Today (Friday 13th January 2017) “The Times” published my letter in response to their article describing how the government had decided to attack the head of the NHS, Simon Stevens, and blame him for all its failings. In the edit a little bit was lost, so I quote the whole thing here:
“For the government to blame Simon Stevens for the crisis engulfing the NHS is akin to the Dutch public of old attempting to blame the little boy who stuck his finger in the dyke. As for not following the government’s “direction of travel” – well, there isn’t one. All credit therefore to Mr Stevens for trying to find it. The government may not like what he says, but at least he is thinking outside the box which, as thinking inside it has manifestly failed to sort things out over the last 30 years, can only be a sensible thing. That said, it doesn’t matter how brilliant a manager is if the business he is trying to run is terminally bankrupt. The NHS as constituted cannot work and it is time to seek radical alternatives.”
I trust that Mr Stevens, should he read the letter, take some comfort from my support. Doctors traditionally bash managers; managers refer to the control of doctors as like herding cats. But successive governments have spent untold time, and money, trying to “fix” the NHS almost from its beginning, and yet successive quotes in newspapers from the 1950s onwards have wanred of impending or exisiting crisis.
Things are very different from 1948. Then, infectious diseases still killed thousands; heart attacks were untreatable, gastric and duodenal ulcers were rife, investigations were primitive and cheap; cancer simply killed. Now antibiotics have saved thousands, heart attacks are treatable, if not always preventable; drugs have almost eliminated stomach ulcers and cancer can be treated. All of this comes at a cost. Investigations that are now routine, such as CT and MRI scanning, are not cheap and drugs that limit disease and extend life are exorbitant. People live longer as they don’t die early from the aforementioned conditions, but live into old age with multiple, life-threatening pathology and often dementia on top. Take such a person and admit them and it will cost thousands.If it’s a different set of health issues then I argue it needs a service designed to fit it.
Tinkering has failed us. We labour under the illusion that the NHS is a business. We have a so-called purchaser-provider system where the purchaser’s outlay is limited because it is constrained by what it gets from government, and the provider side limited because government sets the pay rates for procedures. How such an arrangement can provide, or be expected to provide a surplus is beyond economic comprehension. If government gives too much money to an organisation, all it has done is just that; if it gives too little then the organisation will be in so-called deficit. To make savings it then has to make cuts in service, so it then gets even less money and the spiral continues.
Phillip Collins in “The Times” today argues that the age of the general hospital is over, suggesting that orthopaedic surgery can safely be conducted in small (and he presumes cheaper) units. He is completely wrong because he has looked only at one side of the argument. A small unit may be cheaper (though there is a vast pool of evidence to suggest the opposite) but to divorce specialties from each other runs the risk of serious clinical failure. If there is some unforeseen problem, where is the physician to solve the coronary episode or pulmonary embolus, the sudden loss of diabetic control, the acute hot joint? Where is the vascular surgeon to deal with the postoperative unstoppable haemorrhage? Where are the opportunities to exchange cross-specialty experience, or to train trainees in complication management? What is the cost of providing small intensive care units to rescue the patient who suddenly collapses and requires ventilation? It is the availability of multiple specialties that maintains the safety of medicine. Collins hadn’t thought of that.
This all leads me to the expected announcement that the government will change its planning processes. As well as coming up with ideas it will also test them to destruction in a new departmental analysis system. In the NHS and elsewhere we have been belaboured and bewitched by policy initiatives that have fallen over because no-one has looked at the possible bad outcomes of change alongside the good ones. Take Jeremy Corbyn’s recent idea to limit top wages. Sounds great – economic madness and probably impossible to implement (and top earners will leave the country – pay peanuts, get monkeys, not a good idea. So watch out for the new Department of Alternative Orthodoxy, which will contain a new committee called OfWhat (the Office of “What if?” or the Null Hypothesis Office). All plans would pass through a scrutiny committee whose only role would be to find something that would make the scheme fail. Then there would be no egg on face when some smartass like me pointed out post-hoc why it wouldn’t work, and no need for the enthusiasts to slink away, red-faced with embarrassment at their simple and stupid errors of omission.
Let me give another example. Some years back the NHS became intensely interested in the American system of Health Maintenance Organisations (HMOs). My hospital was approached to consider the system. It was decided that a working group of managers and consultants should go to the States for a week to see the system first hand. There was great excitement. There was no doubt that such a trip would be a good learning exercise and would help us to make a decision on whether an HMO system might work fir us, but I pointed out that if the public got to learn of it, given the parlous financial situation at the time, there would be the most frightful reaction and those that went would be pilloried for wasting resources by going on an expensive junket. The press would have a field day. Somehow no-one had thought of that. They had all looked at the plus side of the equation alone. The proposal was abandoned.
Actually no such department will be established because it is too bold a step. It would tacitly acknowledge the recurrent failures in the present system and no politician would be prepared to do that. Would they?