30 August 2009

Why is the NHS being privatised?

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
  • productivity
  • 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.

23 August 2009

What's my line?

Dr Grumble's youngest son James has a summer job. It's quite a responsible job looking after the disabled. He gets paid £4.59 an hour. Young James does not consider this to be good money but he says that it is all to do with supply and demand. Apparently quite a lot of people want to do his job. He has a friend who has a better paid job. His friend gets £16.00 per hour. Both James and his friend are just 17. What job do you think a 17 year old can do that brings in £16.00 per hour? Perhaps you have guessed. He mans a phone in one of the swine flu call centres. At the age of 17, with scarcely any training, he decides whether the caller has flu or meningits or otitis media or pneumonia or pyelonephritis or one of the many other conditions that can masquerade as flu. It is incredible.

Do you think he works hard in the call centre? The answer is no. One day he received just one call. On that day the government paid a 17 year old £128 to advise a member of the public on their symptoms. It really is amazing how taxpayer's money can be wasted.

21 August 2009

The computer says *!**&

How do you think they mark medical students' final exam papers? The extended matching questions are marked by computer. The students use an HB pencil to give their answer and a computer dishes out the marks accordingly. Do you think the computer might get it wrong? Do you think they might have had a problem with the computer in Cardiff? Do you think it could be that they have had recurrent problems with the computer in Cardiff? No, that cannot be the case because if they had had problems before they would be sure to mark them manually. There is no way a faulty computer could have been the cause of the Cardiff catastrophe. Or could it?

20 August 2009

The ten day doctors

Just imagine the excitement you have when you first qualify as a doctor. All those years of toil and sacrifice finally pay off. You get allocated a job and on the strength of your modest income you take out a mortgage on a tiny flat which you share with your girlfriend who is better paid. Can it be true that you have finally made it? Many doctors think that way when they qualify. But eventually the day dawns when you first work as a doctor.

Imagine the shock if ten days after you have started work the Trust calls you in to tell you that they are suspending you. There has been a mistake and you are not a doctor after all. In fact you failed one of your many exams by one mark. The certificate you were given in a grand ceremony is worthless. Somebody in an office has made a mistake. You will need to fund yourself for another year. You will lose the income you never had. You will lose the home you will no longer be able to buy. It is a disaster. Perhaps you will have to just give it all up.

Mistakes happen. Mistake happen particularly at Cardiff University. Dr Grumble works in another country. He is not close by but even he has heard of the Cardiff chaos. These are not the only mistakes they have made.

Cardiff is not the only medical school where teaching is insufficiently valued and teaching support is inadequate. Unfortunately when there is pressure on budgets it is always teaching and teaching support that gets cut by medical schools. It's odd that. You would think a school was for teaching. But you would be wrong. Medical schools are for research. They do teach but it is not seen as important. It is certainly not their raison d'etre. So teaching gets cut and cut. They think nobody will notice. They think the students have no clout. They think that somehow the students will muddle through. And they know that NHS doctors will, in their own time, plug the teaching gaps because they feel sorry for the students and they have a sense of duty. Getting that to happen is the deliberate policy of one medical school. Allegedly.

15 August 2009

Under 5 mortality rates

There are various ways of measuring the performance of a country's healthcare services. One good one is the under 5 mortality rate. There is not much argument about it. If you are dead you are dead. The data are unambiguous.

In the US they spend 16% of their GDP on healthcare. In England we spend just 8.3%. You cannot expect to get as good results if you spend half the amount. So, with that warning preamble, what are the under 5 mortality rates for the US and for England? The answer is that out of every 1000 live births in the United States there will be 9 deaths before the age of 5. In England out of every 1000 live births just 6 children will die before the age of 5.

It has been alleged that in England we do not look after the elderly or disabled. So how long do we in England live compared with the average American? The answer is that in the US your life expectancy is 77 and in England it is 78. Not bad given that we spend relatively so little.

The inverse care law

Those most likely to need good healthcare are the least likely to receive it.

JT Hart, The inverse care law, Lancet 1 (1971), pp. 405–412.

The [NHS] still operates as a gift economy despite the most vigorous efforts of governments to change it into a business.
Dr Julian Tudor Hart

How do you think Dr Tudor Hart will be voting at the next election?

13 August 2009

What would happen if the government were to dismantle the NHS?

Dr Grumble thinks the government has been doing its best to try and make as much of the NHS as it can private or private-like. New Labour has felt its way forward with private providers and private finance initiatives (PFI). None of these innovations has been successful. The greatest of all the disasters has been PFI. Today's new hospitals will be paid for not by us but by our children and maybe even our children's children. It was a political sleight of hand. New hospitals today to buy tomorrow's votes and hang the cost which will fall to governments trying to bale us out long after New Labour is dead and buried. It is a very selfish policy from a government preoccupied with spin and newspaper headlines.

From time to time it has worried Dr Grumble that the public might be wooed into accepting privatisation of healthcare in the UK - especially from a party right of New Labour. What do you think would happen if a new government set about dismantling the NHS? Dr Grumble thinks he knows. Tony Benn thinks the same. You can listen to his views in the video clip.

12 August 2009

Would you let the NHS take care of your car?

Here's one view of what NHS style car repairs would be like - though it is not a picture Dr Grumble recognises:

Now lets look at how an insurance system might work for car repairs. You buy an old car and you insure it for unexpected repairs because you are worried it might break down. The car is essentially a banger so you pay a lot for the insurance - more than you can afford. If you are employed and need your car for work you may be lucky enough to have your employer buy the car and pay the insurance for you but he will deduct the insurance from your pay. You may not get much choice in what cover your employer purchases for you even though it is effectively your money.

Then, unfortunately, one day you hear a funny noise from the car's engine. You take it to the garage. The garage man thinks it is nothing much but when you tell him you are insured for repairs his eyes seem to light up and he says that he will take the engine apart just to be sure there is nothing wrong. It's inconvenient and expensive but you want to get your money's worth from the insurance and you are a bit anxious that it might break down so you agree to have the engine inspected. The garage man takes the motor to bits and he finds some of the parts are a bit worn. He replaces these and one or two other components that look a bit suspect. It will all be paid for by the insurance. Everybody is very happy. Except that there are lots of forms to fill in and there is some delay before the customer gets his money from the insurance company. The only odd thing about the transaction is that there wasn't actually a lot wrong with the car in the first place.

It is a very odd thing that when it comes to healthcare as the Americans contemplate moving towards a system more like ours we seem to be heading towards a system more like theirs. What is not being adequately addressed on either side of the Atlantic are the reasons for the enormous and rising cost of healthcare. Keeping the lid on spending while ensuring that everybody gets the necessary care is the forgotten challenge. However you pay for your healthcare you do not want to be paying more than is necessary.

On both sides of the Atlantic there are unseen powerful influences all pushing in the same direction - towards private provision. Somebody is making a lot of money from healthcare. Enough to pay for some rather amusing videos. Keeping a lid on healthcare expenditure is not their aim.