTs merged into larger groups. If we can understand this fully, then we can begin to understand why the NHS is in the shape that it is and the challenges which the proposed GP consortia will face.
So what about the 2010 paper? What does it promise that is different from PCTs? I, like many others, suspect the new GP consortia will start to look very like the old PCTs, and in fact will include many of the same staff, simply because this government has not taken the time to understand why those PCTs evolved or how the NHS works. I am not convinced that revolutions produce either permanent change or change for the better – in fact history is littered with examples of revolutions that have produced the new boss, same as the old boss.
According to Equity and Excellence: Liberating the NHS, patients will ‘have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care’. Why? I mean I like being in charge of deciding whether today is an Aldi day or if I would prefer Sainsburys. I like choosing digestives rather than shortbreads. But I don’t want to choose which hospital is best. I want them all to be good. And if they are not good, rather than being given the option to go elsewhere, I want the poorer hospitals to be improved. Otherwise what happens to those hospitals which patients do not choose? Are they branded as failing? Are they bought out by Tescos? Is this really the best use of funding? I don’t want to be in charge of making decisions about my care. I want to be involved, in the way that I was involved in making a choice about taking anti-depressants or not (not, in my case, my horse is fortunately the best anti-depressant I can find and my GP is wise enough to know this). But I don’t want to be in charge. In the back of an ambulance after an accident I don’t want a league table of hospitals presented to me followed by a surreal conversation in which paramedics say ‘well it looks like your leg will fall off, would you like to go to Derriford, they’re good with legs. Oh no, hang about, there’s a problem with your arm, would you like to go to the RD&E instead love?’
Apparently in the new NHS, sorry the New New NHS, there will be a focus on clinical outcomes. Health professionals will be empowered. ‘Doctors and nurses must be able to use their professional judgement about what is right for patients’. Well yes, that’s not exactly contentious. Just hold on a minute whilst I set my time machine for 1997, I’m sure I heard something similar before. The 2010 paper goes on ‘Healthcare will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients’. Pardon. For starters my inner copy editor is annoyed by superfluous hyphens. Adjectives are hyphenated so ‘decision-making what’? Or just ‘decision making’. And anyway, what does this mean? Have you ever been in a hospital? What do you mean by saying that healthcare will be run from the bottom up and then saying it will be run by professionals? Why do you think professionals are at the bottom? And do you not realise that those professionals currently have their own hierarchies and trust me, you disturb them at your peril.
Go further and we have 4. c ‘patients will have choice of any provider’. Really? If I require out of hours care and I’m in Devon, can I really decide that actually I prefer OOH care in Dorset and demand that I get that? This is the problem with offering choice, in reality it may well be a choice of A. or, if you push for it and are really lucky, errm, how about A? There are some services that simply were not meant to be subject to market forces because their very nature and structure does not allow for this. We don’t really have choice with the railways either, since you cannot run two competing services on the same tracks and having two tracks in the same location makes no economic sense. The same is true of healthcare. If you want it to be equally available to all, then ensure that all of it is equally good.
According to 4d I can also, as a patient, rate the services I am getting. Now this worries me. It really, really worries me. Have you ever read online reviews of services? I have. People will review a CD and trash it because basically, it is not to their taste. They will review clothing and say they don’t like it because it was designed for someone tall and they are not tall. If you work in a complaints department within a healthcare organisation you will quickly realise why people complain. The complaints are diverse and whilst many are well thought out and reasonable, some are not. Try explaining to someone that a visit will be carried out according to clinical need, not their transport availability, and they will mark you down. Try explaining that disease is a process and no doctor would have been able to make an exact diagnosis of their very unusual condition early on and they will mark you down. As valuable as patient feedback can be, patients are not always best placed to decide what constitutes good care.
Moving on to 5. j. ‘Quality standards, developed by NICE will inform the commissioning of all NHS care and payment systems. Inspection will be against essential quality standards’. Now that sounds good, on first glance. However, I have a couple of issues. First, how do you really know that your provider is telling you the truth? Because in my experience you can set the standards and providers will give you a report telling you they meet those standards. Personally I would be inclined to check very carefully that that is indeed the case.
This ties into the second and more fundamental problem. Let’s say that a patient is seen by their GP. Their GP refers them into a hospital to see a specialist. The patient decides that the GP should have seen and diagnosed them earlier, that the wait in the hospital was unacceptable and that the specialist they saw in the hospital was uncaring. They decide they will complain about this to the NHS, because to them it is all just the NHS and if they make a complaint it should be to one body. Except that even now, it is not. Their GP is governed to some degree by the PCT, so a complaint about a GP needs to be addressed by them. The complaint about the waiting area and its lack of comfort needs to go to the hospital. Whereas the specialist is provided by a third organisation and a complaint against them needs to go to a social enterprise company. As far as I can work out, this government’s proposals will make this whole scenario worse, not better. The NHS will be more fractured, more diverse, and more confusing to any patient trying to negotiate it if the coalition persist in the idea that multiple providers are the answer.
I could go on. And on. I could spend all week going through this and explaining why I think it won’t work. But what it boils down to is this: If you really want to give power back to the clinicians, how about you ask them what kind of reforms they want? Or have you just realised that if you do that, they will turn you down, given the concerns already expressed by members of the British Medical Association? Why not draw breath and take a long, careful look at the NHS. Work in it for a while, or at the very least spend time talking to those people who do. If you must waffle on about using clinical evidence, then why not actually examine that properly before you just yell ‘Oh look, our rates for cancer survival are a bit pants, let’s have a revolution’. It may not mean that the whole NHS needs reform, again. It might just be that you need to work better with oncology services, or work out why cancers are not spotted earlier. Reforms in themselves do not bring about efficiency – indeed they often delay it.
In my experience the NHS is a behemoth but it is far from monolithic. It is a huge beast that has, like most large organisations, acquired a sort of institutional inertia where change is concerned. If we could turn the clock back 65 years we could relaunch the NHS but we have over 60 years of history as its structures have evolved, put down roots, taken on an almost organic form. Cameron’s changes appear to me to be far more about ideology than anything else, since they have only a very shaky evidential basis. The NHS needs consideration, some careful pruning. Reforms need to be based on evidence and undertaken with a greater understanding of how the various parts of the NHS work and how and why they have grown, otherwise in another 15 years time another government will disband the by then bloated consortia and again announce that clinicians need more power.