The answer is in the last sentence on this film clip. [Sorry the clip has now vanished and Dr Grumble can no longer remember what the last sentence was!]
Perhaps you cannot believe that, as the Americans are looking for a different way to fund their healthcare, we in Britain are moving towards a system more like theirs. But we are. Hospitals now put bills in. One part of the government system is paying another part of the government system. It is very inefficient. It is inefficient because you have to spend a lot of time commissioning services and invoicing. At one time we had absolutely no idea how much things in the NHS cost. We often still don't.
When an outside manager was brought in to look at the NHS he must have been gob smacked. The NHS had no real continuous evaluation of its performance against normal business criteria. Little was known about:
- levels of service
- quality of product
- operating within budgets
- cost improvement
- motivating and rewarding staff
- research and development
Precise objectives for management were rarely set.
- There was little measurement of health outcomes.
- There was little evaluation of clinical practice
- There was less evaluation of the effectiveness of clinical interventions.
Perhaps that is why, at the time, the NHS was easily the most cost-effective healthcare system in the world. But you couldn't ever really prove it because the data were, to say the least, somewhat lacking.
Any young person who reads this now must wonder how the NHS could have worked at all. But it did. And, given the level of funding at the time, it unquestionably achieved a big bang for its buck.
How could this be? In those days junior doctors worked all hours that God gave. Why? Ward sisters ruled their wards with rods of iron. Why? Clinics were conducted in a mad frenzy of work. Why?
Managers from Big Business might think that people with no rewards producing a product that was unmeasured would have no motivation. But there was a lot motivating those who worked in the NHS at the time. Junior doctors were more motivated then than now. Jobs, contrary to what today's juniors might think, were more scarce then than now. Your future depended very much on your latest clinical performance which was closely monitored by tiers of more senior juniors and a very small number of consultants, often just one. If your performance was below par it would be known about.
But people don't just work for money. People in healthcare see the 'product' before their eyes. They see the distress of disease or the distress of a patient lying in a pile of shit. Doctors have always wanted to make people better as soon as possible. Nurses have always wanted their patients to be comfortable. In those days matrons or sisters would be appalled if they ever found a patient left lying in a pile of poo by the then plentiful student nurses. If they saw that happening they would feign a swoon in front of the laggardly learner, pick themselves up and then clean up the patient immediately themselves to demonstrate the seriousness of the matter. That's why Dr Grumble stops ward rounds to do rectal examinations himself. It is to demonstrate the unacceptability of sloppy practice.
The NHS of old seemed a bit like the army at times. Quite possibly we could have continued this way just as the army continues this way. All our NHS really needed was the funding it is now getting. But instead we have gone along the lines of private business and, with that, vast amounts of money are being squandered on commissioning and billing and measuring and bonuses and, bizarrely, even advertising and PR.
Why, for God's sake, are we advertising? Why are we whipping up demand for ever more healthcare? Why are we creating unnecessary demand when we should be meeting necessary needs? Why do we have one part of the system purchasing services from another part of the system? It is like Sainsbury's buying produce from farms that it owns. Of course we all know that the supermarkets give the farmers a tough time. They are always screwing a better deal out of them. Better produce at cheaper prices. That makes sense. But driving through these deals takes time and effort. If you buy your produce direct it might actually be cheaper. There is more than one way of doing things. Really.
In many private hospitals if you have an aspirin they will charge you for it. Keeping tabs on it all is costly but that is the system. In the NHS they do not (yet) bother about the little things and the bills are called coding. It is an enormous effort to get it right and we often don't. Dr Grumble's hospital has some missing millions which may be because we haven't 'billed' for everything.
Why are we doing this? It is because somebody somewhere thinks that it would be better if we operated healthcare like Sainsbury's. We set up enormous expensive bodies to commission healthcare and we get them to bludgeon hospitals to give them good deals just like Sainsbury's bludgeons the farmers. The patients, like shoppers, will go to the place they think is best and inefficient hospitals will go to the wall. It's simple and obvious. Dr Grumble has almost convinced himself of the benefits.
But there are very many flaws to this model. The cost of running such a system is enormous and nobody has sufficient knowledge to do the commissioning to a high enough standard. Purchasing healthcare is not quite as simple as buying apples from a farmer. And for all the government's rhetoric about plurality, contestability and choice, the reality is that you are only likely to have your hernia fixed once. Shopping around is not really what most of us do when it comes to a stay in hospital. And generally the hospital down the road will be the one you are taken to in an emergency and the one you will want to go to if you need elective surgery.
None of this has ever really been thought through. Our government, to its cost, worships markets. Even the baled-out bankers are regrouping and once again are spinning the roulette wheels of the flawed money markets. And in the NHS, private providers, despite their very poor track record, are still the order of the day. The NHS as we know it is doomed.
With an election looming it is well to remember that getting Sainsbury's to tell us how to manage the health service was, originally, a Conservative Party idea. Just what can we expect from the next government?
Sometimes David Cameron looks rather like lipstick on a pig.