Something rotten in the state of the NHS

Te recent news (September 2015 that Addenbrooke’s Hospital in Cambridge has been put into special measures underpins the madness pervading the NHS.  Addenbrooke’s is a fine place, with a great research and teaching record and good clinical care.  So how can the Care Quality Commission decide that the last of these is no longer true?  Why have the Chief Executive and Finance Director resigned (just before the CQC revealed its report, so before they were pushed)?

To understand this is difficult, unless one is prepared to make some awkward and almost unbelievable assumptions.  The context is also important.  But the bottom line is that the whole process of decision-making on hospital performance, and the whole process of hospital funding, are both irretrievably flawed.

In 2015 it has been predicted that over 80% of acute hospital Trusts are going to be running a deficit.  In some cases these are very large indeed.  So when the government says that such deficits are the result of bad management it is suggesting that four out of five hospitals are incompetently managed.  If this is really so then it is an indictment of the management system.  But it isn’t, and sacking managers does not solve the problem.  If you have a bankrupt business then it will go under no matter how brilliant the management may be.  And if 80% of the NHS acute side is effectively bankrupt then we have a big problem.

Bust businesses have two routes out.  The first is to be merged or taken over.  This is a complete failure, as a report in September 2015 from the King’s Fund shows (and I know from my experience in South London).  The second is closure.  But is it possible to imagine closing 80% of our hospitals?  Not really.  So if the situation does not fit the business model, but is immutable, then the model has to change.

We can find another reason why this is necessary.  If you look at Trusts that have “failed” there are two reasons.  the first is that they have failed financially.  In most cases this is because the managers and clinicians have realised that to achieve financial balance requires the axeing of staff (because staff costs are the easiest to reduce, other costs being effectively fixed). The second is that they have failed clinically.  And quite simply those deemed to have failed clinically have done so – because they have cut staff to achieve, or try and achieve, financial balance!  Getting both right, especially when there is an unsustainable debt burden in the form of a (PFI) sub-prime mortgage, is virtually impossible.

This leads inescapably to the conclusion that, if hospitals cannot meet the standards, then the standards must be changed.  If they cannot meet financial targets, then the targets must be changed.  If a business cannot by definition avoid bankruptcy then the bankrupt hospitals cannot truly be called businesses.  It is all made even more complicated when the so-called “purchasers” of hospital services are also bust, and cannot afford to purchase what they need to purchase (which means that patients with lower priorities will have to wait).

Thus – we must accept lower standards in clinical targets.  We must stop pretending that there is “investment” in hospitals when what we really mean is that there is “spending” on them.  We must consider whether there are parts of the NHS service that must be abandoned.  No amount of management shuffling will suddenly unearth brilliant managers who can do the impossible.  And this is all made more acute by the dubious idea that 7 day working in the NHS is achievable without a massive hike in expenditure.  Bullying doctors by imposing punitive contracts is crazy; those than can will retire or emigrate, and meanwhile new drugs turn up which revolutionise the treatment of arthritis, cancer etc at enormous expense.  My departmental budget on drugs just before I left the NHS in 2011 was over £2m, whereas ten years earlier it was nearer £20,000.

So I return to my conclusion, expressed in previous posts, that we need to take out a blank sheet of paper and ignore how the NHS currently runs (I was going to say works, but in the macro sense it doesn’t) and re-invent it in a way that these contradictions and oxymorons disappear.  I await the call!  But I doubt anyone will dare to ask…

I wrote a letter to “The Times” summarising this analysis.  It appeared on September 26th.  It also published a letter from the emeritus Professor of Medicine at Cambridge, Keith Peters, which said much the same thing about changing standards, so I am not the only voice in the wilderness.