In my ignorance, all I can offer is a show of support and indeed I am a paid subscriber and encourage anyone I know to do the same. You guys are wrestling with a Gordian knot and unfortunately there is no Alexander to cut to the chase. Thank you for laboriously and analytically making the effort to unpack the maelstrom of NHS funding. Who else would attempt such madness? Two (not so confused) and I suspect, weary old geezers :-) It’s certainly not an easy undertaking but with your determination to apply logic, evidence and impartial analysis (with no skin in the game), is worthy of praise. I am not experienced enough to be able to add anything tangible in terms of economic analysis, sadly above my pay grade and certainly above my ability :-). Nevertheless you are prepared to take on the unpalatable task of questioning where our money is going, so I salute and thank you both.
So far so good - but the real ' medical grassroots' are the GP surgeries where a root-and-branch reform is imperative. Since 2020 and the deplorable closure of surgeries 'because: covid!', together with the daily misery of trying to get an appointment - face-to-face or telephone - is the main reason why so many patients go straight to A & E, with the results we're all familiar with.
Let's also add the closure of many small surgery-dependences which were part of a large one with multiple GPs. This isn't due to the Lockdown years - this started in the late 1990/early 20002. There were two such surgeries in my area, within walking distance of five or ten minutes: both gone. Now, being a somewhat frail old geezerette, I need taxis to see a - not my - GP ...
But never fear: according to a report in today's Times, Madame Reeves will present the NHS with loads of more money, even though there's no plan on how best to spend it, except for 'increasing productivity', according to Madame Pritchard ... See: more money and all will be well with our NHS in all its entities and manifestations!
Trouble with a bottom-up approach is that you end up with chaos. I will explain. When general practice was being IT-ised it was decided that several different systems should be trialled in different parts of the country, so the "best" could be chosen. Because they were all much of a muchness they all stayed in place for ages, but were largely incompatible with each other so if a patient moved practices there was a good chance that all the data had to be re-entered. In addition none of the systems could communicate with hospital systems, of which there were likewise a plethora. In hospitals, as IT slowly rolled out, different departments had systems that did not communicate. I was involved in local planning to merge three hospitals and the IT planning team discovered that there were 21 systems (patient administration, radiology, pathology, pharmacy, supplies etc) and in each the staff thought that their systems were better than the others. As a result we made no progress. Had the NHS mandated the introduction of a single universal system (and you might be interested to know that many of the Windows systems we were using still had MS-DOS behind them) then we could all have troubleshot the one system. Another chaotic example was the Outpatient booking system called "Choose and Book" for GPs to book hospital appointments. This was introduced as a national system - but based on a small working group of GPs who had for some reason forgotten that the end-users of the data were hospital consultants, and did not consult them. A group of local rheumatologists (whose practice is largely outpatient based) was invited to a soft launch. It was embarrassing. We found so many issues that the launch group was forced to set up a formal consultation with hospital specialists to iron out the problems. As each specialty had different demands the process degenerated into chaos. Implementation nonetheless happened. Consultants found they could no longer prioritise referrals properly, and took five times as long to authorise bookings than it had done with direct GP letters, so many gave up. Those who persevered found that to re-prioritise referrals they had to send the original back to the GP who had to re-refer. You can guess what happened; GPs reverted to sending in handwritten letters. So a top-down system fails as well! That said, the NHS app goes a long way towards patients carrying their own personal health history with hem.
The underlying issue with these and other examples is that people failed to obey Bamji's First Law of Planning: when deciding on a plan, ask one key question - if we do this, what could possibly go wrong? I lost track of the number of times I encountered this failure. Two stick in my mind. The first was when the hospital managers decided to move the board meeting from 8am to 11am, thus forcing all the clinical directors to cancel clinical work, something the managers had somehow overlooked. The second was a reorganisation, presented with a slick Powerpoint slide set. There was much nodding of heads in agreement until I pointed out that an identical proposal had been tried 15 years previously and had failed.
Reform in the NHS has been tried with varying degrees of failure since the early 1950s. We can now do too much at enormous expense. Should we practise futility medicine? Should we stop doing certain things on the NHS? Should hospital inpatients pay accommodation charges? Should all patients pay something for their medications? Just because the NHS was set up to be free at the point of delivery in 1948 does not mean that the principle must be set in tablets of stone now,, not least because if the entire UK population was put on the supposed universal wonder drug Ozempic bankruptcy will not be far behind. The difficulty is in comparability; should a cancer treatment that prolongs life by a few months be compared to the number of hip replacements that could be done for the same money? Should the social costs of a treatment be included in a cost analysis (so you can offset the cost against the likely loss of revenue when a patients can no longer work and turns from taxpayer to benefit receiver)? Only one big management thing for me: should we abandon the purchaser-provider split which duplicates contract costs?
For a bit more depth see my book "Mad Medicine: Myths, Maxims and Mayhem in the National Health Service" (2019)
I have lived through being added to an IT system. Side note my husband was a very experienced Business Analyst. When the system was unveiled to us as Health Visitors, guess what it didn't do what we needed, it was a useless burden or stick to beat us with. I know the development team didn't speak to anyone who did the job we were doing. "We were told you didn't need that " was a recurring refrain. My husband's mantra was I need to spend time with the actual end users , not some manager who doesn't do the job . Bottom line is I was being controlled by a system and not my professional judgement,and too much time spent Infront of a screen instead of supporting and advising families.
The problem with the NHS is the messianic zeal of its votaries for the failing system.
After a medical meeting this year in Belfast where the Irish and British systems were compared,I went to compliment an Irish doctor for how well he described his admittedly imperfect system. His only criterion seemed to be 'What works?'
On the other hand a woman from Wales,of all parts of the UK, was trying to tell us it was the best in the world.
Does that 'woman from Wales' have a name? After all, NHS Wales is such a shining example (not) of what can be achieved in a proper Labour fiefdom, running for a good quarter century ...
The recent post about the inadequacy of audited financial reporting is troubling to put it mildly Join this fact with a government not noted for incorruptibility - putting it mildly again - and we have lot of smoke. Combine these two facts with an evident lack of efficacy on several fronts from ambulance response to cancer detection and we should be forgiven for thinking where there is lots of smoke there is most probably a fire!
Forensic analysis is a must and I don't trust the NHS establishment to do it, unfortunately.
Keep up the good work! The low hanging fruit in the NHS is the huge number of hours going into reporting info which nobody reads and is incapable of analysis. Stop it NOW!
I'm not impatient, simply sad. You could just as well be talking about the university system (a dying world in which far too many people now waste their life). Arguably, universities are now also beyond control, in ways that closely parallel your account of the death of the NHS (itself a microcosm of the country that had the idea). Something has gone horribly wrong with universties. Designed to be self-governing, they worked quite well (not perfectly, but quite well) for a very long time in the bottom-up style you argue for (and I'm old enough to know that!). It's just that we realised far too late that there was something that held such systems together. I'm lost for a word for this mysterious glue - the best I can come up with is "honourable conduct" - well aware it sounds horribly naive. But I still claim we never realised that once you lose it, or give it away, you lose the lot. It will take more than the "should" to get it back.
" You could just as well be talking about the university system (a dying world in which far too many people now waste their life). Arguably, universities are now also beyond control, in ways that closely parallel your account of the death of the NHS (itself a microcosm of the country that had the idea)."
the "western world" just seems to be spiralling down and down
"the best I can come up with is "honourable conduct" "
indeed; now venal self-interest seems to have replaced it
There are numerous problems, few of which will be easy to solve.
There are the heroic, rational codgers and, I'm certain, thousands of NHS employees who are also heroic and caring in their own way.
I was lucky to encounter some of those after a heart attack on 23 December, and subsequently in specialist physio teams etc.
But then there are the GPs in my local practice who had a Practice Nurse sort out my annual diabetes review, who turned out to be a South African student who saw her priority to take Statins and, when I refused consent, insisted I took a "blood pressure" drug to which, it turned out, I was allergic. Who knows if that had something to do with the Myocardial Infarction?
But how well was this pleasant young girl trained and supervised? Doctors in the Practice Surgery are rarely to be encountered and seem often to be locum staff. Only the very hard pressed receptionists seem to have a clue what is going on.
Then you have the Junior Doctor activists (and apparently many Consultants) who apparently care not a fig for the Hippocratic Oath, but only to be paid top dollar.
When I was an Engineering Student back in the 1960s, I got very friendly with a couple of Medical Students who qualified a year after me. They had to do a year as a Junior Doctor in a big London hospital and, frankly, the hours they worked were such that they had little opportunity to spend anything. That was obviously not right. But I do wonder if the most militant of our Junior Doctors of today wouldn't be better suited to professions in selling second hand cars or double glazing.
Please, yes, wind up the NHS and all these other groups who have made themselves irrelevant and useless. And, please do so before they propose another non-evidence based intervention for something they no nothing about. This very worthwhile series of articles (along with the others as well) has shown that TTE may be the outrider, who is so far out in front that the NHS and the other groups highlighted, can no longer see them on the horizon, giving rise to the problem that NHS and others have lost sight of what the word 'evidence' means and why its important. Either that, or someone or some group did a coordinated attack on their dictionaries and ripped that page out.
MEHA! (Make England Healthy Again). Well done, as always. May I suggest and request - a not-very-moderate proposal - once you'll have 'bottemed-up' your (I mean UK) rotten HC system, you come to Germany to revamp the Augian stables (or Dr. Augias sh*t hole).
In case anyone is interested in the NHS and funding of dentistry and how initiatives to increase accessibility are going - or wants a laugh - read this
I see young Wesley is too embarrassed to ask you two old geezers to help him,so he has set up this consultation and I do hope you will oblige by taking part
'A search of the term (Health Security) using an internet search engine confirms an alarming lack of agreement on the meaning and scope of the concept. Of the first 100 citations found on the search, 44 referred only to bio-terrorism or trans-border spread of disease, 36 referred to effects of rising health care costs and health insurance in developed countries, 2 referred only to HIV/AIDS, 10 referred to unrelated matters (e.g. electronic home protection systems), and only 7 referred to ‘health security’ in the sense intended by the UNDP (United Nations Development Program)
'A search of the term (Health Security) using an internet search engine confirms an alarming lack of agreement on the meaning and scope of the concept. Of the first 100 citations found on the search, 44 referred only to bio-terrorism or trans-border spread of disease, 36 referred to effects of rising health care costs and health insurance in developed countries, 2 referred only to HIV/AIDS, 10 referred to unrelated matters (e.g. electronic home protection systems), and only 7 referred to ‘health security’ in the sense intended by the UNDP (United Nations Development Program)
"We badly need a bottom-up structure". If I remember correctly Kaiser permanent, so loved by the Blair government, was run by clinicians/ nurses. In the nineties "Fundholding" gave primary care some influence through contracting for services and generated competition through purchaser/ provider relationships. Waiting lists dramatically reduced particularly for the bottle neck specialties. Sadly that all came to an end with the Blair government and though there remained a quasi purchaser provider split ie Trusts and health authorities it lacked the bite of fund holding.
I worked as a consultant in the South West, and Devon was a hotbed of GP fund holding. It was a poor system in many ways. Two examples. One practice contracted all their inguinal hernia repairs to a private hospital done by a retired thoracic surgeon, who had not done a hernia since being a SHO. There were recurrences within 6 months. Secondly, if an old man came in for a prostate operation for example, and was found to have something else incidental, like a hernia for example it could not be dealt with at the same admission. It had to be referred back to the GP for whatever they wished to do.
I don't quite know why but I am increasingly drawn to that great poem by Shelley - Ozymandias..
Simply substitute the NHS and The RPTB for -
"Two vast and trunkless legs of stone stand in the desert.......the hand that mocked them and the heart that fed.......look on my Works ye Almighty and despair!. Nothing beside remains. Round the decay of that colossal wreck, boundless and bare the lone and level sands stretch far away.
In my ignorance, all I can offer is a show of support and indeed I am a paid subscriber and encourage anyone I know to do the same. You guys are wrestling with a Gordian knot and unfortunately there is no Alexander to cut to the chase. Thank you for laboriously and analytically making the effort to unpack the maelstrom of NHS funding. Who else would attempt such madness? Two (not so confused) and I suspect, weary old geezers :-) It’s certainly not an easy undertaking but with your determination to apply logic, evidence and impartial analysis (with no skin in the game), is worthy of praise. I am not experienced enough to be able to add anything tangible in terms of economic analysis, sadly above my pay grade and certainly above my ability :-). Nevertheless you are prepared to take on the unpalatable task of questioning where our money is going, so I salute and thank you both.
I am in 100% agreement Bilbo. These two old geezers are above and beyond aren’t they?
So far so good - but the real ' medical grassroots' are the GP surgeries where a root-and-branch reform is imperative. Since 2020 and the deplorable closure of surgeries 'because: covid!', together with the daily misery of trying to get an appointment - face-to-face or telephone - is the main reason why so many patients go straight to A & E, with the results we're all familiar with.
Let's also add the closure of many small surgery-dependences which were part of a large one with multiple GPs. This isn't due to the Lockdown years - this started in the late 1990/early 20002. There were two such surgeries in my area, within walking distance of five or ten minutes: both gone. Now, being a somewhat frail old geezerette, I need taxis to see a - not my - GP ...
But never fear: according to a report in today's Times, Madame Reeves will present the NHS with loads of more money, even though there's no plan on how best to spend it, except for 'increasing productivity', according to Madame Pritchard ... See: more money and all will be well with our NHS in all its entities and manifestations!
Trouble with a bottom-up approach is that you end up with chaos. I will explain. When general practice was being IT-ised it was decided that several different systems should be trialled in different parts of the country, so the "best" could be chosen. Because they were all much of a muchness they all stayed in place for ages, but were largely incompatible with each other so if a patient moved practices there was a good chance that all the data had to be re-entered. In addition none of the systems could communicate with hospital systems, of which there were likewise a plethora. In hospitals, as IT slowly rolled out, different departments had systems that did not communicate. I was involved in local planning to merge three hospitals and the IT planning team discovered that there were 21 systems (patient administration, radiology, pathology, pharmacy, supplies etc) and in each the staff thought that their systems were better than the others. As a result we made no progress. Had the NHS mandated the introduction of a single universal system (and you might be interested to know that many of the Windows systems we were using still had MS-DOS behind them) then we could all have troubleshot the one system. Another chaotic example was the Outpatient booking system called "Choose and Book" for GPs to book hospital appointments. This was introduced as a national system - but based on a small working group of GPs who had for some reason forgotten that the end-users of the data were hospital consultants, and did not consult them. A group of local rheumatologists (whose practice is largely outpatient based) was invited to a soft launch. It was embarrassing. We found so many issues that the launch group was forced to set up a formal consultation with hospital specialists to iron out the problems. As each specialty had different demands the process degenerated into chaos. Implementation nonetheless happened. Consultants found they could no longer prioritise referrals properly, and took five times as long to authorise bookings than it had done with direct GP letters, so many gave up. Those who persevered found that to re-prioritise referrals they had to send the original back to the GP who had to re-refer. You can guess what happened; GPs reverted to sending in handwritten letters. So a top-down system fails as well! That said, the NHS app goes a long way towards patients carrying their own personal health history with hem.
The underlying issue with these and other examples is that people failed to obey Bamji's First Law of Planning: when deciding on a plan, ask one key question - if we do this, what could possibly go wrong? I lost track of the number of times I encountered this failure. Two stick in my mind. The first was when the hospital managers decided to move the board meeting from 8am to 11am, thus forcing all the clinical directors to cancel clinical work, something the managers had somehow overlooked. The second was a reorganisation, presented with a slick Powerpoint slide set. There was much nodding of heads in agreement until I pointed out that an identical proposal had been tried 15 years previously and had failed.
Reform in the NHS has been tried with varying degrees of failure since the early 1950s. We can now do too much at enormous expense. Should we practise futility medicine? Should we stop doing certain things on the NHS? Should hospital inpatients pay accommodation charges? Should all patients pay something for their medications? Just because the NHS was set up to be free at the point of delivery in 1948 does not mean that the principle must be set in tablets of stone now,, not least because if the entire UK population was put on the supposed universal wonder drug Ozempic bankruptcy will not be far behind. The difficulty is in comparability; should a cancer treatment that prolongs life by a few months be compared to the number of hip replacements that could be done for the same money? Should the social costs of a treatment be included in a cost analysis (so you can offset the cost against the likely loss of revenue when a patients can no longer work and turns from taxpayer to benefit receiver)? Only one big management thing for me: should we abandon the purchaser-provider split which duplicates contract costs?
For a bit more depth see my book "Mad Medicine: Myths, Maxims and Mayhem in the National Health Service" (2019)
I have lived through being added to an IT system. Side note my husband was a very experienced Business Analyst. When the system was unveiled to us as Health Visitors, guess what it didn't do what we needed, it was a useless burden or stick to beat us with. I know the development team didn't speak to anyone who did the job we were doing. "We were told you didn't need that " was a recurring refrain. My husband's mantra was I need to spend time with the actual end users , not some manager who doesn't do the job . Bottom line is I was being controlled by a system and not my professional judgement,and too much time spent Infront of a screen instead of supporting and advising families.
The problem with the NHS is the messianic zeal of its votaries for the failing system.
After a medical meeting this year in Belfast where the Irish and British systems were compared,I went to compliment an Irish doctor for how well he described his admittedly imperfect system. His only criterion seemed to be 'What works?'
On the other hand a woman from Wales,of all parts of the UK, was trying to tell us it was the best in the world.
Does that 'woman from Wales' have a name? After all, NHS Wales is such a shining example (not) of what can be achieved in a proper Labour fiefdom, running for a good quarter century ...
The recent post about the inadequacy of audited financial reporting is troubling to put it mildly Join this fact with a government not noted for incorruptibility - putting it mildly again - and we have lot of smoke. Combine these two facts with an evident lack of efficacy on several fronts from ambulance response to cancer detection and we should be forgiven for thinking where there is lots of smoke there is most probably a fire!
Forensic analysis is a must and I don't trust the NHS establishment to do it, unfortunately.
Keep up the good work! The low hanging fruit in the NHS is the huge number of hours going into reporting info which nobody reads and is incapable of analysis. Stop it NOW!
I'm not impatient, simply sad. You could just as well be talking about the university system (a dying world in which far too many people now waste their life). Arguably, universities are now also beyond control, in ways that closely parallel your account of the death of the NHS (itself a microcosm of the country that had the idea). Something has gone horribly wrong with universties. Designed to be self-governing, they worked quite well (not perfectly, but quite well) for a very long time in the bottom-up style you argue for (and I'm old enough to know that!). It's just that we realised far too late that there was something that held such systems together. I'm lost for a word for this mysterious glue - the best I can come up with is "honourable conduct" - well aware it sounds horribly naive. But I still claim we never realised that once you lose it, or give it away, you lose the lot. It will take more than the "should" to get it back.
thanks Alan; so well said
" You could just as well be talking about the university system (a dying world in which far too many people now waste their life). Arguably, universities are now also beyond control, in ways that closely parallel your account of the death of the NHS (itself a microcosm of the country that had the idea)."
the "western world" just seems to be spiralling down and down
"the best I can come up with is "honourable conduct" "
indeed; now venal self-interest seems to have replaced it
There are numerous problems, few of which will be easy to solve.
There are the heroic, rational codgers and, I'm certain, thousands of NHS employees who are also heroic and caring in their own way.
I was lucky to encounter some of those after a heart attack on 23 December, and subsequently in specialist physio teams etc.
But then there are the GPs in my local practice who had a Practice Nurse sort out my annual diabetes review, who turned out to be a South African student who saw her priority to take Statins and, when I refused consent, insisted I took a "blood pressure" drug to which, it turned out, I was allergic. Who knows if that had something to do with the Myocardial Infarction?
But how well was this pleasant young girl trained and supervised? Doctors in the Practice Surgery are rarely to be encountered and seem often to be locum staff. Only the very hard pressed receptionists seem to have a clue what is going on.
Then you have the Junior Doctor activists (and apparently many Consultants) who apparently care not a fig for the Hippocratic Oath, but only to be paid top dollar.
When I was an Engineering Student back in the 1960s, I got very friendly with a couple of Medical Students who qualified a year after me. They had to do a year as a Junior Doctor in a big London hospital and, frankly, the hours they worked were such that they had little opportunity to spend anything. That was obviously not right. But I do wonder if the most militant of our Junior Doctors of today wouldn't be better suited to professions in selling second hand cars or double glazing.
Please, yes, wind up the NHS and all these other groups who have made themselves irrelevant and useless. And, please do so before they propose another non-evidence based intervention for something they no nothing about. This very worthwhile series of articles (along with the others as well) has shown that TTE may be the outrider, who is so far out in front that the NHS and the other groups highlighted, can no longer see them on the horizon, giving rise to the problem that NHS and others have lost sight of what the word 'evidence' means and why its important. Either that, or someone or some group did a coordinated attack on their dictionaries and ripped that page out.
MEHA! (Make England Healthy Again). Well done, as always. May I suggest and request - a not-very-moderate proposal - once you'll have 'bottemed-up' your (I mean UK) rotten HC system, you come to Germany to revamp the Augian stables (or Dr. Augias sh*t hole).
Why not copy something that works? Netherlands, say, or France which is widely admired.
In case anyone is interested in the NHS and funding of dentistry and how initiatives to increase accessibility are going - or wants a laugh - read this
https://www.gdpuk.com/news/latest-news/4866-the-waterlogged-dental-desert
I see young Wesley is too embarrassed to ask you two old geezers to help him,so he has set up this consultation and I do hope you will oblige by taking part
https://change.nhs.uk/en-GB/projects/your-ideas-for-change
'A search of the term (Health Security) using an internet search engine confirms an alarming lack of agreement on the meaning and scope of the concept. Of the first 100 citations found on the search, 44 referred only to bio-terrorism or trans-border spread of disease, 36 referred to effects of rising health care costs and health insurance in developed countries, 2 referred only to HIV/AIDS, 10 referred to unrelated matters (e.g. electronic home protection systems), and only 7 referred to ‘health security’ in the sense intended by the UNDP (United Nations Development Program)
https://academic.oup.com/heapol/article/23/6/369/572074?login=false#:~:text=https%3A//doi.org/10.1093/heapol/czn030
'A search of the term (Health Security) using an internet search engine confirms an alarming lack of agreement on the meaning and scope of the concept. Of the first 100 citations found on the search, 44 referred only to bio-terrorism or trans-border spread of disease, 36 referred to effects of rising health care costs and health insurance in developed countries, 2 referred only to HIV/AIDS, 10 referred to unrelated matters (e.g. electronic home protection systems), and only 7 referred to ‘health security’ in the sense intended by the UNDP (United Nations Development Program)
https://academic.oup.com/heapol/article/23/6/369/572074?login=false#:~:text=https%3A//doi.org/10.1093/heapol/czn030
"We badly need a bottom-up structure". If I remember correctly Kaiser permanent, so loved by the Blair government, was run by clinicians/ nurses. In the nineties "Fundholding" gave primary care some influence through contracting for services and generated competition through purchaser/ provider relationships. Waiting lists dramatically reduced particularly for the bottle neck specialties. Sadly that all came to an end with the Blair government and though there remained a quasi purchaser provider split ie Trusts and health authorities it lacked the bite of fund holding.
I worked as a consultant in the South West, and Devon was a hotbed of GP fund holding. It was a poor system in many ways. Two examples. One practice contracted all their inguinal hernia repairs to a private hospital done by a retired thoracic surgeon, who had not done a hernia since being a SHO. There were recurrences within 6 months. Secondly, if an old man came in for a prostate operation for example, and was found to have something else incidental, like a hernia for example it could not be dealt with at the same admission. It had to be referred back to the GP for whatever they wished to do.
I don't quite know why but I am increasingly drawn to that great poem by Shelley - Ozymandias..
Simply substitute the NHS and The RPTB for -
"Two vast and trunkless legs of stone stand in the desert.......the hand that mocked them and the heart that fed.......look on my Works ye Almighty and despair!. Nothing beside remains. Round the decay of that colossal wreck, boundless and bare the lone and level sands stretch far away.