Dicing with death

Once or twice the Jobbing Doctor has commented on how odd it is that he has seen three cases of a condition that he hasn't seen for ages all in one week. The same thing happens in hospitals. Very rare things come in runs. You would think that it couldn't happen by chance but it does. If you listen to radioactive decay using a Geiger counter the blips you hear (listen) are random but they are not evenly spaced. Sometimes the blips seem to occur in runs. So it is with any random event.

If you have ever wondered why it is you have to wait so long for a bus, that too is predictable. Unless the buses are evenly spaced you are more likely to arrive at a big gap between buses - because it is bigger. It's as simple as that. That's why when you travel on the tube they may stop the train to improve the service. It might seem crackers but it is to ensure the trains are evenly spaced which means that people will never have to wait too long. Even spacing is crucial. Dr Grumble has patients whose job it is to control the buses in the same way. Heavy traffic can limit what they can do but GPS gives them the opportunity to try and space the buses evenly along the route. The days of buses coming in threes should be over.




People don't understand statistics. Dr Grumble includes himself in this. It is a difficult subject. Managers certainly don't understand statistics. They spout utter nonsense. We had top management consultants in recently. We paid them a small fortune. They were on about how we should improve our performance to reach that of the best quartile of equivalent hospitals. There was the unspoken assumption that our performance was below par because we are crap. Dr Grumble had been warned in advance to behave. He pointed out serious flaws in the data but was given a stern look. He was tempted to point out that 50% of doctors are below average and should be sacked but he bit his tongue. Mad management speak fools nobody but highlighting the flaws in their thinking is not permitted in today's NHS.

Sometimes though the effects of statistics on individuals are too serious to ignore. Explaining this to managers who just want to cover their backs by sacking poorly performing doctors is a challenge. They cannot understand how sheer chance can make you a killer.

Breast ironing

Why do you think these poor girls are not taught about contraception instead?

A poisoned chalice?

The white paper euphemistically referring to liberating the NHS has made everything clear. The NHS as we know it is to be dismantled. In England anyway. Governments no longer want to be responsible for things. Career politicians want to be politicians. They want to give speeches and spin stories about their achievements. But they do not want to be responsible for running anything. When the NHS fails in some way they want it to be somebody else's fault. Governments have always been like this. They want to distance themselves from trouble. They want to blame others.

Looked at in this light Lansley's white paper is a master stroke. The health service will be delivered not by employees of the NHS but by employees of social enterprises. Lansley will create the largest social enterprise sector in the world. These organisations will deliver healthcare. They will do it for money. And they will make a profit. They will have the imprimatur of the NHS but they won't really be the NHS. Not, anyway, the NHS as it is now. That might sound pretty bad but you may not notice. Most people probably think their GP is an NHS doctor. The reality is that GPs are independent contractors. Patients don't notice so it clearly doesn't matter. It almost certainly has some advantages. GPs can actually be quite innovative and quick to respond to change.

In case it has escaped you, general practices are already social enterprises. They are independent. They work for money. They make a profit. Despite this anomaly many would say they are the jewels in the crown of the NHS. GPs are advocates for their patients. Patients trust them. They still provide the backbone of a cradle to the grave service. GPs know more than most about what their patients need. They have a sense of the sort of quality they want from organisations supplying those needs. They understand the crucial difference between needs and wants. And they have a good feel for the reputation of the suppliers of those needs.




The problem, of course, is that GPs are really just small businessman. They are small businessmen whose main interest is not in the business aspects of their social enterprise but in the good practice of medicine for the well-being of their patients. As things stand most of them have neither the time nor the inclination to commission NHS services on behalf of Andrew Lansley. Those in the know, an example would be Sir Richard Sykes, say they don't have the expertise either. But, frankly, neither did the previous incumbents.

Lansley's main aim has been met. Handing £70 billion of taxpayers' money to a bunch of independent commissioning amateurs distances the Con-Dem government from the NHS. It puts doctors in the driving seat which has been seen as being essential if change is to be effected. And it puts the blame for when things go wrong onto GPs.

How to amuse yourself in hospital

Commissioning

The other day Dr Grumble, quite by chance, happened to meet John Savings, the man who taught Prince Charles to lay hedges. Dr Grumble asked how he got into hedgelaying and he told the story of a lady who wanted Mr Savings to build a fence at the end of her garden where there was a scruffy hedge. Mr Savings explained to the lady that it would be much cheaper for him to relay the hedge. The lady was doubtful. She needed something to keep her children off the road. Mr Savings showed her how he could make the hedge secure. The lady was over the moon and commented on Mr Savings' honesty. He could have charged much more for grubbing up the hedge and supplying his customer with a brand new fence. But he didn't. Mr Savings is just not like that.





What is the purpose of that story? It is to explain that in a purchaser-provider relationship the provider usually knows much more about the product that the purchaser. It shows that in traditional relationships trust is the key element. And it shows that people like Mr Savings don't just try and screw what they can from the customer. They try and do what's right. They are not motivated just by money.

Dr Grumble has long suspected that those who commission services for the NHS do not know what they are doing. They do not know any more about the sort of NHS service Dr Grumble provides than the lady who wanted a new fence knew about hedges. Because providers tend to know more about a product than purchasers, customers ask those selling them things for advice. When your car is on it last legs you ask the garage man whether it is worth spending money on it or if you should sell it for scrap. In general you take the advice you are given from somebody you trust. It is odd then that no commissioner has ever asked Dr Grumble for advice about what they should be purchasing from him. And it is a shame that the main interest of the Grumble hospital is in extracting as much money from the purchaser as we can. Our managers no longer see themselves as custodians of the taxpayers' money. They see themselves as a quasi-private organisation whose main purpose is to make money. This is not the fault of our managers. It is the fault of government. There can be only one reason why New Labour and now the coalition government want it this way.

Last week Dr Grumble met a very senior NHS figure. He cannot say who but he is a titled man with first-hand familiarity with the commissioning system. Devilish Dr Grumble plied him with a few drinks and then asked him whether those responsible for NHS commissioning were up to the job. The answer was an instantaneous no. Clearly this important personage knew that, despite their £100k salaries, these people do not know what they are doing. It is not a surprise really. It is almost inevitable.

So is this why Andrew Lansley is now going to give the job to GPs? Does it make sense? What does the senior personage think? You might think he would be pleased. Who better than GPs to know what patients need? But he is not at all pleased. He doesn't think that jobbing doctors have the necessary skills to spend £80 billion of taxpayers money. And some of them just don't want to. The trouble is that those who do want to may not be the best people for the job. If you are good at being a doctor why do something else?

Could there be a better way? Of course. Instead of giving the money to jobbing GPs and getting them to buy the services they need from the hospital you could give the money to the hospital and ask them to provide the services the GPs' patients need. That way you could get rid of all that expensive commissioning and the people who really know about the services, the providers, would decide what is needed. Why has nobody thought of that?

The reason, of course, is that this is not about value for money. It is about privatisation. The problem is that Big Business will not behave like Mr Savings, the honest royal hedgelayer. Goaded by shareholders they will set out to screw as much money from the taxpayer as possible. That is the raison d'être of Big Business. Why can nobody see that? OK, some can but they are very much voices in the wilderness.