/ NHS - this is grim
not, I fear, confined to mid staffs
Roy Lilleys news items on nhsMangers.net have been covering this for a long time. Well worth a read for those concerned with NHS management problems. I'ts a subscribe feed and I'm not sure how to link them here.
Perhaps this will be the end of this smug "Our NHS is the envy of the world" tosh. The fact that it is free at the point of delivery is fantastic and something the UK should rightly be proud of but it really starts and ends there.
With an 86 year old father I seem to spend half my life at hospitals and I've been genuinely appalled by the lack of care and sheer laziness of some staff.
My equally elderly father-in-law was recently in hospital. He was rail thin to start with but somehow lost a stone while in hospital. We found out later that ward staff would bring meals, plonk them where he could not reach them and an hour later come back and take away the untouched plate without checking why he was not eating or why he was sinking fast. Absolute idiocy and a complete lack of compassion.
At a Leeds hospital I sat in a waiting room for an hour listening to two staff telling each other how over-worked they were. Neither did a stroke the whole time I was there.
My only othere experieince of health care was in France and it way better. Even my doctors in the UK told me how lucky I was to have fallen ill there rather than at home.
At least we have an NHS. The idea of hoping you don't get ill because you can't afford treatment just fills me with horror.
Only last week, my doctor rang me in person to remind me to have a check up. Very impressed!
My Grandma has spent a lot of time in Stepping Hill over the last 6/7 years, and while it's not all bad, there have been some pretty alarming judgement calls during her care. Mind you with the limited budgets, limited staffing, overcrowding etc I'm not surprised. Every member of staff we encountered apart from a couple of doctors have been amazing, it's an organisational issue IMO.
Not as bad as it was made out to be in the papers though.
It does seem though that they've given up on her now. Given the circumstances I'm finding it hard to blame them though, fighting to prolong her life now is just going to reduce the quality of the life she has left, and I'm very much undecided as to what the right course of action is.
Maternity, childrens wards are usually outstanding in most hospitals.Its a priority.My local in Warrington has been brilliant in that area as well.
Its the general wards and in particular elderley care where the care maybe questionable. Strikes me as it being only some hospitals where the management is not strong.
It won't be. The NHS is the closest thing in Britain to a religion (ironically worshipped by those who hate religion in every other circumstance), so critisism of it is not social comment, it is blasphemy. And we all know what religious zealots do to blasphemers.
The claim will be made, repeatedly, that the staff are all angels and paragons, if only they had more resources. It is not true, it is very far from true, but repitition is a tried and tested method of propagating a lie.
Tell me about it.
Got injured in France, patched up by excellent French health care, all was going well till it came to repatriation to the UK. UK hospital arranged for admitance several days before, phoned the evening before to confirm, phoned on arrival at UK airport to notify time. As the ambulance pulled in (2 hours later) to the hospital, it was announced "we've decided not to take him". Doctor who had supervised transport "Why not? What do you expect to happen to this patient". Shrug of shoulders, in response to both questions, as patient was left in ambulance in late afternoon, on a very cold day in January.
The rest of my "treatement" by the NHS was, up to the very last bit, if anything worse, despite all the difficult bits being done by the French, but I won't bore you with that, apart from mentioning that I was discharged by a UK hospital with a leg that was badly infected due to their "care", and within a couple of days was twice its correct size and stinking.
Of course the excellent French health care system has substantial private involvement (with government oversight), but private suppliers actually competing to supply health care is considered about par with baby-eating by NHS worshippers.
i hate to interrupt your rants but you do know that private suppliers are heavily involved in the NHS now?
There again they pay considerably more tax in france.....do you want to pay more?
A pretty fundamental question.
In the UK, may dad had private insurance for me...the consultant that saw me privately was appaling, more concerned about the money that could be made from having me as a patient and made further errors resulting in permenant nerve damage. The NHS consultant who took over from him was exceptional, down to earth, kind, and showed genuine interest/enthusims for my case, using it for teaching/case study at a conference. All the theatre staff, ward staff, physios, ambulance crews etc where all excellent.
So what does this say... the NHS isn't perfect...
The same sh*t and worse happens in other countries, private healthcare can be worse sometimes, there are excellent kind people working in the NHS as there are health services elsewhere in the world.
and we spend about 100 billon pa on that
UK needs an adult discussion with itself me thinks.
Ive worked in the NHS for over 20 years and it is the worst i have ever known it. The issue is very much about 'culture'. We have had successive reorganisations and the money wasted is sickening....literally millions even in a small community based Trust where I work.
We now have a culture where over the past 10 years or so the good solid nhs professionals have been sidelined, or moved on, or retired or have taken themselves in to purely clinical and non managerial roles.
The culture of those in management positions now is one of compliancy at all costs....to the detriment of patient care and clinical decision making. Priorities based on numbers, money, image, PR, avoidance of litigation etc.
Where i work there are 3 people including myself who untill 3-5 years ago were clinical managers (clinicians managing teams/services) with caseloads and clinics still. All 3 of us have now moved by choice in to purely clinical roles (including significant cuts in salary) because non uf us were prepared to manipulate waiting lists, produce untrue stats, bully staff and operate in a culture where senior managers bully, direct and manipulate.
I have personally been threatened, as have my other colleagues with all kinds of insidious threats especially regarding referrals to our respective professional bodies etc.
As an example of poor practice, our service merged with another some years ago....resulting in non qualifies members of staff taking on serious assessments without training and without the required competencies or ability to undertake the assessments. It is truly shocking.
The only difference in the Staffs inquiry is that it involved critical care/A&E ETC.....there will be hundreds of examples like mid staffs everywhere.
The culture is flawed from the top down....lets just watch the politicians squirm out of this now as they will for sure.
Non of the above excuses in any way, however, the individual responsibility of duty of care to clients. Those staff involved in neglecting their duty of care to the degree described need to be routed and sacked.
It's a public sector/cultural issue, I'm sure. I studied NHS management in the mid 90s and the models that were being promoted then were antediluvian - or at least, pre 1950s. ('Find somebody to blame and sack 'em!' seemed to be the main message.) Yet academics, civil servants and lay managers were buying into them. I never quite worked out why - I had a living to make - politicians must take some of the blame, clinicians quite a lot more (for sticking their fingers in their ears and saying 'lah lah lah, I'm a DOCTOR/Nurse, just sign the cheque...') but above all the managers who, IMHO, would last about 30 secs in a private enterprise that didn't do all its business with the NHS.
The NHS is being choked. It has neither sufficient resources nor funds to work well.
It has not had the opportunity nor leadership to adapt and evolve with the country over the past 60 years.
It is a brilliant institution.
I think Peter Carter might have dug himself a grave.
The RCN looked a bit limp on Newsnight, no surprise there.
How I love Gerry Robinson, his enthusiasm and 'can do' attitude are to be applauded.
Can't say more than that, as I fear if I start, I shan't stop!
You just summed it up really well. I agree with all of those points. I would add that my parents who are the same age live in Spain and Spanish hospitals and healthcare is way better.
The NHS is a complete mess.
Very interested to hear this and I can't say I'm surprised.....
I've not read it yet but I can't believe the NMC managed to escape criticism - equally limpid & unfit for purpose organization except you have no choice but to pay them annually. Professionally I welcome the report - nursing needs a kick in the nuts and neither the NMC or RCN are ever going to provide it.
> There again they pay considerably more tax in france.....do you want to pay more?
> A pretty fundamental question.
Probably not, but Simon's issues are primarily ideological, plus a little one eyed.
> I've not read it yet but I can't believe the NMC managed to escape criticism - equally limpid & unfit for purpose organization except you have no choice but to pay them annually. <
Indeed and loving the fact they keep putting up the reg fee again! 70 odd quid to 100, I don't think we even get a card for this round ;-) I think it'll be my final year though. Time to move on and do other things.
> and we spend about 100 billon pa on that
> UK needs an adult discussion with itself me thinks.
They need to cut down on the health tourists too, not so long ago an investigative programme showed how easy it was to get free care just by getting referred by a G P or sending away under a false names for a European health card .
However the tourists may well take their 'business' elsewhere in Europe if the care is so bad here!
> There again they pay considerably more tax in france.....do you want to pay more?
> A pretty fundamental question.
It is not the amount of tax/NI taken which should be compared but the amount spent on the healthcare system.
> Perhaps this will be the end of this smug "Our NHS is the envy of the world" tosh. The fact that it is free at the point of delivery is fantastic and something the UK should rightly be proud of but it really starts and ends there.
It's really a matter of personal experience isn't it? You've had a bad one.
Last year I underwent cancer surgery and I've nothing but praise for the speed, quality of care, consideration and advice I was given from the preliminary investiations, biopsies, pre-op advice, the skill of the surgery team, care whilst in hospital, the smooth co-operation between the medical team and the phsysio and cancer nurse specialist in the aftermath and the follow up consultations with the consultant.
So I've had a good experience (if you can call having cancer surgery good!), and have nothing but praise for the NHS.
During the pre-op period I looked at a number of options including going private and if I had been able to afford this route it would have cost in excess of £20,000, but I don't think the outcome and quality would have been any different, but I might have got free hospital parking for the numerous outpatient visits I have had to make prior to and since the surgery!
> Probably not, but Simon's issues are primarily ideological, plus a little one eyed.
He bought a special spittle-proof computer. The man's unstoppable.
At least some of you have hospitals, they have closed down the local a&e in Kendal and are now trying to close down the nearest in lancaster meaning it would be a 45 minute drive from Kendal (much further from most the lakes) to the nearest emergency hospital. Great for those who cannot last that long. Thanks NHS
> I think Peter Carter might have dug himself a grave.
> The RCN looked a bit limp on Newsnight, no surprise there.
I haven't seen this but I suspect there is little he COULD have said, given that the RCN is a union that represents individual members, as I explain below, and not a regulatory body.
> How I love Gerry Robinson, his enthusiasm and 'can do' attitude are to be applauded.
I remember he did a programme once where he went in to a Trust and tried to sort it out- to no avail. He simply did not have the authority or support of the Trust in question to do so. This is a common theme with most workplaces- the knowledgable, conscientious people are ignored, eventually get frustrated (if they have not been discredited first) and they leave.
> Can't say more than that, as I fear if I start, I shan't stop!
>I've not read it yet but I can't believe the NMC managed to escape criticism - equally limpid & unfit for purpose organization except you have no choice but to pay them annually. Professionally I welcome the report - nursing needs a kick in the nuts and neither the NMC or RCN are ever going to provide it.
The full report is available online.
I have just spent the morning going over the Executive Summary and Recommendations, and various people's responses including a summary of the Govt response.
With regards to the RCN, it is first and foremost a Union. It is there to represent members of that union, and one of the ways it does that apart from the usual union representation is via the provision of excellent healthcare-related educative articles and assistance; it is often involved in high-level consultation with regards to health care practice/policy formation. It is however NOT a regulatory authority for individual qualified nurses or Health Care Assistants, or any employer. It has NO power or authority to intervene with Trusts or any other employer with regards to standards of health care. Trust me, there are plenty of other bodies that do this including the Care Quality Commission, the GMC (for medics) and the NMC(the Nursing and Midwifery Council, formerly known as the United Kingdom Central Council for Nursing, Midwifery and
Health Visiting); (note that the NMC is only for qualified nurses- there is currently no process of registration or regulation for non-qualified Health Care Assistants; the latter requirement to do so (via the NMC) is a recommendation of the Report but I note that one of the Govt's responses is to say that this is not a priority. There is in hand a national care and training standards programme being put tohgether and it has been adopted by some bodies and regions for Health Care Assistants, but this incomplete and not compulsory.
I agree with your comment about the NMC- we pay a HUGE amount as qualified nurses to this body only for them to investigate and impose sanctions on a qualified nurse for poor practice on an individual basis. No other advice, role or support is given. They too have no regulatory authority to intervene where an entire process or Trust or body is involved.
I was listening to R4 on the way to work this am and there was an interview on there which indicated that there were currently 41 of these individual investigations on qualified nurses going through pertaining to Stafford Trust, and 42 via the GMC for various medical staff on the same basis. (or it might be 42 and 41 respectively, forgive me).
You will note that there there is NO regulatory, registration or investigatory systems for managers or Health Care Assistants.
Having trawled through the Exec Summary etc, it threw up absolutely no surprises for me. Where staff have tried to raise concerns- the "whistleblowers"- they have been comprehensively crushed by the Trust, and everyone else ignored. The emphasis with this Trust (and it is not unique) is on meeting targets and financial plans. The targets include areas such as waiting times, etc that we are all familiar with and as users of the NHS welcome. However, achieving these waiting times within a declared financial straitjacket (or, worse,an ever-tightening one) means that something else has got to give. This particular Trust achieved enough of its targets including financial targets to achieve Foundation Trust status and to maintain it. On paper, it all looked good....Quality of care and the patient experience are not part of this formula.
Peter Carter (PhD, etc) visited the Trust some time ago for 2 hours in 2008 and recieved very positive feedback from visitors and patients in the few areas within the Trust he saw- hence his positive comments at the time. It think it is important to put those comments into context.
The saddest part of all this for me was that, again, the real function of nursing has been comprehensively ignored both by the Trust and by the report- that nurses can and will give compassionate care whenever they can but they cannot do this when they are not resourced to do so. There is a small mention in the report about staff/patient ratio, and I promise you that this can work if there is a will do make it. More often though this ratio is eroded by "skill mix" reviews and changes with the net result that the nursing care of the patient is ever reduced, with nursing functions such as putting out meals and drinks being passed off to non-nursing staff such as domestics who then have no follow up in ensuring the patient is actually fed or eats the food.
I often train nurses (both qualified and non-qualified) coming into my workplace and if I can I try to emphasise to them that the "art of nursing" as I put it must be done and done right; that art encompasses four basic tenets. They are; to keep the patient FED, WARM, PAIN FREE and CLEAN. Get any of those wrong or ignore it, and all the fancy drugs and treatments in the world simply won't work! Behind those 4 tenets lie all the caring and well-being for patients that nurses are there for.
I just wish nurses could be "allowed" (ie given the time and resources) to do what they went into nursing for.
You're right, it is time that nursing was reviewed and "given a kick up the arse"- but it is the whole CONCEPT of nursing that needs looking at.
You do, of course, have the choice of using private health care. I hope there is some locally avilable for your needs, should be emergency care, intensive care, major ops, etc.....
An interesting blog about this style of management in the IT business seems very relevant and is a good read!
Is it an uncomfortable subject or are we far more interested in rubbishing laser beams from out of space theories?
Aware that the plural of anecdote is not data, my own experiences are limited but generally positive. Yet this seems to be a post code lottery where in certain geographies you were basically turning up to a "free at the point of entry" dignitas. Didn't seem like that at the Olympic opening ceremony
Further to my comments at the top of this thread I thought it worth sharing Roy Lilley's view:
"A few more F words - News and Comment from Roy Lilley
Well, I've done it. With a bucket of builder's and a box of Hobnobs, I've ploughed through the Francis Inquiry Report.
I'm not sure I'm going to be too popular for saying this but I'm underwhelmed. True, it is a huge document, forensically written but as an epitaph to the dead and a tribute to the relatives it falls short. Hundreds have died and no one is to blame. Collective responsibility brings a welter of apologies but no real regret, no remorse and no repentance. Francis points a finger but makes no direct allegations. Francis admonishes without naming names.
Hours before the Francis report was published Number 10 had decided that its 290 recommendations were not enough. One more was needed. The Prime Minister announced he alone had the solution; an Inspector of Hospitals. If that is the solution I suspect Francis would have said so. Why didn't he? Because he knows what we know; it is bureaucracy that got us into this mess. More bureaucracy is the last thing we need. Daft idea but the lad has to look busy so he's had his two-penny-worth. That's the trouble; everyone will want to have their two-penny-worth. Two hundred and ninety one recommendations will become 291 headings, 500 sub-sets, 1,500 reports and three thousand complications, report-backs, work-groups, committees and a shed-load of costs.
Francis backs away from holding individuals to account. I wonder what would have happened if David Nicholson, boss of the SHA, happened to be working for Sir David Nicholson the boss of the NHS. Would Sir David have given David the sack? Leaders get the organisations they deserve. I listened to Niall Dickson, boss of the GMC, delivering a shambling performance on the BBC's Today programme. Dickson was one of the BBC's finest journalists. I wonder if Dickson the journalist would have let Dickson the bureaucrat off the hook so lightly.
When it comes to structures, Francis abandons his lawyer's forensic for establishment fog. Monitor is to pass most of their powers to the overburdened, drowning CQC. What happens to Monitor? What happens to the market, to regulation? Answers are there none.
The NHS will now infect itself with post-Francis-itis. Expect conferences, seminars, study groups, papers, reports and mind-numbing PowerPoint presentations picking out bits and pieces to suit the organisation and the event and the presenter. That is the problem with Francis. There is something for everyone; it is intricate, detailed and will be twisted, obfuscated and messed about-with. I suspect Francis will generate a multi-million pound industry.
The Francis conundrum is easy; corporate priorities were given precedence over organisational purpose. Answer; give organisational purpose precedence over corporate priorities. I am not sure 291 recommendations really tell us how. Cash will always trump care.
Francis talks about 'culture change'. Effectively making the people we have make the services we've got, work better. On that basis Francis fails. What we've got doesn't work. Never will. Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS' customer-base has changed but the organisations serving them have have stood still.
Will Francis 'work'? I have no idea but if I was forced to bet the farm; I'd say no. Francis is complicated when the NHS needs simple. Francis is a jungle and the NHS has a reputation for hiding in the undergrowth.
The massive Francis report will be the NHS' F-word for quite a while. What is missing from his report are a few more 'F' words;
"Fund the front-line fully, protect it fiercely, make it fun to work there, that way you'll make Francis history."
Have good weekend."
I am appalled at the lack of leadership, widespread willingness to avoid doing something on the basis of not wanting to do it and therefore delegating it inappropriately, the widespread jobsworth "no I can't do that, I finish my shift in 20 minutes, so it will have to be tomorrow" attitude, widespread use of the phrase "we"...."we'll do this...we'll do that" without saying who is to do it, so everyone assumes someone else is to do it, mraning that often, it just doesn't happen, the ridiculously cumbersome bureaucracy and paperwork I have to plough through to get simple things done, the lack of teamwork. Then again I am spoilt, I've worked in a totally different environment where leaders lead and inspire as opposed to managing, teamwork works and people know who is doing what.
On the other hand, a lot of people in the NHS bust their nuts to do their very best. A lot of people in the NHS are very, very good at what they do, and work exceptionally hard to make things happen in a difficult working environment. But it's the bad things that leave the lasting impression. Importantly, it's just the same as any other workplace; there are grafters and idlers, good people and bad people, good decisions and bad decisions, good leaders (rare) and bad leaders, too much bureaucracy. People seem to think this is restricted to the NHS, which it isn't!! But of course because health and death are part of eachother, it is more shocking in healthcare. It is the same as any other large organisation in this respect.
I think the public sector suffers from an overabundance of middle management and a very poor standard of management that, much as it promotes blind change in an organization, refuses to accept change in its own structure and (self) promotion.
When the constraints of the private sector are removed - because the public sector never really goes bust - then the crap of targets, measurements and performance monitoring completely obscures the requirement for vocational aptitude, common sense and the delegation of real responsibility to front line staff.
If the police dealt in the business of keeping ill people alive then a mid Staffordshire scandal would be heading our way.
You're wrong about that. Succesful organisations (sadly I think I can only think of private sector ones) have a buzz about them, an energy, a commitment to shared goals, a culture where people don't want to be seen as the weak link; unsuccessful ones have people huddled in every corner telling everyone how they'd love to do a proper job if only they could...
I have seen really large organisations (Tarmac; IBM; Matalan; M & S) flip from one state to the other in a matter of months.
The difference is always leadership. Get the NHS a health minister who isn't a total pr@t, who is willing to acknowledge that he/she doesn't know all the answers, is willing to face down his/her critics without committing to anything that hasn't been thought through; who is willing to sack every Trust chair, whatever knighthoods and bureaucrat titles they may have if that's what it takes; and it could be changed. Everything else would follow. Hmm.
Lilley has been a perceptive and informed observer of the NHS (more specifically, hospitals) for many years. He is worth listening to.
>Succesful organisations (sadly I think I can only think of private sector ones)
Not sure, I've worked in a public organisation with the positive attitude you describe, but in general terms you are right, more likely to find it in private organisations.
I find it hard as a clinician these days to actually follow and be 'led' as the actual leadership is so poor and interested primarily in a political and financial agenda coupled with bullshit PR and image. It is really not interested in quality of care where I work.
The clinicians in the team I work in are great....really committed and focused on the right things but management and 'leadership' is not congruent with the direction of the team. We actually do set out to sabotage certain plans and ideas coming down from above.
Everyone in an organisation - from the smallest to the largest - can and will do that if they don't 'believe'.
I suspect that widespread 'sabotage' in the NHS doesn't directly kill patients, but it doesn't do anything for maximising use of scarce resources either.
We have a waiting list and when anybody on that list is coming near the 18 week target we are leaned on by managers to contact the client and ask if they wish to stay on the waiting list (its actually the parent/guardian who is asked as its a childrens service). That in itself is reasonable, however, we are then expected to enter on the computer system that they have had an 'intervention' which would then create a new start date for the waiting list.
It is unethical, untrue and is motivated to manipulate the actual 'wait' time whilst our Trust pursues its application for Foundation status. I and others have refused to do this.
There's a similar scam in Cumbria. Patients are given a date for day surgery several months in advance and they make arrangements, book time off work etc. based on that date. A couple of days before the op they get a phone call along the lines of "Can you come in tomorrow?" Due to childcare or time off work many won't be able to. They are then deemed to have refused surgery and removed from the waiting list.
Mindless application of poorly designed targets and the perverse incentives they sometimes create is much of the problem.
Too much power in the hands of a sick management culture is much of the rest. Individual managers are often very good but they toe the line for the sake of their careers.
Doctors have been too easily governed...again for fear of career blight and loss of resources in their individual departments if they rock the boat and become labelled by senior management.
Trusts have a whistleblowing policies but people who attempt to whistle blow need more support and protection.
If you want early treatment, say you're on holiday soon but don't book a holiday?
Staffordshire was revealed due to assertive relatives of patients and not by inspectors, managers, medical or nursing staff so helping those assertive members of the public will be the most effective first step.
The professionals come out of this badly - absolute protection/anonymity for whistle blowers would help but wouldn't be necessary in a properly functioning organisation.
> There's a similar scam in Cumbria. Patients are given a date for day surgery several months in advance and they make arrangements, book time off work etc. based on that date. A couple of days before the op they get a phone call along the lines of "Can you come in tomorrow?" Due to childcare or time off work many won't be able to. They are then deemed to have refused surgery and removed from the waiting list.
>> Cumberland Infirmary Carlisle. The local papers in the last year have reported three women dead of breast cancer after having CT scans there and told they were OK. Operations being cancelled in the ops. theatre for people with pace makers as there was no cardiac staff to switch them off for the duration of the operation. That was last week. Ten times more staff/management disputes than adjacent NHS trusts. Incompetent financial management. And this headline from the News and Star on 24/1/2013. I quote "Bowel cancer ops death rate 'bad luck.' Patients dying after surgery nearly four times average" That included Whitehaven hospital which is run by the same trust. The bad luck quote was from their consultant colorectal surgeon. Patients being given CT scan "results" based on scans from two years ago and not their recent scans. That was two weeks ago.
I could go on, but I don't want to depress you.
Mrs Ridge works for them. Nothing you could say could top her tales.
> At least we have an NHS. The idea of hoping you don't get ill because you can't afford treatment just fills me with horror.
All my kids were born at Stepping Hill and I thought the care was wonderful, the hospitals in Spain are supposed to be superb, and indeed my experience has been so, but to get the service is bloody expensive.
Thought it worth linking this to the new NHS whistleblower news.
The problem has been an open secret for years (pressure on trusts from above to compromise safety to meet targets; with some forced or pushed when they complained).... wonder if its got legs as it implicates a lot of powerful people in the DH, SHA's, ex-ministers etc. It's never been just trust boards at fault.
So they should not suffer consequences of supporting the opposite?
I loathe the idea of these scummy senior bureaucrats getting away with their oleaginous shenanigans, - I've worked with some of these b*stards - but I'd rather the style of NHS management - something that should only exist to enable people to contribute the best they can in achieving agreed objectives and outcomes - was set from the top, rather than a seeing few wasters being hung out to dry for reasons of political expediency.
I've experienced it too. There are several people I know who have been hung out to dry by managers who found them inconvenient (usually because they put patient safety or clinical integrity with regard to the patient), using accusations that relate to things like swearing / being rude. One guy got dismissed basically because he had called a colleague (both of them consultants) an effing bastard. The fact that the guy was being an effing bastard was apparently irrelevant. The case that stuck out for me though was that of Otto Chan, who inconveniently for some of his colleagues and management had discovered tens of thousands of unreported X-Rays in the basement of the hospital. Rightly seeing this as a patient safety issue and reporting it resulted in his eventual dismissal for gross misconduct principally under the pretence of maltreatment of trainees. Frankly, I doubt a there was a more competent trainer of trainees, and he was a great loss to London being almost certainly the best trauma radiologist in the UK, at what is the main hub for dealing with severe trauma in London because of the helicopter emergency medical service:
I remember in the 80's as a Staff Nurse we were being encouraged to 'whistle blow' if needed by the occasional decent manager but the reality was very different as Mr Pink found to his cost. http://www.independent.co.uk/news/uk/nhs-whistleblower-wins-pounds-11000-damages-health-authority-pu... more here http://www.guardian.co.uk/society/2008/mar/12/nhs.health
One would hope that the upside of these tragedies is that the NHS is no longer treated as sacrosanct, that its faults can be acknowledged and a rational discussion be had about reform
rather than eitheri ignoring its faults or blaming them all on lack of funding. Centralised targets, rigid bureaucracy, and promotion of the producer interest over that of of the user seem to be at the heart of the mid Staffs case.
However, given the current obsession with horse eat I am not entirely convinced that either the major parties or the media are really prepared to undertake an honest discussion.
They are supposed to take on board the EU reciprocal deal, but no way do they, the Spanish health service is no way equivalent to the NHS, except for emergencies. So how do you get yourself out for 'possibles', You don't unless you pay a lot of cash.
Al, that's a rubbish arguement. The fact that youhave to pay in Spain does not make the 'free' NHS good.
I've never come across anyone who wants to get. rid of the NHS nor anyone who wants to get rid of the free at the point of delivery principle - tho some may argue for restricting that th UK citizens but that's a different arguement. What most critics argue is that the NHS is very expensive and should give better value for money. To do that it needs to be better run and a good start would be to take a good look at it, see what's going wrong, acknowledge those flaws, get rid of this ridiculuous 'envy of the world' complaceny, stop trying to blame everything on lack of resources and instead buckle down to some serious work.
not the best in the world, but not at all bad. dont take my word for it, the King's fund know a lot more than most of the armchair pundits on here
and as to efficiency, it is the *most* efficient system in international comparisons. again, dont take my word for it, the commonwealth fund have researched it, in comparison to the US, australia, NZ, germany, canada, netherlands
page v for the summary table of findings
thats not to say it cant be more efficient, or better, of course it can. but it is a myth that the current way of funding it is worse than other ways that have been tried, and from the point of view of containing costs and eliminating perverse incentives, it would appear to be the best.
Greece *was* in the EU 10 years ago, has been a member since 1981. The Greek NHS was very variable, some hospitals are good, others are... interesting to put it kindly. At the moment, with the money problems, they are lacking basic supplies...
If it transcends barriers of wealth then, yes it is. It doesn't mean its the best quality per buck, but it does mean that its far more equitable and efficient. Mark my words, you'll be paying for your GP appointments within ten years at the most. Ignoring lack of resources is ridiculous. Central targets have always been a part and parcel of the modern NHS, initiated by Thatcher and successive Governments since (no Government can resist the desire for such control, because of the electoral consequences!)... ... Thatcher's targeting of efficiency, as if the NHS was just another business, has inspired ever more blinkered thinking along those lines.
If there is one factor responsible for problems like Staffordshire (whatever the material endpoints evidenced), that would have to be almost 35 years of efficiency pressures. Its not that efficiency is per se bad (of course not), but it is that naive managerial/political conceptions of efficiency that are utterly inappropriate within the NHS. The last decade's fad of imposing process improvement / six sigma type standards being a case in point, because unlike airports, or factory lines, or the usually focussed nature of businesses, the NHS is by its very nature chaotic, because people don't follow any form of a distinct process through a hospital... ...why? because no one person is the same, because psychology of patients intervene to make diseases variable in their presentation, because increasing proportions of patients have multiple illnesses, not one, because the nature of one disease, or operation, is itself highly heterogenous, and because the investigations and treatments that are appropriate vary as much as there are patients!
Yes there are areas that are more amenable to such efficiency improvments, e.g. lab services, which even in pathology are reasonably heterogenous, but alot less so than a patient's path through a hospital, and cleaning.. ..well that's usually outsourced and done atrociously, and is absolutely a clinical issue that is not under clinical professional control. Worse, targets like the "4 hour wait" add to the chaotic nature of the system by subverting triage and clinical intervention on purely clinical grounds for political expediency, which further enhances the chaotic unpredictable nature of the system. The reality is that the NHS is nevertheless highly efficient as is evidence in numerous published studies that you can find online, see the King's Fund or:
What is happening now is that the system is under such strain the cracks are appearing, just as anyone who understand the process improvement theory should know, you can only push a system so far before cracks emerge. Of course people will all be able to sight obvious areas that are weak, inefficient, and unprofessional, but the causes of these things are multifactorial, and don't resolve simply to the kind of answers being bandied about with regard to Staffordshire.
Nickinscottishmountains hit on an accurate observation about the lack of leadership, and jobsworth culture, but what he may not be witness to is the fact that the erosion of professionalism within the NHS is a function of the decreasing autonomy of professionals within the NHS and the increase in outside auditing. In the early 70s weekly surgery reviews were the norm wherein a highly hierarchical system, SHOs, Regs, Consultants had to account for their performance that week:
- why did X have a paralytic ileus for so long, could it have been a function of the operation, describe how the operation occurred Mr Z
- why did N die? What was the presentation, were there difficulties within the operation, what was the cause of death?
Instead, this internal autonomy disappeared with along with the paradoxical acceptance of a basal level of mistakes within clinical activity (post Bristol heart scandal), the wresting of clinical authority and hierarchy and replacement with managerial decision making, the disenfranchisement of doctors whose professional training was dumbed down and the power of the colleges diminished etc, and now we are coming full circle with, instead of autonomy and professional responsibility (which did have an overburdensome and erroneous paternalistic quality) to the modern bureaucracy of numerous appraisals, external auditing of trainees, continued professional development, and now revalidation and the publication of surgical performance figures. Who'd want to do the job, as difficult as it is, when people are trying to die on you as much as they are, when the training has become so shite (again as a function of efficiency and universities saving money, and wanting to be able to say we have X new consultants (it doesn't matter if they've had several years less training than previous consultants!)) and all eyes are looking at you, is it any surprise that your thinking of your own backside rather than the patient in front of you, is it any wonder that you want to get out of there at shift end? Privatisation is not the answer, but enabling and then trusting professional responsibility is the way forward. Re-establish hierarchy, re-establish responsibility, make senior clinicians responsible junior doctors and patients again, and sisters responsible for nurses and patients again.
Look again at the reasons for increased /GDP or spending on health. A large majority over the last 30 years has to do with increased wages and purchasing costs, and the bloating of primary care. The primary care has expanded while providing less of utility - it has less training than ever, refers more to secondary care than ever, the "family doctor" model has evaporated along with a ridiculous contract initiated by Labour in which GPs have been nefariously allowed to opt out of "out of hours" work, but which can only be blamed on the Conservative era that encouraged fundholding and the business minded GP that has encouraged. At the same time successive Governments retort the mantra that GPs and primary care needs to be where the bulk of future NHS patient activity occurs, thus we see numerous DGHs closing, and the requirements for patients to travel further to super hospitals, while poorly trained GPs who should have the most burdensome of training as true generalists (but don't), who are poor at retaining clinical responsibility for patients away from secondary care referrals (as evidenced by the constant increases in admissions to A+E, medical and surgical admissions units), do less and less work for more and more money. Hospitals aren't the problem, they are the solution, along with proper training of doctors... ...it doesn't matter if you are treated by somebody with the label "GP" or "consultant", what matters is that you are trained to the hilt!
An interesting rant. One point I take issue with is the assumption that airport or factories are simple processes compared with what you do. I appreciate it is an analogy. Have you ever really thought or even seen how complex an operation it is to put together for example an Airbus and to make sure it flys right and not kill anybody. Your assumption that you cannot learn from these outside things is I would suggest wrong.I appreciate it is more focused, but you still can learn.
Being self employed I know enough about profit and loss to scratch my head as to what's going on.
Apologies for taking so ling to reply - I did something unforgiveable and went climbing instead.
Al your reply fell at the first hurdle. The NHS is not free. It is free at the point of delivery, which is great, but it actually costs a bloody fortune.
Secondly I do not ink it und rsourced, othe than if you take the view that it will always be under-resourced until everyone can walk in off the street and have instand treatment for any and every condition with no rationing, no waiting lists etc but that can never happen.
I have had considerable experience of being on the receiving end of the NHS both as a patient and as accompanying others and to call the care patchy is flatering in the xtreme. Some is excellent, some is poor and some is downright dangerous. I have personally seen examples of people being over-worked and some of people working at what appearred to be a reasonable level but both have been out-weighed by people who have been woefully under-occupied.
That is a management problem, a question of allocating the resources you have most effectively. But until it is accepted that the NHS is not perfect, it cannot improve. And is it not just this faceless 'management' that needs to be looked at. nor is throwing more cash at it the only, or even the best solution. As someone said higher up, the NHS is the acceptable altnative to religion these days. But until itvis accepted that work shy and incompetent people exist at al levels - and I.ve seen nurses, doctors and paramedics who fit that bill with my own eyes, - the NHS will continue lto flounder
> "Apologies for taking so ling to reply - I did something unforgiveable and went climbing instead."
going climbing is fine, its the straw men your post is littered with that is unforgivable...
" Secondly I do not ink it und rsourced, othe than if you take the view that it will always be under-resourced until everyone can walk in off the street and have instand treatment for any and every condition with no rationing, no waiting lists etc but that can never happen."
it is under resourced not in absolute terms (£100bn + is of course a lot of money) but in comparison to similar countries. we spend less of our GDP on healthcare than most other OECD countries:
and likewise fewer doctors per capita than most other OECD countries:
"But until it is accepted that the NHS is not perfect, it cannot improve"
Can you point to the bit where anyone said it was perfect...? it is hugely flawed. but on the whole a little bit less flawed than just about any other country's system.
"But until itvis accepted that work shy and incompetent people exist at al levels - and I.ve seen nurses, doctors and paramedics who fit that bill with my own eyes, - the NHS will continue lto flounder"
more straw men... the NHS employs more than 1 million people, of course there are lazy, incompetent and downright unpleasant people, by the thousands. it employs people, not angels, heroes or robots. there are ever more complex systems in place to monitor the performance and competence of staff, but there will never be a day when every employee is a paragon of virtue. and there will always be a tension between having people spend time collecting ever more detailed information to try to prove they are not harold shipman, and having them actually treating patients.
as to the NHS floundering, did you actually read any of the links you've been provided with? here's the commonwealth fund one again, since you seem to have missed it...
page v has the summary table: the NHS does very well on efficiency, equity, access and safety, and less well on timeliness and patient-centredness.
now, you've been provided with evidence from researchers working in the field of comparative healthcare that the NHS stacks up well in comparison to other comparable countries' systems, despite being relatively less well funded and under-doctored. feel free to cite some evidence that suggests the contrary, if you can find any, but if all you've got is more straw men, ad hominems and ranting, perhaps you'd be better sticking to the climbing...
disagree, at least in part. Acute hospitals have very high bed occupancy rates of people with dementia, admitted often because there is no alternative that could keep them in the community safely, but whose medical condition per se doesnt necessary require in patient care.
while in hospital, they often find it hard to adapt to the environment of an acute medical ward, and too often they end up given sedation with all the risks that entails. add some hospital acquired infections, falls onto an unforgiving surface and unnecessary investigations, and the outcome of the admission can often be a depressing one.
but to keep them out of hospital, there needs to be investment in the right sort of medical and social care, which can be accessed when needed. so i disagree that primary care is bloated, other than it may be over-invested in the wrong areas. there are lots of initiatives to try to fill the gap i refer to, but in an era of 20% + reductions in the funding of social services, its hard to see how these can make much of a real difference.
we have to hope though, cos there's no extra money coming for a long time...
I don't assume that factories / aeronautical industry / airports involve simple processes, I assume that they have processes that, while they can be complicated, are nevertheless mappable. It is the fact of their being mappable that allows these processes, undertaken in for example Boeing, Lockhead Martin etc, that allow them to be facilitated by lean, and six sigma type processes. Even in biotech, where my wife worked on lean / six sigma (black belt level) the pathways can be really complicated, but they are still mappable. The problem with the NHS is that very few parts are any where near so mappable. In any case, its not really my assumption, its evidenced by the analogies being used by those who are advocating and providing lean / six sigma type courses for management / clinical management in the NHS, as I am a personal witness! I didn't say, and do not think that there are not aspects of efficiency and quality maintainable in industry that are not applicable and can be learnt from, but I am saying the provision of solutions being provided within the NHS is not appropriate, and falls on the ears of a quality of NHS management that in general (there are certainly many exceptions) doesn't understand how these things may or may not be relevant, may or may not require significant adaptation, may or may not contain any more than a philosophical, rather than a pragmatic message.
> disagree, at least in part. Acute hospitals have very high bed occupancy rates of people with dementia, admitted often because there is no alternative that could keep them in the community safely, but whose medical condition per se doesnt necessary require in patient care.
> while in hospital, they often find it hard to adapt to the environment of an acute medical ward, and too often they end up given sedation with all the risks that entails. add some hospital acquired infections, falls onto an unforgiving surface and unnecessary investigations, and the outcome of the admission can often be a depressing one.
> but to keep them out of hospital, there needs to be investment in the right sort of medical and social care, which can be accessed when needed. so i disagree that primary care is bloated, other than it may be over-invested in the wrong areas. there are lots of initiatives to try to fill the gap i refer to, but in an era of 20% + reductions in the funding of social services, its hard to see how these can make much of a real difference.
> we have to hope though, cos there's no extra money coming for a long time...
I think we probably just see things from different angles, and probably agree quite a lot. I do agree that hospitals do have a very high bed occupancy rate, especially with people with established chronic diseases and dementia, but that was part of the problem I was citing in the increase in admissions to MAUs, SAUs and via A+E. One stark lesson here is to make geographical comparisons. For example, go to the North West of Scotland, Skye etc, well away from Inverness, there are GPs who cover large geographical regions, and moderate populations, and yet manage disease that I wouldn't have felt comfortable doing within the safety of a medical ward. They are damn good at what they do, managing people with dementia, palliative patients, patients with severe heart failure, CAP etc and doing so very competently. Compare that to a city like Dundee where it is all to easy to push a patient into secondary care. I remember taking the admission bleep, it was crazy. You'd get a GP call with a patient notorious to suffer from constipation, with a story that sounded like constipation, and you'd encourage them to manage in the community, advise what to do. Go up downstairs, and find that the same GP would be trying a slightly modified story to get them admitted via the MAU. This is what I meant by the problems of under-training in general practice on the one hand, and the lack of out of hours commitments on the other, also exacerbated by the loss of the "family doctor" concept. How can it be anywhere appropriate that a GP can be a GP with no more than 4yrs of specific training (it was 3 until last year)?! They are generalists, in an unprotected environment, and they have less training than almost all other sub-specialties within medicine. It should be the opposite way around. GP training should be 8-10yrs with numerous appropriate rotations, remembering that all these people are still providing a service! I absolutely agree that you need a competent primary care sector, including social services, but the reality is that spending in these areas has increased markedly, particularly on wages, without a con-commitment increase in measurable value produced within the sector.
Less training than before Shipman? Surely you jest. One of my close friends is a G.P. trainer and I know how much effort and thought goes into his registrar trainees. And the insistence on a quality, well supported medical rotation.
Not a medic but many of our trainees are leaving to G.P. & Australia, U.S. and Canada because training is effectively non existent (Emergency Medicine). Too busy or something.
I should add that it is absolutely extraordinary how short sighted decision making can be. There is one opportunity in which it is possible to make a really big effect on the performance of hospitals, and how they function, and that is in the architectural design of new hospitals. In that respect, short term financial decisions, archaic and simplistic architectural notions, are put well before, a design of a hospital orientated toward clinical endpoints, and patient flow through the system, one point at which an basic understanding of a patient's passage through the hospital can be made more efficient. Unfortunately.... ....in the cases I know about... ...there is failure here at the first hurdle.
> The problem with the NHS is that very few parts are any where near so mappable.
When I worked in 'Lean' in the 80's, people I worked for used to come up with that sort of excuse all the time.
Anyway, 'Lean' is a bit past it's sell-by date to say the least, is that what is being foisted on the NHS at the moment? out-dated management theory & techniques? no-wonder the NHS is dazed and bewildered.
Your initial rant highlighted a few problems within the clinical structure of the NHS and its present problems - specialists/hospitals blaming GPs and vice versa. i.e always someone else's fault.
Hospitals are busier than ever often taking completely unnecessary admissions sent from OOH centres/paramedics who don't have access to a full patient record. Therefore if a GP went back to covering their own patients overnight things would instantly improve? I doubt it... Doing vast numbers of hours on call isn't healthy which is why the system had to change in the first place.
Hospitals moan that GPs aren't seeing enough patients, aren't doing enough to keep patients at home where the real problem (from a GP perspective) is they are saturated with crap administrative jobs that they are being forced to do by LHBs/PCTs such as changing Microgynon to Rigevidon or Diclofenac to Ibuprofen, or Atorvastatin to Simvastatin etc etc etc etc to save a few pence only to have to reverse all the changes a few months later due to patient demand or a change in supplier/cost. They're having to write pointless and endless letters to support someone's appeal against an appeal hearing that they are not any longer entitled to DLA after 20years of claiming the same.
Similarly GPs moan that when a patient is admitted they are discharged within 24hours without a diagnosis and without a management plan - usually a discharge letter follows about a month later. Sub specialism and inadequate training in consultants mean that patients are no longer treated holistically when they end up in hospital.
I have endless examples for each but one example of a GP becoming too business minded rather than getting on with the actual job of treating patients was one who decided it was more important to take an afternoon away from the coalface and spend it auditing patients on the "wrong" prescription of NSAID - thereby leaving his partners to pick up the tab of doing the job they're paid to do, thereby creating resentment.
An example from the other end is a hospital so desperate to discharge an elderly lady who had fallen at home that they saw her in A&E, diagnosed her with no bone injury and sent her to a community hospital run by a different GP practice to the one she was registered. On first assessment by the GP when she arrived he noticed that she was quite ill with Pneumonia and admitted her straight back to the DGH. The F2 who had seen her in A&E had correctly treated the consequences of the fall but not the actual cause of her fall in the first place.
Where do the answers lie? I fear things are only going to get a lot worse with the present coalition plans. They promised not to mess with the NHS prior to coming into power and have now done just that. No one in the NHS knows who to trust and thereby that creates resentment again.
Having said all this, the NHS really isn't all bad. Why are there so many "health tourists" if it is?
However I called it as I have seen it over three hospitals and two if not three trusts and I still believe there is much that could be put right with the NHS if it were capable of self criticism rather than merely constantly demanding more cash.
> When I worked in 'Lean' in the 80's, people I worked for used to come up with that sort of excuse all the time.
What was your answer to them then?
Nope not at all. What Blair did was to get rid of "floating" SHOs. So the reality was most doctors would do some A+E, some paeds, some surgery, some form of general medicine, trying different subspecialties, and did so for many years, all of which time they were providing a service, and getting valuable experience in the process. Only once a decision was made would they then commit to a subspecialty like general practice, already with a wealth of experience. The point being, that for most of the 70s, 80s, and even 90s the avg time from completion of junior house job to becoming a GP was 7 years - its currently 3. You are right in one sense, because the avg time, after commitment to the specialty, hasn't really changed, but the experience and breadth of knowledge of doctors within the specialty most definitely has. Not only that, but in GP specific training at 3 year we are behing most of our European counterparts. 4 years, which I think has been secured by Claire Gerarda last year, should improve things, but it isn't nearly enough.
>Why are there so many "health tourists" if it is?
Because it is free at the point of delivery and better than whatever they have at home. There are not plane loads of french or U.S. passport holders turning up here for freeloader healthcare.
It wouldn't be free for US passport holders.
I don't know the figures, but I am pretty sure quite a few French come over for health care. I've seen a few myself.
I've seen a few Yanks too, but they were genuinely tourists.
no worries, i could see what you were saying, and picking up on typos would have been poor form anyway...
i think it highlights the difference between anecdote and system level analysis. i dont doubt for a second you are telling it as you have seen it- and like probably everyone else, i could give stories of both good and poor treatment from the NHS
but i think it just highlights how hard it is to do healthcare well- did you look at the links? the NHS really does do well when benchmarked against other systems, and it does so on relatively less money
but that's not to say its perfect, not by a long chalk. though i think you are straw manning again with your last comment- i think it *is* very capable of self criticism- though that's not to say every practitioner and every trust board is equally capable. mid staffs is clear evidence of that.
as for demanding more cash... 20% savings to be found over 5 years from every trust. demanding more cash in the current environment would be a waste of breath, "doing more with less" is where the NHS is now, and for a long time to come...
I'm not sure what you're saying here, but the change that Blair initiated was that post junior house jobs (subsequently called pre registration house officers (PRHOs) and then foundation years (FY1&2)) was that you could no longer float as an SHO. This grade was scrapped, and you had to commit directly to a specialty (e.g. GP), and thus:
- you're overall clinical experience went down
- you have less time to try different aspects of medicine to establish strengths and weaknesses and which subspecialties you relatively enjoy
- many of our junior started going abroad, particularly OZ, NZ, South Africa and Ireland, where training was more substantial, and would give them other clinical experience before returning to the UK to do a job.
- these people who go abroad get more experience, but don't provide a service (hich they've been trained for in medical school) during that time
In my view, this was a seriously backward step.
> In my view, this was a seriously backward step.
Depends - working from 2005 -2008 in London emergency dept nobody was checked. Now everybody who gets admitted is. Europeans have reciprocal rights.
What I'm saying is that they leave training because it is non existent. From the horses mouth. ST3's that have spent a year on a horrendous shift pattern have had zero input from consultants.
And many other countries too, but not USA.
We very rarely check passports, but I usually ask people were they are from, out if interest as much as anything else.
Although access to primary care and access to secondary care is different when you're from overseas.
> I'm not sure what you're saying here, but the change that Blair initiated was that post junior house jobs (subsequently called pre registration house officers (PRHOs) and then foundation years (FY1&2)) was that you could no longer float as an SHO. This grade was scrapped, and you had to commit directly to a specialty (e.g. GP), and thus:
> - you're overall clinical experience went down
> - you have less time to try different aspects of medicine to establish strengths and weaknesses and which subspecialties you relatively enjoy
> - many of our junior started going abroad, particularly OZ, NZ, South Africa and Ireland, where training was more substantial, and would give them other clinical experience before returning to the UK to do a job.
> - these people who go abroad get more experience, but don't provide a service (hich they've been trained for in medical school) during that time
> In my view, this was a seriously backward step.
+1. spot on with the analysis. too-early specialisation is a real problem.
> Europeans have reciprocal rights.
> And many other countries too, but not USA.
Sure lots of commonwealth and overseas U.K. territories.
> We very rarely check passports, but I usually ask people were they are from, out if interest as much as anything else.
Me also. But no pressure from the trust to flag the non eligible.
> Although access to primary care and access to secondary care is different when you're from overseas.
No idea. Never worked in it.
After 5-6 years of medical school and 2 years of practising still no idea what you want to do? Any other field of endeavour and you would be laughed at. The antipodean guys come over here and generally out perform U.K. medics with their short training and reasonable work life balance. How so?
thats not the point. the experience you get at medical school of most specialities is by necessity brief and doesn't necessarily give a good idea of what working in it would be like. but the bigger point is the broader perspective and knowledge you bring to whatever role you end up in having worked in a number of specialities before settling on one. that used to happen, current training structures make it harder to do.
and are you sure about "any other field"...? my brother trained as an accountant, worked in the field in scotland, before moving through different roles for a number of employers, til he's now mostly IT project managing. i thought changes in role over a career were pretty much the norm these days, and healthcare was a bit of a dinosaur with its current inflexibility...
as for the comment about "antipodean guys", i have no experience of that so can't offer any meaningful comment on it,
Which hospital are you in and in what role?
I generally agree. There is a dearth of experience in medical school training, but I don't think it need be that way. One problem is that previous preclinical/clinical divided courses provided more ward based time, and the prevalence of a hierarchy at which you were expected to always show up, whichever your current specialty rotation. What I mean is that the hierarchy, competition, professionalism starts from the off. If you want to show your face in theatre you need to have:
- seen the patient first
- be able to scrub up properly
- know the relevant anatomy very well, so being scrutinised on the anatomy is not "being got at", but an opportunity to learn and show you've earnt the privilege if
- know the operation from start to finish
- know and be able to recite the operation well enough to be able to knowledgeably assist, open, close etc
Aren't these reasonable basic standards to assist in theatre? They used to be the norm in the 1970s. They certainly aren't now.
One of the impetuses for MMC was supposedly a lack of "training opportunities" for surgical SHOs, or at least the reason for the pressure in that direction from the RCofS, because of most hands on experience devolved from consultants going to regs and rarely to SHOs. Though consultants getting increasingly conservative of allowing regs or SHOs from leading any operations. Reg experience became increasingly confined to late night theatre lists, with little chance of hands on day elective list experience. Were consultants wrong not to trust juniors? Well they had themselves to blame, because they oversaw the changes in professional responsibility that allowed a depreciation in medical student education and ethical standards. Just as an example, interested in a career in surgery, my father had carried out >50 appendicectomies, cholecystectomies, gastrectomies before leaving medical school having led them under senior supervision in Aberdeen. Now that undoubtedly reflects the focus and ambition of my dad, but it was possible then, because you could prove yourself to be in a position to take on such responsibility. Not any more. The training is just too weak....
During his first SHO, he was in North Uist, rowing out to patients on Berneray, picking them up peritonitic, taking them to Benbecula, and carrying out the appendicectomies there.
That world has gone on the basis of needing to have certain numbers of operative experience before such practice is justified. Superficially that makes sense, but if you have the anatomical knowledge, there is a uniformity in managing tissue plains and dealing with bleeders which makes that conservatism a nonsense. Still, it is that conservatism thtoughout the ranks that is the reason for a lack of perceived training.
I've had experience in both systems (NHS and overseas). It is a sideshow to the rest of the thread, but potentially worth expounding upon.
I went to med school (London) in 1990 and qualified (MB, BS BSc) in '96. Exposure to various specialties at med school was very limited - a whole week in anaesthesia and ICU, for instance. Unless you knew you only wanted to be a paediatric neurosurgeon / GP / dermatologist at med school it was rare for any of us to have a plan for 'when we grew up'. 2 house surgeon posts and then 6 months in A&E was the standard recipe, at which point many things could probably be crossed off the careers list.
I chose a medical (not surgical or GP) career and over the next 2 years worked in renal medicine, med admissions, cardiology, gastroenterology, Care of the Elderly, stroke medicine, and respiratory medicine before moving sideways into anaesthesia and critical care / ICU (another 3 years around different anaesthetic specialties and ICU).
Many of the medical jobs were so busy that it was impossible to attend teaching - one that sticks in my mind usually started about 7 am and I think the earliest I ever got home was 7pm, for a job that allegedly ran 0830-1630 - and that was without any on call on top. The chances of me leaving the patients to go to teaching between 2-4pm on a thursday were basically nil. After being warned for not attending teaching I offered to put a claim in for the extra 500 hours or so I had put in for free. I wasn't warned again, but the job still remained unsustainable. A colleague did the job the following year and spent several months off sick - despite my complaints nothing had been done to improve matters. Adding in the hundreds of hours of study needed for the postgraduate exams (which remain absolutely the most exhausting experiences of my life so far) and the lot of the SHO back then was basically a balance of personal survival/sanity against a seemingly infinite task.
At the end of this early battering at the hands of the NHS (like many who have been battered and abused I had developed a symbiotic dependency and/or a degree of survivor guilt) I had developed many, many skills and had a much broader base of experience than many of my colleagues who were, by this time, running through the system in a much faster time - but on half the hours.
Then I married a kiwi, and did a year in ICU in NZ. Fewer patients, better staffing ratios, time for teaching and learning, an environment where it was assumed that you would spend time off climbing, walking, running etc rather than drinking and vegetating. I learnt more in the year than the 3 previous. A few years later in my (UK) specialist training I did the same again - 1 year out of 5 in NZ, during which I learnt more about my speciality than I had in the other 4 years. More time, better teachers, better work/life balance (despite longer hours), and the indefinable pleasure of being in a system where the default answer to a request is "sure" rather than "**** off, I'm far too busy". The culture in medicine in NZ is one of dedicated training, and I think principally this reflects having enough time to do so, from top downwards.
Thus it was 12 years after leaving medical school I became a consultant: as best as I can judge I was towards the end of a time when it was possible to work very hard, for a long time, in many fields whilst accumulating skills and knowledge. A good graduate from med school these days could be a ('junior") consultant in less than half the time. In the NHS this scares me: it was only late in the piece that NHS training has improved from a 'work a million hours, you'll pick it up sooner or later' model to actually being trained and (to a lesser extent) having time to be trained. In NZ trainees come through even faster, but the quality of training is so much better than in the UK that the absolute time is not needed in the same way. Having said that, many of us feel NZ is still too quick although in the larger centres at least is offset by a better collegial atmosphere and co-operation.
In addition, back in the day I functioned in a team where we all turned up come what may. With a good team, you kept a good team. Of course the same was true for a less good team... These days EWTD compliant rosters mean a different doctor every day for many patients, which risks repetition, confusion, assumption and omission.
I should also point out that the hoary old cliche of the NHS consultant dividing his time between golf course and private patients is close to a myth: in 10 years of NHS work I came across one of these types, whom we all avoided like the plague. Some colleagues were better than others - it were ever thus - but hard to recall anyone who fundamentally didn't try to do their best.
I can recall trying to prevent a manager ejecting an asylum seeker from a large hospital in the Manchester region as he "wasn't entitled to care". We had a big argument including the fact he was pretty much unconscious and thus, even ignoring the human aspect, couldn't actually leave. The manager tried picking him up... Fortunately a consultant came down from ICU and gave him the mother of all tellings off and we took him straight to the unit where he fairly rapidly passed away of an entirely curable disease.
That was 2003. Most hospitals I worked in c. 2000 to 2008 checked on entitlement, and tried to bill where possible. It happens here in NZ too for non-emergency care.
The latest from Roy Lilley with a useful link at the bottom......
Make your voice heard - News and Comment from Roy Lilley
It seems there is only one question. My in-box is overflowing and last week, as a guest at four conferences (different topics and different places), the only conversation.... should the Big-Beast quit? He took another hammering in the papers at the weekend ( http://www.dailymail.co.uk/news/article-2279415/If-wont-quit-just-sack-MPs-bereaved-families-demand-... ).
The NHS' reputation is damaged. In many NHS establishments front-line care is in a bad way. Let's take a pace back, have a cuppa-builder's and a think about the issues. First, the structural stuff.
Reorganisation; unnecessarily complex, half-baked CCGs granted authorisation with more strings than a marionette, in a desperate attempt to meet arbitrary political timescales. Little GP buy-in, over 80% of CCGs will be bossed by a non-GPs Accountable Officer. There is a dislocation between what the Carbuncle thinks is happening and what is actually happening.
Clinical Support Units, or Services, or whatever they're called; set to Hoover-up fortunes in administration fees that would be better used at the front-line. Their future, as private concerns, outside the H&SCAct, the reach of Parliament and the purview of the NHS... unregulated and unchallengeable.
Foundation Trusts; many 'too big to fail', sitting on huge surpluses that would be better used at the front-line. Wanna-be FTs, mostly a rag-bag of no-hopers shoe-horned into FT status by the Trust Development Authority (http://www.ntda.nhs.uk/ ) which, itself costs millions to run. There is no organisational imperative for all hospitals to be FTs, only political embarrassment if they don't. More money leaching out of the front-line.
Monitor soaks up more front-line cash by pretending to regulate a market whilst fighting a turf war with the Office of Fair Trading who claim it is their job ( http://www.oft.gov.uk/news-and-updates/pressstatements/2012/94-12 ). More money dredged way from front-line care. The Francis Report has made it pretty clear; he'd like to see Monitor dismantled. The boss of Monitor earns circa £200k - for what?
The CQC, unable to move a tray of food within reach of a patient, or provide a bed-pan, powerless to stop the quality failures that are destroying public confidence. Their budget is eye watering; more money syphoned from front-line care.
Woeful Boards with useless NEDS who've gone native, turn a blind eye to desperately poor care and a deaf ear to those who would protest. They owe their jobs to the DH and their political networks; their distorted perception of loyalty creates a dysfunctional climate of fear. Boards conference-call their lawyers when they should be speaking face-to-face with patients and staff.
Money; the very idea that you can take £20bn savings out of the budget without damaging the front-line is ludicrous. We are probably 10,000 nurses short, care is suffering. Flat-line funding against 4% growth p.a., with the squeeze set to continue after 2015 means the NHS has been hobbled and unlikely to recover.
Second there are the management issues. Bullying is rife. Time after time I get emails that start with, 'Please don't mention my name, but I have to tell you.....' If half are from axe-grinders and grudge-bearers that still leaves about 20 a week that are genuine. The tip of an ugly iceberg that will sink the NHS. The NHS is managed up-wards obsessed with not embarrassing Ministers or senior management with even a whiff of failure. The DH exists to suck-up to Ministers and blow hell-fire on everyone else.
Staff; undervalued, frightened to speak up, let alone speak out. Thought of as dispensable and disposable when they should be seen as partners-in-care. Their numbers slashed, others dumped into the private sector, ignoring their sense of vocation. People traded as commodities. A woman centric workforce and customer base, management dominated by middle-aged men in suits.
This is Our-NHS and its failures and foibles are excused buy the old fashioned notion that there is enough good going on for us not to worry about the bad.
So it is, we are left with the question; is the Big-Beast the man to fix all this? A fix that might take five years or more. Does he have the time, the energy, the health, the strength, the skills, the vision, the support? If the answer to any of these questions is no, then expect him to be gone inside three months.
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> One would hope that the upside of these tragedies is that the NHS is no longer treated as sacrosanct, that its faults can be acknowledged and a rational discussion be had about reform
This is often claimed but the evidence for it seems somewhat slim that people arent willing to discuss improvements.
its just many people arent convinced the answer is privatise it and that seems to be the predetermined answer to any questions about "reform".
> This is often claimed but the evidence for it seems somewhat slim that people arent willing to discuss improvements.
No, it just recognises that, rather than being sacrosanct, the NHS has seen the constant attention of reformers over the last 30yrs, and another set of reforms would obviously not be wise... ...ideology took over.
or because he realised that people might consider that there was never going to be a free and open debate and that all that would happen is the private sector involvement would be accelerated.
Lucky those suspicions were unfounded, ah wait a second.
Oh and while we are on the subject. If the NHS is so untouchable how come Labour first and then the tories have been taking it down the private sector involvement route so heavily and avoiding having a debate.
> No, it just recognises that, rather than being sacrosanct, the NHS has seen the constant attention of reformers over the last 30yrs, and another set of reforms would obviously not be wise... ...ideology took over.
Well, what we now know about mid Staffs and may yet know about other places when the whistleblowers get to talk suggests further reform was just what was needed.
But of course open debate would imply open discussion of private provision and of course that would be be sacreligious.
I live in Spain , supposedly the second best system in the EU, and compared to the NHS its Dickension. I should be going to the doctor, have been and been told my reciprocal UK rights are only in the case of emergency. I have to pay, I can't afford it so I don't go. I may have something life threatening but until it manifests itself there is NO FREE TREATMENT, even if in the long run it may save their health service money and me a lot of grief and pain. You just don't realise how good the NHS is.
> Oh and while we are on the subject. If the NHS is so untouchable how come Labour first and then the tories have been taking it down the private sector involvement route so heavily and avoiding having a debate.
For just the reasons I am alluding to. If it is openly debated the producer interest rallies around to accuse the propenents of destroying the NHS etc.
The problem with suppressing debate is that, as Labour has already discovered with immigration and the working class vote, it comes back to bite.
ah so there isnt an open debate because people will argue against it?
So instead the private sector involvement will be pushed through covertly and using careful election pledges.
As for producer interest, its fairly clear which side is winning that one. Possibly not entirely unrelated to how many senior MPs end up as advisors to private health companies.
this really is entertaining. its like Bruce on the falklands.
so just to check in your world view.
They are to scared to discuss it but instead just pass laws for it instead?
> ah so there isnt an open debate because people will argue against it?
> So instead the private sector involvement will be pushed through covertly and using careful election pledges.
> this really is entertaining. its like Bruce on the falklands.
> so just to check in your world view.
> They are to scared to discuss it but instead just pass laws for it instead?
They can be both. One is pre-election the other is post election.
Even post election the debate was couched in such terms that most people don't really understand what is happening. Do you really think that there has been a free, wide ranging and open discussion of what the failings of and options for reform of the NHS in the public arena?
yes and I wonder why.
nope but then again it is clear what the government preferences are (and the previous government) and how little interest there is in a discussion.
Which is why the claims of producer interest ring hollow, If there was any real weight or consideration given to them then what is going on currently, wouldnt be.
Well said....for once.....at least Spain is comparable with the UK. Comparing the Uk to a country like New Zealand is just not real world.
> I live in Spain , supposedly the second best system in the EU, and compared to the NHS its Dickension. I should be going to the doctor, have been and been told my reciprocal UK rights are only in the case of emergency. I have to pay, I can't afford it so I don't go. I may have something life threatening but until it manifests itself there is NO FREE TREATMENT, even if in the long run it may save their health service money and me a lot of grief and pain. You just don't realise how good the NHS is.
Many of do realise how good the NHS is, and value it highly, and thus come on to defend it here. However, you can't expect a group of people who care for patients not to have a pre-disposition to identify areas that are weak and in need of improvement, especially when there are so many on threads like this who take advantage of an area of failure (isolated from international comparison) with which to proffer their peculiar ideological bent! Perhaps, we should resist the apologetics, but I don't think so, it dilutes the otherwise hilarious ideological answers with a more nuanced reality that has nothing to do with socialism or capitalism, but seeks to preserve and enhance what is an equitable, and in general, very well performing, cost effective health service.
> But of course open debate would imply open discussion of private provision and of course that would be be sacreligious.
Just make sure it is criminal to suppress whistle-blowing, with punitive sentences that are individual and not corporate, and prevent anyone involved, managers, nurses, doctors from being allowed to continue in those careers. You don't need to reform the whole damn NHS.
And I say whatever faults it is the best in the world.
Well yes, that's part of what I was trying to say!
particularly since a)suppressing whistle blowing isnt exactly unknown outside the NHS and b)at least with the NHS you have a chance of a FOI request.
> Just make sure it is criminal to suppress whistle-blowing, with punitive sentences that are individual and not corporate, and prevent anyone involved, managers, nurses, doctors from being allowed to continue in those careers.
Simply deals with a symptom not the disease or the causes of it.
There are structures and processes in place to deal with such problems already.. ..but they can't be dealt with if there is a culture of hushing the problems up.
> There are structures and processes in place to deal with such problems already.. ..but they can't be dealt with if there is a culture of hushing the problems up.
Well lets go for:
- complaints against doctors whether for clinical or other reasons
- managers obstructing clinical end points
See the case of Otto Chan I linked to above.
> Well lets go for:
> - complaints against doctors whether for clinical or other reasons
> - managers obstructing clinical end points
Whistleblowers will have a limited impact on ill judged top down targets and an entrenched and protective bureacracy. After all, patients apparently haven't.
Anyway, we've been through this one before. I don't want to turn into Hokker and TobyA.
You seem to be under the impression that tens of thousands of unreported X-rays is treating patients humanely and likely to negligible clinical untoward effects.
I've said on this forum many times before that there are some real problems with nursing, and as a result, it doesn't surprise me what is happening at mid-Staffordshire, and elsewhere. Nursing professionlisation has been a double edged sword, in that it has suited Governments to have cheaper nurses doing technical clinical work that doctors used to do, but it is not surprising that a consequence of this has been less time spent doing classical nursing activities: talking to patients, washing them, keeping patients comfortable and keeping wards clean. In my experience most nurses are excellent and care a great deal for their patients, but there are some that don't. The most common untoward occurrence that I've seen numerous times is patients being given meals that they aren't fit enough to feed themselves with, and without someone intervening would leave them to go hungry - that's not good enough. The context has always been a very busy ward environment, but it's no excuse. There is no doubt that the NHS is less humane than it used to be, but that is I believe a direct result of efficiency requirements and an overall greater cost effective functionality. To put it simply, these things are a direct result of reform upon reform with neither measuring the changes being made, nor enabling local mechanisms of local professionalism. The conservatives of the 1980s set the trend and its not stopped since. You can't have it both ways... ...push a system as hard as possible, and then complain about the symptoms when the system starts failing. However, as Al rightly points out, whatever the areas of failure that we are discovering, the NHS performs fantastically well on an international scale, and is extremely cost-effective, but the reforms of the last thirty years have transformed human empathetic care for patients into "patient care", which means technical patient management, and nothing to do with humanity. I wonder what solutions you envisage that maintain overall performance, cost effect, and don't carry a risk of deteriorating patient care? Despite my positive faith in the value of the NHS, I can see numerous areas in which the NHS is performing poorly. Indeed, I wouldn't be surprised if all large hospitals UK wide could be said to have some such problem, maybe not in terms of obvious neglect, but for example, outsourcing cleaning to private companies who do not have clinical endpoints in mind, who do the job poorly and incompletely probably causes a similar scale in terms of number of deaths per hospital as is being suggested for mid-Staffordshire due to hospital acquired infections such as MRSA, VRSA etc... ...that is also neglect.
No, whistleblowers can have some effect, and draw attention to when these things are wrong, the problem is that management and civil service are extremely good at diverting attention, but then neither is a Tory Government, happy to maintain existing targets, introduce others and impose a hugely ideological piece of experimental legislation on the public.
> You seem to be under the impression that tens of thousands of unreported X-rays is treating patients humanely and likely to negligible clinical untoward effects.
It's very hard, even for the best managers, or the best medical, to provide the best service if the targets from the top and therefore the institutional culture is wrong.
> No, whistleblowers can have some effect, and draw attention to when these things are wrong, the problem is that management and civil service are extremely good at diverting attention,
Yes,but a limited effect (as I said) unless the culture and structure are liberated. Are you now agreeing with me?
It depends on what you envisage. You haven't put any head above the parapet yet! It is quite possible to free up the structure and performance of the NHS without resorting to privatisation, but it means going back to Bristol heart scandal, Alder-Hey, Harold Shipman, and learning a set of different lessons. Paternalism, can be bad, but it is a symptom of a profession who is used to taking responsibility.. ..dealing with "paternalism" has also dealt with "professionalism" (detrimentally). Sequestration of organs was well over the top, but now getting post mortems is difficult, more stigmatised than it was, and is becoming very rare.... ....which is absolutely outrageous, because it is one damn good mechanims to pick up how well people have been treated, whether the putative diagnosis was right etc. If you don't have post mortems, you remove one major clinical governance mediated corrective mechanism. These things should not need politically expedient top down answers, which is what we got, but they do need clinically orientated responses and changes that can be applied systemically. So I might be agreeing with you somewhat, but not as much as you think... ...there needs to be divorce from political influence, but systemic clinically relevant targets, and strategies are still necessary to maintain a cost-effective, equal, and resilient NHS.
> It depends on what you envisage. You haven't put any head above the parapet yet! It is quite possible to free up the structure and performance of the NHS without resorting to privatisation, but it means going back to Bristol heart scandal, Alder-Hey, Harold Shipman, and learning a set of different lessons. ...So I might be agreeing with you somewhat, but not as much as you think... ...there needs to be divorce from political influence, but systemic clinically relevant targets, and strategies are still necessary to maintain a cost-effective, equal, and resilient NHS.
My point is simply :
1) the mid Staffs tragedy highlights that are very serious cultural and instituional failings in the NHS which the media and politicians have failed to recognise for many years
2) that hopefully ths andother scandals will provoke a serious wide open acknowledementand discussion of these issues.
3) this would logically suggest that serious cultural andinsituional change is required.
4) As you know,my personal view is that private provision within an NHS structure is a reasonable option but at the very least it should be honestly discussable and discussed without making a party unelectable
My point is simply :
What makes you think:
a) that they are genuinely cultural and therefore systemic, rather than local?
b) that if they are cultural that they are culturally limited to the NHS, and not a reflection of societal cultural in general?
We should always look to improve ourselves and our institutions, especially with regard to looking after patients... ...but that sentiment isn't going to help, because frankly, that sentiment has always been there.
You might need to change the whole of society to do that... ...are you ready for that?
Since you raise it, in what way would private provision help?
> My point is simply :
> What makes you think:
> a) that they are genuinely cultural and therefore systemic, rather than local?
Secondly because the culture and systems highlighted in the report are broadly in place across the NHS ie.Top down imposed targeting, powerful self interested bureacracy.
> We should always look to improve ourselves and our institutions, especially with regard to looking after patients... ...but that sentiment isn't going to help, because frankly, that sentiment has always been there.
> You might need to change the whole of society to do that... ...are you ready for that?
> Since you raise it, in what way would private provision help?
Actually dissonance did. We've been through it before and you know the arguments.
a) I agree about the top-down targets issue. However, I think Mid-staffs did have other serious management problems which were rarer (and should make them liable for corporate manslaughter in my view), even if the real root pressure was from above. Lincolnshire (and others not yet coming forward) show clearly what happens to those who Trust Boards who complain about targets, on the grounds of public risk, and THAT message was loud and clear to Trust boards across the NHS. However, Mid Staffs went beyond this as they knew the death stats and ignored it and partly covered them up and treated internal complainents very badly. The SHA should also carry part of the blame as this size of problem shouldn't have been possible and I think Nicholson should go for that reason alone.
b) The record of problems and resolution process for problems in the private providers in the Health Service arguably show the opposite (certainly they are not clearly outperforming the average equivalent public providers and are largely chasing high profit potential niches). Do you really think whistleblowers are treated better in the private sector??
c) The NHS is the voting public's baby and they elect politicians. Quite right too, as the many private and semi-private arrangements in the world cost as much or more per capita to run; this is irrespective of genrally unrealistic expectations from the public of the NHS. The best example is the biggest the private dominated US system costs the state more per capita before you even take a penny of insurance money from the public. This isn't to say the NHS cant be improved but it isnt a terrible system when compared to peer systems in other western countries and the levels of state funding.
Of course the most cost efficient system in the world is in Cuba (but they trade-off elements of their democracy for this).
> b) The record of problems and resolution process for problems in the private providers in the Health Service arguably show the opposite (certainly they are not clearly outperforming the average equivalent public providers and are largely chasing high profit potential niches). Do you really think whistleblowers are treated better in the private sector??
The private sector providers to the NHS are still largely under the aegis of a self interested bureacracy.
It is not just how whistleblowers are treated it is the reaction when the whistle does get blown.
You're having a laugh!
Winterbourne View was not exposed by the market, by politicians or the inspection/quality regime.
> You're having a laugh!
> Winterbourne View was not exposed by the market, by politicians or the inspection/quality regime.
As I thought was clear I was referring to the reaction to failure not the revelation of it.
So basically those employed to manage in the private and the public sector have the same reaction to failure - they try to avoid washing the dirty linen in public.
> So basically those employed to manage in the private and the public sector have the same reaction to failure - they try to avoid washing the dirty linen in public.
It actually depends on the culture. The best run institutions in both encourage transparency and self analysis. It is very difficult for junior management to do this if senior management penalises it.
A monopoly, private of public is less likely to do this because the penalties for failure are limited. A public sector monopoly which politicians have a vested interest in protecting are doubly unlikely to be transparent.
However, you still seem to be discussing something different to me which is the media and political treatment of the NHS and examination of and reaction to failure.
The BP comparison, although far from exact, is instructive. A big organisation in which the culture of safety was insufficient and disaster ensued. When things when wrong there was massive public and media criticism, the share price fell so that management and behavioural change was unavoidable. Big business and capitalism was blamed etc etc.
Compare that to mid Staffs and the NHS.
I agree culture is the key but no difference between public & private sector there.
Enron, Libor, several decades of financial services miss-selling stories, bankers who didn't understand banking or who needed bailouts etc all reflect culture at those companies.
Yes, but lucrative bonuses disincentivise transparency and the penalties for failure in the private sector are weak. Senior management get a golden parachute or keep their nice pensions and bonuses when the excrement hits the ventilation years later. The vested interests are just as strong.
A corrective share price fall, media coverage or political condemnation is reaction that is too late. Reactions are a poor preventative unless they result in some change (cultural?) in the organisation.
But at BP they have, even in the banks they have-new management, new capital requirements, probably break ups, large scale withdrawal from business lines etc.
My original point was "One would hope that the upside of these tragedies is that the NHS is no longer treated as sacrosanct, that its faults can be acknowledged and a rational discussion be had about reform
rather than either ignoring its faults or blaming them all on lack of funding" but it isn't happening and can't happen because without the plitical will to do it there is no external mechanism to force it to happen.
Banking must have had several turnovers of management without any cultural change in response to miss-selling stuff that come along every few years for the last 20 years (endowment mortgages, pension opt outs, inappropriate investments for the elderly and more recently interest rate swaps). I don't see any good reason to think the culture has changed this time.
So far the effective external mechanism has been assertive relatives - we need a web 2.0 NHS ;-)
> Banking must have had several turnovers of management without any cultural change in response to miss-selling stuff that come along every few years for the last 20 years . I don't see any good reason to think the culture has changed this time.
Well, you probably don't follow the subject very closely. lots of regulatory and legal changes and more to come.
> So far the effective external mechanism has been assertive relatives - we need a web 2.0 NHS ;-)
That has eventually effective in getting an enquiry and report but not the follow up discussion and reform.
> Well, you probably don't follow the subject very closely. lots of regulatory and legal changes and more to come.
I'll believe that when it happens.
Actually new regulations don't bring a a new culture, it's just a different set of rules to dance around.
> Well, you probably don't follow the subject very closely. lots of regulatory and legal changes and more to come.
Which represent external factors imposed from outwith, not internal culture change or any reason to see why it effect a change!
> I'll believe that when it happens.
> Actually new regulations don't bring a a new culture, it's just a different set of rules to dance around.
Indeed, and not that dissimilar to targets and standard setting, and besides which, this doesn't represent the trustworthiness of large private enterprise to keep its own house in order... ...rather the opposite!
Winterbourne staff broke laws and were prosecuted. Plenty of NHS staff have been jailed over the years; just not this particular nasty bunch at Mid Staffs who have done some exceptionally immoral but not so clearly illegal things. I suspect the muted response on contractual rather than legal action is the SHA, DH and government (and last government) know that as a common pact with the devil it may blow back on them.
Those other national systems do indeed have really good practice that we can learn from but this equally applies to the good bits of the NHS for them. They also have bad bits as well. A fair judgement looks at good and bad, ability to pay and per capita expenditure and the very different cultures some operate under (esp Japan). I still see the NHS doing well overall in comparison even if service in some countries is better (and more costly) elsewhere. I think the US is a very fair comparison (and a strong warning) as its the only system where the private sector has been allowed to completely dominate the agenda; its not even as if regulation in the US is weak...its just bloody expensive and very social divisive.
This is a super peice of writing that reflects on how our system compares to the only one that seems to be offered up as an alternative.
I am not sure any of us in the UK really understand the US healthcare system. As Americans continualy point out to me , they have their own NHS, its called Medicare, and there is a medical safety net. Its just we in the UK do not understand how it operates.You only have to see how much the Federal Govt spends on it, to understand that there is public healthcare in the USA.
> This is a super peice of writing that reflects on how our system compares to the only one that seems to be offered up as an alternative.
The climbing equivalent would be to try and stop discussion of bolting Horseshit quarry by asserting it would lead to wholescale bolting of Cloggy
"just like in France" and that this was the secret plan of the Horseshit bolters.
Yep but that US state funded system along with all the other state costs adds up to more per capita than the UK system does. Then everyone from half way up the wealth ladder buys private health insurance on top of this. So yes the system isn't entirley private but it is driven by the ideology of private heathcare. It is overall massively inefficient and incredibly unfair. Basic Medicair doesn't cover eveyone: only the old (over 65), disabled and some 'end point' dieseses.
> Yep but that US state funded system along with all the other state costs adds up to more per capita than the UK system does. Then everyone from half way up the wealth ladder buys private health insurance on top of this. So yes the system isn't entirley private but it is driven by the ideology of private heathcare. It is overall massively inefficient and incredibly unfair. Basic Medicair doesn't cover eveyone: only the old (over 65), disabled and some 'end point' dieseses.
You have left put Medicaid which covers 40 million people in low income families. I believe Medicare and Medicaid actually spend more per capita member than the NHS.
The huge failing is that this still leaves 40 million or so people uncovered for anything but emergency treatment, and that the private insurance systems although producing quite good outcomes , as you say, are very costly.
Yes, but presumably that is across the piece ie.including the uninsured and the government healthcare systems. Private of course depends on what cover you can afford and it's not cost effective.
Haven't checked the numbers recently.
you keep coming out with this. The evidence really doesnt support your claims about this all powerful NHS bureaucracy controlling everything. There is absolutely massive private sector involvement and has been since Labour.
Oh and as for debate, well it was the tories who werent willing to discuss their plans. Possibly because, for example, handing over a NHS hospital to a company with a not overly impressive track record aside from their donations to the tories might raise a few eyebrows.
> you keep coming out with this. The evidence really doesnt support your claims about this all powerful NHS bureaucracy controlling everything. There is absolutely massive private sector involvement and has been since Labour.
No, because they knew the smears about destroying the NHS and imposing the US model would be rolled out as usual. I didn't see nulabour exactly highlighting its introduction of private sector provision either.
If you look I didn't: "and all the other.." is a clue. There is significant basic emergency cover as well (otherwise we would have never watched ER!). Plus lots of options. It is all in fact very complicated.
My point is that most US folk saying Brits don't understand how good their system is in my experience seem almost as unaware themselves. You say Medicare and Medicaid spend more per capita as if that is a good thing... it not like this is giving exceptional service ... it just shows how inefficient their system is: that this incredibly basic cover ends up being so very expensive. By far the most common critique of the European models I've heard in the US is that they are 'socialist' which is neither true nor sensible (if it was clearly proven socialist health was superior is it better dead than red?)
you seem to have failed to spot the all powerful. However to take your point, considering the split into the different trusts most of the bureaucracy is at the regional level which wont be that different from many large companies (after all the NHS is now heavily influenced by the same management consultants which advise those companies). What is across the board is the central govs targets and measures.
To take targets and measures. How exactly is private health companies being involved going to get rid of them? If i am going to be choosing my healthcare on competitive grounds (aside from the cheapest) I will be wanting to see a shedload of figures showing their performance.
no, probably because they, as well, didnt want a debate which might get in the way of the donors (amazing how many senior politicans end up on private health boards).
Strange how a requirement to be bound by FOI isnt placed on these companies if having an open system is considered good.
I am, to be honest, amazed that you are still going on about the NHS when they have pretty much done everything to it that you seem to think is required.
> I am, to be honest, amazed that you are still going on about the NHS when they have pretty much done everything to it that you seem to think is required.
And if 1200 people got killed (by one department alone) of a private company you'd be agreeing that a few procedural changes should be announced and all would be fine?
The patient needs to see relevant and reliable statistics and be able to act on actual experience. eg. If the hospital is meeting it's target to treat patients within a timeframe but then failing to ensure they eat, drink and take their drugs there needs to be a way of patients or more likely their carers acting on that information. A self protecting top down monopoly culture is not conducive to it.
But if you think it's all fine, so be it. Just don't get old and ill without a good friend or family to care for you in hospital.
Anywhay the latest...
Mean it - News and Comment from Roy Lilley
The result of our poll will come as unwelcome news to the Big-Beast. 91% of you think he should step down. Is it fair to say he has lost the confidence of the work-a-day NHS?
I recognise him as the man who did his best to blunt the worst excesses of LaLa's stupid reforms. Nevertheless, the mess on the ground is unbelievable and a top-down empire is being rebuilt with the bricks from demolished PCTs. The Beast only knows top-down.
You could argue that he spotted the need for NHS austerity and the so-called Nicholson Challenge was an attempt to put some rationale behind the use of resources. The QIPP agenda an attempt to give savings some shape and purpose. The reality is the scramble to save money and the fear of not doing so, has descended into cuts, redundancies, damaged services and the NHS running on the vapour of vocation.
It is equally possible to say that the NHS is a loose federation of the awkward squad and managing it with anything other than an iron grip would be impossible. The problem is 'grip' has been translated into control and as the situation turns more desperate has become rule and command. Where inspiration and management talent runs out, force and bullying takes over. Bullies always work for bullies.
I know the Big-Beast has been an unfortunate victim of circumstances; a busted economy and ham-fisted political meddling. What might he have done differently? Everything or perhaps nothing. He is what he is. His know-how comes from years, unchallenged, at the top. The Carbuncle won't challenge him. Too many owe their positions to him and the others know too little about running one of the world's largest healthcare systems.
Some say, in time, all NHS staff end up hating the boss. Wrong. Many NHS leaders have been held in high esteem and affection right to the end.
In Pulse Magazine, so-called, GP leaders backed the Beast; Laurence Buckman (BMA), said blaming Sir David was not 'useful'. What would be? Mike Dixon, NHS Alliance, twaddled on, blaming 'the system'. Er, whose system if not the Big-Beasts? RCGP chair Lady GaGa, confusingly said 'leaders should be held to account' ... but, 'Sir David should not resign'. Er?
Maybe they all benefit from too close a relationship with the Carbuncle and DH and have more than a small interest in buttressing an establishment that they are part of.
The HSJ rushed to the Big-Beast's aid, commissioning an old-school opinion piece by another Knight of Healthcare John Oldham (Who?). Normally a good guy but this is just hopeless; 'Leaders do shape the culture of the organisation,' he says. Er, isn't that the problem; 'the culture of the organisation'? He should have read another Knight's comments in the Telegraph! Oldham seems to imply the NHS is too dislocated and big to manage. Nevertheless, a good tactical move for the HSJ; if the Beast stays they remain his friend and stay in the tent. If he goes, they were 'striking a balance', and stay in the tent.
We are now left with the hope that the dark-art of changing 'culture' will save us. No one knows how.
Will whistle-blowing phone-lines, law and regulations encourage people to say the things that they have seen cost others their jobs, homes and families? Culture takes years to cultivate and grow. We have just months to change the working climate.
The NHS needs an urgent fresh start. The Carbuncle won't do it, it is merely a branch of the DH; full of ex-DH staff who owe each other. The sensible ones have jumped ship.
The NHS is badly damaged. If LaLite had any sense he'd make a clean sweep at the Carbuncle. If Malcolm Grant, chair of the Carbuncle, had any nous he'd do it first; before he is sucked into the vortex of yesterday's management proclivities. The pressures of money, morale and muddle creates a toxic cocktail that will corrode the NHS and eat into the heart of the service.
I'm sure the Big-Beast thinks he alone can save the day and there is no one else. Others take that view, too. Not true; were he to be run over by the apocryphal Number 9 bus, there are several who could step-in.
David Nicholson is a good man but emblematic of a past the NHS needs to scrape from its boots. We cannot have a fresh start and mean it, without new leaders who mean it.
Feel like having a rant? Please be my guest! Use this e-address
Know something we don't - email me in confidence.
i love the way you invent random arguments.
a)no one is suggesting that nothing should be done b)nice selection of the figures.
Now lets see the stats for the private health companies shall we?
> i love the way you invent random arguments.
> a)no one is suggesting that nothing should be done b)nice selection of the figures.
2) If we take the lower figure (700?) is everything OK then?
It would certainly be an important thing to do.
apart from you are failing to explain how private provision is magically exempt from this. If anything competition encourages the manipulation of information to provide the best possible shine on the figures.
hell i have bupa. Although a cursory glance will show, surprise surprise, that they are not immune from issues (take the various elderly care home issues they have had).
> apart from you are failing to explain how private provision is magically exempt from this. If anything competition encourages the manipulation of information to provide the best possible shine on the figures.
Winterbourne view scandal: Government reviews 34,000 patients to see if they should be moved to NHS. implication:private care is the problem.State care the solution.
Did we see the reverse post mid Staffs?
looks at the recent handing over of "failing" hospitals to private contractors and gets confused at your point
yes because that happens so often. Also, ermm, various senior staff have been removed. Admittedly some pop up again elsewhere but again thats not exactly a public sector only problem.
sorry i missed this, could you please provide the link? All I can see is a reference to 3400 people who needed reviewing as to whether hospital care was the best option or whether alternate options, eg community based, would be better suited. No mention of whether private or public is better suited.
well since the government are busy pushing as much as they can already into the private sector, including already handing over one hospital I am again failing to see your point?
The latest from Roy:
...thank you Prof Edwards
News and Comment from Roy Lilley
There is a new phrase appearing in the lexicon of the NHS. No self-respecting manager will fail to use it. No set of PowerPoint slides is complete without it. No cockamamie new idea will not have it as a pre-fix. Front-line staff will be sick of it. Reports will be peppered with it and Board papers sprinkled with it.
The new phrase? 'Post-Francis'. Like anno-domini, the NHS is set to become NHS PF.
No one would say the Francis Report isn't important. Few will be frank enough to say it is not very good. It is an avalanche of detail but misses the point. Sum up Francis in a few words? Easy; 'keep doing more or less the same but do it better'. The Francis Report was commissioned for two reasons; to give a sense of closure to the relatives and to make sure it couldn't happen again. On both counts it fails.
Over a thousand, more perhaps, souls ended their days in dreadful circumstances and not a single senior person will carry the can. If British Airways killed three plane loads of passengers would it keep the same management and press-on, business as usual? There is no closure in telling a widow her husband was killed by 'a system'. There is no closure in telling a daughter her mother died from 'culture'. No son will rest-easy to know their mother or father was a victim of 'bureaucracy'. It was men and women who designed the system, bred the culture and used bureaucracy as camouflage.
The bereaved want to know who was responsible for designing and running a system that failed them, allowed a culture to proliferate and become a killer. A bureaucracy to fester into a silent assassin. Francis fails them and creates an environment where it's still OK for no one to be in charge, no one to blame. Yes blame. A word we all dance around. Blame. People have been killed and there is blame to be blamed. If I were a relative I would say there were controlling hands that should be in handcuffs.
Frances second failure? The 'system' that he implies is responsible for this debacle is left intact. The only structural change hinted at; the confusion between Monitor and the CQC. He could have said the complexity is such that the law must be changed. He does not. He contents himself, in the criticisms of organisations to saying; they must do better.
There will be a flurry of Post-Francis activity but little will change unless structures change. The NMC will continue its sclerotic journey to the knacker's yard, the GMC will push their noses further into their pomander and walk on the other side of the street. Royal Colleges will polish-up their chains-of-office and dazzle themselves with the glitter. Healthcare Assistants, who look after the majority of our vulnerable, will go unregulated; there is no money to do it.
What will prevent another Mid-Staffs? Funding the front-line, protecting it and making it fun to work there might have half a chance. Post Francis will simply mean money for conference organisers, consultants and report writers.... if we let it.
We were fortunate that Professor Brian Edwards sat through the Francis Inquiry and regularly reported, his unique take, exclusively for us.
Today, thanks to the generosity of Prof Edwards, we are pleased to be able to offer you, free, a pdf version, of his collected essays, reports and commentary, due to be published as a Kindle, on Amazon, later next month. http://library.constantcontact.com/download/get/file/1102665899193-1229/Final+Ver+1.pdf In this unique book he takes us on a journey through the evidence, day-by-day and includes his insights. His great common-sense makes Francis make sense. Download it and read it and make your own mind up about Francis.
I doubt many of us have the time to read Francis; Prof Edwards gives us a stripped version, Francis Unplugged. The main recommendations, the key players, what it means and the highlights are all there.
If Francis is going to make any difference at all we need to get behind what he says and figure out if we can use it to make a difference in the bit of the NHS where we work. This excellent book points the direction. Please download and read it, have an informed view with our compliments and thank you Prof Edwards.
Feel like having a rant?
Please be my guest! Use this e-address
> sorry i missed this, could you please provide the link? All I can see is a reference to 3400 people who needed reviewing as to whether hospital care was the best option or whether alternate options, eg community based, would be better suited. No mention of whether private or public is better suited.
> well since the government are busy pushing as much as they can already into the private sector, including already handing over one hospital I am again failing to see your point?
As you keep complaining; it's being done by stealth which is not a terribly good way to do it.
I'd like to thank abr1996, ben b and Jimbo W for their enlightening posts on this thread.
And others, no doubt, but those three stand out. I know this post isn't contributing much to the debate, but I need to go away and read it more carefully. I think ben b's posts sound closest to my secondhand experience.
The one thing I will say about private corporation management is that they can also have a very similar mentality regarding enforced changes due to management whims/latest buzz-phrase 'initiatives', with no tolerance of criticism (constructive or otherwise), and no measurement of the effect of changes, but with lots of PR puff about how great and successful that changes are (when, since there's no measurement, there's no way of knowing...)
well yes but the bit i am struggling to understand is why the powerful lobby, well arent. If they are able to shut down any debate
Oh and in relatively local news to me. Looks like going for the private sector option doesnt solve all the NHS problems in terms of patient care.
> Oh and in relatively local news to me. Looks like going for the private sector option doesnt solve all the NHS problems in terms of patient care.
A third patient has died after routine surgery at a privately-run NHS hospital in Hertfordshire, a BBC investigation has discovered.
I look forward to the BBC's highlighting an investigation into a "publicly run hospital"
well since it is being used as an argument for private sector involvement, apparently so.
looks at recent news and gives up.
> well since it is being used as an argument for private sector involvement, apparently so.
> looks at recent news and gives up.
Don't give up. Skim the BBC headlines and find the phrase "State run" or "public sector run" hospital used in a negative context-and not in the form of a reluctantly used quote of another source.
oh ffs. Firstly how about you do it for "private" used in a negative context and in the headlines?
Then once you switch to saying what about the main body do you really not see
why they would need to state that a NHS hospital was privately run?
If i read NHS i would conclude that it was public sector by default (admittedly this approach may need revising over the next few months).
definitely give up now.
> oh ffs. Firstly how about you do it for "private" used in a negative context and in the headlines?
> Then once you switch to saying what about the main body do you really not see
> definitely give up now.
And I have done it for private and it confirms what my point. Given how much of the NHS is not privately provided (as you keep reminding us, obviously the the term "NHS" should be used for everything or the distinction private or public should always be made. It's a worthwhile exercise in understanding how the media works. You are more naive than I had you down for.
Nicholson live on BBC news channel in front of the select committee(available through IPlayer later). The labour MP (Valerie Vaz?) isn't helping with her questioning but he demonstrates an amazing lack of record for vists and actions for such an important man... some would say this is exactly the best way to avoid accountability in a top down target driven culture (hearing and especially recording bad news is bad news as you may have to formally recognise the system is faulty.. keep it all in the locality with a strict control on complaints and they have to get on with it).
I would liken it to the US media referring to the British company BRITISH Petroleum during the Gulf oil spill.
Can you imagine the reaction if BP or BA had killed 400-1200 people?!
> I acknowledge the Scottish example is interesting but you're not really getting my point on this which is the identification of private hospitals as private hospitals but not State provided hospitals as State provided hospitals.
Well the distinction in the UK is between private and NHS hospitals, and the term NHS was prominent throughout. If you really think there is a deliberate (or even non-deliberate) attempt to hide the fact they are publicly run, I think you are imagining things.
Further, everyone assumes NHS provision is publicly owned and run, even if it isn't always. So rather than private provision being unduly criticised, in fact in your scenario it gets away with bad practice as some of it is lumped under NHS, which you seem to think is given an easy ride.
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