Peas in a pod?
A good few of Dr Grumble's readers take the view that the NHS is an inefficient behemoth and the more it can be privatised the better. It is a reasonable view to take. They could be right. They might well be wrong. What grieves Dr Grumble most is the lack of public debate on the topic. Reading between the lines of what New Labour has done and what the Conservatives seem to think they should have done more of, it seems to Grumble that the only major difference between the two parties is the rate at which they think the privatisation process should proceed. But you have to read between the lines. Privatisation of the NHS is not something either party wants to be explicit about.
One of Dr Grumble's colleagues, Professor Parrot, takes the view that it has been easier for New Labour to move towards NHS privatisation than it would have been for the Conservatives. Rightly or wrongly Labour is more trusted as a custodian of the traditional NHS than the Conservatives. The paradox is that the NHS could just be safer in Conservative hands. Whatever they say we all know the Tories are not really the party of NHS. In the event of a Conservative government an untrusting public would be on the lookout for shenanigans and privatisation of the NHS would be high on their watch list. Any 'progress' in this direction would have to be very cautious.
How far has Labour be able to expedite its covert privatisation plans? The figure below from the Department of Health gives an idea. Since the election of Tony Blair, spending on the purchase of healthcare from non-NHS bodies has gone up over fivefold.
Click the table to enlarge
Many of the Grumble readers might think this is a good thing. And they could be right. But health services managers might not be so enthusiastic. Take a look below at the views of these top managers on the role of markets and competition to increase quality.
Click the graph to view.
OK. Dr Grumble can hear his critics. The table just shows the views of health service managers. What else would these people say? But they weren't just NHS managers. The managers whose views were surveyed came from Australia, Belgium, Canada, Denmark, Finland, France, Germany, Hong Kong, Italy, Malaysia, the Netherlands, Norway, Poland, Singapore, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and the United States. Just like Dr Grumble they do not think that the use of markets and competition is a particularly good way of improving quality. Top of the list for improving quality the most was better coordination of care. How is piecemeal privatisation going to achieve that? What kind of structure would you think is best to achieve better coordination of care? Dr Grumble will leave you to decide.
References
Department of Health Annual Report 2009 (pdf)
19 comments:
What do you think about the 'Co-Op' idea Dr Grumble?
http://chezsams.blogspot.com/2010/01/looking-up.html
Would you be happy to work in one and also own a share of a hospital wholly own by those who work in it?
Sam, you have spotted a weakness in this post which is that non-NHS bodies are not necessarily private. It would be interesting to know just how much work went to private companies and how much to charities and to other possibilities such as partnerships and co-ops. But for the DoH to have given us that information would have revealed the dirty word that is never allowed a mention.
Actually my bank is a co-operative and it only invests in things that are ethical. Mrs Grumble shops at the Co-op. And I have insured with the Co-op. But if these things really worked in cut-throat markets they would have taken over more than they have.
John Lewis which is a partnership (I think) is currently very successful but they too have not taken over the world. I had a patient who was quite high up in John Lewis and I asked her why there aren't more organisations that are similar. Her answer was to do with unfortunate aspects of human nature.
The reality is that if these alternative structures worked in the market place you would expect there to be more of them. I suspect the ruthless pursuit of profit for shareholders can be important whether we like it or not.
My problem with markets is not particularly that there are shareholders creaming off some of the money. My problem is with the market in healthcare and not just profit making. Running a market is expensive and in healthcare it is not necessarily efficient. It hasn't created cost-effective healthcare in America. I am not convinced it has anywhere. Markets tend to encourage spending. We need to minimise it if we are to afford the heathcare people really need and not the healthcare they may want.
The reality is that the government doesn't much care who runs the NHS as long as they don't have to do it themselves. They would be happy to consider the third sector or co-ops or partnerships. There are examples of these already. But my own view is that many charities are extremely inefficient. I don't know about co-ops and partnerships. They might be better.
Of course it will mostly be private companies that take over the NHS. Charities, co-operatives and partnerships do not spend large sums of money on buying influence with governments. Governments and opposition parties need benefactors and will see that these people are rewarded.
A Co-Op is simply taking the current foundation trust model a step further. So, rather than taking charge of how you do business at a local level and have a say on how money is spent, you will also own that business. So, it will be in 'your' interest that the hospital does well. If you look at 'John Lewis', which is a Co-Op, your argument that this model hasn't takin the market by storm is a bit flawed, because it hasn't gone down either! And a Co-op is not in business to take the market by storm; it's a low risk business, unlike 'Top Shop' for example. One of the differences, is that it doesn't have continuous expantion ambitions. So you concentrate on what you have, improve and modernise but expansion is very limited .. call it 'niche' market if you like.
And, actually, it is a well established .. and VERY stable business model that has never suffered the fluctuations of the 'cut throat' private markets. Of course, law risk, also means profits are modest in comparison to the big shark's, but it runs at a profit nonetheless .. and that's even sort of guaranteed. Did we ever hear that John Lewis was on the brink of buncrupcy, for example, because of the current recession .. or any before?! NO! .. It's profits may go down a bit but as it is in the interest of it's owners, the staff, to stay afloat, they do so - their best to keep it above rough waters.
So, IMHO, this is the most suitable business model for the NHS. Since, the NHS provides a service and, so the idea is to try and achieve high effeciency, while keeping costs down - and this can be done by staff having a direct interest in innovation to keep up with their surroundings, and a modest profit on top! Sort of a good bonus at the end of the financial year for everybody working there .. You'd even know before hand if you will get it or not, because you are on the shop floor and are very much involved :-)
I think it's a very stable model and a brilliant idea to apply to healthcare, hospitals, polyclinics .. walk-ins .. 'all over!'.
... and you haven't answered my question Dr G! ;-)
Sam, most people like to do their jobs well. I want to do a good job for my patients and I wouldn't myself be more motivated to do that by owning a share of the hospital where I work. I can see that superficially it is a nice idea but I think it is a nicer idea that a hospital belongs to the public and is a public asset that people value.
... and people value John Lewis too - and treat it with respect, because they 'trust' it, lots more than the sharks in all the fancy malls!
But, we will agree to differ on that one ... even though this 'tweek' has the potential to improve effeciency, performance and optimum value over all, as well as protect the NHS from the sharks swimming about .. ensures staff do not stagnate but always aspire too! :-)
We don't necessarily disagree. It is just that I don't know all the answers and I wouldn't be going in this direction at all if I had my way.
I strongly believe that the old system was not as bad as our masters like to make out. And how can you improve on our present ratings when 91% of patients treated in hospital consistently rate the overall quality of care they receive as 'good', 'very good' or 'excellent'? You won't hear politicians say this. Ask yourself why. But this data is in the DoH's own documents.
What I have been repeatedly trying to point out in this blog is that the system is not as bad as it has been made out to be. The NHS was grossly underfunded. All they needed to do was tweak the old system and gently put in more money. As it was they threw the baby out with the bath water.
Every hospital doctor wants to work in a good hospital. We always have an interest in improving the place we work in whatever the system. But somtimes I don't think the same is true of managers who are more here today and gone tomorrow. I was very much against targets. I was wrong. Their effect has been important in focussing the attention of managers on problems which previously only affected coalface workers - such as patients piling up in corridors because there were no beds or insufficient resources to deal with a waiting list. Until recently most managers showed no interest in these problems. What I am saying, Sam, is that you might be right that managers need to be motivated. It is difficult for a manager to do a job and be rewarded by seeing a satisfied patient. They may need sticks and carrots and a sense of ownership of the hospital might be helpful. It is easier for doctors to be motivated by seeing the fruits of their labours. You see that coming over in quite a few of the medical bloggers who crow when they have done a good job. It is true of both the younger blogging doctors and the older blogging doctors. We like to get it right, do a good job and make a difference. And doing that is not as easy as people who are not doctors seem to think. We tell each other when we have made a clever diagnosis because we are pleased and we like to show off. Even Professor Parrot does it!
"It is just that I don't know all the answers"
In business, you never do! No crystal ball to look into for answers. Instead, it's predict, predict .. and more predict! ... there is market research before starting a business, expanding and/or launching a new product .. then there is calculation of risk - law, medium and high! .. And it depends of how tough and how experienced you are! - and how you regard 'money' too! Then again, many a tough businessman went down .. and many a new wet behind the ears ones shot up!
But that's the challenge and the thrill, isn't it? .. to 'Try'!
:-)
The Co-operative or John Lewis Partnership idea has much to commend it. The thesis that it is "a nicer idea that a hospital belongs to the public and is a public asset that people value" doesn't hold much water. Does ot make much difference to the public? I haven't heard much criticism from the public that our major airports and flag-carrying airline are no longer public assets.
-I just have to add this article title to this debate. It's from your reading list Dr G but I can't access because I am not registered.-
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"Leaked FTN document: no job guarantees for foundation trust staff
29 January, 2010 | By Steve Ford
Staff working for foundation trusts are at risk of compulsory redundancy because of the impending public sector spending squeeze, a leaked report suggests."
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And that above forced redundancy, without even reading the article .. is because the staff 'do not own' those trusts! ... It is much more difficult to get rid of 'partners' of any business than those who are simply are an 'employee' of that same business! Always, the employees go first!
Of course partners can be disposed of too - in theory - but in practice, it is very difficult to do so as you have to prove that they are deficient to the point that they have become a liability! One that is obstructing the business from growth or even pulling it downwards! ;-)
Which is another quality of the co-op, all partners, ie, all workers, know those doing their jobs properly and who are not .. for those below standard, Serious 'structured' training is given, but failing that, there would be grounds of dismissal ... and that's in the interest of everybody ... proper team work! One that works! ... Unlike the current gang culture all over the public sector, which stifles growth, effeciency, productivity, innovation .. you name it, it is below standard because of stagnation! After all who cares, it's only 'government'!
And as David said, the public do not even notice, add 'unless things go wrong', because the public care about the service not who provides it .. and name me 'one' co-operative where things went so wrong, they were in the public eye for as long as when a fully privatised establishment did when it messed up?!
Of course everything has two edges ... like, a co op will only pay to suit the effort! So no payment without 'quality' services rendered, eh?! Not you good Dr G, but 'some' may find that concept unsettling!
:-D
David, I would agree that the public don't care too much about who owns their airline. As long as they can get from A to B with the service they want at a fair price they are happy. There used to be arguments that only the state could ensure safety when it came to airlines but this argument is now rarely used and everybody would agree that states do not run efficient airlines. Surprisingly, given the cut-throat cost cuttings, the cheap carriers seem, mostly, to be able to maintain safety. On the other hand in the recent snow one cheap airline did cancel rather more flights than others because of thin infrastructure.
Some have criticised privatised airports.They would say that when the state ran airports they were designed to have what the state thought the public wanted - a view of the planes and plenty of seats. Now there are few places for the ordinary public to sit, marbled floors and rows of shops. Airports are places where the rich tend to focus so a disproportionate number of shops or for the very rich with a small number of unpriced designer items on sale and very little activity - because they do not need to sell much to make money. There is enough money to be made from the shops for the taxpayer not to have to worry about supporting airports ever again. The price of having no seating is one worth paying but airports are not good places when things go wrong and there is nowhere for masses of the public to sit while they wait. This too was apparent in the recent snow.
Interestingly hospitals also have shops and, like airports, now charge as much as they can for car parking. The latter has been criticised. The shops nobody seems to worry about. The shops in the Grumble hospital are clustered around the main entrance where everybody passes. We no longer have the WRVS or the Friends. Instead there is a very expensive coffee shop. And there is an upmarket opticians. Like the airport they are not cheap places on the whole and they are not suitable for the poor elderly who have no money for this sort of thing. The subsidised canteen is long gone. Does it matter? Yes. Close to the entrance we should have the medical services we need for the very sick and the poorly mobile. Accident victims need to be close to the scanners but instead the X-ray department has been priced out and put on another floor substantially worsening the trauma care we can offer. And the elderly deserve a cheap cup of tea for God's sake.
Sam, none of us wants to be sacked but surely if you are looking for efficiency a flexible workforce is essential. There are major disadvantages to having, say, hospital consultants on short-term contracts but if you need to rationalise services there are advantages too.
The problem we are heading for with hospitals is not whether we are government owned, a charity, a partnership, a co-operative or private. It is the way we are being paid and the idea that the patient can be a discerning customer and that you can use the market and patient pressure to sort out all the problems of the NHS. It is an idea that is so seductive that I know many cannot follow my arguments against it. But, perhaps with exceptions, it is not something that has made healthcare cost-effective in the US - nor, I think, anywhere else. The mistake we are making with this (and I accept it is unstoppable) is very great and is going to cost the taxpayer dear. If you are going to run such a system you might as well privatise the lot and I am sure that is the intent.
Let's hope that Dr Grumble is wrong and that we will see loads of cheap efficient safe hospitals (in London it will be polyclinics) all competing with each other like the airlines. Unfortunately the more you think about it the more it seems like cloud cuckoo land.
"Now there are few places for the ordinary public to sit, marbled floors and rows of shops. Airports are places where the rich tend to focus so a disproportionate number of shops or for the very rich with a small number of unpriced designer items on sale and very little activity - because they do not need to sell much to make money."
That depends on which airport we're talking about, because like specialist hospitals, they do not all cater for the public at large as you seem to think. I imagine the one you're describing here is Heathrow, terminal 1, 2? Because then this lack of suffecient seating is intended, because those terminals make their money from the 'regular' business traveller, not the 'buy it cheap' once a year travellers. You don't want expencive paying business travellers to sit down, you want them to roam about the duty free and buy their destination business gifts at your place , rather than sit in your airport then buy on 5th Av NYC, for example. And they know, if you make the seating area too comfortable and/or too large, those 'rich' and needing to buy clients will sit! Also the reason why all the marble, the exclusive shops, etc.
However, the ordinary traveller is left free to sit on the tables provided by all the restaurants, coffee shops .. etc, without having to order, so long as it has an open plan space ... did you know that, those usually either buy little or bring their own .. those are the ones mostly sitting down. Again, that is also intended. In the case of terminal 3, the lackish seating is more for security reasons.
But then Heathrow mainly caters for scheduled flights .. and not the low cost (Stanstead, The City), or package tour carriers/Charter (Gatwick). The story is very different there because those know that rows of exclusive shops will just stand idle, so they don't have them (Or little in comparison), duty free is very limited too and mainly caters for cigarettes, alcohol and perfum! Then there is lots of space for people to sit, even on the floor, in case of delays. Heathrow is not designed to cope with long delays because it's parking fees for carriers are too high, so ...
The clever thing about all of them is that they know their clients .. and design themselves around 'those clients' needs .. and that's how they make money .. and that's how allied services, trains, coaches .. etc .. make their money too. Actually, your example of airports is the 'perfect' example of the 'client centered' approach and how effecient and streamlined the operation is on a day to day basis. Perfect economic cycle in action model too
"if you are looking for efficiency a flexible workforce is essential."
And that you have in The NHS now, do you? You are talking about the few consultants on short term contracts, but, what is the percentage of those compared to the whole on 'permanent' contracts? Managers, porters, technicians .. etc .. I don't know .. you do.
Then again, who said that a co-op is not flexible?! You just need to 'justify' why are you disposing of staff! Surely, this is good for 'hard working, effecient' staff too .. and that's how ownership develops .. then loyality, not only to the establishment but to the product and the quest for innovation too.
My impression of you Dr G is that you are the concervative type .. you were the last one to decide on that Swine Flu, for example .. You are cautiuos ... which is fair enough, because enterpeneurs need those like you to hold their brakes sometimes - otherwise the world would've gone crazy! .. as if it isn't already :-)
.. oh, yes! I just forgot to say, that the day the NHS manages to operate as effecient and as streamlined as airports, ie, each hospital, polyclinic, etc .. catering for the type of clients that uses them (Or shall we call them guests :-)in a way say Terminal 1,2 of Heathrow does for affluent areas .. and terminal 3 (for a diverse area of London for example) ... Stanstead for say, (not very affluent areas of England), etc .. you can then celebrate a proper effecient, productive, innovative .. and much 'appreciated', therefore streamlined .. and loved NHS too.
:-D
The world is very much shades of grey. Medicine certainly is. When physicians make mistakes in diagnosis it is because they get it fixed in their minds what the diagnosis is and then get the facts to fit the wrong diagnosis. It is the worst mistake to make. You must always look at the facts and then make the diagnosis from them. It is never the other way round.
Now who do you think made the mistake of getting the facts to fit the conclusion? He has been in the news recently - again.
You see it a lot in the comments here. People take a view and then find the facts to fit the view. In reality with issues like diagnosis or, say, management of the NHS there are never enough facts to be certain of the right way forward. The most dangerous thing of all is to be certain of the diagnosis because the signs and symptoms seem overwhelmingly to point in one direction and then not question it. Sometimes when patients fail to get better from, say, pneumonia doctors may change the antibiotics. Dr Grumble would always start by questioning the diagnosis.
You see this sort of mistake everywhere. My feeling is that as a group doctors may be less bad than most. In medicine you have to make decisions but very often the information is insufficient to know for sure you are right. And even when it seems certain you are right you can still get your fingers burnt. You learn of uncertainty the hard way.
With regard to the swine flu I felt fairly certain that JD was right. I also thought that the models that our management were feeding to us predicting the catastrophe ahead were much less likely to be right than JD's hunch. If you had asked me to put my money down it would have been on JD but the truth is that nobody could have been certain because the future is essentially unpredictable.
The other thing to mention is that your view of the world is very dependent on where you are looking from. For example, JD tends to see lots of self limiting conditions. The 'flu he saw would tend to be mild. The only 'flu I ever see is 'flu that is bad enough to reach hospital or intensive care. That biases your view. If you read the Daily Mail for long enough you will tend to believe it. There are people where Dr G lives who never ever lock their front doors. Others have bars on the windows and alarms. We all live in the same world but we interpret things differently.
So to get back to airports your interpretation of the fitness for purpose of the terminal does rather depend which one you are talking about. I was actually thinking of terminal 5. The fact that it is plainly designed to maximise income for the owners with very little consideration of the needs of ordinary passengers does not mean that I think it should be nationalised. Some things generate income readily and should be allowed to do so. If they do not do what we want of them the answer is regulation. The problem with healthcare funded by the government is that it does not generate income it just consumes taxpayers money. This is a fundamental difference. People fail to grasp this because of their view point. You cannot extrapolate from airlines and airports which can be profitable and should not need government support to hospitals which are always going to need government support even if they are private.
The private operators will rip off the NHS as did the IT companies and the PFI people. It is not at all the same as an airport which does not get its income from the taxpayer. The way to keep NHS care as cheap as possible is not to turn patients into customers and have them shop around, it is to work out a way to keep the lid on spending. Privatisation will never do that. Private organisations try to maximise spending - just like the airports. It's OK for airports but it is not OK when the patient as customer is not using his own money. If I was shopping outside the Gucci stores and the taxpayer was footing the bill Mrs Grumble would have a new handbag. The fact that others cannot see this is that they view the problem from the wrong direction.
"The way to keep NHS care as cheap as possible is not to turn patients into customers and have them shop around, it is to work out a way to keep the lid on spending. Privatisation will never do that."
Let's just keep 'Co-Ops' in perspective here Dr G, because that's what we are discussing, not full privatisation. Of course, this is a way of 'keeping a lid on spending' through involving all the workers, who are also owners as we have already discussed.
"The fact that others cannot see this is that they view the problem from the wrong direction."
Maybe, only that I don't believe there can be a 'wrong direction' to any problem that needs to find the best solution.
:-)
My understanding is that the government is quite happy to embrace co-operatives, partnerships or the third sector as healthcare providers. They really don't care provided they are not themselves the providers. There are a whole host of reasons for this. The problem whether the bulk of providers remain as they are or become one of the models you prefer is the same.
At present the Grumble hospital provides services it is not paid for. We are happy to do this because we see it as our job to provide to the local community whatever is needed whether we are paid to do it or not. That includes admitting drunks who have nowhere else to go and keeping in elderly people who are not ill but need more social support than they have. This is extremely expensive. When the market takes a real hold we will not be able to continue to do this because we will appear inefficient alongside private organisations who will just do what they are paid to do. To survive we will have to do the same. The drunks will have to be kicked out onto the streets and the elderly will be left to struggle without proper social support. This, presumably, is why the US manages with many fewer hospital beds than many European countries.
The point is that it won't really matter whether we are a charity, a co-op or a partnership. Each organisation will be paid in the same way according to a level playing field (we hope) and organisations will only be able to deliver what they are paid to do otherwise they will appear inefficient or become non-viable .
My own feeling is that if we have to have the system we are being forced into which is inevitable but misguided, it would be a good idea, in principle, to allow all the models to co-exist and the purchasers could choose where to put their money. In practice, having worked for private organisations (I still do a bit) I think they will win out because being profit-focussed they will work harder to get the money in than the alternative providers and they will pay greater attention to advertising and window dressing.
"the Grumble hospital provides services it is not paid for. We are happy to do this because we see it as our job to provide to the local community whatever is needed whether we are paid to do it or not. That includes admitting drunks who have nowhere else to go and keeping in elderly people who are not ill but need more social support than they have. This is extremely expensive."
Dare I say that this is wrong? Admitting drunks and socially isolated old people into an extremely expensive 'hospital' because there is no other way to deal with the 'problem'?!
IMHO, this needs to change too because it is 'stark' waste of resources! Not just accept the status quo as a 'must'do! I suppose this is where clinical leadership in collaboration with management of both health and social come into focus. You've identified yet another 'major' problem that needs sorting; what to do with those being admitted to 'expensive' hospitals when they do not have a need to be in that 'healing' setting? .. and the answer, simplified, would be to have more provision of old people's homes, care centres for the drunks .. etc - Then again, that moves you on to yet another set of problems; many exisiting care homes are failing their 'clients', whether privately or publiclly owned, a future of more and more older people .. and drunks that need serving .. And who's going to pay? .. etc - and your job doctor, is to sometimes 'insist' on change so that this catagory can be properly served and at a reasonable cost too.
Again, there can be many solutions that nobody cares to look at because of bureacracy. Example, there are so many private landlords out there who can provide a cheap service for the socially isolated elderly but they are scared off because of all the requirements for adapting their properties, guaranteeing that even if they comply, they might not get 'the business' long term .. etc .. If this was to be 'simplified' and 'encourage'a new model, say private landlords attached, regularly checked, and being paid by the local hospital, for example, where doctors in charge like yourself can send the elderly you mention .. then visit, and nurses too, away from an expensive hospital setting but close enough to manage those patients ..it would help solve the problem, don't you think? ... - How about 'foster an old person'? Where if you have a free room in your house, you can take in a 'healthy' but socially isolated older person to live with you as a member of the family? Much like the current fostering of a child!
.... and when am I going to get my 'million' pounds from that innovation fund for all those 'bright ideas' I keep putting forward, eh??!!!
Ahem ... :-D
Dare I say that this is wrong?
Of course it is. It has been this way since the year dot. It is a question of who pays. The social services won't help because they want the hospitals to look after these patients for as long as they can wangle.
But we are not talking about socially isolated people. Yes, there were times in the distant past when we would keep tramps and similar types in over Christmas so that at least they were warm and got fed. That stopped a long time ago. The people I am talking about need a lot of support to be looked after outside hospital. They are not acutely ill and do not need hospitals. It is just that there is nowhere else for them. But they are much more dependent that you seem to realise. They are unable to feed themselves etc.
An additional problem is that the private care homes suddenly decide they cannot take on the more dependent patients while they are in hospital. They don't kick them out but once they are in hospital they can decline to take them back.
By the way there are also more medical things that we do that we do not get paid for. We are in a transition phase at the moment.
One advantage of privatising it all might be that the hospitals would become very aggressive and throw vulnerable people out so somehow the social services would be forced to pick them up. It is not something I look forward to. It's just not what caring for people is about.
"Dare I say that this is wrong?
Of course it is."
A breakthrough! We both agree on something! DR G, now collectively, solutions can be found!
But it seems that I won't be collecting my million pounds .. yet :-( .. No problem ... how long is the road to Damascus? ...
So those patients are dependant and are not as healthy as I thought. Fair enough, let's revise my idea then ... Let's still keep the 'foster a granny' idea for the healthy independant old persons .. And let's keep the private landlords too. Only this time the hospital/local GP/polyclinic will lease houses for market rents, much as local councils now do to house those on benefits, but we will use them in two ways; either to house healthy independant older people in groups of 3/4 in smaller houses. In which case, you do not need to alter/adopt these properties at all because the aim is to provide company/minimum care at law cost and because the users are healthy/mobile/can do things for themselves .. and perhaps provide a home help that goes cleans/cooks on daily basis .. Cheap!
Or, get, for bigger properties, landlord permission to adapt with promise to reinstate at the end of the tenancy - those can then be adapted to suit less independant older people in groups of say only 5/7.. and maybe have a live in carer or two to feed/clean/cook for the residents ..
Both to be visited by docs, nurses and social workers depending on need. Can I even suggest that purpose built blocks be built/refurbish existing to fit purpose, on exisiting hospital grounds and be sold off to the staff running them - based on that Co-op model?
Please feel free to criticise my idea any which way you can, because that would make us both think more .. and maybe .. EUREKA .. Damascus! :-D
But then, I am sure you have better ideas, since you are the one with his hands in the water.
So, just for the sake of the excercise, please release yourself from political/ideological private/public .. etc limitations for a while .. what would you do to solve this problem?
Sam, we are getting into areas that are beyond my area of expertise. What I would say is that the Grumble family had three elderly grandparents, one bed bound and another very nearly bebound and, despite my cirticisms, it is remarkable what care can already be provided in the community. When I was a student it used to be said that families should provide the care but when this problem coincides with young children to look after, two parents at work and grandparents in another part of the country you realise why this never happened.
I think the present arrangement is a reasonable one when it works but it has been said to me (by hospital managers) that looking after people in the community is not cheaper than placing them all in a home of some sort. But most people want to stay in their own homes if they can so cost is not the only issue.
The problem, as I said, is that arranging these things takes time and hospitals are the stopgap. When hospitals get ruthless, as they are now, the patients bounce back - just as they said on the news this morning.
So I would deal with the problem by doing what we do now better. Which is how I would deal with most of the problems which face the NHS and social care. There is no magic solution. Every government there has ever been has thought that there is a solution to the enormous cost of healthcare and that's why constant reorganisations are the order of the day. The latest ideas are by far the worst we have had in my working lifetime but nobody in power or likely to be in power realises it. Curiously, some of the things the critics of the NHS point out as problems were not problems before the major changes brought about by New Labour and, unfortunately, suppported - even encouraged - by the Conservatives. The system has been made much worse not better but New Labour has got away with it because they have poured much more money in - much of which has not be well spent. PFI works because of the enormous sums spent on it. It will be the same when the NHS is privatised. It will work but it will cost a fortune.
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