The ConDems NHS (What Do We Make Of It So Far).

Well er... not a lot!

Six months down the line from the lack of any decisive victory over, well anyone, lets look at what has been achieved and what is planned.

GP Commissioning has been lauded, as the only way forward for the majority of Healthcare within the NHS. It is the Lansley answer, to all the previous 'top down', centralised decision process, that hallmarked the reign of NuLabour, but is largely the path that had already been ordained by Andy Burnham, before his demise as Health Secretary (and what a piss poor one he was). There is some 'spin' to this. GP's are the front line of all Medicine and Healthcare. The first point of contact (except for A&E), where the public becomes patient. Thus, it is posited that they should control the purse strings and commission any services, or treatments that, spring from that Primary Care role. In the process, we largely rid ourselves of the cumbersome and expensive, Primary Care Trusts (PCT). Except of course, that for all their faults the PCT's did most of the Admin, the Commissioning and Governance. And of course they provided the 'out of hours' cover the GP's wriggled out of for 6% of salary.

If then, the GP's are to cover all of this, they will have to undergo a step change in roles. One that they have little or no experience of, and, judging by the lack of enthusiasm displayed by many, one they have very little desire to fulfill. They will likely have to engage some of the Managers they have expressed considerable disdain for, or another organisation to undertake all the 'back office' work. Step forward the Private Sector, be it in the form of the 'Big Four' accountant/management bodies, or one of the many Private providers (Welcome to the Boots - Price,Waterhouse,Coopers, Healthcare Consortia, operated on behalf of NHS UK plc). I do not wish to be a merchant of neither doom nor gloom, but a void tends to be filled by the one who is quickest on their feet, and these people are pretty damn quick. When you ( a GP) are floundering in a mire of bureaucracy and red tape; have no real idea of the ramifications of what your new role needs, to give it credibility, with the National body that approves your Consortia; if someone offers you a 'model' that removes the doubt, many will grasp it.

Maybe some will gravitate toward the 'not for profit' social enterprise model, which could be a good thing, but the pitfalls and dangers, not the least of which is the very real possibility of 'inheriting' the debt and forward contracts of the existing PCT's, which Lansley has said he will not cancel or guarantee, may well put you off. Put you off, without the sort of financial 'clout' and dubious, but successful creative accounting capability of a well known Accounting LLP (remember the inspired auditing of the Banks that got us here in the first place).

And what about assuming the role of procurer of the drugs and supplies, now that NICE is to be emasculated? How do you evaluate the claims of 'Big Pharmas' products and devices, in a world of pitfalls and dubious trials, all proclaiming much, but generally delivering very little, except possible death in a bubble pack? How do you evaluate and procure an out of hours service for your patients? Do it yourself? There is a singular lack of enthusiasm to go back to that, I'm sure. Certainly from the sigh of relief that emanated from BMA Towers, when the Government gave it to the PCT's to provide, would lead one to that view. And, I'm pretty sure that giving GP's their 6% back will be met with howls of derision as an inappropriate value for such an onerous task.Will you spend your hard won budget at the local trust Hospital or contract with the ISTC or even BMI for routine operations?

I am not certain that such decisions should, or even could be made effectively by GP's. I am certain that many will not even want to. This is the largest change in Healthcare since the birth of the NHS. Whilst consultation is taking place, it is largely with those organisations, that most feel have failed to deliver a just and fair NHS that addresses inequalities; the GP bodies (see last post). I do have hope; not a lot, because I have little faith in any breed of Politician, especially those that are trying to make me happy, whilst removing hope of any prosperity in the next, how ever many years. I'm not at a time in my life, like many others, where there are years available to me, to observe these policies through to any conclusion.

I despair of the much that is happening. The complete madness of a 'responsibility deal' with the major fast food retailers (McDonald's, Pepsico etc) is akin to placing regulation of game keeping with the poachers. As is enjoining with the major food and drink suppliers, to promote 'health'. That any of these, will actively pursue a policy based upon any motive, other than self interest and profit, is somewhere between naivety and lunacy. They already produce products laced with the toxic, man made, chemicals that have likely caused much of the ailments that modern flesh is heir to. To devolve even more power of damage to these architects of high carbohydrate diets, infiltrated with High Fructose Corn Syrup, Soy fed meats, Hydrolysed Vegetable Protein and other injurious additives is madness of a scale only to be found in the USA. Do we wish to emulate a society where the food lobby guides Government Policy and the Drugs Industry then feeds off the damage? Because that is where we are going. If Lansley and Cameron have their way, that is where we will arrive.

PS This is one view. That from the Black Tower. If nothing else it is amusing.

The Dept. of Health in the Dock (again).

The Editorial in the Lancet this week upbraids both Politicians and Doctors (mainly GP's) for failing to address Healthcare inequalities. It's is not very kind to Health Officials, and targets the Permanent Secretary particularly. In less than edifying language Margaret Hodge, was scathing about the failure to deliver the promise of NuLabour to remove these inequalities, despite the vast increase in the NHS budget and thirteen years of power.


The editorial was particularly strong in it's condemnation of the Profession and GP's in particular, for the vast rewards they have reaped, since 2005, when they took on the new contract. This saw income rise to an average of £105k, with some making £250k, by virtue of the bonuses paid for the achievement of goals within the Quality Outcomes Framework (QOF). These were mainly politically motivated objectives, that saw routine Healthcare reduced to a target culture, whereby GP's could derive payments for taking and recording things like blood pressure, or BMI, for certain patient cohorts. Worst of course, was the need to attain certain levels within QOF to reap a reward, which heralded the 'lipid' testing of perfectly healthy people, and the subsequent dosing of them with statins, or antihypertensives (whether they needed it or not).

Substantively, I agree with the sentiment of the Lancet article, although some of the detail is a bit 'overblown'. After all, some the GP's, who stand accused of indifference to their patients plight, may just have been exercising some scientific 'triage' of the goals set by various QOF's, and found them wanting of evidence of efficacy, and simply ignored them. Well more power to them, but why don't they stand up and be counted? As for Hodge, well she has an appalling record, in voting for all the Blair reforms in Healthcare, including the setting up of Foundation Trusts, yet she has obviously now 'seen the light' and wishes to align with the patient. The report is here.

When the 'blessed' Tony came to power in 1997, he was in a unique position. The majority of the country saw him as a reformer, with an evangelistic zeal, to drag Healthcare and Education into a new dawn, with reforms that were purported to be  based on scientific agenda, not the thinly disguised and hugely expensive, 'privatisation' of these core needs of the populace. Instead, he failed to carry through his promises but gave us the 'spin' of his continuation of the previous lot's desire to sell off the assets we all owned, for a handful of beads and a sack of corn.  Neo-Thatcherite to the core, he embraced private sector solutions to the urgency of improving Health (and Education) that were hugely expensive, and with it spawned legions of highly paid management cadres, who sucked up most of the money, building 'empires' to justify their ludicrous elevation within Healthcare.

He fostered many of the 'Quangos' that the ConDems are now pulling apart, on the premise that Governance was all about measuring process, at the expense of outcomes. The disenchanted Doctors, many of whom hated the rhetoric, failed to champion their patients and saw the chance to better their position by negotiating a new deal that placed them as financial equals to the Consultant cohort. Some at the time (2005) could not believe that they escaped from out of hours cover, for a paltry 6%. One of the senior negotiators for the BMA, even said he thought they were "having a a laugh". And, of course they were, all the way to the Bank! This single act alone hugely increased costs, but more; the outcome of QOF was to elevate costs even more, as the tests to prove it's effect spiralled.

So, money was spent that achieved little of any substance, other than the enrichment of most within the NHS, except the 'coal face' workers, who found themselves more and more, isolated from the patients they were there to serve. Management found ways to cut costs, that deprived patients of standards of care enshrined in that contract we all have with those we pay to help us when we need it. Emerging from this, large numbers of complaints began to arise, that then gave birth to a whole new Bureaucracy, given the task of 'managing' these. Not, I must add resolving them, because that does not seem to have been the objective. Obfuscation, delay, and even lies, were then employed, to prevent the delivery of truth, justice or candour. 

Well, that was then, and this is now. The Coalition has suggested, even promised to change, all that has gone before. But Neo-Thatcherism is not dead, and now lives on in all politicians, with little to separate any from all. Practice Based Commissioning was already being rolled out by Brown's lot, before he lost the election. Calling it GP Commissioning does not change it, although at least it was not wholesale, it was a slow 'rollout'. Wholesale change, may be a good thing, although trying to cut a ludicrous 20% in the process is both unrealistic and unattainable. It will be just the same as before; figures will be produced to prove it's happening, that some Select Committee in five or ten years time, will tell us were untrue. Some very good people will lose their jobs and evidence based Healthcare will continue as before, without any evidence to back it's ludicrous policies. We'll all get fatter, get Diabetes, Heart Disease and Cancer and interventions to allegedly reduce the incidence will fail, just as they have for the last thirty years. The good Doctors will retire early, the bad one's will become leading lights in GP commissioning. Everything will be different, but stay the same.

Oh, and patients; you thought you had been screwed already, now you're really going to be f****d.

Is This How To Run A Railway?

 

No, this post is not about the appalling Railway system of the UK. It is an analogy for the NHS.

As the ConDems savour their power, with increasing confidence, imbued with the enthusiasm of born again Christians, maybe we should compare it to that which occurred, when the major transportation system of the UK was sold off to the highest bidders, ( the lowest, in truth)  for each region, or service. The end result of the Tory plan was a disjointed 'mish mash', of competing companies, supported by ever increasing volumes of Taxpayer Gold, that made millionaires of some, bankrupt  a few, and produced a worse service than we ever saw under the old British Rail. We also saw the rise and demise of Railtrack and its substitution with Network Rail, the governing body of the Industry and owner of the Infrastructure. It is a Company Limited by Guarantee and thus has no Shareholders. The DfT is a member, but does not own it. It pretty much does what it likes because Blair, who set it up, did not want the sort of Governance that had plagued him with other bodies. The result has been a huge increase in accidents, poor or even absent maintenance, overcharging, overcrowding, lack of any real democratic input or control.

So what has this to do with the NHS, one might ask. Well we are going down the same road. NICE is to lose its role of cost benefit analysis and negotiation with 'Big Pharma' the (piss poor) Care Quality Commission will be replaced by Monitor, because all Trusts will become Foundation Trusts. PCT's will become no more, being  replaced with GP Consortia in the role of the Commissioning bodies; poacher and gamekeeper under the same hat. ISTC's, the 'Big Four' accounting and management bodies (PwC, KPMG etc), will be handed roles on a plate, to organise or even provide services,despite their complicity in the debacle of Banking Audit, and the Private Healthcare companies, are 'to be encouraged' (bribed), to bid for contracts, to provide and commission services, for Healthcare. And the useless Complaints System will become a battleground of even more complexity and futility, being hamstrung by the lack of any Public Scrutiny brought about by the constitution of the changes.


Just as in the Railways, there will be a bewildering array of bodies, organisations, some spawned from 'Big Pharma' themselves, all trying to make a profit out of misery and accident. The rigid safety mechanisms overseen by the military precision of the engineers who ruled British Rail (nearly all ex REME engineers) was supplanted by companies who lost lives due to lack of safeguards and planned maintenance. The result has been escalating costs, obscene profits, lack of forward planning and danger to the passenger.


For passenger, substitute patient and you will see what I am getting at.