Sunday 29 October 2023

Reforming the NHS and the laws of politics

Many years ago as a young local councillor, I discovered that politics is bedevilled by the sheer irrationality of our electors.  London Transport (as it then was) proposed to make some perfectly sensible changes to the bus network in my area, and held a public consultation.  A woman rose and made an impassioned speech in two parts: 

(A)  the current bus service was shit;  and 
(B)  it mustn't on any account be changed, in any particular.

I was very glad it wasn't me in the chair, because I find it really difficult dealing with stuff like that ( - the same motive that caused me to recoil from being foreman of the jury on which I sat recently; and was heartily grateful someone else accepted that solemn duty).

The public's attitude to the NHS is the same, only on a truly monstrous scale.  Here's an extract from a piece in LabourList last week
Normal people are very capable of holding contradictory views in their heads, especially in subjects about which they know little but feel strongly ... paradoxes, which have regularly been witnessed in opinion research ... are of profound importance as Labour thinks about how to frame its NHS offer running into the next election. They are:
- Everyone loves the NHS and yet in focus groups it quickly becomes apparent that absolutely everybody has a personal horror story about waiting lists or botched admin. These stories flow from them like a public policy fever dream.
- Everybody knows that the NHS is in desperate need of reform – and yet in focus groups almost nobody believes such reform will work. Getting people to imagine a high-performing NHS is very, very hard.
- Everybody knows that the NHS is in desperate need of investment – they see it with their own eyes every time they visit a hospital. And yet nobody believes it will make any difference to the service they are experiencing.
The piece goes onto say that "[Wes] Streeting’s speech at [Labour party] conference seemed to try to reflect these paradoxes and even solve some of them."  He's also recently told the Royal College of GPs that Labour "won’t entertain requests for blank cheques", which is rather what they have in mind.

Assuming he & the rest of Labour are seriously preparing for power (as well they might), I very much hope this all means they have taken heed of Drew's Laws of Politics #1:  Never buy off anyone at a higher price than absolutely necessary.  Virtually no voter will change their allegiance based on the precise nature of Labour's NHS policy next year.  But Labour could get itself into needless trouble by promising the earth, tempting though that must be.  Now one might say: Satrmer is such an accomplished liar and shameless U-turner, he can say whatever he will and then renege on it as PM, just as quickly as he always has with any other pledge or promise he made to the Labour faithful since 2019. 

Still, he'd probably rather not.  Might Labour then be the first party to come to power with a bit of a free hand on the NHS?  We do all really know it can't go on like it is.



dustybloke said...

The NHS does not need “investment”.
Recently, I’ve read of NHS spending that makes me weep. Male menopause is not a recognised medical condition but a trust is going to pay workers in its ambulance service their salary for up to a year while the sit at home and cope with their misery. The NHS pays diversity advisers £127,000 pa. If said advisers gave them advice they would be sacked. Can anyone imagine a diversity adviser recommending “more white nurses”? The silent advisers will be paid six figures pa for the rest of their lives, given the rate of inflation bottled up in our economy.
I’ve seen estimates of our unfunded public sector pensions being an off balance sheet liability in the trillions. So a few more billion in 2040 is going to make much difference?
NHS staff, like all public sector workers, are not paid on results. So the results are appalling. Of the London hospitals only a handful are recognised by doctors as being competent. I speak as a long term patient who has had several full and frank discussions with senior consultants.
The NHS needs a dramatic reorganisation whereby incentives and rewards are based on results. The GMC and BMA will fight tooth and nail to prevent this.

druid144 said...

I am a few months older than the NHS. I have seen countless attempts to reform the beast, reorganisations, initiatives, cost saving exercises ...
Every one, without fail, has ended up with less service for more- much more- money. No wonder surveys find :-

- Everybody knows that the NHS is in desperate need of reform – and yet in focus groups almost nobody believes such reform will work. Getting people to imagine a high-performing NHS is very, very hard.

djm said...

Everyone loves the NHS..........

Do they heck as like

It's W A Y past its sell by date & evisceration is urgently required

Nick Drew said...

What "everybody loves" ... is that it is *free*

it may frequently be shit, but you get at least something - *for nothing*

the distant folk-memory of indigent people going without medical care had a powerful and lasting effect on my parents' generation - and not just the traditional working classes: a lot of middle class people went through some hard times during the Depression

nobody dares mess with this powerful folk memory

iOpener said...

The ordinary folk are quite right:

1. The NHS is shit.

2. Any changes the elites make in efforts to make the NHS less shit, will in fact make it worse shit, because the elites are not elite, they are shit.


jim said...

The UK spends less on the NHS than any comparable European country. We spend a bit more than the poor countries and less than France, Germany etc. Been that way for decades. You don't get what you don't pay for.

The UK spends less on children's education than any comparable European country. Been that way for at leat the last decade. You don't get what you don't pay for.

The UK spends more on housing costs than any of its comparable neighbours. Good for the banks, not so good for GB plc.

To change the above situation will be a bit tricky for any government wanting to stay elected - as the Tories are discovering.

Diogenes said...

NHS, power utilities, housing, water services, roads etc.

Running a country and providing services for its (taxpaying) citizens is complex. Control of half the wealth of the country is in the hands of elected (I use the term loosely) politicians. However most of the actual services are provided by private companies which is increasing year by year.

So is the problem with politicians or with the private sector?

Jeremy Poynton said...

"Everyone loves the NHS"

Nope. I would say that more and more people are starting to despise it, and rightly so. The more money we pour into it, the worse it gets. Though I should say that applies wholesale to the public sector now.

If the NHS is so underfunded, how is it that they can afford DEI jobs on eye-watering salaries, here, there and everywhere. This would indicate to me (and yes, I am a cynical old bastard completely fucked off with what this shambles of a "conservative" party have done to the country) that they have far too much money.

Jeremy Poynton said...

"As an Englishman living in France who worked in the NHS some long time ago, it is of great sadness to me that both political dogma and the refusal to accept criticism of what has become a national icon manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the UK."

Those amongst us who recall the beloved late Anna Raccoon, will remember her writing on the difference between her treatment for terminal cancer in France, and then back here, when she moved back here to die. And certainly, Lil's experience at the hands of the NHS re her cancer is a total disgrace.

Trauma and emergency is the only way we would have anything more to do with them. They're not bad at that and orthopaedics, but we are damn sure Lil's appalling post breast cancer treatment led to her "terminal" bone cancer. Which would have been terminal had she accepted Chemo II as recommended. Her original oncologist was a disaster.

Old Git Carlisle said...

If I recall it correctly when asked how he got the medical profession to accept the NHS . The Bevin said 'I stuffed their mouths with Gold' . Enough said???

Sobers said...

"We spend a bit more than the poor countries "

And get a considerably worse service than those 'poor' countries.

"Those amongst us who recall the beloved late Anna Raccoon, will remember her writing on the difference between her treatment for terminal cancer in France, and then back here, when she moved back here to die. "

Ditto those of us who read the late Jeremy Clarke's column in the Spectator, that chronicled (among much else) having his cancer treated in France, where he lived in his last years.

Caeser Hēméra said...

@Jim - in terms of % of GDP, we're the sixth globally, with France, Germany and Austria being the European nations ahead of us.

In terms of *public* spending, I believe we're number 1. Which indicates one of the problems, the lack of private funding. Others are staffing, incessant meddling from central government, internal politics and historical underfunding (which actually ties in the public vs private)

The problem is, if you mention private funding you inevitably get comparisons with the US, as though we're the only two nations on the planet with health services, and there isn't a wealth of models in-between.

There are regulatory questions (see Babylon), and the health care network is almost as efficient at backside covering and job shifting as the Eton one is. In both public and private sectors I'm well aware of "missing" documents and prevarication to brush problems under a rug and avoid legal unpleasantries.

And back on to the regulatory aspect, the Tories have a poor record with it, undermining the argument for privatisation and capitalism in general, which doesn't help any arguments. If they busy sat whistling whilst private investors saddled water companies with massive debt, extracted billions and let the infrastructure rot with the expectation that the bill payer will get rinsed, what the merry hell could they do to healthcare? Rapped knuckles until the concept of enlightened self interest displaces I'm Alright Jack.

If the NHS has any chance of continuing there needs to be wholesale changes with how technology is purchased and used, clear-headed understanding of AI, acceptance of some measure of private insurance, and acceptance of responsibility, potentially with criminal sanctions in the worst examples, in exchange for better pay.

Maybe it's pay, maybe it's weariness, but there is a wide scale lack of professionalism and duty of care within the NHS at all levels. For every 'angel' there are a fair few cretins.

I'm perfectly fine paying better money to the 'angels' out of taxation and the savings from the cretins losing their pensions, jobs, and freedom.

Matt said...

Even the BBC are starting to notice how shite the NHS is -

Sackerson said...

I have recently suggested that two things would help reform the system:

(a) renegotiate GPs' contracts so that (as before) they have to provide 24/7 cover, this is even more possible now that they have been moving to the group practice model for years;

(b) make the highly paid hospital managers constantly patrol and check what's going on, like supermarket supervisors, rather than play with spreadsheets in their offices.

Sobers said...

"I have recently suggested that two things would help reform the system:"

A third:

Stop making nurses do degrees, all it does is give them ideas above their station. All they want to do once in a hospital is wander around tapping away at iPads playing at being doctors, leaving the real nursing to the skivs (who are the real angels in the NHS, whose pay is shite and who are the type of people with helpful temperaments who used to become nurses in the old days, such as when my mother trained at St Thomas's in the 50s. A better nurse you'd never find, but who would never have got a degree first). All degrees in nursing do is give them 'Boss b*tch' attitude. Can the lot of them and get people in for whom nursing is a vocation, not a power skirt career.

dearieme said...

"the distant folk-memory ..." is partly a fabrication, isn't it?

If it weren't for my vague childhood memory of a couple of codgers mentioning something they called "The Panel" I wouldn't have known that there was a system of government insurance to pay for some medical care long before the NHS was set up.

Nobody ever mentions The Panel nowadays, perhaps because acknowledging its existence would make less plausible the picture painted of pedestrians having to step over the hosts of ill people dying in the street.

Anyway, the NHS is balls. Let's copy something better, being careful to clear out armies of managers and executives who would otherwise bugger up whatever is introduced.

The key will be new incentives but they will work far quicker if the old hands are binned pronto.

jim said...

Anyone here tried change management. Can't be done on an underfunded organisation, any sort up 'upward change' costs money. Sure, you can get rid of the shit bits - until you discover they were not so shit after all. Just hiding more disinvestment. Of course you can do 'downward change' - chucking people out. That seldom improves a service organisation - the beatings will continue until morale improves.

A colleague spent a while in a French hospital. Found it dull and dingy but the treatment was good. The reason for dull and dingy is that the building was funded by an insurance company. The French outsource as well.

We might well decide to force folk to cough up £20 a visit to the GP - except for the poor, the old, the sick, the lame, the unemployed. But imagine the b%^ls up Crapita would make of the IT systems to say nothing of the cost. Might as well put a jam jar on the GP's desk. And an ID card would be needed to weed out the p^&s takers.

Then a private service contribution might be an idea. For those who want their private bits relocated and those who want their hip fixed this side of a blue moon.

All fairly simple to do but the politicians would have to deliver results - and they are no good at that.

Nick Drew said...

jim - a French hospital ... dull and dingy but the treatment was good

Same experience in Spain earlier this month: family member took a fall, broken limb. The usual seemingly inefficient first-responder stuff, very reminiscent of UK (two ambulances - why? Sitting in hotel carpark for 15 minutes after initial stabilisation - why?) but once at the dingy hospital she got swift X-ray + competent treatment on production of GHIC card + passport: brightly-lit NHS A&E couldn't hold a candle to it

(UK A&Es are brightly lit because the druggies hate it. NHS also lets Army trainees, SAS etc patch up Friday/Saturday night drunks etc for random-wound-sewing practice, another disincentive if you're a piss-head near a training centre)

electro-kevin said...

Rip off consultancy fees and suppliers. How can Labour possibly disagree with reforming that side of things ?

Nick Drew said...

Kev - I think that's right, and notice something further. In a move I greatly approve of, they've said they'll retrospectively go after the Covid profiteers' corruption. At the very start of large-scale government procurement (however misguided in retrospect) for addressing Covid back in '20, it was patently obvious the profiteers and scam artists would be out in droves. This inevitability should have been catered for in the Covid legislation up-front.

Retrospective legislation is an abomination: but deciding to use existing law purposefully and punitively after the even is well within bounds - as Cameron did with the 2011 looters.

electro-kevin said...

+1 to all that.

Friends of friends bought a £4m harbour house in Cornwall on Covid profits alone, selling to the NHS. At a time that we were all making sacrifices for the national good.

Sobers said...

Going after the Covid profiteers is all very well, but will that include Big Pharma? If not it'll just be the usual 'prosecute a few low level minions and let the Big Cheeses off' scandal management technique.

There's more than enough evidence in the covid vaccine trial data to nail Pfizer and Moderna to the wall for fraud and put them out of business. If the government won't do that then why go after the little people instead.

electro-kevin said...

Sobers - because there were other 'little people' baking for the NHS workers for free, giving out vaccines ... for free, then those like me who were buying scrubs for their offspring working in the NHS ... for free ! Because the NHS only gives them two day's supply and we don't want our bairns having to come off shift and do the washing every third day.

PS - those pilfering (say) £4m off the NHS (I've seen the photos of the wonderful house they bought with it) are NOT 'little people'.

It would be great for morale and an electioneering win for the Tories.

Sobers said...

"those pilfering (say) £4m off the NHS (I've seen the photos of the wonderful house they bought with it) are NOT 'little people'."

They are in comparison to the billions the drug companies made out of the vaccines.

If you are going to ignore the blue whale in the room, why bother making a fuss about the Jack Russell in the corner?

[The drug companies made over £100bn out of covid vaccines, so £4m is 0.004% of that. A blue whale weighs up to 150 tonnes, 0.004% of that is 6kg, or one Jack Russell]

Anonymous said...

NHS communication is bloody awful btw - shouldn't be considering the vast army of non-med people they employ, what are they all doing?

But knowing our current lot - or indeed any of them - the answer would be to spend a lot of money on a computer system.

Anyone looked at their "NHS app" ? The records on there of GP visits are almost meaningless.

Caeser Hēméra said...

The NHS app is terrible, confusing and a morass of permission exchanges without much information on why.

There have been pushes to improve it, and there have been some victories, but then you start to get killed by committee.

Having gone through processes to get systems that work with the NHS, the technical aspects were easy enough to understand. Then you get to the UI/UX aspects, where you've got to wade through changing opinions.

On Monday a committee headed by Dr Smith will say "Place those on the left and in RED"

By Wednesday, Smith is elsewhere, replaced by Dr Jones, who will wonder which blithering idiot thought parking that data on the left in red was a good idea, plainly it should be on the right and in blue.

Forward to Friday and Dr Akbar won't sign off on it until it's on the left and in some obscure Pantone colour.

So having played the game, you go above their heads and implement as you originally wanted it, just so long as the relevant information is easily spotted by the reader (e.g. bold where it should be, big alert icons next to something that might kill someone).

Of course that week of faff has cost you £50k in staff and IT costs in the meantime.

So the app probably started off as something really good, but what was delivered had gone through the digestive processes of the NHS, finally deposited as the steaming turd we have.

Sobers said...

"NHS is still pretty good if they think you're going to keel over next week - you'll be in and a surgeon will be at you pdq."

I've always said this. But how much of healthcare is that urgent? 10%? 20%? The rest of it is the boring grind of organising non-urgent appointments, tests, follow ups and operations. And the exciting sexy emergency stuff has a pretty good feedback mechanism - f*ck it up and the bodies start piling up pretty quickly. Whereas failing completely to deal with Mr Smith's bad back or Mrs Jones's piles isn't going to kill them, so there's no comeback on those tasked with doing the work.

That is entirely whats missing from the NHS - feedback mechanisms. If you f*ck this person's care up, your organisation (and ultimately you) lose out somehow. Fix that problem, and the system will reform itself.

Sackerson said...

@Sobers 1:56 - my dear GP friend said making nurses have degrees selected for academic tyoes and against the ones who knew how to do TLC. It is also my impression that the former don't want to get their hands dirty and so cluster round the computer station.

jim said...

Appropos TLC, way back my mother spent her last years in a care home. I talked with the matron and she mentioned she prefered to hire plumper ladies to do the nursing. She found them calmer and better at the job than the thin ones.

This observation does not necessarily read across to how to run a modern 'get them in, fix 'em and get them out' hospital.

Anonymous said...

Sackerson - "Project 2000" - the "Conservative" reformation of the NHS to take nursing training out of the ward and into the lecture theatre - was a disastrous initiative that has definitely reduced the standards of nursing care.

I assume the architects of the new system have been as usual rewarded and critics demoted. After all, they've been proven to be able to "manage change", and change, apparently is always a good thing.

When did the Conservative Party stop trying to conserve? Presumably around the same time the Labour Party stopped caring about labour.

Trashing the UK is a project with bipartisan support.

Anonymous said...

OT, ND, but have you seen the effects of "no longer being beholden to chap Russian gas" on European manufacturing?

Probably even worse in Germany.

Europe has one* major productive economy, and the US has f****d it while we all stand and cheer.

* tbf Italy and even Switzerland have some decent engineering - I see the original Tesla die-casting machines were Italian - and now the Chinese have cloned them at presumably half the price.

Still, we can take comfort in our world leading eyebrow threading, Kurdish barber, and nail-bar sectors! And drug profits laundering, but I repeat myself.

Jeremy Poynton said...

Concluding thought.

Even if we came up with a good alternative to the NHS, unwinding it and moving it to a new scheme is, I have NO doubt, way beyond our means, as we are no longer capable of any major task, whether it be infrastructure or public services.

Look forward to completely unmanaged decline.

Kids - get the hell out.

Anonymous said...

Demography is destiny.

"Kids - get the hell out."

Yes, because Canada's 5 years behind us and Australia's 10 years behind!

Iceland I'm afraid is too small to take us all. And it's dark 6 months of the year.