The FT has reported this morning that:
A government-commissioned report has painted a damning picture of a health service where bullying and harassment of staff is rife and there is little attempt to harness the NHS's huge collective buying power.
Enormous variations in everything from sickness absence to the costs of hip prostheses were uncovered by the inquiry, led by Lord Carter of Coles.
There will be a lot of nonsense written about this as a result but as far as I can see just two real issues emerge. One is concern about a bullying culture: it does exist. It is an issue. I accept that. I have seen its consequences.
The other will be much hand wringing about supposed inefficiency. So let me be clear: it does exist. It is an issue. I accept that.
But let's not for a minute confuse the two issues. I am not an expert in addressing a culture of bullying. But I do know something about markets, quasi-markets and organisation structures and what I can say, beyond a shadow of a doubt, is that if there are buying and other management inefficiencies in the NHS then they can be blamed fairly and squarely at successive governments who have thought that introducing market practices would help its efficiency.
They were wrong. Markets do not drive everyone to efficiency, especially when NHS organisations cannot, ultimately, fail. All they can do is create division.
That results in learning and best practice not only not being shared, but in that sharing being discouraged.
And it results in a loss of buying power.
And duplication of systems.
And vastly too much accounting.
And excessive costs in managing all this as a result.
The fact is that you can have an efficient NHS. It would be National and its job would be to concentrate on supplying Health Services.
Or you can have a divided and distracted NHS, as we have. There the aim is Local and it is Empire Building.
I know what I want.
I know which one is cheaper.
I know which one the country needs.
I doubt that the change required to deliver it will happen. Because market dogma comes first. At cost to us all.
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Failing to make use of its buying power = higher prices paid for drugs (not a coincidence I suggest)
I await the announcement that virgin care is to be sold to a US medical conglomerate (following normal biz practice)
As I’ve said before, the NHS is required to jump through hoops in an orgy of self-immolation to the gods of “medicine after money”.
We are now having “clinicians” alter prescription medication without the knowledge of the doctor who originally prescribed those meds, those clinicians only having access to prescribing data and not to medical history (clinician meaning anyone who works within the practice apparently), this activity is to save money by providing cheaper meds….unfortunately, having no access to medical history, they have no knowledge of previous bad reactions to the meds they provided to save money…
A patient presents him/herself to a doctor, with a known condition which has a known treatment regime. In this insane world, the known treatment cannot be precribed because the GP is not allowed to prescribe it (antibiotic resistance).
The patient then has to be referred to a hospital, where he/she will undergo various tests xray/blood/urine/skin-saline so that they can arrive at what the condition/illness is (even though it has been known for years (money). Having arrived at a diagnosis the consultant can then provide a treatment regime for the GP to provide, because the CCG will not allow the GP to prescribe that same treatment (and may even penalise the GP if he/she does provide the treatment).
So, after a dozen visits to a hospital 30 miles away, the patient gets the treatment….unlucky of the local hospital has a treatment contract with one a lot further away….still, the London specialist hospital may deign to open a clinic at the local hospital (staffed with that same local hospitals staff !!!!!!!)
Insanity is catching (on)
Meanwhile, back in Private Health Heaven, 400,000 people die every year from preventable medical errors (and rarely a newspaper story about it)
Much of that I recognise
The key point here, and not just with the NHS but also with so many organisations who have been taken over by this private sector ethos model, is how efficiency is defined.
In some respects this has resulted in almost a mirror image of the scenario we have in the economics of the State in which the State is held as the exact equivalent of a household. The point about organisation, and therefore organisations, is to harness the emergent properties of operating cohesively to achieve outcomes which are greater than the sum of the individual parts. Unfortunately, this is not the definition of efficiency that market competition operates under.
The availability of ICT systems has been harnessed to create organisational structures and processes which see the organisation as the equivalent of the lowest single unit within the organisation. Consequently you get the silo mentality, or what some refer to as stovepiping, where everyone is competing with everyone else to increase their excel spreadsheet numbers at the expense of everyone else. As a result you get not only organisation producing less than the sum of the parts but also rampent bullying. True anarchy in every sense.
The duplication of systems, the increased complexity of internal accounting, and the over management of everything in the vain pursuit of ever more ways to control, measure and determine real time outcomes second by second will be stranger to people working across many sectors from communications, energy and transport through to government, emergency services and charities as well as the NHS.
And ultimately it is self defeating and results in real inefficiencies and ineffectiveness on an epic scale except on the only thing that counts under this system, the made up and manipulated numbers on the spreadsheets which determine the individual career paths of the coper’s who produce them who have lost sight of their purpose in pursuit of running their own personal fiefdom. Hence the level of bullying and maliscoiusness among the managerialist class regardless of what nominal sector they happen to be working in (public, private or third sector) which are essentially meaningless distinctions today.
it’s like a beggar they neighbour holograph-on the micro it’s beggar thy neighbour as well as on the macro.
Max Keisers oft used image of the circular firing squad is apposite here (the one giving the orders is NOT in the circle!)
“The duplication of systems, the increased complexity of internal accounting, and the over management of everything in the vain pursuit of ever more ways to control, measure and determine real time outcomes second by second will be stranger to people working across many sectors from communications, energy and transport through to government, emergency services and charities as well as the NHS.
And ultimately it is self defeating and results in real inefficiencies and ineffectiveness on an epic scale except on the only thing that counts under this system, the made up and manipulated numbers on the spreadsheets which determine the individual career paths of the coper’s who produce them who have lost sight of their purpose in pursuit of running their own personal fiefdom. Hence the level of bullying and maliscoiusness among the managerialist class regardless of what nominal sector they happen to be working in (public, private or third sector) which are essentially meaningless distinctions today”
Describes my experience as a Social Worker in adult mental health to a T. And the more budgets are squeezed the more the focus on the data and the spreadsheets all to the detriment of the clients who sadly become of secondary importance to the “data”
Which makes me really angry
Exactly the reason I left teaching way back in 2000 (a job I loved if a mite stressful at times!). When I made the decision I remember well a teacher who was known as a ‘section 12’ with responsibilities for special needs and ethnic issues said ‘this job has become data collection.’ That was 15 years ago, heaven knows what it is like now!
It took some years before I got over the anger of being ‘driven out ‘ of I job I was dedicated too.
The circular firing squad is but one possible circular analogy which can be used here.
I recall over forty years back in the barrack room one of us had one of those multi band radios popular at the time where you could pick up transmissions from what were then considered exotic far away parts of the globe like Kaula Lumpa and Tokyo. Given our location and mission one of the stations which used to have us in stitches was the English transmission of Radio Moscow. Listening to this dismbodied voice regularly waxing lyrical about the size of the tomato harvest in Ukraine, the steel tonnage output from Magnetigorsk or the coal output from the Siberian mines or wherever brought forth a dystopian world a million miles from anything else inhabited by real human beings.
It’s not so funny now. Years later when I learned about Frederick Taylor and how Lenin adopted his scientific management techniques to “modernise” the still feudal Russian economy at the time the West was moving onto Human Resources techniques what struck me was that Taylor’s system lacked one key control feature which is now in place and being utilised Soviet style as described previously.
Engineers I know still on the tools when I retired spend more time inputting real time data onto the i-phone based smart phone describing what they are doing than they do on the task in hand. They have spy in the cab trackers in their vehicles to ensure they stay in the “envelope”, and productivity is constantly monitored with the sole purpose of “managing” a percentage out of the door to save on redundancy costs. Risks are taken with safety on certain processes in the hope that nothing occurs which might come back to bite management in the bum. Not that those responsible will ever be at risk personally if anything goes wrong as no one stays in the same place for more than five minutes.
It does not surprise me to see this experience mirrored in the social services. Although I have to conceed to being disappointed in experiencing the same sort of nonsense in the voluntary sector post 1997. As with economics and neo liberalism and politics with neo conservatism, work and neo Taylorism based on ICT powered number crunching is no accident. Money may well be the stated aim but I’ve never witnessed any situation where whenever there was a conflict between money and control which was not settled in favour of control.
This is the universalism of the corporate model
And it is a bad one in most cases
Successive changes applied to the NHS seem almost designed to reduce efficiency, increase waste and hammer morale. Utterly depressing.
Just a little personal experience. My 16 year old grandson had an emergency appendectomy last week. He went into hospital on Tuesday at 15.30 in great pain with a high temperature. He was not operated on until after 11 the next morning by which time he had peritonitis. As a result he was not able to be discharged until this Monday. When I asked why he had not been operated on sooner I was told that they don’t like to operate at night because there are not enough staff on duty and there were other more urgent cases the next morning.
Our NHS is slowly being starved of resources in order to soften us up so the vultures can swoop in.
There is also the increasingly perverse situation (aka Tory neo-con logic) that by reducing the necessary NHS funding and resources for an aging population, the resulting increase in waiting times for surgery and treatment is now being addressed by outsourcing the overspill to the raft of new private hospitals appearing on the scene (often in ex-NHS facilities and using ex-NHS staff!).
It is privatisation through the back door and it is being engineered through very deliberate policy and financial design.
Which very rarely have intensive care/high dependency units. So their mistakes/emergencies get transported to an NHS unit.
And then they are transferred to a pay-bed at the same NHS hospital. Private rarely does IC/HD because of the high quality of training,and high staffing levels; which are very costly, so the profit is lower. I promise not to mention private use of NHS MRI facilities…
And a few years ago FlipchartRick presented his NHS management report….somewhat different from that presented by a government/biased-parties:
https://flipchartfairytales.wordpress.com/2014/01/15/is-the-nhs-really-over-managed/
Since then we have seen NHS middle-management somewhat degraded, and a whole rake of private sub-contractors paid to do the job of providing poorer care at higher prices and with non-medical administration….
http://chpi.org.uk/wp-content/uploads/2014/08/CHPI-PatientSafety-Aug2014.pdf
The distressing thing is that the report seems to point out all the problematic areas without concluding that they all stem from the one basic problem, succinctly summarised in the failure of marketisation in your headline.
The way this is being reported is that it is not a failure of marketisation but a failure of the NHS per se.
The use of a ‘willing idiot’ from the Labour party to lead the report in order to make the report look objective is also worth noting.
Agreed
The private members bill NHS commission, looking at the NHS, wishing for all party consensus. We await Lord Prior’s report, also looking at same thing. Will charges be brought in. Betrayal is what has happened to our health service. A publicly funded service, with well funded social care, inequality addressed, to help keep us well, in mind and body. Investment in young people, health and sex education,. like civilised people wish for, for all. We are witnessing the destruction of the NHS, make no mistake, where pursuit of profits is King.
On Facebook today my tory ex colleague has just come out with that old chestnut about private industry being so much more efficient than the NHS and all public services.
I had to ask him re our old company:
How much was spent on fees to management consultants for restructuring and due dilligence?
How much was wasted on diversification which was abandoned when it became a bit harder than relying on govt defence contracts?
How much was wasted on joint ventures which quickly came apart at the seams?
How much was wasted on trying to win contracts in Kazakhstan which never materialised? Note that the MD later got himself a nice little earner with the Kazakh government.
I’ve just written a paper about the weaknesses of the neoliberal management paradigm for international development which speaks to lots of issues raised above. It compares the logical positivist philosophical assumptions underpinning the neoliberal management new public management model with more realistic assumptions that come from complexity science and anthropology. It is easy to show that the neoliberal management model’s assumptions about the nature of problems and solutions, social change, human behaviour, human relationships and the nature of evidence are all flawed and create the idea that managers have control and can identify ‘best practice’ and implement it, which is nonsense if you look at evidence and theory from complexity science and other places which present a more honest account of the messiness of the real world.
This ay be of interest https://books.google.co.uk/books?id=hATrBgAAQBAJ&pg=PA153&lpg=PA153&dq=haynes+complexity&source=bl&ots=x8vtmIVD9f&sig=0izDR3bTt6cb4HQb0u6SRneOqaE&hl=en&sa=X&ved=0ahUKEwig1oWs1eLKAhUEvBoKHb-DBmUQ6AEIUDAI#v=onepage&q=haynes%20complexity&f=false
Katy
I note that is niot the paper
Might you share it with me?
I would be interested
The link with logical positivism (an absurd notion if ever there was one) is too little discussed
Richard
Katy
I assume by the term complexity science you mean cybernetics
Meanwhile, we have this “on the ground” example of the failure of the private health sector:
http://www.thecanary.co/2016/02/04/camerons-mass-privatisation-nhs-services-just-dealt-deadly-blow/
@Andrew. I fear these “privatisation failures” will just mean neoliberalism will modify its strategies in wealth extraction from the paying NHS public. The adaptive monster is learning lessons.
Perhaps as or more important than the competition aspect is the fragmentation that it is producing. Which directly leads to loss of knowledge of patient information, good practices and learning, and economies of scale in purchasing. One might criticise the NHS for not having been as good as it good be in sharing good practice and learning, but fragmenting it and privatising will make that radically worse.
Be useful to have some more references to data on errors and deaths in private medicine. Ive not forgotten being in a Nuffield private hospital after an accident abroad, hence on private, insurance covered health. Right next door to a large NHS hospital so as someone pointed out, if anything difficult happened, patients could be rushed round there through the specially provided corridor.
I read all of these with a kind of informed disinterest because I keep hearing the line from Roy Campbell about the English novelists in South Africa:”You praise the firm restraint with which they write – I’m with you there, of course: They use the snaffle and the curb all right, But where’s the bloody horse?”
What are you/we going to do about it. The NHS is on its knees. Why not a vote of no confidence in Hunt in particular from his employees and shareholders (us)? We can then do the same for Osborne.
Because the government would win it in the only forum where it counts
We can of course hope for the Tories to suffer some defections, scandals and other such unfortunate events in marginal seats this year, lose their slender majority and have an election forced upon them!
Richard,
The only forum that counts? You mean public opinion? If so, I don’t think so. The language of economics is now beginning to take its place in this arena at last. It is the most convincing, and after five years of cajoling and imploring the various activists to change their perspectives some of the key ones are starting to do so. But they need our help to get it so that they can translate value, demand and waste into implications across the health and care landscape, i.e quality if life.
Will you help them?
N0 – I was thinking the Commons
I see you are thinking something else
I am doing all I can, I suspect
I really am at my limits right now
“The only forum that counts? You mean public opinion?”
Which public opinion is that then? Because, public opinion not being homogenous, there is more than one. And guess what, decision makers like to pick and choose which public opinion counts – blatant clue: it’s the public opinion which suits their decisions and the status quo.
Which brings us to the second pertinent question which is;
How is “public opinion” arrived at?
Does everyone, without exception, talk it through, weigh up up all the facts, analyse every issue rationally according to the principles of the scientific method bequeathed to us from The Enlightenment? I’d genuinely like to see that, because it would be a unique and unprecedented spectacle.
Or do a majority take their cue on what is accptable opinion from the corporate heirs and followers of Berney via so called opinion formers in what, without a hint of irony, continues to maintain it is the fourth estate (sic)? You know, the sort that despite the contrary evidence continue to insist that there were WMD in Iraq and that it is scientifically possible for a skyscraper to collapse in on its own footprint.
Context plays a big part here and the deliberate witholding of information and constant presentation and repitition of lies and misleading information warps much of what is referred to as public opinion. One recent example being the Assange case and the UN tribunal.
Even when individual personal experience is totally at variance with the information we are presented with 24/7 there remains a substantial chunk of what is referred to as public opinion which refuses point blank to believe their experience and, most certainly, hanging ones hat on the peg of public opinion being the forum that counts is a pearl of an example in that regard.
Dave
Sorry about the late reply. Was watching some rather uninspiring rugby.
Public opinion: I agree. It (NHS marketisation) is not really in public consciousness. My parish in Sheffield is professional middle class. The unawareness of the impact of marketisation is dismaying. This, and the inability to view most government activity and public sector performance properly through an economic lens, means that we have a huge responsibility to get it out there. It also means that it is an education process, not a persuasion programme on the most important issue of our time. If the NHS goes down, as it is assuredly doing, to the forces of neo-liberal thinking, then the battle for the soul of England is lost to the Barclays, Murdochs and oligarchs who are the masters of Hunt and Osborne’s souls. Hence my proposal for a vote of no confidence across England.
So, we need a strategy. The activists are nor getting anywhere. (I have been one for five years now and it is simply exhausting to no effect.)Labour is dumb. Just what will people rally around? Apart from Richard, who or what else? The BBC is wilfully blind. Only 3% of the population pay attention to the national papers, while over 50% get their views from the local media.
John Ruskin managed to enrage the entire business population in 1860 with his “Unto the Last” tracts that he had published in the Cornhill Magazine. Could the social media deliver the same? How do we turn the really useful observations above into action? Could the Reinstatement Bill on the 11th be a beginning? We simply have to stop this tragedy now.
I think there will be a catalyst eventually
The one thing we can be sure of is it will catch is by surprise
This can hardly be called a Tory NHS success story!
http://www.theguardian.com/society/2016/feb/07/barts-london-hospital-trust-biggest-overspend-nhs-history
Well Richard, it looks as if one aspect of privatisation is failing, but another is going strong.
The care.data scam seems to be hotting up. That would be the mass capture of all NHS patient data by the HSCIC. I note that all the non-private boards members have been ejected from the NHS’s care.data discussions group.
http://www.theregister.co.uk/2016/02/08/care_data_nhs_kicks_privacy_advocates_out/
and note that an old digital-NHS boss has fled to field to a private company….
https://www.opendemocracy.net/ournhs/tamasin-cave/tim-telstra-and-tech-takeover-of-nhs
Guess what; one of the big four are involved:
https://opendemocracy.net/files/Care%20data%20and%20McKinsey.pdf
And then there’s:
“700,000 patients continue to have data sharing objections ignored”
http://www.pulsetoday.co.uk/your-practice/practice-topics/it/700000-patients-continue-to-have-data-sharing-objections-ignored/1/20031072.article?PageNo=2&SortOrder=dateadded&PageSize=10#comments
Late last year my local doctor’s surgery had to write to all of its patients past and present to explain that their data had somehow been supplied (by someone outside of their control?) to a 3rd party who was now contacting people about selling them things.
I personally received several medical/pharmacy/insurance promotional letters and even a series of phone calls shortly before and for a few weeks after receiving the doctor’s letter. I took the letters into the surgery and was told that hundreds of their patients had already reported similar correspondence.
So if it’s that easy to tap into and use one doctor’s surgery’s data, just think what will happen when the private health and insurance marketeers get hold of all the NHS data!
Just how irresponsible is this government going to be with our own private and very personal data?
Well: The data is ABOUT you, but ownership rests with who possesses it.
Much was made of partially-anonymised hospital data being supplied, for next-to-nothing, to various insurance companies. Not much was said, by our ever-supportive “free” press, when it turned-out that with a minimum of effort the partially-anonymised data could [easily] be linked with individuals, and had been.
Really, nothing much has changed with the massive capture being planned by the HSCIC (and their backers…..who readily enlist ex-employees of both the health department and HSCIC) of all NHS patient data. As previous links have shown, the HSCIC is ignoring the data protection act (indeed, the health and social care reform act gives them wide-ranging exemptions from that act anyway) and also many peoples complaints. Including doctors, who remai the guardians of that data in law, and are breaking that law by allowing the data to be captured by the HSCIC. The H&SCR act in another sense makes it illegal for doctors to refuse access to the data by the HSCIC. Either way, doctors/practices, are breaking one law or another. The information commissioner has washed its hands of the affair (doubtless many high-pay-work-free jobs have been offered in exchange)
This government is the most totalitarian in the “free” world…
And another. Obviously not linked 🙁
http://www.theregister.co.uk/2016/02/08/nhs_promises_42bn_to_go_paperless/
I might say the same
So we have (or perhaps had) the best healthcare system in the world (on almost every count in this Commonwealth Fund 2014 report) and the Tories think we should follow some of the examples of those with worse outcomes and almost always higher costs (US especially!).
What planet do these nice but dim blue bloods live on – a little bubble world that nobody else recognises as reality?
http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror