The National Health Service continues to attract headlines mostly of the doom and gloom variety despite the counter attractions of terrorism, immigration, Europe, UK Steel and Jeremy Corbyn. What are we to make of it all? Is it yet another case of the shepherd boy calling wolf so frequently and fraudulently that when the beast did appear and the alarm cry was voiced abroad, no one took any notice – and the shepherd boy did not live to tell the tale?
I have selected a few headlines and extracts to illustrate the NHS problem. The first two point to the alleged scale of the problem. The second two point to a possible contributory factor, namely, the tendency of departing managerial failures to help themselves to large slices of NHS funds that might well have been originally allocated to more constructive purposes.
It can’t be the case – or can it? – that there is a special NHS fund to ensure that bungling bureaucrats are compensated for their departures. The evidence suggests that there is just such a fund for just such a purpose, a clear case of those at the top looking after their own.
“Tell the truth, Prime Minister: that if you won’t inject billions more into sinking hospitals, it’s RIP FREE NHS CARE”
Sir Thomas Hughes-Hallett, Mail on Sunday, October 11 2015
“Hospitals heading for £2bn overspend. NHS hospitals have run up a record overspend of £1 billion in three months prompting regulators to warn that the heath service cannot carry on as it is.”
The Times, October 10 2015
“Boss behind chaotic call centre service got £300k pay off on top of his salary…. The official responsible for the disastrous launch of the NHS out-of-hours hotline (Mr John McIvor) was paid almost £500k last year, the Daily Mail can reveal. He earned the huge package while senior responsible officer of NHS England’s NHS 111 Implementation Group even though the launch of out-of-hours service was condemned by doctors’ leaders as an abject failure”
Daily Mail, October 1 2015
“Outrage over £410k payoff to NHS chief”
The Times, September 30, 2015
“What do you think about England, this country of ours where nobody is well?”
WH Auden, The Orators
It might be instructive to approach the NHS problem from a couple of different angles rather than get bogged down in an interminable and inconclusive debate about which government spent how much and when on the NHS
Why not start with the patients, or, as some players in the game might say, the customers?
What about them? How might they contribute to a recovery of the NHS?
Doctors today are faced with an impossible task which is to provide the public with an unattainable combination of perfect health and maximum self-indulgence. Either of these demands taken singly would pose formidable difficulties. Taken together, the combined demands are mutually exclusive. A reasonable standard of good health typically requires that people are not overweight, don’t smoke, go easy on narcotics and take some exercise. Many patients today refuse to accept these joyless injunctions and talk airily about impaired quality of life, and stresses induced by austere life styles. The inevitable outcome has been a shortfall between the promises and the fulfilment of the various health commitments made by government health departments of various political colours.
Imagine yourself behind the desk of a GP during surgery hours. You have to deal with an interminable procession of patients who are, in many cases and to varying degrees, personally responsible for the ailments about which they have come to acquaint you. Additionally, you will be dealing with some patients people anxious to enlist your support to add their names to the growing list of the disabled in order to improve their financial positions. The rapid growth in recent years in the number of people officially classified as disabled is one of the more mysterious features of the health sector, given the huge growth in resources allocated to health matters over the same period. It is just possible that there may be a tenuous relationship between the increase in the numbers of the disabled and the access to a standard of living not available by the more usual route of working, and even less so to those for whom the only alternative is to claim the lesser and more capricious benefits available from the social security system. The medical profession has the unenviable task of attempting to stem the flood tide of claimants. Stories, not all of which can be apocryphal, are widespread of acting performances in surgeries which warrant the accolade of an Oscar award, performances which combine the dramatic exaggeration of the ailment in question with menacing hints to the doctor as to the consequences of any refusal to agree with the claimant’s diagnosis. Not surprisingly, most doctors give up the unequal struggle and supply the occasionally dubious applicant with the necessary paperwork.
Is it for this that our doctors studied for five years followed by a couple of years as a junior doctor on low wages and long hours? What an appalling prospect. And it does not end there. The patients of today, urged on by an unending supply of do it yourself medicine kits, think they know better than the doctor what their various problems are, assuming that they have problems in the first place, and what the remedies ought to be. Our harassed family doctor is faced daily with this prospect. A tsunami wave of the self-indulgent, the obese, the smokers, the drug addicts, the alcoholics, the indolent, the hypochondriacs, the malingerers, and those who attend for the exuberant social life to be found in all surgeries. Whatever their motive and medical condition, the patients all collectively demand that their doctor convert the sow’s ear brought into the surgery into a silk purse to take home. There we are, an endless procession, all insisting (we know our rights) on our God-given right to perfect health.
In his novel The Good Soldier Schweik, Jaroslav Hasek outlines the medical treatments meted out by doctors to patients suspected of malingering by the Czech authorities during the First World War. The treatment was designed to encourage all patients to get fit as quickly as possible by imposing upon them a series of torments which increased daily in severity. The treatment initially provided heavy doses of aspirin and quinine to keep the patient profusely sweating. These were followed by the application of the stomach pump, the application of the clyster, and, finally, on day five, by swathing in cold wet sheets. By day five (remember, the treatments were accumulative) all patients were either dead or had reported back for active service. The dictionary definition of a clyster is not wholly clear, but sufficiently so to persuade me that I would rather not undergo the experience. I suspect that some doctors, on reading Hasek’s laconic account, would secretly feel that they would like to try it out on at least the most flagrant of the suspected malingerers.
What steps can the profession take to minimise these pressures? It often seems to be the case that doctors are engaged in a vast damage limitation exercise rather than in a positive program of health improvement. It is not politically advisable even to hint that an enormous improvement could be brought about in the nation’s health by simple regimes of diet, exercise and abstention from narcotics.
One splendid example of the latter contributory factor to health is readily available. Given that the root cause of a patient’s bad chest is often smoking, the obvious action to take is for the doctor to refuse any further treatment until the patient stops smoking. That is the common sense solution. So, what about putting in place measures which entail a reduction or in some cases the complete withdrawal of medical facilities to those who choose to adopt a lifestyle designed to trigger the ailments in question, that is those whose ailments are self inflicted? According to Sir Thomas Hughes-Hallet – and, as a member of the Board of Trustees at the King’s Fund and former chief executive of Marie Curie Cancer Care, he should know – the NHS itself is on a life-support system. Desperate circumstances demand robust remedial action.
The technicians or, as they prefer to be called, the doctors
“Add to that the insane new contracts awarded by Labour to GPs, who were given a huge pay rise while being relieved of the chore of working evenings and weekends”.
Richard Littlejohn, Daily Mail, January 6 2015
Richard Littlejohn, in a long protest about the prospect of five months of mendacious electioneering, notes the ludicrous New Labour cock up in which the Health Minister approved an arrangement in which GP incomes were substantially increased while simultaneously and massively cutting the unsocial hours required by their previous contracts.
This ineptitude recalls the quote by Nye Bevan: “In an island almost made of coal and surrounded by fish, only an organising genius could produce a shortage of coal and fish – at the same time.” Yet, sadly, that is what happened,
Let me explain. The pay and conditions of GPs improved dramatically a few years into the New Labour Administration. For reasons which remain unclear, the pay of GPs was increased by over 50 per cent while their surgery hours were cut. All this in return for doing the same job as before – treating NHS patients for whatever ailments, real or imaginary, they wished to discuss with their doctor.
Naturally, GPs were both delighted and suitably discrete about this turn of events. Wisely they did not trumpet their triumph to the outside world and, when pressed, described the increase as a modest gesture which recognised the poverty they had been forced to endure in addition to their daily torment in the surgery.
A succession of New Labour health ministers, questioned as to what had been done and why, alternated between claiming that a pay increase for GPs was long overdue – it wasn’t – or that the size of the increase had been exaggerated – it had not – or that doctors were being rewarded for their greater productivity – not a bit of it – or, as a last resort, blaming the previous incumbent in the job. The last explanation was probably the correct one.
Just to complicate matters, at the same time the job demands placed on doctors were sharply reduced by the simple expedient of not requiring them to cover night shifts and weekend shifts. Some suspicious observers felt that this was a Malthusian ploy designed to reduce the surplus population.
At the time, I could not understand how anyone could be so incredibly stupid as to give one group of state employees a huge pay increase in return for doing a lot less work. I sought in vain for an explanation for this blunder in the pages of The Journey by Tony Blair, his account of his years in Number 10. Not surprisingly, I was disappointed. One startling feature of Blair’s book is the frequency of the use of the words “modernise”, “progressive”, “reform”, and “radical”. The book would lose up to 10 per cent of its content if these interminably repeated words were simply deleted.
The other startling feature is the reluctance of Blair to supply any details of the changes that he has in mind. The reader can only assume that for Blair the endless incantation of these key words is a substitute for actually doing anything other than to make a bad situation a great deal worse. The book is long on froth and sadly short on the specifics of his slogans.
The measurement of the performance of medical professionals is gaining momentum and The Times recently published performance tables for the various branches of the profession such as heart specialists and orthopaedics specialists. Those about to undergo surgery anxiously study the tables and are jubilant if our hospital is at or the near the top and gloomy if the opposite is the case. The lawyers will ruthlessly exploit all mistakes. The next step will be to locate an office for a lawyer in every local surgery so as to miss no opportunity for lucrative litigation.
So, what help might the medical profession have to offer the NHS in what may be its terminal decline? Not much because the major problems, together with the relevant remedial measures, lie elsewhere.
“When I consider life, tis all a cheat:
Yet, fooled with hope, men favour the deceit;
Trust on and think tomorrow will repay:
Tomorrow’s falser than the former day”
We must now turn to the root cause of the NHS problem. Put simply, the NHS is to a significant extent managed by people who combine ineptitude, insensitivity and cupidity in roughly equal proportions. This raises the question: are these cases the bad apples in the huge NHS barrel in which the great majority work tirelessly and with great passion – their words – to maintain the noble aims of the founding fathers back in 1948?
I think not. I suspect that the top layers of the NHS are teeming with managerial mediocrities with a flair for humbug and self-enrichment. They get away with it because they can get away it, and this is in large measure because the main political parties are far too busy either abusing one another or attempting to bamboozle the electorate to enquire about where the money directed to NHS actually finishes up.
Back in 2002, I wrote a book which I called A Cushy Number. In this, I explored the demands made on and the rewards collected by a selection of professions such as teachers, lawyers and politicians. My main sources of data were newspapers and magazines, and I would collect cuttings to illustrate my points about this or that profession.
The largest number of cuttings concerned the various sharp practices carried out in boardrooms by senior business and City managers. Not far behind was the huge collection of cuttings that I amassed concerning the collective sharp practices of senior managers in the Leviathan that is the NHS, this gigantic out-of control bureaucracy.
Time was when people such as almoners and matrons administered the NHS with a tiny fraction of the huge resources now allocated, but these delightfully simple arrangements no longer operate. Managerial bureaucrats saw their chance and moved in, rather like gold prospectors in the Yukon, but without the insecurity entailed in the latter activity.
Politicians faced with the reluctance of the NHS to respond to any model of effective managerial control resort to more and more reorganisations, not to solve the problem (impossible) but to create the illusion of activity. These reorganisations have the down side of resulting in surplus bureaucrats who cannot be sacked.
What happens in practice is that a fanfare of trumpets promises a dynamic new beginning, and the surplus bureaucrats saunter round to the back of the institution where they are readmitted on better terms and conditions.
A case study: Sir David Nicholson
The facts of the case that suggests that the performance of Sir David Nicholson in his last two jobs in the NHS was not impressive.
Sir David was chief executive of the West Midlands Strategic Health Authority, overseeing the Mid Staffordshire NHS Foundation Trust for a period when death rates were found to be high.
Sir David issued a full apology, saying “I apologise to them on behalf of the NHS as a whole and for the fact that those patients, relatives and carers found themselves in the position where they not only had terrible things happen to them but the very organisation they looked to for support let them down in the most devastating of ways.”
Sir David’s worst critic could not have put it more trenchantly.
In September 2011, the Daily Telegraph revealed that Nicholson, then chief executive of NHS England, claimed expenses of more than £50,000 a year on top of a basic salary of £200,000 and benefits in kind of £37,600 at a time when he was asking the health service to make £20 billion cuts by 2015. His claim was three times an MP’s accommodation allowance.
Sir David has been interviewed in the media to express his concerns about problems in the NHS, problems to which he himself had made a significant contribution. However, not everyone was against him. On February 2 2013, The Guardian reported: “The boss of the NHS is set to survive this weeks damning report into the Mid Staffordshire hospital scandal despite calls for him to resign by relatives of some of the hundreds of patients who died. The NHS chief executive Sir David Nicholson enjoys the rock solid support of David Cameron and the health secretary Jeremy Hunt, according to well placed NHS and Whitehall sources.”
Three months later, on May 21 2013, Nicholson was quoted in The Independent as saying: “I have only ever had one ambition and that is to improve the quality of care for patients.” That should not have been too difficult with Sir David in charge.
Sadly, the story of the NHS in recent years is reminiscent of the story of Britain’s financial sector, in which those senior managers who chose to loot the system – far too many of them – were and remain remarkably free to do so. The consequences of this freedom degenerating into license are there for all to see. There would seem to little prospect of reform unless those in a position to do summon up the will to do so. Few are convinced that Jeremy Hunt is the person for this particular challenge.
What, then, should the right person do, if they can be found and put in post What can be done by the rest of us to bring these managerially challenged mediocrities under control?
Some measures to improve the NHS might include:
* Grasp that the problem starts at the top – the NHS will not recover if this elementary point is not understood.
* Ensure that under-performing senior managers and those detected in sharp practice are sacked – not reorganised, not made redundant but sacked. Start with the low-hanging fruit and move on from there. And it may be that there is a lot of scope to reduce the head count at the top while simultaneously improving NHS performance,
* All redundancy financial arrangements must be scrutinised and signed off by politicians rather than by fellow NHS bureaucrats.
* All terms and conditions surrounding re-organisations should be referred to an independent body for confirmation, amendment or rejection.
* There should ben immediate review of the employment contracts of NHS bosses with a view to deleting “rewards for failure” sections.
* We need edict issued by the Health Secretary that those who blow the whistle on dodgy deals will be fully protected. Only the sharp practitioners need have any fears on this score
* Essential is an end to the practice whereby large rises have been justified because this bureaucrat or that one takes over all or part of the work of another bureaucrat – it is probably the case that both jobs could be dispensed with no adverse impact on the NHS.
* The recovery of misappropriated funds to be vigorously pursued, and those who have been “at it” to be taught a collective lesson.
I have no doubt that the NHS technicians – sorry, doctors and Nurses – will be happy to pour out their accumulated frustrations if requested. And they ought to be so requested.
There is certainly room for improvement.
“£450k hospital boss leaves failing trust – for another top job. Jackie Ardley oversaw catastrophic problems which led to the trust being put into special measures. But rather than being held to account the freelance boss has moved on to another executive post elsewhere,”
Daily Mail September 21, 2015
“NHS bureaucrats have been handing themselves extraordinary bonuses amid the worst financial crisis in a generation. More than 400 Department of Health civil servants last year shared rewards totalling £1 million for apparently performing above and beyond expectations. This included one of the NHS’s most powerful women, Dame Una O’Brien, whose role is to ensure the health service runs efficiently. She was handed a £17.5k bonus, taking her total pay package to £240k.”
The Times, October 13 2015
To what extent have politicians contributed to the decline of the NHS? What is the extent of their collective responsibility?
In addition to the inept decision to raise GP salaries and cut GP unsocial hours taken during the Blair years, we should note the acquiescence of New Labour in the looting of the NHS by the very people entrusted with the responsibility of running it
The performance of the coalition Government with regard to its management of the NHS was just as bad as that of its predecessors, and either it failed to grasp what was happening on its watch or it did know but was afraid to act.
The flow of scandals remained steady during the coalition years and has if anything increased in the first few months of the Conservative-only administration under the stewardship of Jeremy Hunt.
So the prospects of the miracle cure for the NHS – the consummation devoutly to be wished – are not promising. If nothing is done the expressed by fear Sir Thomas Hughes-Hallett may well come to pass.
The Tory Government should implement the actions suggested actions suggested above quickly and energetically. The Labour Opposition must hold them to account.
Doctors and nurses have their part to play to bring bureaucratic sharp practices to the attention of the (just about free) press. And those people who are, to a significant extent, responsible for their own ailments, must shape up.
This article was first published in Tribune on December 23, 2015
Image courtesy of BBC