Dispatches - NHS in Crisis
Discussion
Megaflow said:
...
ETA: I don't agree with the title of this, but it covers the subject very well I think: https://snowdon.substack.com/p/how-to-argue-with-a...
I agree with the title whole heartedly. I have bookmarked that excellent page! Thanks for the link!ETA: I don't agree with the title of this, but it covers the subject very well I think: https://snowdon.substack.com/p/how-to-argue-with-a...
The trouble is that no amount of analysis can get away from the fact that the NHS improved between 2000 ish and 2010 and has declined ever since. From the inside it’s patently obvious. Whether that’s a direct result of different policies, levels of spending or whatever it’s clear from my experience and many of my colleagues.
Anyway it seems that thesis is about to be tested again over the next 5 years at least which is probably no bad thing
Anyway it seems that thesis is about to be tested again over the next 5 years at least which is probably no bad thing
tele_lover said:
A few random points about my encounters with A&E:
-A few years ago I walked in to A&E during summer. Behind the reception desk they had a Dyson air chiller, the type which cost £300+. It could have been a staff member's personal one, but I doubt it.
-Where I used to live, the local A&E deliberately hired multiple receptionists to work the twilight shift. Later I wrote a letter and was officially informed this was for security reasons (even though the receptionist was behind a screen and there's security officers around). So they spend £20k a year to chat with someone all night.
-I was at A&E with a relative during the time of the junior doctor strikes (but this shouldn't be related). We waited for 3 hours just to see the initial triage nurse. During those 3 hours, I think I counted 7 people were seen. Initial triage usually takes 5 mins. Most of the time the initial triage nurse was wandering around. During the same night I saw one nurse keep popping outside every 30-45 mins for a cigarette and another nurse was carrying chairs around the department. They were acting like there weren't patients waiting.
I can only wonder what happens across the rest of the NHS.
I love what the NHS stands for but it's so badly managed.
Dyson fans. Infection control, bladeless. -A few years ago I walked in to A&E during summer. Behind the reception desk they had a Dyson air chiller, the type which cost £300+. It could have been a staff member's personal one, but I doubt it.
-Where I used to live, the local A&E deliberately hired multiple receptionists to work the twilight shift. Later I wrote a letter and was officially informed this was for security reasons (even though the receptionist was behind a screen and there's security officers around). So they spend £20k a year to chat with someone all night.
-I was at A&E with a relative during the time of the junior doctor strikes (but this shouldn't be related). We waited for 3 hours just to see the initial triage nurse. During those 3 hours, I think I counted 7 people were seen. Initial triage usually takes 5 mins. Most of the time the initial triage nurse was wandering around. During the same night I saw one nurse keep popping outside every 30-45 mins for a cigarette and another nurse was carrying chairs around the department. They were acting like there weren't patients waiting.
I can only wonder what happens across the rest of the NHS.
I love what the NHS stands for but it's so badly managed.
You could spend another £500b per annum on the NHS trust and still the same issues would exist.
It would just pay for new better equipment to diagnose and treat patients better.
Then as someone said you’ll be treating 90 year old folks and prolonging their lives the same as what we do for 70 year olds at the moment.
We could treat most things, get the drugs that ICB’s won’t fund and buy higher quality clinical products.
IT systems all updates, Estate all improved etc etc.
It would just pay for new better equipment to diagnose and treat patients better.
Then as someone said you’ll be treating 90 year old folks and prolonging their lives the same as what we do for 70 year olds at the moment.
We could treat most things, get the drugs that ICB’s won’t fund and buy higher quality clinical products.
IT systems all updates, Estate all improved etc etc.
740EVTORQUES said:
Megaflow said:
The answers to all of those has been proven time and time again the private sector. I worked for a company that was on this continual boom and bust cycle. We made money for a couple of years, everybody would get carried away spunk a load of money up the wall, then we'd start to lose again.
A new GM came on board and started a program called 'Turnaround' it was a brutal 2 years, every single expenditure was analysed and its value to the business calculated. We consolidated office space, everyone gave up their desks for ones half the size, to enable that to happen.
It worked, we went from boom and bust to steady continual growth and a few years after that when we had proved it worked, the parent company allowed us to invest a 9 figure sum in two new products that have enabled that growth to continue.
Savings through efficiencies happen every day in the private sector (I feel at this point I should remind people I have *never* said we need the private sector in the NHS, because that will end up with a US system) because that is how business works. The NHS needs to think more like the private sector. As an example a box of paracetamol costs literally pence in the supermarkets, you can bet the NHS is paying more, even though it is a bigger organisation and should in theory have even more buying power than the supermarkets.
For example, as I type this, lets assume the NHS has a budget of £250bn but with a bonus system in it, every thing under that £250bn that is not spent, gets split between the employees as a bonus. I bet they become a lot more interest in efficiencies and waste then, because that is how the private sector works.
PS: I spent 25 years as a cost engineer, and I'd love to get started on eifficieny savings in the NHS, I reckon I'd have a field day!
The trouble is that you fundamentally can't treat healthcare in the same way as industry or retail or whatever. The drivers, motivations and rewards are just not the same. A new GM came on board and started a program called 'Turnaround' it was a brutal 2 years, every single expenditure was analysed and its value to the business calculated. We consolidated office space, everyone gave up their desks for ones half the size, to enable that to happen.
It worked, we went from boom and bust to steady continual growth and a few years after that when we had proved it worked, the parent company allowed us to invest a 9 figure sum in two new products that have enabled that growth to continue.
Savings through efficiencies happen every day in the private sector (I feel at this point I should remind people I have *never* said we need the private sector in the NHS, because that will end up with a US system) because that is how business works. The NHS needs to think more like the private sector. As an example a box of paracetamol costs literally pence in the supermarkets, you can bet the NHS is paying more, even though it is a bigger organisation and should in theory have even more buying power than the supermarkets.
For example, as I type this, lets assume the NHS has a budget of £250bn but with a bonus system in it, every thing under that £250bn that is not spent, gets split between the employees as a bonus. I bet they become a lot more interest in efficiencies and waste then, because that is how the private sector works.
PS: I spent 25 years as a cost engineer, and I'd love to get started on eifficieny savings in the NHS, I reckon I'd have a field day!
Edited by Megaflow on Friday 28th June 15:18
The output in healthcare is limitation or better prevention of suffering and death, and while you can cost interventions, you can't, at least in our society, really limit them. At the same time, the needs and costs rise, and the impact of technology perversely makes more conditions survivable and thus more not less expensive. At the same time you have population that sees it as a right (rightly so IMO) not a privilege to access such care, and a workforce that is driven by outcomes not profit or efficiency.
How are you to drive efficiency when there is always a tension between doing the best for an individual patient, re-enforced by a personal, moral or medico-legal drive and the imperative to be efficient with resources?
What does efficiency even mean when in many cases the resource use is essentially open ended? I've seen many £100,000's of pounds spent on one patient in a way that while morally and ethically justifiable, makes no business sense.
I have no doubt that you would like to apply private sector style reforms to the NHS, but I also have no doubt, having witnessed many attempts at this from very bright people from the 'big four' and others, that you would not succeed if you do not accept that healthcare can never be a business in the way you are suggesting.
If healthcare followed more normal business practices, then we would insist on levels of resilience that would require additional layers of staff, backups of equipment etc that woudl be ruinously expensive, the NHS operates on a knife edge. You can see this by the effect of the recent cyber-attack in London, there's no spare capacity to deal with black swan events like this as the system is pushed to the limit all the time. Where is the efficiency to come from?
You describe a model where material costs reduce by 3% PA, how about one where costs increase by 10-15% PA as the work becomes harder and more complex?
The fact that all healthcare systems across the developed world are under various forms of stress irrespective of how they are organised tells you that NHS efficiency is very much not the bigger picture.
(Before you ask, private healthcare only works as a wort of business as it is a very selected profitable subset of the whole need and is not comparable.)
I do hope that Labour have learned the lessons of the past 15-20 years and do not try once again to impose private sector solutions as that will be doomed to failure, it's been tried so many times already.
There are services like A&E that cost a fortune to run and not profitable hence why the private sector have never been involved.
Megaflow said:
For example, as I type this, lets assume the NHS has a budget of £250bn but with a bonus system in it, every thing under that £250bn that is not spent, gets split between the employees as a bonus. I bet they become a lot more interest in efficiencies and waste then, because that is how the private sector works.
Nah. Knowing some people in the NHS they'd spend nothingYou need their bonuses linked to some sort of quality of service. Waiting times, satisfaction etc.
Say the NHS budget is £240bn. You hold back £20bn for bonuses. Then you split it based on how each hospital has performed. Maybe even split it down to each team. I don't know enough about the NHS how to split it, but you get the idea.
Downward said:
tele_lover said:
A few random points about my encounters with A&E:
-A few years ago I walked in to A&E during summer. Behind the reception desk they had a Dyson air chiller, the type which cost £300+. It could have been a staff member's personal one, but I doubt it.
-Where I used to live, the local A&E deliberately hired multiple receptionists to work the twilight shift. Later I wrote a letter and was officially informed this was for security reasons (even though the receptionist was behind a screen and there's security officers around). So they spend £20k a year to chat with someone all night.
-I was at A&E with a relative during the time of the junior doctor strikes (but this shouldn't be related). We waited for 3 hours just to see the initial triage nurse. During those 3 hours, I think I counted 7 people were seen. Initial triage usually takes 5 mins. Most of the time the initial triage nurse was wandering around. During the same night I saw one nurse keep popping outside every 30-45 mins for a cigarette and another nurse was carrying chairs around the department. They were acting like there weren't patients waiting.
I can only wonder what happens across the rest of the NHS.
I love what the NHS stands for but it's so badly managed.
Dyson fans. Infection control, bladeless. -A few years ago I walked in to A&E during summer. Behind the reception desk they had a Dyson air chiller, the type which cost £300+. It could have been a staff member's personal one, but I doubt it.
-Where I used to live, the local A&E deliberately hired multiple receptionists to work the twilight shift. Later I wrote a letter and was officially informed this was for security reasons (even though the receptionist was behind a screen and there's security officers around). So they spend £20k a year to chat with someone all night.
-I was at A&E with a relative during the time of the junior doctor strikes (but this shouldn't be related). We waited for 3 hours just to see the initial triage nurse. During those 3 hours, I think I counted 7 people were seen. Initial triage usually takes 5 mins. Most of the time the initial triage nurse was wandering around. During the same night I saw one nurse keep popping outside every 30-45 mins for a cigarette and another nurse was carrying chairs around the department. They were acting like there weren't patients waiting.
I can only wonder what happens across the rest of the NHS.
I love what the NHS stands for but it's so badly managed.
Or just be brutal in rationing care. The ‘State’ has no real interest in keeping old people alive, so have a cut off for access to NHS that is the same as the retirement age. As much of the cost is in the last few months of people’s lives, reallocate this to ongoing health care for working age people (annual medicals, incentives to get fit etc)
Of course, voters have to accept that their mum might get killed from a flu, or not their broken hip fixed unless they go private but them’s the breaks.
Of course, voters have to accept that their mum might get killed from a flu, or not their broken hip fixed unless they go private but them’s the breaks.
740EVTORQUES said:
Quite apart from the moral aspect, more older people vote than younger this isn’t likely to happen, remember how we turned off the economy largely to protect older people during COVID?
Yep, it’s not a serious suggestion, more in line with Swift’s ‘eat the babies’ during an Irish famine. But when you look at spend vs age/ expected number of years left, it’s the first thing a ‘management’ approach would take. Why are so many resources going to customers that don’t have much of a ‘lifetime customer value’ left… tele_lover said:
Megaflow said:
For example, as I type this, lets assume the NHS has a budget of £250bn but with a bonus system in it, every thing under that £250bn that is not spent, gets split between the employees as a bonus. I bet they become a lot more interest in efficiencies and waste then, because that is how the private sector works.
Nah. Knowing some people in the NHS they'd spend nothingYou need their bonuses linked to some sort of quality of service. Waiting times, satisfaction etc.
Say the NHS budget is £240bn. You hold back £20bn for bonuses. Then you split it based on how each hospital has performed. Maybe even split it down to each team. I don't know enough about the NHS how to split it, but you get the idea.
Remember the 18 week waiting pledge under Labour? I was in exactly this position, I caused a couple of ‘breeches’ cancelling planned ops to operate on an urgent patient at high risk of dying without surgery. (He was a delightful 95 year old)
Got an earful from a manager because they were performance measured against these targets but was I able to ignore this. What if the whole team was financially motivated around a target like this though but the Doc alone has a medicolegal imperative to do the best?
Not saying that staff shouldn’t be appraised to make sure they are doing a good job but you can see how private sector style performance related pay in the NHS can easily turn the wrong way.
Don’t you want your medical staff to be prioritising what is good for you not what is good for them?
(I got grateful Christmas cards from him for 5 years till he passed away incidentally.)
The NHS was never not in crisis.
The Beveridge Report of 1942 informed the thinking that led to the formation of the welfare state and ultimately, in 1948, the NHS. Unfortunately the report was flawed and within 12 months the NHS was in a financial deficit. That, coupled with ever increasing demand from an expanding population, has resulted in a service that is doomed to failure.
That the present UK healthcare system is unsustainable is blindingly obvious but no government will ever grow the balls to really tackle it. To do so would be political suicide, any government that attempted to do so would be voted out before it stood a chance of succeeding.
The Beveridge Report of 1942 informed the thinking that led to the formation of the welfare state and ultimately, in 1948, the NHS. Unfortunately the report was flawed and within 12 months the NHS was in a financial deficit. That, coupled with ever increasing demand from an expanding population, has resulted in a service that is doomed to failure.
That the present UK healthcare system is unsustainable is blindingly obvious but no government will ever grow the balls to really tackle it. To do so would be political suicide, any government that attempted to do so would be voted out before it stood a chance of succeeding.
740EVTORQUES said:
tele_lover said:
Megaflow said:
For example, as I type this, lets assume the NHS has a budget of £250bn but with a bonus system in it, every thing under that £250bn that is not spent, gets split between the employees as a bonus. I bet they become a lot more interest in efficiencies and waste then, because that is how the private sector works.
Nah. Knowing some people in the NHS they'd spend nothingYou need their bonuses linked to some sort of quality of service. Waiting times, satisfaction etc.
Say the NHS budget is £240bn. You hold back £20bn for bonuses. Then you split it based on how each hospital has performed. Maybe even split it down to each team. I don't know enough about the NHS how to split it, but you get the idea.
Remember the 18 week waiting pledge under Labour? I was in exactly this position, I caused a couple of ‘breeches’ cancelling planned ops to operate on an urgent patient at high risk of dying without surgery. (He was a delightful 95 year old)
Got an earful from a manager because they were performance measured against these targets but was I able to ignore this. What if the whole team was financially motivated around a target like this though but the Doc alone has a medicolegal imperative to do the best?
Not saying that staff shouldn’t be appraised to make sure they are doing a good job but you can see how private sector style performance related pay in the NHS can easily turn the wrong way.
Don’t you want your medical staff to be prioritising what is good for you not what is good for them?
(I got grateful Christmas cards from him for 5 years till he passed away incidentally.)
Or, how often did your situation occur? Was it often enough to affect a year of performance?
No, but the target was no 18 week waiters. It always creates an issue when the real solution is more capacity.
Another example, to avoid ambulances queuing outside A&E, patients are moved to ‘board’ on a ward as extras, one per ward, to free up space in A&E,
They’re not being treated and are ‘extra’ so there aren’t staff to look after them but it superficially addresses the A&E queue which is the political priority.
Its really, really hard not to incentivise these sorts of things when you set narrow targets which is why medics are so distrustful if any kind of management performance monitoring, prefering the traditional imperative of clinical priorities.
There do need to be incentives, but I’ve no idea how to structure them to avoid these issues, it’s hard.
(You can view this all as just bad management, setting the wrong targets, and I don’t disagree with that by the way, but it’s a common theme in healthcare when politicians try to manage clinicians.)
Another example, to avoid ambulances queuing outside A&E, patients are moved to ‘board’ on a ward as extras, one per ward, to free up space in A&E,
They’re not being treated and are ‘extra’ so there aren’t staff to look after them but it superficially addresses the A&E queue which is the political priority.
Its really, really hard not to incentivise these sorts of things when you set narrow targets which is why medics are so distrustful if any kind of management performance monitoring, prefering the traditional imperative of clinical priorities.
There do need to be incentives, but I’ve no idea how to structure them to avoid these issues, it’s hard.
(You can view this all as just bad management, setting the wrong targets, and I don’t disagree with that by the way, but it’s a common theme in healthcare when politicians try to manage clinicians.)
Edited by 740EVTORQUES on Saturday 29th June 08:51
Downward said:
Exactly if you run a bakery and your oven breaks down Friday night you don’t open the shop Saturday and pay all your staff to stand around doing nothing.
There are services like A&E that cost a fortune to run and not profitable hence why the private sector have never been involved.
There’s private A&E and urgent care centres in several EU countries that work well and divert those with private healthcare away from state hospitals There are services like A&E that cost a fortune to run and not profitable hence why the private sector have never been involved.
I don’t see why a similar system wouldn’t work in the U.K.
Earthdweller said:
Downward said:
Exactly if you run a bakery and your oven breaks down Friday night you don’t open the shop Saturday and pay all your staff to stand around doing nothing.
There are services like A&E that cost a fortune to run and not profitable hence why the private sector have never been involved.
There’s private A&E and urgent care centres in several EU countries that work well and divert those with private healthcare away from state hospitals There are services like A&E that cost a fortune to run and not profitable hence why the private sector have never been involved.
I don’t see why a similar system wouldn’t work in the U.K.
Because you can only do that if private hospitals are large broad speciality institutions as they are in the USA.
It’s a totally different system to how private healthcare works in the U.K. where private hospitals are much smaller and narrow in focus and lack the facilities of NHS hospitals for complex and especially emergency care.
You can only support such a system of large private hospitals where a very significant proportion of the population has insurance. And when you get to this stage you leave a underclass that are consigned to the (now politically abandoned as the people with a voice are catered for well by the private sector) rump public service - as in the USA.
Very few people would hold that out as a model we want to follow.
Remember most doctors would be massively better off in a private service, where salaries are generally much higher. Doctors arguing for the NHS is not self serving, quite the reverse.
Edited by 740EVTORQUES on Saturday 29th June 11:17
RSTurboPaul said:
Downward said:
tele_lover said:
A few random points about my encounters with A&E:
-A few years ago I walked in to A&E during summer. Behind the reception desk they had a Dyson air chiller, the type which cost £300+. It could have been a staff member's personal one, but I doubt it.
-Where I used to live, the local A&E deliberately hired multiple receptionists to work the twilight shift. Later I wrote a letter and was officially informed this was for security reasons (even though the receptionist was behind a screen and there's security officers around). So they spend £20k a year to chat with someone all night.
-I was at A&E with a relative during the time of the junior doctor strikes (but this shouldn't be related). We waited for 3 hours just to see the initial triage nurse. During those 3 hours, I think I counted 7 people were seen. Initial triage usually takes 5 mins. Most of the time the initial triage nurse was wandering around. During the same night I saw one nurse keep popping outside every 30-45 mins for a cigarette and another nurse was carrying chairs around the department. They were acting like there weren't patients waiting.
I can only wonder what happens across the rest of the NHS.
I love what the NHS stands for but it's so badly managed.
Dyson fans. Infection control, bladeless. -A few years ago I walked in to A&E during summer. Behind the reception desk they had a Dyson air chiller, the type which cost £300+. It could have been a staff member's personal one, but I doubt it.
-Where I used to live, the local A&E deliberately hired multiple receptionists to work the twilight shift. Later I wrote a letter and was officially informed this was for security reasons (even though the receptionist was behind a screen and there's security officers around). So they spend £20k a year to chat with someone all night.
-I was at A&E with a relative during the time of the junior doctor strikes (but this shouldn't be related). We waited for 3 hours just to see the initial triage nurse. During those 3 hours, I think I counted 7 people were seen. Initial triage usually takes 5 mins. Most of the time the initial triage nurse was wandering around. During the same night I saw one nurse keep popping outside every 30-45 mins for a cigarette and another nurse was carrying chairs around the department. They were acting like there weren't patients waiting.
I can only wonder what happens across the rest of the NHS.
I love what the NHS stands for but it's so badly managed.
Our Children’s and Cancer services are full of stuff that wouldn’t normally be funded by the NHS, as that’s where most of the donations come to.
wisbech said:
740EVTORQUES said:
Quite apart from the moral aspect, more older people vote than younger this isn’t likely to happen, remember how we turned off the economy largely to protect older people during COVID?
Yep, it’s not a serious suggestion, more in line with Swift’s ‘eat the babies’ during an Irish famine. But when you look at spend vs age/ expected number of years left, it’s the first thing a ‘management’ approach would take. Why are so many resources going to customers that don’t have much of a ‘lifetime customer value’ left… RSTurboPaul said:
wisbech said:
740EVTORQUES said:
Quite apart from the moral aspect, more older people vote than younger this isn’t likely to happen, remember how we turned off the economy largely to protect older people during COVID?
Yep, it’s not a serious suggestion, more in line with Swift’s ‘eat the babies’ during an Irish famine. But when you look at spend vs age/ expected number of years left, it’s the first thing a ‘management’ approach would take. Why are so many resources going to customers that don’t have much of a ‘lifetime customer value’ left… Doctors don’t employ QALYS in clinical practice generally.
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