Coffee House

What the NHS really needs

4 January 2014

3:50 PM

4 January 2014

3:50 PM

I blamed the pheasant casserole, but I did it an injustice. Its only contribution to the drama behind my disappearance in mid-December was a residue of lead shot in the small intestine that briefly confused the radiologist. The real villain revealed by the scan was my appendix, which had taken on the raging, bull-necked, bug-eyed appearance of Ed Balls faced with a set of improving growth figures.

And so it was that I spent a week in the Friarage at Northallerton, a small ‘district general hospital’ that has survived every NHS restructuring to date and is cherished by the citizenry of rural North Yorkshire. For someone who hasn’t been hospitalised since 1957, this was the Full Monty: the ambulance in the night, the agonised wait in A&E, the sudden euphoria of morphine; and when the crisis had passed, the stultifying routine of life on the ward, waiting for the relief of the next visiting hour or doctors’ round or tea trolley or troublesome patient. But at least it gave me time to think — not just about the state of the health service, but about the ailments of the nation in 2014 and beyond.

Of course I shouldn’t leap to generalisations on the basis of a single skirmish with the NHS. But I’ll say this: given limitless demand as longevity rises, inevitable scarcities and bottlenecks of resources, bureaucratic risk-aversion driven by fear of the Daily Mail, and voters’ reluctance to pay more tax for anything, including their own healthcare, it’s a miracle this giant contraption is as robust as it is.

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Could it be more efficient? Of course it could, in every corner. It took 60 hours after admission — and a clearly foolish threat to discharge myself — before they finally wheeled me past a scanner appeal poster and fed me into the space-age machine that settled the diagnosis. Staff levels sometimes looked lavish, at other times strained or skeletal. There was no means of knowing who was in charge at any given moment. As for keeping track of the patient, I kept thinking, ‘Why don’t they buy some software from Travelodge or DHL or Ocado, instead of all this scribbled paperwork and duplication?’

But I couldn’t accuse anyone, from consultant surgeon to catering assistant, of not trying their best within an imperfect system, or not caring. I eavesdropped through the curtain on a young nurse — near the end of a 12 hour 40 minute shift, in which the 40-minute lunch break is unpaid — gently comforting a patient whose spirits had crumpled after he woke from a bowel operation to find himself with a temporary stoma bag. It was done with real empathy, and it made me think that the ethos of the NHS is good even if the nuts and bolts are loose.

And in the end, the ‘patient experience’ is far more about ethos than about macro-management structures whose prime objective is cost elimination. What’s needed here is not yet another bout of Whitehall-driven top-down re-engineering, destabilising networks and pitting one entrenched interest group against another — but bottom-up kaizen, the Japanese factory-floor philosophy of continuous improvement.

This is an extract from Martin Vander Weyer’s column in this week’s Spectator. Click here to read the full piece.

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Show comments
  • Tom Tom

    Basic Management consultancy on the floor could sort out so much. My own experiences tell me how easy it is to improve process-flow, information-flows, repairs, basic admin. tasks – doesn’t need a lot of money, just focus. Instead “management” is focused upwards to please the next bureaucratic layer to gain recognition and promotion until it reaches the top floor where Whitehall Memos and Targets meet the Execution-Interface and Janus-like figures smile to Whitehall and scowl to staff below.

    You could de-bug much of the operating problems by Kaizen

  • Alexsandr

    we need to stop being romantic about hospitals and put health care where it should be -in the community.
    we need GP surgeries that have enough resources so they can operate 7am to 10pm 6 days a week and sundays too. We have 24 hour everything else. why is GP service locked in the 1920’s. That will probably fix a lot of the A&E problem.
    The ambulance services need more and better paramedics. Someone fixed at home is better than carting them to a hospital. Especially the elderly who find A&E daunting.,
    Serious cases need to be in large A&E units with the expertise for the complexities. But we need to be careful in sparsely populated areas to make sure journies not too far.

  • Ron Todd

    My last hospital visit arranged by a GP, was chaotic I ended up walking round the corridors trying to find the one person in the building who knew why I was there carrying a folder marked ‘confidential do not show to patient’ The time before that I saw a consultant who spoke little English and used a student to translate and who made it clear that as I was not a private patient he would not take the time to tell me what was actually wrong with me. The doctors dressed like they had just walked of the street the nurses wore a variety of outfits and were indistinguishable from the cleaners.

    • HookesLaw

      You expect us to believe you? You clearly need an optician not a doctor if you cannot recognise nurses. I visit hospitals regularly and can easily tell the difference.

      • Ron Todd

        perhaps practice helps. Why would I lie? It was an eye problem but I doubt being able to see better would have made much difference.

      • Margot

        A local hospital has put all ‘caring’ jobs into blue scrubs so you need to be clued up on the significance of varying shades of blue to know if you’re talking to someone who’s turned up on the ward two weeks ago or a ‘matron’ who’d been around for years.
        A point which was only touched on in a few words is the 12 hour shift system. Take many commute times of over two hours and you get a workforce totally knackered – a workforce that is dealing with life and death situations. Not good. But not likely to change as it fits the convenience of admin and staff – just the patients that come off worse.

  • rick hamilton

    I recently underwent serious surgery at a medical university hospital in Tokyo. The surgeon spoke excellent English and had been trained at a world famous hospital in New York. I cannot fault the expertise and attention to detail of his team. Now for the crunch. I had to pay part of the cost myself !!!!

    So what, if the bulk of the cost is borne by the national health system and the patient pays (in my case) 10% which was about the cost of a short holiday, what’s wrong with that? In Japan you choose which hospital to go to, which clinic, which doctor and if you want a second opinion you can take your medical records to any other practitioner. This means there is competition, which in the end is the only driver of higher standards.

    The idea that health care is somehow an altruistic charitable cause is nonsense. You get what you pay for in life in my experience and if there is no connection betwen the payment and the service provided, you will generally get mediocrity – or worse. My experience of the NHS is that patients are treated with kindness, but without any great personal attention. That’s because there is no difference in the financial rewards received by a good hospital or a bad one. In Japan the bad one loses all its patients and goes bust. In the UK it is a case of “lessons will be learned” – but are they?

    • HookesLaw

      And if you are unemployed or chronically ill or mentally ill or any number of causes where you do not need a short course of treatment?
      Do Japanese hospitals go bust?
      http://www.economist.com/node/21528660
      ‘more than three-quarters of public hospitals operate at a loss’

      As ever you take a slice of life and treat it as truth. ‘Like other service industries in Japan, there are cumbersome rules, too many small players and few incentives to improve. Doctors are too few—one-third less than the rich-world average, relative to the population—because of state quotas.’
      ‘Complicated cases get too little attention. The Japanese are only a quarter as likely as the Americans or French to suffer a heart attack, but twice as likely to die if they do.’

      Etc…

      Health services all over the world are in trouble. Stop picking on the NHS.’

      • rick hamilton

        There you go, treating the NHS like a religion : no criticism can be tolerated.

        I related my own personal experience which is truth, and my understanding of the Japanese system as described by local people, including doctors.

        If you read the link you have given as a panning of the Japanese system, that’s your privilege but that is not how I read it. It is even headed “The Japanese health care system is the envy of the world” Yes, it has problems – like all health systems as you point out – largely due to an ageing population but they are taking practical steps to look after geriatrics at home rather than debating the issue endlessly.

        How many NHS hospitals operate at a loss and how would you know anyway? Last time I looked at The Economist World in Figures – admittedly some time ago – it said Japan had the highest number of hospital beds per thousands of population whereas the UK was 17th after Albania. You might be able to learn something from other countries if you try.

        • Tom Tom

          Yes because since Margaret Thatcher started cutting hospital beds to
          save money – we had >1 million beds in the 1960s and are around 250,000
          now with a much bigger population, then again in the 1960s it was part of the Cold War precautions in the event of war/disaster.

          How do you know if a hospital runs at a loss when 3% NHS spending is reclaimed by the Treasury as a “capital charge”. BTW lots of US and German hospitals run at a loss……it is hard to know how to make money out of a hospital. Is it an hotel or an airline or a job shop or a production line ? What costing do you use ABC-Costing or Job Shop Costing or Average Costing or Marginal Costing or LRAC ?

    • Tom Tom

      How much did you pay ? Who paid the rest ? Why didn’t you pay the whole bill on Amex and reclaim ?

  • James Allen

    I remember years ago reading a King’s report that argued the biggest problem with the NHS was the continual top-down reorganisation. Nothing’s changed. But fundamentally an organisation that is funded by government can never be run ‘bottom-up’. That is why some degree of privatisation or ‘marketisation’ (like a European insurance system) is required.

    • Daniel Maris

      Looking into this I see that Belgium’s system gets the highest rating from our expats:

      “Belgium’s healthcare system is rated by Expatica.com, a UK expatriates web site, as having one of the best healthcare systems in Europe. Dating from 1945, its quality is largely down to its sponsorship by competing mutuals, and provisioned by a mixture of state and non-profit hospitals. Each mutual is funded by the state, the funding dependent on its membership numbers.” (Guardian)

      This is very like what I have suggested before – a health voucher scheme.

      Maybe we should look at this. The good thing about it is that it delivers choice and efficiency. There may be a mutual (Mutual A) that can give me more health choices than Mutual B (e.g. maybe the option of a two day spa visit every year). If so, I may migrate to that mutual. Or it may address my particular health needs – perhaps it will incorporate homeopathic remedies or whatever. But each mutual, because it is competing for members has to try and operate as efficiently as possible. It probably pays doctors no more than the market demands for instance.

  • Daniel Maris

    The morphine seems to have worked – you’ve ended up praising a nationalised socialistic tax-funded mega organisation.

  • starfish

    The problem with the Nhs is like most public services it is process focussed not output focussed. Of course it claims that it is the latter and will reel off lists of numbers treated,nurses hired, operations done etc but that is a consequence of internal processes monitoring activity, many imposed from the outside. The required output is people cured or with conditions satisfactorily managed.
    Bit like health and safety really. The desired output is a safe and healthy working environment for workers and visitors to workplaces but it has turned into a box ticking bureaucratic nightmare

    • HookesLaw

      The problem with the NHS is that Labour use it as a political football. This govt have said they are more focussed on outputs rather than targets and the Labour party and the BBC continue to look at and criticise artificial targets not being met.

    • Tom Tom

      You have no idea. Labour introduced “Treatment Episodes” to suit idiots
      like starfish based on Brown’s love-in with Lord Simon and the need to
      measure outputs. It was farcical

  • AndyWilson

    Martin, first of all, I hope Your recovery is going well. It’s a shock when you’ve been on good health – and something like this happens. Keep Writing :-)
    I agree that, overwhelmingly, NHS Staff are caring and do great job. But… NHS Systems are … erm.. Rubbish! Like You, I’ve spent a career in the City (where I wrote Computer programs to Give Fund Managers some insight into the Stocks they were buying – and Stop them (and Dealers) Selling ones we didn’t have). All was well until I retired.
    I found I had Glaucoma and was referred to a Regional Hospital – all kitted out with huge Touch Screens and a Volunteer to help use it. The thing was, it wasn’t connected to the Eye Clinic! There they push round trolleys with V.Folders as of old.
    A change of Medication? The first batch Must be bought from the Hospital Pharmacy and repeats from your GP. Communication thereto? FAX!! What chance of reading a Doctors Handwriting at my Local Surgery? Confusion and Delay.
    It turns out I’ve got High BP too. My Drug usage has gone from one to 3 to 5 pills as Doctors guess how to fix it. Guess, I say, because it’s always a different Doc and there are No Notes to refer to. I could go on – and hope to since they now tell me that I need a Double ByPass and a new Heart Valve! Funnily, I feel OK, mostly, but they’ve gone in an looked, so it must be so… mustn’t it?
    This all can be solved. Computers CAN Do it, they really can. What screws it up is the way the Civil Service goes about it. They Employ Consultants! We used to do that in the City. What else would You do when You don’t know how to fix a problem – Employ someone who can – of course! Except that’s not the way it works! We used a famous company beginning with A, that doesn’t exist anymore. They were interested in fixing the Problem (a bit), but they were really interested in Selling More Consultants! Before long the Cost had exploded – and Senior Management couldn’t keep track. If it was a Regulator matter, ‘A’ took over and we got …. the same systems that they’d writing for someone else who had a similar problem. Cost as New, of course and the Confidentiality Clause, so no-one else would know.
    Until we think out of the box and, as You suggest use Systems that (1) already work and (2) can be easily modified to fit with changing circumstance, we’re going to be spending a fortune, getting not a lot and having, most importantly, a demoralised NHS.

    • HookesLaw

      You have been discovered ill and are receiving treatment. Best wishes, but what is wrong with that? Where is the NHS going wrong? Why do you doubt that you have a heart problem??

      And just because you have worked in computers does not mean that it’s somebody else’s fault that NHS or govt computer projects have gone wrong.

    • Tom Tom

      Do you know why the Japanese developed faxes ? Because they could not
      get EDI on Kanji so they innovated. Japanese Corporations run on faxes.

      Hospitals
      do not charge for prescription drugs but the GP does so the Hospital
      wants the GP Budget to pay for them but must give you a supply until you
      can reach your doctor. It seems sensible but you do not.

  • Fergus Pickering

    Nice piece. I was in Saint Thomas’s for a fortnight. Couldn’t fault it except for a bossy Scots Male Nurse, but who can do anything about bossy Scotsmen. Besides, he knew what he was about. And I came out in good shape – I mean alive and pretty well.

  • DavidL

    Good article. Your experience mirrors mine (in a London Teaching Hospital): excellent medical and largely very good nursing care, set against total administrative chaos (and disgusting, really disgusting, unhealthy food). As a former public sector manager myself I have learned that management in the public service is about deploying the resources available in the way that best helps the front-line professionals to do their jobs effectively. Constant reorganisations work directly against this principle. The NHS has been uprooted in 1974, 82, 90, 98, 2004 and 2012. Chaos imposed about every eight years, with plenty of tinkering inbetweentimes.

    • Fergus Pickering

      Oh come. Have you never eaten a school dinner?

      • DavidL

        Oh yes Fergus. 13 years of school dinners. Not one of them worse than the slop they served me for a week in the Royal Free.

        • Fergus Pickering

          Ah well. Either your school dinners were better, or my hospital food was better. Or perhaps you’ve forgotten about school dinners. How long ago was it, old fellow?

          • DavidL

            Probably too long.

      • McClane

        A school dinner? That’s a bit of a digression from the topic.

        • Fergus Pickering

          Not at all. We are talking about institutional food. It is all the same though I think a bit better in prisons because they have more money to spend.

          • Mike Purves

            A Naval Officer told me that the per diem food budget for his sailors was less than that for prisoners and about the same as for MOD guard dogs.

      • HookesLaw

        I know for a fact all the work that goes into looking at delivering good food in hospitals. Opinions and prejudices come easy.

  • cornelius

    A free health service cannot work with unrestricted immigration, and the constantly rising cost for treatment of diseases that could not be treated 50 years ago.

    • Fergus Pickering

      So why should it be free? Not that it is. heard of eyes and teeth, have you?

      • cornelius

        What is the point of this pedantry? As you well know, the charges are not the full economic cost – no way near. Prescriptions and food are peanuts in the grand scheme of things. Additionally, completely free coverage would be viable if different choices were made by our governments a generation ago.

      • Tom Tom

        Because Fergus the ones that cannot pay will not take the drugs and
        complicate treatment. Prescriptions from GPs are charged but in
        hospitals it would rather complicate treatment if you turfed people out
        of bed who could not pay for the antibiotic after getting MRSA or having
        a transplant

    • HookesLaw

      Are you suggesting that these immigrants do not pay taxes? Have you actually seen the immigrants who work in the NHS? UK people in Europe make use of European health services.

      • cornelius

        As you well know the majority of immigrants in UK pay no way near the level of taxes to break even in terms of net exchequer cost (around £11,000 per person).

    • Tom Tom

      It is not FREE. It costs the average British worker a higher monthly contribution than the average Us worker pays for healthcare

      • cornelius

        please enlighten me on how UK taxes are hypothecated towards healthcare. In any case your main point is well made, however the key point is a lot of the consumers of health care in UK are not in fact paying anything.

        • Tom Tom

          NO UK taxes are hypothecated…that ceased c. 1937 when the Unemployment Insurance fund had to be propped up by General Taxation and Road Fund tax went into General Revenues. The Treasury loathes hypothecated taxes.

          • Ron Todd

            The television tax is a hypothecated tax.

  • Ron Todd

    Envy of the world. The first people to have a colour TV in our street were the envy of all the neighbours. If they were still using that same TV they would be the envy of nobody the NHS is a 1940s institution with various unaccountable quangos bolted on who envy’s it now? Very few people have been held accountable in any meaningful way for the Mid Staffs slaughter. In any large nationalised tax payer funded institution there is a danger that the priority becomes maintaining the organisation not looking after the customer. The senior managers have to please their political masters the middle managers have to appease the public sector unions . And where the unions are involved the measure of success is going to be how many people does it employ.

    • Andy

      No one envied the NHS. This is just deluded nonsense. If they had why has no other country in the world copied it ? Could it possible that it doesn’t work and never has.

      • HookesLaw

        Other countries have NHSes. They are indeed funded differently but that funding is from compulsory contributions, from individuals and employers, which are de-facto taxes. And those health services are in debt and they are looking at the services they offer and those compulsory contributions are rising.
        You may favour say the French system but most people would baulk at the sums paid by the French for it.

        It is absurd to say the NHS does not work. Of course it does.

      • Tom Tom

        Other countries have made their mess differently. Germany employs far
        more in health care than Britain once you add the Krankenkassen to the
        Hospitals and its costs are wildly out of control. The NHS is copied –
        it is fantastic at cost-control and studied by Germany and other
        countries

      • Tom M

        I agree with your sentiments but I think the Italian health service is operated more or less on the same basis as the NHS.
        When you consider that the French health service, for example, was created at the same time as the NHS and their’s works. You have to ask what is it that we can’t do properly when it comes to large nationalised organisations in the UK.

        • Andy

          The reason why the NHS is so poor is simple: it is because it is other peoples money. Same as the BBC. It is a virtual monopoly and that is why it is poor. It needs competition and new ways of doing things so that the ‘kit’ is better utilised. You would be dismayed if you know how much ‘down time’ there is with very expensive machinery. No business could work that way, and nor can the NHS.

          The huge mistake that was made in 1947 was to ‘Nationalise’ the health service. My local hospital is (was till it was closed) built on land my family gave, with a hefty donation for its construction, along with many donations from other local families. Hospitals were Charitable Trusts run by Trustees who took an interest in that hospital and how it was run. That’s what we should still have. We need to hand Health back to the people, get the stupid politicians like the idiot Burnham out of any connection to it. Make the patient a consumer and let the consumer drive the services rather than the producer dictating the terms. The doctors, nurses etc will hate it, but that is the right way to go.

          • Tom M

            Amen to all of that.

    • Tom Tom

      The British Army is an 18th Century Institution using 1970s equipment.
      The British Government is a Victorian Institution. The NHS is not “an
      institution” but a logo on a series of regional hospitals and health problems

  • telemachus

    Martin Vander Weyer
    I do not know who you are but you have it taped
    Cameron said no more top down reorganisation and then instead of stopping Lansley sent Clegg in to rescue him
    *
    And the result
    *
    24 hour A&E trolley waits, reported 8 hour waits in a CT scanner corridor, 16 hour queues in ambulances at the hospital door and massive numbers of nurses seeking psychiatric help.
    *
    The solution
    *
    First Smug Hunt must stop micromanaging doctors and lambasting nurses and truly value them
    Then he must take Andy Burnham’s plans to integrate health and social care and invest the enormous savings in frontline care
    *
    I know it is only a short 16 months before Andy can get to this, but why do we have to suffer until then

    • Fergus Pickering

      Good Heavens I wouldn’t hire Andy Burnham to organise a piss-up in a brewery. Why on earth should anyone suppose he can do better? It was under the last Labour lot thatall the scandals happened, wasn’t it? Or have you forgotten?

    • Andy

      You should suffer at the end of a rope. Least we forget it was under the Fascist Labour Party that we had murder at Mid Staffs. Now go hang, cretin.

      • Daniel Maris

        No call for such violent language. Hope you never get your hands on any political power.

    • saffrin

      If Andy Burnham gets his hands on the NHS the Liverpool Pathway will be compulsory for all, including any visitors.
      Labour wrecked the NHS as did they wreck everything else.
      The only reason Labour still show in the polls is their immigrants know they are fools.
      London, 60% immigrant.

      • HookesLaw

        London is not 60% immigrant – if you really believe that then its a mental hospital that you need.

        • saffrin

          It was reported a few months ago white Brits count for 40% of London’s population.
          Who am I to argue?
          PS; If they aint white, they are immigrants. Descendants of make no difference.

  • Shinsei1967

    However implementing an Ocado/DHL-style tracking system (however useful this key be) is somewhat beyond the parameters of a kaizen bottom-up continuous improvement system.

    Sometimes you just need someone senior at the top to sign off on an expensive piece of kit/IT. Not to say that it can’t be trialled and installed gradually so that improvements can be made at an early stage,

    Hope you feeling better !

  • HookesLaw

    Indeed Mr Weyer, the importance of best practice from the bottom up. And of course the NHS is ahead of you.
    https://www.evidence.nhs.uk/qipp

    Perhaps you should find out more before rushing into print, the results of such investigation might then change the slant of your article.

    • HookesLaw

      So the ‘famous five’ do not like me contradicting the author and pointing out that the NHS does indeed emply reform from the bottom up?
      As ever the usual suspects are not interested in the truth and prefer fantasy to reality.

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