Politics of Health Care
Philip Colins spells out a number of awkward home truths in tho article for The Times about the politics of the NHS.
For years everyone has talked a great game about putting patients in the driving seat when it comes to health care services, but when push comes to shove what takes priority are the interests of managers and other 'providers' within the system.
And while there are examples of exemplary care within the NHS there is little doubt in my mind that the service would be much more responsive, if Mrs Smith really was put in charge.
To save the NHS we must let Mrs Smith run it
By Philip Collins - The Times
Integrating the fractured parts of the health service will achieve nothing unless the patients who use it are in charge
A viable future for the National Health Service is in the hands of Mrs Smith. Health services in Torbay, where the 80-year-old Mrs Smith lives, had an awful reputation. Mrs Smith staggered through the care system like Ariadne dragging a thread through the labyrinth. With every new meeting she had to repeat her life story.
Stung by her torpid journey through their lifeless corridors, Torbay’s officials tore up their bureaucracy. Disparate players came into concert and Mrs Smith set the tune. The various NHS fiefdoms pooled their budgets to make the money work for Mrs Smith. It worked for all the other Mrs Smiths too. Emergency hospital admissions of the over 65s were all but eliminated as the elderly were treated where they were most happy — at home. Health standards went up in strict relation to costs going down.
There is only one more thing to say about the fabled Mrs Smith. She is fictitious. She is a character made up by Torbay’s officials to describe how their dismally complex system looked to an actual person. Yesterday Simon Stevens, the excellent new chief executive of NHS England, delivered his plan for the next five years, which will, in essence, take power from producers and give it to consumers.
In the misleadingly bloodless prose of a government body, the Five Year Forward Review sketched a revolution in what it calls the “factory model” of the NHS.
Mr Stevens points out that unless the trajectory of the NHS is altered, a deficit of £30 billion per annum will pile up by 2020. He proposes collapsing the boundaries between the GP and the hospital and bringing services of all kinds together under one roof. He wants a major reorganisation of emergency services and makes proposals for taking a lot of care out of the NHS and into the family home. It is all on the money and the only anxiety is how on earth it will ever happen.
The NHS, like the monarchy, changes at a glacial pace. All the rows have been going on since the beginning of time in 1948. “The overall state of general practice in England is bad and deteriorating,” said the Collings survey in The Lancet in 1950. “What is most needed at the present time is the prospect of a period of stability,” said RH Turton, the minister of health, in 1956. “Patients who are fit to live in the community should not be in large mental institutions,” said the Royal Commission on Mental Illness in 1957. “Our basic purposes”, said the health minister Baroness Serota in 1970, “are to unite the NHS and to integrate its separate services.”
Every one of those questions is a big deal in the Stevens review, but the biggest deal of the lot is Baroness Serota’s ambition of integration. It is hard to leave the house these days (at least I find it so) without stumbling into a seminar on NHS integration. That is partly because fragmentation was deliberately written into the origins of the NHS. When hospitals were nationalised in 1948, consultants became salaried staff in hospitals owned by the state. Primary care, meanwhile, was established in GP services that were constituted as private franchises.
The founding fathers of the NHS established this separation of powers to ensure that, as with the American constitution, no single body could enjoy untrammelled power. Or, to change the metaphor, as Professor Rudolf Klein says in The Politics of the NHS, this is a restaurant where one person orders the food, another one eats it and someone else again pays the bill.
The task of integration is therefore colossal. In any given health authority a thousand people, spread across 15 professional cultures, would have to come together to produce an integrated mental health service. More than four fifths of the services required to keep frail elderly people out of hospital are not, in any case, NHS services. Primary and secondary care have separate budgets, different access to data and workforces that rarely communicate.
To suppose that this array of autonomous bodies, which together comprise the leviathan we know as the NHS, can somehow, against all precedent, wish itself integrated is a truly fond hope. The sinister-sounding Health and Wellbeing Boards, set up in 2010, are the latest incarnation of this recurrent error.
Yet achieving integration is now something worse than a fond hope; it is a necessity. Already, 70 per cent of the health budget is spent on the 15 million people who are looking after their own chronic disease. Patients with dementia, diabetes, arthritis and hypertension take half of all GP appointments, two thirds of outpatient appointments and seven of every ten inpatient beds. There is also strong evidence that integration improves the quality of cardiac, cancer and stroke care.
Healthcare, in an old country, is a continuous, rather than an episodic, service. It has to be integrated around the individual. Integration by central fiat, though, is a fool’s errand. In a recent international survey the NHS Confederation concluded that integration which begins from the attempt to cajole institutions into partnership produces no significant improvement to care.
They don’t even achieve any integration as there is no way to force people to work together who would prefer to maintain their professional distance. The government, in its wisdom, forswore the only command at its disposal when Andrew Lansley abolished the NHS targets regime. Competition is still too weak to exert serious pressure. Notwithstanding the shadow health secretary Andy Burnham’s silly moan about privatisation, a decade after Labour licensed competition, a mere 4 per cent of hip and knee replacements are done by the private sector.
That leaves only the one option — which is that Mrs Smith had better be made the gaffer. This must be the animating idea of NHS reform. It is there in the review but without a sense of urgency or much indication of how hard it will be. A 2010 Commonwealth Fund report compared healthcare in seven wealthy countries. The NHS came top for care and efficiency but, on putting patients in control, it came last.
The political debate about the NHS is, in this context of peril, a feeble embarrassment. When the changes start, NHS England will need political air cover. The voluble friends of the NHS could turn out to be its worst enemies. Mrs Smith deserves better than she is getting from her politicians. Although she does not exist, she is everywhere.
Here's what Alex Neil had to say about his own proposals by the way and it doesn't seem to me that there's
“But let me be clear – there is absolutely no complacency and we will go on striving for improvement while staying true to the founding principles of our NHS.
“That is why we must do more to listen to, and promote, the voices of those we care for. We need the voices of our patients, those receiving care and their families, to be heard in a much clearer and stronger way. The introduction of Patient Opinion has provided a new and vital way to gather views.
“However, we will not stop there. That is why I will be bringing forward proposals for a new system of listening to, and promoting, the patients’ voice. I have tasked Healthcare Improvement Scotland and the Scottish Health Council to develop these new proposals.
“Their task is straightforward – develop a system that means we do more to truly hear the voice of patients.”
Nothing in that to get worked up or all defensive about if you ask me, but the RCN have form in this area as you can read below.
Here's what the independent Francis Report into Mid Staffs had to say about the RCN:
Royal College of Nursing
1.98 At Stafford, the RCN was ineffective both as a professional representative organisation and as a trade union. Little was done to uphild professional standards among nursing staff or to address concerns and problems being faced by its members.
1.99 A prime reason for this was a lack of effective representation from elected officers on site. Further, the support avaialable from RCN officials at a regional and national level was limited.
1.100 The RCN is not, of course, a regulator but a combination of a professional representative body and a trade union. However, it does represent a group of qualified professionals and seeks, as it should, to promote high standards of service and conduct. The evidence reviewed in this report suggest that the RCN has not been heard as might have been expected in pursuing professional concerns about the standard of care.
1.101 It appears there is a concerning potential for conflict of intersst between the RCN's professional role of promoting high quality standards in nursing, and its union role of negotiating terms and conditions and defending members' material and other narrow interests.
Ouch! - was probably the intitial reaction of the RCN to such devastating criticism of its role at Mid Staffs - and I suspect that the other NHS trade unions behaved in a similar fashion.
The lesson to learn is that NHS trade unions cannot champion the cause of services users and their families - who need a strong voice of their own to balance the many vested interests which control the NHS.
What's needed in the NHS and elsewhere in the public services is more People Power - and less control by the senior managers and bureaucrats who run the show at the moment - sometimes for their own selfish ends.
Hospital Trip Advisor (4 February 2013)
I am beginning to think that Dr Peter Carter - the chief executive of Royal College of Nursing (RCN) - is losing the plot.
The leader of the country's largest nursing union was in the papers at the weekend - making some rather extraordinary claims about poor standards of care in the NHS - and here's what Dr Carter had to say:
“Will there be another Mid Staffs? Yes, sadly there will be. There are 1.2 million people employed in the NHS and there is a hospital in every town. It would be foolish to say everything in the garden is roses.
Mid Staffs cannot be an isolated incident. The fact is, the service is under huge strain. Trusts are not thinking intelligently about how they deliver care and are simply cutting the numbers of frontline staff. Our members have a personal and professional responsibility to raise concerns.
The vast majority of patients still get good care, but that is no consolation to those who don’t. Mid Staffs has got this massive profile now, but there have been many others like it . . . Bristol Royal Infirmary, Basildon, Alder Hey. The report into Maidstone and Tunbridge Wells [where hundreds of patients died after an outbreak of the superbug C-difficile] is painful to read. On the wards there were beds that were eight inches apart ... what the hell were the managers doing, but also what was going on with the nursing culture? There was a culture of bullying and intimidation.
If the board had spent time walking the wards, talking to patients and staff, just doing their jobs, they may have saved hundreds of lives.
You wouldn’t expect staff at Kwik-Fit to get by with a bit of TLC and a bit of common sense. These are old people ... their bones are like porcelain, their skin is like tissue paper. They need highly skilled specialist care. The idea that four or five unskilled staff can take care of 30 elderly patients is nonsense.”
Now these comments come in advance of the report on Mid Staffordshire NHS Trust - where poor standards of care said to have caused up to 1,200 unnecessary deaths between 2005 and 2008.
So the first point to be made is that the scandal of Mid Staffs happened at a time of plenty for the NHS - which means that, broadly speaking, resources and money were not any part of the problem.
The second point I would make is that the NHS is one of the most highly unionised industries in the UK - and the RCN is one of the largest, most influential trade unions - with lots of RCN members in senior management and leadership positions.
In which case I fail to see how it can sensibly be argued that Trust's board members were somehow responsible for saving hundreds of lives - when there were all these staff around who were paid, some of them very generously as well, to look after patients.
I happen to think it would be a good for NHS board members to interact more with patients and their families - but surely this would be much more practical if the regulatory bodies in the UK made more unannounced inspection visits - and actually asked patients and families for their views on the standard of care received.
My mother died five years ago after and before she passed away my mum was a frequent visitor to her local hospital where - I think it's fair to say - that some of the care she received was very poor.
But no one asked my mum what she thought of her care - nor any of her family - which strikes me as very odd in this day and age - because feedback from patients and families is the obvious way to highlight underlying problems.
To paraphrase Dr Carter's own analogy - I think I receive much better customer care from Kwik-Fit than my dear old mum did at times - from her local NHS hospital.
A former health secretary in the last Labour government - Alan Milburn - came up with an interesting idea recently with his suggestion that the NHS needs an equivalent of Trip Advisor- so that patients and their families can provide useful feedback after a hospital visit.
People power meets patient power - now that really ought to be part of the answer.
Integrating the fractured parts of the health service will achieve nothing unless the patients who use it are in charge
A viable future for the National Health Service is in the hands of Mrs Smith. Health services in Torbay, where the 80-year-old Mrs Smith lives, had an awful reputation. Mrs Smith staggered through the care system like Ariadne dragging a thread through the labyrinth. With every new meeting she had to repeat her life story.
Stung by her torpid journey through their lifeless corridors, Torbay’s officials tore up their bureaucracy. Disparate players came into concert and Mrs Smith set the tune. The various NHS fiefdoms pooled their budgets to make the money work for Mrs Smith. It worked for all the other Mrs Smiths too. Emergency hospital admissions of the over 65s were all but eliminated as the elderly were treated where they were most happy — at home. Health standards went up in strict relation to costs going down.
There is only one more thing to say about the fabled Mrs Smith. She is fictitious. She is a character made up by Torbay’s officials to describe how their dismally complex system looked to an actual person. Yesterday Simon Stevens, the excellent new chief executive of NHS England, delivered his plan for the next five years, which will, in essence, take power from producers and give it to consumers.
In the misleadingly bloodless prose of a government body, the Five Year Forward Review sketched a revolution in what it calls the “factory model” of the NHS.
Mr Stevens points out that unless the trajectory of the NHS is altered, a deficit of £30 billion per annum will pile up by 2020. He proposes collapsing the boundaries between the GP and the hospital and bringing services of all kinds together under one roof. He wants a major reorganisation of emergency services and makes proposals for taking a lot of care out of the NHS and into the family home. It is all on the money and the only anxiety is how on earth it will ever happen.
The NHS, like the monarchy, changes at a glacial pace. All the rows have been going on since the beginning of time in 1948. “The overall state of general practice in England is bad and deteriorating,” said the Collings survey in The Lancet in 1950. “What is most needed at the present time is the prospect of a period of stability,” said RH Turton, the minister of health, in 1956. “Patients who are fit to live in the community should not be in large mental institutions,” said the Royal Commission on Mental Illness in 1957. “Our basic purposes”, said the health minister Baroness Serota in 1970, “are to unite the NHS and to integrate its separate services.”
Every one of those questions is a big deal in the Stevens review, but the biggest deal of the lot is Baroness Serota’s ambition of integration. It is hard to leave the house these days (at least I find it so) without stumbling into a seminar on NHS integration. That is partly because fragmentation was deliberately written into the origins of the NHS. When hospitals were nationalised in 1948, consultants became salaried staff in hospitals owned by the state. Primary care, meanwhile, was established in GP services that were constituted as private franchises.
The founding fathers of the NHS established this separation of powers to ensure that, as with the American constitution, no single body could enjoy untrammelled power. Or, to change the metaphor, as Professor Rudolf Klein says in The Politics of the NHS, this is a restaurant where one person orders the food, another one eats it and someone else again pays the bill.
The task of integration is therefore colossal. In any given health authority a thousand people, spread across 15 professional cultures, would have to come together to produce an integrated mental health service. More than four fifths of the services required to keep frail elderly people out of hospital are not, in any case, NHS services. Primary and secondary care have separate budgets, different access to data and workforces that rarely communicate.
To suppose that this array of autonomous bodies, which together comprise the leviathan we know as the NHS, can somehow, against all precedent, wish itself integrated is a truly fond hope. The sinister-sounding Health and Wellbeing Boards, set up in 2010, are the latest incarnation of this recurrent error.
Yet achieving integration is now something worse than a fond hope; it is a necessity. Already, 70 per cent of the health budget is spent on the 15 million people who are looking after their own chronic disease. Patients with dementia, diabetes, arthritis and hypertension take half of all GP appointments, two thirds of outpatient appointments and seven of every ten inpatient beds. There is also strong evidence that integration improves the quality of cardiac, cancer and stroke care.
Healthcare, in an old country, is a continuous, rather than an episodic, service. It has to be integrated around the individual. Integration by central fiat, though, is a fool’s errand. In a recent international survey the NHS Confederation concluded that integration which begins from the attempt to cajole institutions into partnership produces no significant improvement to care.
They don’t even achieve any integration as there is no way to force people to work together who would prefer to maintain their professional distance. The government, in its wisdom, forswore the only command at its disposal when Andrew Lansley abolished the NHS targets regime. Competition is still too weak to exert serious pressure. Notwithstanding the shadow health secretary Andy Burnham’s silly moan about privatisation, a decade after Labour licensed competition, a mere 4 per cent of hip and knee replacements are done by the private sector.
That leaves only the one option — which is that Mrs Smith had better be made the gaffer. This must be the animating idea of NHS reform. It is there in the review but without a sense of urgency or much indication of how hard it will be. A 2010 Commonwealth Fund report compared healthcare in seven wealthy countries. The NHS came top for care and efficiency but, on putting patients in control, it came last.
The political debate about the NHS is, in this context of peril, a feeble embarrassment. When the changes start, NHS England will need political air cover. The voluble friends of the NHS could turn out to be its worst enemies. Mrs Smith deserves better than she is getting from her politicians. Although she does not exist, she is everywhere.
Patients' Voices (5 June 2014)
Scotland's health minister, Alex Neil, made some sensible proposals the other day about strengthening the voice of patients in the NHS.
Now who could see anything problematic in that, but here's a terribly defensive response from one of the main health unions, the Royal College of Nursing (RCN), which sounds to me as if patients (or their families) say anything critical then the staff and the unions expect to consulted about what happens next.
Commenting on the announcement from Cabinet Secretary for Health and Wellbeing Alex Neil MSP that he will bring forward proposals for a new system of listening to, and promoting, the patients’ voice RCN Scotland Director Theresa Fyffe said:
“If we are to achieve an NHS in Scotland that truly focuses on patients, we need to listen to their concerns and give them the means for their voices to be heard. That’s why we supported the introduction of Patient Opinion into our NHS last year. We believe that all patients should be able to feedback their views on the care they receive, both positive and negative, so health boards and the Government can use this constructively to improve and change how things are done.
“At the same time, staff must also have a voice and be listened to. Patients’ views can affect already demoralised staff, who are trying to do their best under pressure. Health boards must therefore listen to what patients are saying and then listen and support staff to make the necessary changes to improve how care is delivered. Both patients’ and staff’s feedback and concerns are important and must be heard locally and nationally, if our NHS is to become ‘world class’.”
“If we are to achieve an NHS in Scotland that truly focuses on patients, we need to listen to their concerns and give them the means for their voices to be heard. That’s why we supported the introduction of Patient Opinion into our NHS last year. We believe that all patients should be able to feedback their views on the care they receive, both positive and negative, so health boards and the Government can use this constructively to improve and change how things are done.
“At the same time, staff must also have a voice and be listened to. Patients’ views can affect already demoralised staff, who are trying to do their best under pressure. Health boards must therefore listen to what patients are saying and then listen and support staff to make the necessary changes to improve how care is delivered. Both patients’ and staff’s feedback and concerns are important and must be heard locally and nationally, if our NHS is to become ‘world class’.”
Now this seems like a whole load of baloney to me because the NHS is one of the most highly unionised areas anywhere in the public sector and the staff already have a very strong voice and ability to express their views.
And as events at Mid Staffordshire Hospital have shown there have been terrible cases of neglect and poor standards of care within the NHS, so the problems are not always about staff working under pressure.
To my mind it's complete humbug to argue that "patients' views can affect already demoralised staff, who are trying to do their best under pressure" because what that sounds like to me is people getting their excuses ready without even listening to what patients and their families have to say.
Here's what Alex Neil had to say about his own proposals by the way and it doesn't seem to me that there's
“But let me be clear – there is absolutely no complacency and we will go on striving for improvement while staying true to the founding principles of our NHS.
“That is why we must do more to listen to, and promote, the voices of those we care for. We need the voices of our patients, those receiving care and their families, to be heard in a much clearer and stronger way. The introduction of Patient Opinion has provided a new and vital way to gather views.
“However, we will not stop there. That is why I will be bringing forward proposals for a new system of listening to, and promoting, the patients’ voice. I have tasked Healthcare Improvement Scotland and the Scottish Health Council to develop these new proposals.
“Their task is straightforward – develop a system that means we do more to truly hear the voice of patients.”
Nothing in that to get worked up or all defensive about if you ask me, but the RCN have form in this area as you can read below.
Voice For Service Users (5 March 2013)
Trade unions are experts at lots of things - especially at telling other people what to do and how to do it.
But in my experience trade unions are seldom keen to accept any critical assessment of their own performance or the kind of independent scrutiny - which operates routinely in many other areas of public life.
But in my experience trade unions are seldom keen to accept any critical assessment of their own performance or the kind of independent scrutiny - which operates routinely in many other areas of public life.
I wrote a post last month about the lack of leadership from the trade unions during the care scandal at Mid Staffordshire NHS Trust - in particular the largest nurses union, the RCN.
Royal College of Nursing
1.98 At Stafford, the RCN was ineffective both as a professional representative organisation and as a trade union. Little was done to uphild professional standards among nursing staff or to address concerns and problems being faced by its members.
1.99 A prime reason for this was a lack of effective representation from elected officers on site. Further, the support avaialable from RCN officials at a regional and national level was limited.
1.100 The RCN is not, of course, a regulator but a combination of a professional representative body and a trade union. However, it does represent a group of qualified professionals and seeks, as it should, to promote high standards of service and conduct. The evidence reviewed in this report suggest that the RCN has not been heard as might have been expected in pursuing professional concerns about the standard of care.
1.101 It appears there is a concerning potential for conflict of intersst between the RCN's professional role of promoting high quality standards in nursing, and its union role of negotiating terms and conditions and defending members' material and other narrow interests.
Ouch! - was probably the intitial reaction of the RCN to such devastating criticism of its role at Mid Staffs - and I suspect that the other NHS trade unions behaved in a similar fashion.
The lesson to learn is that NHS trade unions cannot champion the cause of services users and their families - who need a strong voice of their own to balance the many vested interests which control the NHS.
What's needed in the NHS and elsewhere in the public services is more People Power - and less control by the senior managers and bureaucrats who run the show at the moment - sometimes for their own selfish ends.
Hospital Trip Advisor (4 February 2013)
I am beginning to think that Dr Peter Carter - the chief executive of Royal College of Nursing (RCN) - is losing the plot.
The leader of the country's largest nursing union was in the papers at the weekend - making some rather extraordinary claims about poor standards of care in the NHS - and here's what Dr Carter had to say:
“Will there be another Mid Staffs? Yes, sadly there will be. There are 1.2 million people employed in the NHS and there is a hospital in every town. It would be foolish to say everything in the garden is roses.
Mid Staffs cannot be an isolated incident. The fact is, the service is under huge strain. Trusts are not thinking intelligently about how they deliver care and are simply cutting the numbers of frontline staff. Our members have a personal and professional responsibility to raise concerns.
The vast majority of patients still get good care, but that is no consolation to those who don’t. Mid Staffs has got this massive profile now, but there have been many others like it . . . Bristol Royal Infirmary, Basildon, Alder Hey. The report into Maidstone and Tunbridge Wells [where hundreds of patients died after an outbreak of the superbug C-difficile] is painful to read. On the wards there were beds that were eight inches apart ... what the hell were the managers doing, but also what was going on with the nursing culture? There was a culture of bullying and intimidation.
If the board had spent time walking the wards, talking to patients and staff, just doing their jobs, they may have saved hundreds of lives.
You wouldn’t expect staff at Kwik-Fit to get by with a bit of TLC and a bit of common sense. These are old people ... their bones are like porcelain, their skin is like tissue paper. They need highly skilled specialist care. The idea that four or five unskilled staff can take care of 30 elderly patients is nonsense.”
Now these comments come in advance of the report on Mid Staffordshire NHS Trust - where poor standards of care said to have caused up to 1,200 unnecessary deaths between 2005 and 2008.
So the first point to be made is that the scandal of Mid Staffs happened at a time of plenty for the NHS - which means that, broadly speaking, resources and money were not any part of the problem.
The second point I would make is that the NHS is one of the most highly unionised industries in the UK - and the RCN is one of the largest, most influential trade unions - with lots of RCN members in senior management and leadership positions.
In which case I fail to see how it can sensibly be argued that Trust's board members were somehow responsible for saving hundreds of lives - when there were all these staff around who were paid, some of them very generously as well, to look after patients.
I happen to think it would be a good for NHS board members to interact more with patients and their families - but surely this would be much more practical if the regulatory bodies in the UK made more unannounced inspection visits - and actually asked patients and families for their views on the standard of care received.
My mother died five years ago after and before she passed away my mum was a frequent visitor to her local hospital where - I think it's fair to say - that some of the care she received was very poor.
But no one asked my mum what she thought of her care - nor any of her family - which strikes me as very odd in this day and age - because feedback from patients and families is the obvious way to highlight underlying problems.
To paraphrase Dr Carter's own analogy - I think I receive much better customer care from Kwik-Fit than my dear old mum did at times - from her local NHS hospital.
A former health secretary in the last Labour government - Alan Milburn - came up with an interesting idea recently with his suggestion that the NHS needs an equivalent of Trip Advisor- so that patients and their families can provide useful feedback after a hospital visit.
People power meets patient power - now that really ought to be part of the answer.
