Welcome to the two tier NHS

How long will it be before the Conservative’s plans for the NHS turn it into a two tier system?

No time at all seems to be the implication of the news that Care UK has won the contract to provide health care to prisoners in the North East.  Which is fine except that the NHS bid was better on every single metric except one – price.

So, the long and short of it is that prisoners are to get a second class service and price trumps all other considerations.

Will this survive a determined political and/or legal challenge?   I don’t know but even if such a challenge emerges and is successful, I suspect that all that would happen is that such decisions would be driven underground while preserving some fig-leaf of transparency and accountability.   Will savings be due to genuine efficiency gains made while preserving or improving services or only down to surreptitious cost-cutting to provide a lesser service with no efficiency gains?  And how will anyone outside the system ever know which is which?

The Coalition likes to foster the impression that the NHS will be safe in the hands of people like the GPs that we all know and trust.   But will it?   That trust derives in large part from GPs being on the patients’ side, a medical but not a financial gatekeeper – our guide into the labyrinth of the NHS.   Most of us are in no position to exercise knowledgable “choice” so we rely on our GPs for good and unconflicted advice.   But if the Conservatives are following the sort of salami strategy they’ve used before, then it’s only a matter of time before targets for cost savings are added to the mix.  They will presumably be spun as “efficiency targets” or some such, but either way GPs will be forced to choose – good advice or higher pay.

Moreover, it’s unlikely to be your friendly GP that’s calling the shots.   It’s a pretty safe bet that established firms like Care UK will be quicker off the block to elbow themselves into pole position in the Conservative’s new system than the average group of GPs in a busy practice (a process possibly helped along by a few strategic donations).   As their homepage explains they are, “… a leading independent provider of health care and social services. … These services include the operation of NHS walk-in centres, GP surgeries and treatment centres …”.    And the prize is huge, nothing less than substantial influence over the direction of a big slice of government spending; someone is going to get very, very rich on the back of this but it’s hard to see that the quality of care will increase.

Bottom line; market, or more accurately faux-market structures are just don’t have the universal applicability of Conservative fantasy, and are certainly not suitable in health care.

Multiple organ failure

All of us now know what family and friends of patients at Stafford Hospital have known for along time – that it is a deeply dysfunctional organisation.  Its grotesque failings arethe bitter harvest of a NHS system which is itself experiencing multiple organ failure.

But it is not just the hospital management that has failed; the entire regulatory structure has failed leading to around 400 excess deaths between 2005 and 2008 according to the Healthcare Commission.   That must be the tip of a very large iceberg.

Government targets are to blame for much of the trouble.  As the BBC reports:

Staff told the Healthcare Commission that there was “pressure, pressure, pressure” on them to meet the four-hour A&E waiting time target.   Several doctors recounted occasions where managers had asked them to leave seriously ill patients to treat minor ailments so the target could be met.  One gave an example of being asked to leave a heart attack patient being given life-saving treatment.  Nurses reported leaving meetings in tears after being told their jobs were at risk after breaching the target.

None of this is new; I have been hearing stories like this for years yet the government remains wedded to the concept of targets for everything despite the huge weight of evidence that (a) they don’t work, (b) that cheating on the measures is endemic and (c) they create perverse and distorted outcomes whether its treating minor ailments first as in this case or ‘teaching to the test’ in schools or whatever.  I suppose that for a control-freak PM from a Party with centralising instincts, targets must seem like a wet dream of a solution.

The reality is that most of the things that government runs are complex systems full of messy, awkward, non-standard things like, er, people.   Complex systems cannot be managed by targets and the sooner this is taken on board the better for all concerned.

But even aside from the problems created by the targets what of the regulatory superstructure?

The Healthcare Commission is the independent watchdog for healthcare in England but Monitor also has a finger in the pie as regulator of  NHS Foundation Trusts – which since 1st February includes the Mid Staffordshire NHS Foundation Trust.

The problems in Stafford were first spotted as long ago as summer 2007 by researchers based at Imperial College which rather raises the issue of what value the Healthcare Commission adds and whether it is sensible to have two bodies working in the same general area.

Meanwhile, foundation trusts are (in Monitor’s words) “a result of the Government’s drive to devolve decision making from central to local organisations and communities.”  (Evidently this does not extend to setting their own targets!)  Yet it seems that Monitor did not check with the Healthcare Commission what its view was of Mid Staffs and, to judge from its website, its approach is primarily to do with finance.  I found no mention of patient care.  Incredible!

In this context it is perhaps not surprising that the findings of the Healthcare Commission’s investigation include this shocker (their emphasis):

An analysis of the trust’s board meetings from April 2005 to 2008 found discussions were dominated by finance, targets and achieving foundation trust status. There is little evidence that poor standards of nursing care were identified and discussed.  The investigation found that poor results of surveys of inpatients or staff were not discussed in public. It found that a doubling of the rate of C. difficile infection in the early months of 2006 was not released to the board nor the public.  The investigation also found that in 2006/07 the trust set itself a target of saving £10 million. This equated to about 8% of turnover. To achieve this, over 150 posts were lost, including nurses. This was in a trust that already had comparatively low levels of staff.

So what I think is that we have a picture of a system where the message from the top is all about finance and dead-brain targets that must be met no matter what.  Where managers have sufficient courage to go out on a limb to some extent and defy the system then it might more or less work.   Where if they don’t, it collapses.  The message from Health Secretary Alan Johnson is clearly what this they should have done.  Unfortunately for patients this is not the direction his department is driving in.

But, of course, how the NHS is managed and regulated is all of a piece with how the successive administrations have sought to run the rest of the government estate since Thatcher; Labour (and Conservative) fingerprints are all over this.  It is no coincidence that we are seeing collapse in the NHS at the same time as in the financial markets.  Stand by for more storms.