painful lesson on healthcare in the NHS Bermuda triangle
The prime minister was blunt. âNo gain without painâ was his Easter message to the National Health Service to celebrate his third attempt to reorganise it.
Two days later I felt the pain. It was a stabbing sensation from a burst cyst and it occurred in two equally alarming places. One was the right groin and the other was mid-Wales. The latter is currently the NHSâs Bermuda triangle, where doctors, ambulances and entire hospitals simply disappear from the radar each time I visit.
Not long ago this part of Wales had a 24-hour GP service in the village and two hospitals, one offering surgery, within 10 miles. Now the 24-hour service is a Cardiff call centre with a response from a locum doctor 25 miles away in Dolgellau.
The latter explained that under NHS rules I had to visit her in person before she could refer me for an operation a further 40 miles away, either in Bangor or in Aberystwyth. If I were you, she said, I would drive yourself to an A&E somewhere, take a good book and hope for the best. I suddenly saw what Blair meant by his new âpatient-driven, choice-basedâ NHS. You drive, we choose.
To the public the present NHS âcrisisâ must be baffling. Not a day passes without a bad news story in the press. Deficits are soaring, hospitals going into virtual administration, drug treatments being decided by the High Court and 6,000 staff about to be sacked. Even in fashionable Kensington and Chelsea the health trust has recently found itself with Â£6m in invoices not accounted for and the auditor not noticing. The same auditor, Price Waterhouse Coopers, is then called in to audit the loss, doubtless adding its own invoice to the pile.
Yet I can dimly see method in Blairâs pain and gain. There is at last an NHS ânarrativeâ. Waiting lists are down and gleaming hospitals are rising at least in the big cities. The much-quoted Â£800m deficit is no big deal in a service costing Â£72 billion. It is only getting publicity because, at last, the government is refusing to rob Peter to pay Paul. The pus of inefficiency is finally starting to ooze from the NHS patient.
The British health service had by the mid-1980s become an unsustainable racket. Doctors were running hospitals according to mind-bending restrictive practices. Theatre productivity was pitiful. Nurses and paramedics were treated by doctors as serfs. A&E patients were handed from one clinician to another in a ludicrous make-work scheme. Drug companies, computer firms, management consultants, negligence lawyers and staff unions were walking away with the till each night.
By 1987 the Tories had doubled spending and the money had vanished. Margaret Thatcher lost her temper. Wailing to Panorama about the âbottomless pitâ of NHS costs, she set in train what became the 1990 NHS Act and two decades of reform.
Any Briton who smugly insults public administration in France or Italy or Paraguay or Papua New Guinea should study Britainâs NHS, c1990-2006. Thatcherâs reform began as essentially sound. She introduced fundholding doctors and trust hospitals, forcing GPs to be more resource-minded and trying to release hospitals from the grip of a reactionary medical profession. A bureaucratised NHS would be supplanted by a market-led local one.
The 1990 Act was scuppered first by the Treasury and then by the Labour party. The Treasury refused to allow hospital trusts financial autonomy, even denying them freedom to negotiate their own wages. They lost control of their costs and simply dumped the bill on the exchequer. Yet as a recent report for auditors KPMG by Rupert Darwall â a director of the Reform think tank â has shown, Thatcherâs fundholding yielded a more dramatic fall in waiting times than did Labourâs extravagance.
When Blair came to office in 1997 he wrecked this structure out of sheer political vengeance. His health secretary, Frank Dobson, dismantled fundholding and the internal market and reduced the NHS to administrative chaos.
There followed three structural reorganisations, roughly in 1998, 2002 and 2004 (though connoisseurs have counted seven). There are now 572 hospital and primary care trusts. Community health councils give way to patient forums. Some 40 quangos float round Whitehall as flotsam left over by some overnight headline-grabbing initiative. Last week, desperate for a good news story, Patricia Hewitt came up with âdignity nursesâ.
Within two years of being created, some 30 âstrategic health authoritiesâ are to be cut to 10 and 303 primary care trusts to be cut to 100. Millions of pounds have gone on these reorganisations, which are completely unrelated to health care. Some Â£15 billion (some say Â£30 billion) is being allocated to a nationwide âchoose and bookâ computer for which nobody unconnected with the project sees any need. It would have been of no use to me last weekend, in contrast with a tiny fraction of that sum spent on a modicum of local healthcare.
After a further doubling of health spending Blair has returned to where Thatcher was in 1987, with fundholding, trust hospitals and internal markets. This time he appears to mean it, but he will need to keep his nerve.
The âmissing billionsâ that caused such anguish to trust budgets this year resulted from Brownâs disastrous insistence that Whitehall, which means the Treasury, negotiates NHS pay. The resulting 2004 pre-election award to doctors sent GP pay to Â£100,000 (and reportedly to Â£250,000 for some). It came as a bolt from the blue to hospital treasurers. So has the new national tariff for hospital operations. Neither took any account of local costs and wrecked all long-term planning. Four top childrenâs hospitals, including Great Ormond Street, have indicated that the tariff may bankrupt them.
Hospitals are the financially threatened species of the new Blair/Thatcherism. By allowing hospitals to borrow at will â rather than borrow from him â Brown has allowed them to build up a Â£6 billion liability at private rates of interest with twice as much in the pipeline. A big hospital such as Queen Elizabethâs Woolwich predicts an annual debt charge of Â£100m, money it certainly does not have. British hospitals will soon be fighting for their lives.
The government appears to have accepted that an NHS hospital is no longer regarded by staff or patients as a philanthropic charity but as a factory supplying an expensive service, lucrative for some. Blair says he expects 40% of operations to be performed privately. But if hospitals are to revert to their 19th-century status their independence must be real.
Hospitals must be free to collaborate, plan their specialisms, liaise with âcottageâ outposts and not have the Treasury and the NHS central costs imposed on them, whether expensive staff or expensive drugs. Otherwise they will end up like Railtrack, healthcareâs infrastructure authority with ministers meddling in every bedpan.
Blair is clearly relying on his new breed of highly paid and entrepreneurial GPs to hold and disburse NHS cash. It is a version of Thatcherâs original (but diluted) Enthoven plan whereby âmoney follows the patientâ. Gone will be the local general hospital offering a table dâhÃ´te service within easy range of patients, which is why northwest Scotland and mid-Wales are being denuded of beloved institutions.
On the other hand local GPs, their pockets and âcommissioningâ budgets bursting with money, may band together with local authorities to run new health centres, perhaps even hospitals. Already Wychavon council in Worcestershire is doing just that.
If there is any superfluous tier in all this it is the once-vaunted primary care trusts. They should be put out of their misery.
GPs should go back to the arrangement before the war, under the wing of elected local health committees. They were cheap and they worked. There will be âpostcode lotteryâ rows. But democratic accountability will be clear, as in Scandinavia, Germany and other countries where healthcare contrives to be better than ours yet is not ânationalisedâ. In Denmark just 5% of patients need treatment that cannot be supplied within the remit of their elected county health authority.
It is possible, just possible, that this is the âgainâ of which Blair was talking. Of the pain there is no doubt.
Certainly a cold winter, and colder than any in the last ten years by about 2 degrees C, but worst winter ever? No. I remember 1962/63. Just. A lot of snow in Berkshire! Feet. What did we have this year? Two inches!mistersoft said:Didn't she say that despite the one of the worst winters ever there were no bed shortages?
Apparently, a recent published book called "Freakonomics" covers the distortion produced by setting such targets. I haven't read it yet, but it is on my list!Cuddles said:NHS, Police Service, you name it...set targets and then reaching the target becomes more important than achieving the aim. They are not one and the same, despite what most (i.e. human not civil servant/government advisors) people might think. This allows the target of reducing costs by closing wards or police stations or post offices to be met, while people die, can't get cash or have to borrow a phone to report their house has been emptied by burglars again.
Politics eh...the realistic alternative to working for a living.
The reason there were no bed shortages , Were from the reports in the local media all the operation's were cancelled and only emergency patients were admitted.mistersoft said:Didn't she say that despite the one of the worst winters ever there were no bed shortages?
They must have used a government sponsored weather service that delivered weather to suit or just lied about it.
I don't suppose those being made redundant would agree with the claim 'Best Year Ever'.
Are we supposed to believe that?
Sorry the one brain cell sees through the lies.
Even the weather isn't safe from being suitably doctored.Litotes said:Certainly a cold winter, and colder than any in the last ten years by about 2 degrees C, but worst winter ever? No. I remember 1962/63. Just. A lot of snow in Berkshire! Feet. What did we have this year? Two inches!mistersoft said:Didn't she say that despite the one of the worst winters ever there were no bed shortages?
I work in such a unit, (as well as others) and I've seen patients getting shunted out of the assesment unit into other wards far too early because there's another load that have to come in. It's dangerous and puts the next ward under far more pressure than they should be under.ViroBono said:Some of the targets are met on paper, whilst not actually changing the situation at all. Take A&E waiting times - once a patient has waited for almost the 4-hour limit, he's moved to an 'observation unit', or a 'medical admissions unit', where he continues to wait, though the A&E target for waiting time has been met.
Good rant thoughhealer said:I work in such a unit, (as well as others) and I've seen patients getting shunted out of the assesment unit into other wards far too early because there's another load that have to come in. It's dangerous and puts the next ward under far more pressure than they should be under.ViroBono said:Some of the targets are met on paper, whilst not actually changing the situation at all. Take A&E waiting times - once a patient has waited for almost the 4-hour limit, he's moved to an 'observation unit', or a 'medical admissions unit', where he continues to wait, though the A&E target for waiting time has been met.
<<She also said "so-called job cuts" in recent weeks mainly affected agency and tempory staff and were reducing a "very innefficient and wasteful form of spending>> Yes, sure, that's why my number of shifts has been cut down and why half of my family and freinds are worrying about our futures. If you want to cut innefficiencies, get rid of the middle management who are turning hospitals into a business, you know its bad when the ward operator is told that a patient has died and they reply "oh good, that's a free bed"
Nipping down to Boots for a pack of plasters.healer said:Too true mistersoft, I dont get it too badly, but the senior nurses cant seem to move for paperwork.
Oh and has anyone else that works in a hospital noticed that everything has a price tag on it now INCLUDING plasters?!?!?