28 December 2009

No hope for 2010

The Ferret Fancier links to two important articles: one is about the dramatic increase in spending on NHS management and the the other about how David Cameron has been listening to NHS privatisation campaigners.

The Ferret Fancier says this is to do with the NHS market and privatisation. Who can blame the Ferret for stating the obvious when it seems that neither the present government nor the Conservatives are capable of seeing this fundamental truth even though it is staring them in the face? As a result we have the ludicrous situation of the Conservatives tut-tutting about the increased spending on NHS management while proposing as a solution even more rapid privatisation. It's like seeing a house on fire and hosing it down with petrol.

Whatever the present government or the Conservatives may say about preserving current levels of health service spending we all know that there are tough times ahead. Our only hope is to extract more efficiency from the current funding. That is the one thing we can all agree on. More money needs to be spent on patient care and less on those who manage that care. That's not to say we don't need motivated managers. But they need to be managing the delivery of healthcare not markets. Managing the NHS market is costly. Moving money from purchaser to provider is costly. Appraising competitive bids is costly. Grumble could go on. It could all be justified if these processes could wring better quality and greater efficiency out of the system but we all know that the opposite is the case. Private providers are a wily lot and can run rings around government purchasers. It's inevitable. Given that context is there any good reason to believe that private providers are likely to be better than government providers? Of course not. The private providers of healthcare are like the private providers of computing for Connecting for Health. These greedy people just focussed on milking the NHS cash cow for what they could get while delivering as little as they could get away with - which turns out to have been almost nothing. Why don't governments learn from their mistakes?

Is there any hope? In a way there is. If all this money is being wasted and funding is going to be tight then all we have to do is claw it back from all those very clever people now being employed to run a market that far from helping is actually getting in the way of delivering our core business - patient care. Unfortunately politicians do not listen to the likes of Dr Grumble or his darling, Allyson Pollock. They don't need to. They do need the voters. But when it comes to the future of the NHS the hapless voter has been left with Hobson's choice. Now why do you think that is?


English Pensioner said...

As a mere patient, it seems to me that the main problem with the NHS is administrative madness, a disease which mutates and multiplies rapidly and which the medical profession has failed to get under control, partly because some of their members are becoming infected.
Our local hospital has been merged with one about twelve or so miles away. Departments have been transferred between hospitals to "prevent duplication" and as a result, among other things, we no longer have a maternity facility. Unfortunately, there is no reasonable public transport, particularly for expectant mothers as the other hospital is about a mile from the station.
However, administrative staff have expanded. Each hospital had its own finance officer; both remain in post and we now have a uber-finance officer in charge, presumably with all the associated staff. No doubt the same happened with all the other administrative departments. In addition, a number of "inter-site co-ordination" staff have been appointed to ensure "conformity of practice" (my informant didn't tell be if this conformity was in medical or admin practice).
From experience in industry, I'm sure this sort of thing would not have been allowed to happen. You have only to read any daily paper to discover that company mergers usually involves considerable staff cuts, particularly in non-productive departments. Why is it otherwise in the NHS?
Personally, I would like to see all hospitals privatised and patients being able to select one of choice with the bill being picked up by the NHS in a similar manner to those with private insurance. I understand that this works in France, so why not here?

Dr Grumble said...

Personally, I would like to see all hospitals privatised and patients being able to select one of choice with the bill being picked up by the NHS in a similar manner to those with private insurance.
We are almost there already. For every patient that Grumble sees in outpatients a bill goes in. What the hospital gets paid depends on the tariff for the particular condition. Sending in the bills is a costly process and that is why we are spending more money on managers.

There is no point in having a system like this unless you have a market. To some extent the NHS has dipped a toe in the water of an open rather than just an internal market with private providers competing with the likes of Dr Grumble. The private providers were paid more for doing less - the government did not want a level playing field. They tended to cherry pick with the NHS getting landed with the difficult cases and there was good evidence of serious problems with the quality of some of the providers. Incidentally there is little doubt that the GP out of hours provision is mostly costing very much more for a much worse service than we had previously.

It's disappointing that so few people can see this truth though even the government seems to realise that its fingers were burnt by the private providers. The seductive argument is the one you have given, English Pensioner. Your system would work given enough funds as it worked for the wealthy in the US. The problem there was that the poor were not covered and the costs ran out of control. Suppliers of services always want to add value and charge more if they can. The new NHS is now beginning to do this with unnecessary tests or procedures when before it minimised care. This is not the way to solve the problem of healthcare everywhere in the developed world which is how to contain costs. Don't forget that until recently we had an extremely cheap service which though bad was not shockingly bad.

What Grumble is saying is that we had a good but underfunded system for keeping costs under control and changing to a market system is neither driving up quality nor keeping costs under control. There has also been much more waste - previously NHS management costs, contrary to popular belief, were the lowest of any equivalent healthcare system.

But there is no doubt, English Pensioner, that you will essentially have your way. The problem will be that there will be insufficient funds to provide what you want which is a hospital on your doorstep or better a choice of hospitals. With the increasing costs of healthcare this is just not possible from a state funded service and we are not going to solve the problems until we realise this. Also many of us doubt the wisdom of shopping around when it comes to healthcare.

Markets give people what they want not what they need. Amazingly you can even sell water to people. The NHS needs to focus on providing people with what they need and not what they want.

It is very unpopular to say this as everybody wants to receive what they want and have the taxpayer pay for it. That, of course, is why it is not a proper market and if we go on thinking this way we will only be disappointed.

Julie said...

Thanks Dr Grumble. I was enjoying my morning until I read this.
At least we have a choice up here re the SNP. I think that if Scotland ever becomes fully independent, it will be because of stuff like this and the fact that the two main parties have abandoned the poor; not because of nationalistic fervour. They cannot plead ignorance of the situation in the NHS; there is enough info as to what is going wrong if they really want to hear it.

Dr Grumble said...

Quite right, Julie. Thanks for the reminder. There is hope in Scotland where the SNP is a credible opposition with alternative policies.

The route the English NHS is taking now seems unstoppable. It will be a very interesting experiment if Scotland goes in the other direction.

I think the Scots and the Welsh do think rather differently about these things. They have more of a social conscience. I am not entirely sure why. History has something to do with it and the fact that London is dominated by wealthy financiers and big international players may not be helpful.

Dr Grumble said...

Take a look at this post for some thinking about the NHS that you no longer hear in England.

Dr Grumble said...

Or this one for the origins of the NHS.

Garth Marenghi said...

this week's bmj is particularly relevant with talk of potential problems ahead from the scandinavian systems as the markets are introduced there

the scottish system's progress will be very interesting and i would suspect that they will do much better than us because of their less willing acceptance of the privatisation,

the arguments such as the english pensioners for privatising it all do not cut the mustard for me just because the logic is not there in these arguments

the NHS was a very good basic system until the government starting fiddling with it

we'd have been much better off keeping the NHS fully publically funded and delivered, while thinking of ways of increasing the size of the independent sector without directly funding it

there would be cunning ways of doing this, but to argue that we need it all privatised is nonsense, just look stateside to see the disgraceful inequality that exists, anyone wanting this for the UK should think very long and hard for what they wish

Dr Grumble said...

What is striking is the similarity between what is happening in Sweden (which is often held up as a model of how things should be done in healthcare) and what is happening in the UK (which is also seen as a model by some organisations in the US). Now why do you think that is?

For those that have access the article can be found here:

Here's an extract which gives a flavour of the similarities between the Swedish and UK policies:

The current government ... is working towards creating a market in health care. It also hopes to export its health services to other European countries, either by treating foreign patients in Swedish hospitals or by operating services abroad. Changes in legislation in 2007 enabled privatisation of hospitals and creation of for-profit companies.
In 2008 almost one third (29%) of outpatient visits were to private providers, paid for by public funds. In July 2009, the state monopoly on pharmacies was abolished, opening the way for private pharmacies. Although relatively few people have private health insurance, the proportion insured increased from 2.3% in 2004 to 4.6% in 2008.

A few county councils are implementing extensive patient choice reforms such as choice of provider in primary care and in other specialties to improve responsiveness and access to care and strengthen patient rights. National legislation last year means that all councils will have to introduce such measures.