Saturday, 4 October 2008

A system built by lunatics

I am possibly being a little kind in describing those that continue to tinker with the structure of the NHS as 'lunatics', there are other words that better fit their misguided actions. It is tricky to get across the sheer stupidity of the way the system is run to people who peer into the goldfish bowl from the outside. Although I reside within the bowl I shall try to describe it for someone who is looking in.

Lord Darzi's recent NHS review talked a lot about improving quality, and we know when the government talk a lot about something they invariably are about to do the exact opposite, just like the NHS constitution in fact. This NHS Review also talked a lot about reform being locally driven and patient centred, this was just as central government ordered Lord Darzi's portacabins to be erected in every PCT so that the old and vulnerable would have to walk that bit further to see their varying not so local doctor; in fact they may no longer be able to see a doctor, this government seems intent on empowering anyone to do jobs that used to be done by people with lots more training and medical degrees, quality, err, anyway that's another story.

In surgery the government pays hospitals for the operations that they perform, this initially sounds sensible, however when one probes beneath the surface it is far from sensible. This is because the tariff system was not thought through, they forgot about numerous surgical procedures, meaning that the most complicated and specialist surgical procedures frequently result in the same remuneration as the most simple and straightforward procedures. This is results in the big specialist surgical centres routinely losing money as they are taking on the most complicated, expensive and unrewarded work. These big centres of excellence dared to point out to the hair brained managers that the payment system was stupid, the managers just said that the specialist centres were inefficient.

Meanwhile ISTCs are paid for work they don't even carry out, and a lot of their work appears to be slightly shoddy to say the least. The tariff based system doesn't even work for the NHS alone, as centres that carry out lots of bad, quick and cheap operations will make lots of money, while centres that carry out lots of tricky specialist work well but expensively are being driven out of business. Take fractures of the neck of femur for one example, if one treats this with a bad and arguably negligent operation which is also cheap then one can make a lot of money, however if one carries out a good total hip replacement in some patients one will start to make a lot less money. The same goes for many other fractures, where fixing fractures badly with cheap materials is much more profitable than fixing fractures well with expensive devices.

I'm sure you get the point, the system is barmy, it has been created by morons who were obsessed with the gimmick of the market who understood nothing of the clinical practice of medicine. It results in market forces pushing standards of care lower against the best interests of patients. As I have been rather frantic at work recently I haven't had much time to read, but I always try to find time to read Dr Grumble, he has a wonderful knack of being able to succinctly sum up the daftness of the NHS we live and work in.

PCTs sum up the daftness, they used to be small organisations, they are now huge bureaucratic monsters which are run by people who have no understanding for what they throw money at. It is simply amazing that people with no medical training are allowed to spend thousands of our money on evidence-light health initiatives without a public health doctor in sight, it is as barmy as a country being run by ministers who are shuffled around so frequently that they barely have time to learn the name of their new department. The more they talk of quality, the more you should feel very very afraid.


Dr Grumble said...

With so much NHS madness about the Grumble posts almost write themselves but thanks all the same for the compliment.

Read Dr Grumble while you can. If the EU has its way and we all have to register our blogs with Brussels you will be on your own, Garth.

the a&e charge nurse said...

Ferret - there is a very good article in the BMJ

The author, Nigel Hawkes, asserts "almost all the changes that have ben introduced in recent years are driven by power............."

He goes on to detail the sense of "ground hog" day, the blizzard of circulars emanating from the DoH, there is even a nice parody of M C Eschers never ending staircase [Ascending & descending].

If we take the bigger picture, the timeline of NHS reforms [god, I HATE the word, reform].
Are todays protagonists [Darzi et al] any worse than the creators of Thatchers "internal market", say.

More depressingly, if we can't even trust eminent clinicians to get it right [NHS reform], then I guess there is little hope that the concerns you correctly identify will ever be addressed once we acknowledge the long term pattern of dysfunctional meddling ?

Garth Marenghi said...

Indeed, Hawkes is one of a small band of people who genuinely understands and expresses the dysfunctionality of the NHS.

As you say the cycle of fiddling with the NHS will continue no matter who wins the election, it is a regressive fiddling driven by a hunger for political power and not driven by a need to improve the service for those who work in it and who it serves.

Until the idiots in Whitehall start to listen to the medical profession then the same errors will go on, currently they hand pick the odd malleable turncoat a la Darzi.

The real grass roots need to be genuinely engaged, no more pretending, it needs genuine action.

The problem is that all this government has done is empower idiots and disempower the educated and more objective.

For example as regards medical training PMETB has been empowered and the colleges disempowered, this has been catastrophic.

The solution is not some lame advisory body like NHS MEE, it is to get rid of PMETB and empower the professional organisations like the royal colleges.

The more they try to control, the worse they make things.

Anonymous said...

Ferret - In David Smail's analysis the whole point of the 'idiots in Whitehall' and their host of subordinate managers, is that they don't listen to clinicians. The hunger for political power that you mention, whose rationale and machinations he describes, has in his view necessitated the recruiting or co-option of such an unheeding and manipulable cadre. In such an analysis it's not a matter of ever expecting that they will listen, of rationally persuading the ignorant of the error of their ways. To the extent that this analysis is correct the only remedy is of a more practically and openly political action than the already greatly valuable blogosphere.

Ref: Smail, David: The Origins of Unhappiness. Harper Collins 1993. Chapter 4: Case Study: The 1980s

Anonymous said...

PS. The referenced chapter appears in edited form on David Smail's website.

The Shrink said...

PCTs don't exist as real entities you can touch, people exist, thus PCTs are in essence teh sum of the people working within them.

I've worked in one PCT which was so ghastly, bureaucratic, chaotic, inefficient and so divorced from the reality of clinical care that it was unacceptable. Thus, I didn't accept it and moved on elsewhere.

I work in a mental health Trust now but have excellent links with the local PCT, meeting commissioners in the restaurant or they pop in for coffee or we have flurries of emails. In part thisi is because of their culture (they're just much better), in part it's the geography (they're close) and in part it's the staff backgrounds (several of them used to work in our Trust). Either way, I'd have to raise the (tiny) notion that not each and every PCT is rubbish. Sometime, just sometimes, it's possible to find decent people who've been clinicians and still meet clinicians so still have some sense of both the big picture and the local clinical detail.