Monday, 30 June 2008

More NHS Spaghetti anyone?

The management structure of the NHS has always reminded me of a huge pile of spaghetti. The shape is generally conical, like almost every management structure, but so convoluted are the workings between apex and base that trying to track where the money goes or how the ideas move is like tracing the strands of spaghetti as they wind in-out, up-down and around. Some strands are long, some small, some thickly coated with sauce, some almost bare, and no one can possibly work out how the strands interweave without taking the whole thing apart. It is a complete mess and mangle.

Today we learned of Lord Darzi's new plan for the NHS. Not surprisingly much of it is just window dressing wrapped in management speak: "personal care plans", "dashboard", "quality accounts". We know the result of this nonsense already - more form-filling for doctors and nurses, more managers required to audit the forms, more number crunching from Whitehall and an annual statement from the government that things have improved since this time last year. There is no wide-ranging proposal to address the biggest problem with the NHS - government interference in a professional service for political purposes.

We recently saw the most blatant example of this type of interference that i can remember, the Deep Clean. No less than £57million of additional money was promised to pay for all hospitals to be cleaned thoroughly in an attempt to counter the spread of MRSA and c. difficile infections. True though it is that £57m is a drop in the NHS ocean, it is still 57m quid thrown at a gimmick designed purely to show that the government was doing something. Not surprisingly the Treasury did not fund the whole £57m as it had originally promised and the total spent on the project was more than £65m, only about 60% of which was spent on cleaning, the balance being sucked into the bottomless pit of administration. Little effect on infection rates appears to have resulted but a big dent was made in existing hospital budgets. It was, like all such knee-jerk gimmicks, counterproductive. Even if infection rates had been cut substantially it was a one-off exercise and did not look to the main causes of the problem.

Of far greater benefit would have been the introduction of simple old-fashioned accountability. The person in charge of a hospital ward should be accountable for its cleanliness. Ask any nurse with 30 years' experience and he or she will tell you that when they started work the wards were spotless. Matron was responsible. She could lose her whole career if the state of her ward caused illness or death and she made sure that those under her command cleaned everything thoroughly every day. Now who is responsible? The chief nurse no longer has control because he or she is given priorities based on government diktat by the ward manager, complying with the latest priority from Whitehall takes priority over other spending. The ward manager no longer has control because he or she is simply doing what has been passed down the chain; the same for the department manager, the hospital chief executive and the area trust. By the time we reach that level everything is so remote from the dirty ward that it doesn't matter how many more people can pass the buck up the chain. No one is directly responsible so one possible incentive to cleanliness is missing.

There is, of course, a simple solution; move cleanliness of wards to the top of the list of priorities and then apportion the remaining budget between the many other competing claims for funding. That is how things are done in private hospitals and the levels of infection are negligible. But to approach it in that way is impossible because the government has set targets for waiting times and failure to meet those targets will cost votes. Because the government might suffer, so heavy sanctions can be applied to a hospital or trust which misses the targets. Again political interference gets in the way of doing things properly.

Every private sector business which provides goods or services to the public looks to delivery first and tailors its operation to suit the needs of the customer. A company which manufactures hospital beds must make beds which hospitals want to buy, namely beds which have the features required by clinicians for the benefit of the patients. The customer is asked what is needed and the manufacturer must make it in order to stay in business. If the bed maker operated like the NHS the managing director would decide on the design and require that everyone should have access to just that one design. It is a recipe for commercial disaster but within the NHS it would be claimed to be a great improvement because there is no "post-code lottery" over which patients get the best beds.

Lord Darzi goes a small way to addressing this problem in his proposal for a pilot scheme by which people with long-term health problems are given control over their own "personal care budget" (another ghastly slogan, but the benefit is in the substance not the slogan). We wait to see just how much control the patient will have but it is a welcome first step towards making the service respond to the needs of the customer rather than the political interests of the governing party.

Much more will be needed before the NHS turns from a pile of spaghetti into an efficient organisation ... from little acorns etc.

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