A Letter to my MP

Dear Dianne Abbott,

After much consideration, I have decided that it really is about time that you, as my MP, put my interests at the forefront of your thinking. Gone are the days when every four years or so, you could break off from your busy schedule of evening television programmes to remind us all just how great you have been at doing whatever it is that you do. I think it's about time that you put us, your constituents, at the heart of your thinking.

Recently, I got together a group of citizens and we held a "Citizens Summit" at 'The Fox Reformed' on Stoke Newington Church Street. I asked them what they would like to see from you, their MP. Their responses were interesting and I have sifted through them to find those that are neither physically impossible nor morally repugnant. There were a few left.

First of all, we want to see you at a time and place that is convenient to us. I work away from Hackney so I expect you will make reciprocal arrangements with your Newham colleague so I can visit him during my lunch hour. Also, I'm taking the mother-in-law to Prestatyn in the new year, so I would be grateful for contact details of your colleague there just in case I feel like an evening chat.

Now your website doesn't actually give details of your constituency "surgeries" (I think that's the term) but I do have a number of irritating minor ailments, so I need to know where I can make several appointments stretching through Christmas and the New year. At the same time, I wish to be reassured that should I have a short-term crisis with my brown recycling bin, you will be on hand to get things done. Now I just thought I should warn you that I may, or may not keep these appointments.

When I do visit you, it may be that I will need to speak to someone else as well. I would like you immediately to make me an appointment with that person, again at a time and on a date of my choice. Of course, I would expect you to confirm it in writing.

Finally, I am enclosing my proposals for "Payment by Results". This exciting and radical plan represents the biggest shake up in parliamentary procedure since Dennis Skinner said something constructive and no more that mildly offensive. Quite simply, MPs will be reimbursed on the basis of "outcomes" rather than at present. I suggest fifty five quid for a consultation; twenty pounds for writing a letter; let's say thirty quid for each day in excess of fifty days a year that you actually turn up at Westminster and say something .. ( I was about to say "useful" but let's not run before we walk).

Even more exciting will be the Enhanced Payments to which you will be entitled once we have completed a survey of your constituents. We will mail a number of them at random and ask them questions about what they think of you and your effectiveness as their democratic champion. I attach a sample questionnaire but suggest that you pay it little heed. It's not the one we will actually send out to people.

Finally let me offer you some soothing words about those dreadful rumours that have been circulating. Of course at this stage, nothing can be ruled out but I am happy to reiterate that at this moment in time we have no plans to introduce private contractors into the House of Commons to take over constituencies where performance may be below par. That doesn't mean to say that we won't be pushing to expand those parliamentary walk in centres. You know the ones. You turn up; they listen attentively; and then they tell you that you need to see your own MP for that particular problem. Whilst they don't actually add much value, we do think that they sound good and we'll get lots of brownie points from our friends and neighbours.

I look forward to seeing you next Saturday afternoon at about six-ish. I have this nasty rash on my front drive .....

Do shoot the messenger. Just make sure it's the right one.

The real problem with a well-functioning democracy is that our representatives need you and me to re-elect them every now and again. This would be more than a tad difficult unless he or she can convince you that: (a) they're doing a good job; and, (b) their opponents would do it worse. Recent governments have perfected the art of making all news sound good or as we all know, "finding good days to bury bad news".
The NHS has been until now a rich vein of positive-sounding anecdotes. So it should be considering how much of our money they've thrown at it. I just wish they would act more responsibly and consider the wider implications of the claims they make.
It's all very well managing patients' expectations to make it sound as if things are now under control - "the NHS is safe with us" - "an appointment when and where you want". The whole "spin thing" depends on Joe Public not reading the small print and by and large he doesn't. At least, not until he walks up to the GP reception desk and asks for a hospital appointment on Thursday at the hospital near his Mum in Cardiff where he's staying for a week or so. It's left to us to explain the small print.
You can understand why Mr Public is puzzled. He's been told: "when you want it". He's not been told that he can choose, but it is only from any one of a number of appointments all of which are three months or more from now. He's also more than little pissed off that he can choose to go where he wants but only as long as it's to any one of four local hospitals. Cardiff is in another country as is Edinburgh and Belfast. As usual, it's the GPs' reception team that have to explain the precise realities and how they vary from the crowing and the disingenuous claims being made for purely political gain.

Good Housekeeping

Imagine you are manager of your household's finances. Your spouse tells you that you will receive £xoo each month to keep you both in food, bog rolls, cleaning stuff as well as pay the gas and electricity bills and all the other domestic minutiae. The amount on offer is barely sufficient but, with careful management and a keen eye on the money-off bargains and the dented tins shelf at your local supermarket, you reckon you'll get through the month.

With me so far? Now imagine it's the twentieth of the month.

Your spouse tells you that it isn't £x00 pounds after all. It's £x00 less £250. Oh and by the way, that applies to last month as well so you owe £250 in arrears and the housekeeping fund is empty.

How do would you feel?

Welcome to the wacky world of NHS financial planning.

Free for All

It seems to me that taxation is a kind of unwritten agreement between me and the politicians. I agree to give the money and in return they give me and mine with all the sorts of stuff that can only be provided by pooling my money with every other citizen's money. Our A&E services are available free to anyone who really needs them and this is a very good thing. I wouldn't want it any other way. GP services are another matter entirely.
GPs are there to provide the basic support for our residents in the management of their healthcare and to help them when they need medical help. It's "free" but only to the individual. The NHS bill in our borough alone is well over a billion pounds a year. That's funded by our taxes (I actually wish people would call it "paid for"). As I said, I am happy that they use some of my money to provide emergency medical services to anyone in need. I am less than happy that these same politicans seem quite happy to provide the full range of NHS benefits to anyone that walks up to the counter and asks for them.
Before you jump to label me some sort of fascist, racist uncaring hard-hearted xenophobe, let me acknowledge that if someone is in our country and is unwell, I am glad that we are compassionate enough to ensure that they are treated.
I am a relative newcomer to the NHS - I'm over half way through my fourth year. I work in a GP practice that is popular with most of its patients and our GPs are an amazingly dedicated bunch of extraordinarily nice people. From my perspective, our patients are really fortunate in healthcare terms to be living in our neck of the woods. When I first started working for them, I found it almost impossible to comprehend how easy it was for anybody, and I really mean anybody, to obtain NHS care from them. There is no working system that checks to see if a person is entitled to NHS care. I found it incredible at the start and still do.
The only real determinant of entitlement is whether or not the applicant is "ordinarily resident". This is a common law term which is the Government explains: "The term “ordinarily resident” is not defined, but its established meaning is that a person is ordinarily resident if they are normally residing in the United Kingdom (apart from temporary or occasional absences), and their residence here has been adopted voluntarily and for settled purposes as part of the regular order of their life for the time being."
In other words, you can turn up at our reception and say that you have come here voluntarily and for settled purposes etc. Nowhere does it say that you are entitled to live here. Nowhere does it say that you have to work, pay taxes, be a citizen of the European Union.
It didn't seem fair to me then and doesn't feel fair now. I know that we register "medical tourists" all the time. We provide NHS prescriptions for people with long-term chronic conditions who have arrived to stay with relatives or friends and who have no medication and no medical insurance. All they have to say is that they have come to live here. I am not allowed to check their immigration status and I have no way of checking their entitlement. Health service regulations on the subject provide complete "decision tree" guidance at the bottom of which is "if the person still appears not be entitled, the person can still be registered at the GP's discretion". In these litigious times, witholding medical treatment can be ruinous to a GPs bank balance so the medical insurers tell us to register them.
The upshot is that if you can get through immigration at Heathrow, you will get "paid for" NHS care. It's as simple as that whatever the government might say otherwise.

Let's All Focus

You will pleased to note that the NHS decided to concentrate its efforts.

"Other key themes to emerge (sic) from the consultation process were: " ...investing in services for people whose health and well-being may be at greater risk, for example: minority ethnic groups, teenagers, and people on low income."

Well let me see. The population of England and Wales in 2001 was recorded as 49,138,831 people.

• Sixteen percent of these are aged 65+ and we can hardly leave them out. That's 7,862,213 pensioners.
• Add to that the thirteen percent of the population who are teenagers and that's another 6,642,321.
• That leaves 34,634,405 of whom eight per cent come from ethnic minorities - 2,770,752.

I could go on but simply add on pregnant women and those in post-natal care, the long-term chronic sick, victims of accidents and crimes and somehow the focus starts to become a tad blurred.

Dont forget that since 43% of UK NHS spending goes to the elderly, that leaves just 57% of funding for the rest of us 84% of the population.

It's the sort of gibberish that is pleasing to the ear and meaningless to the wallet. Do we really live in a society where teenagers are counted as " ... people whose health and well-being may be at greater risk"? If so, we are all deeply in the proverbial.

"Your health, Your care, Your say" but who PAYS?

Read the new government White Paper? With its zippy touchy feeley title, it can only be a political winner. This government "listens". It puts us first. It drives me bonkers.

The whole "listening exercise" with its preposterous "citizens summit" and its "panels of stakeholders" seems to me to be a complete abrogation of strategic management by the Department of Health and the National Health Service. Don't tell me that it was worthwhile because it was important to listen to what the public wants. That has as much value as asking my granchildren to design the menu for school dinners. Perhaps I can suggest a new title? "What shall we promise you to get your vote?"

If the mercury wasn't already popping out of the top of the sphygmomawotsit, to conveniently forget to ask these wise public people to consider costs makes me really angry. Of course I want to visit my doctor when I'm ill, any time day or night, weekends, bank holidays, when I'm doing the weekly shop. Of course I want all the services I might need all installed nearby just on the offchance I have a knee strain or a rather unsightly rash. I'll take it all as long as it doesn't cost me anything.

Staying open a bit longer is simple. All you need to do is .... well, stay open a bit longer? Oh, you then have to either recruit additional staff or pay overtime. Then there's the security guard since there are some strange night dwellers where we live. Oh and since we are a service, we have to provide sufficient staff to guarantee the service despite sickness, holidays and absenteeism. So where's the problem? A receptionist or two, a security guard, a doctor and a nurse should do it. Oh and a cleaner. Maybe the caretaker might not like working longer hours but it's probably OK.

The whole thing is a disgraceful piece of political posturing done at the taxpayers expense and which has served to raise expectations without proper regard to the sensible use of NHS funds. We need an honest and open debate about the true and ever-rising costs of providing complex and costly drugs and treatments and how this can be properly funded. Just like twenty years ago we needed the same thing about pensions. We didn't get it then and it isn't happening now. Instead we get platitudes, slogans and expensive and meaningless Labour propaganda dressed up as national policy.

Chronic New Initiative Syndrome

It seems absurd that the same government that spouts so much guff about "joined up care", "integrated patient care pathways" and other equally noble sounding objectives, is the same lot that bombards from all points of the compass with new initiatives. One of this month's flavours tastes of "Long Term Conditions". Pareto still rules and the "80/20" rule is as valid for patients and costs as it is in commerce for customers and revenues.

Some patients have permanent health problems that will require medical support for the rest of their lives. They represent the largest single cost to the taxpayer so getting their care wrong will in turn be the largest single waste of NHS funds. "Long-term conditions" now attracts the attention of The Management. Reducing 5% of the biggest cost saves billions of pounds. So far so good. As always, it is in the execution that all hope of simplicity is abandoned.

Down in our neck of the woods, we have now had about four separate initiatives "addressing the issues" of patients with long-term conditions. Teams of well-meaning, kindly people come and tell us why things are going to be ... better .... connected ..... coordinated .... None of them talk each other. All of them are only funded for a couple of years (as a trial). All of them are designed to provide "navigators" or "modern matrons" or "enhanced nursing services" and each of them will provide a single?? point of contact for the patient. If only.

They are, in essence, additional and duplicate layers helping these patients to claim benefits, arranging care from social services and generally trying to be helpful. Patients (or as the new breed insist, "clients") get to know their new navigator/coordinator/matron/ whatever and start to build a relationship with them. The professional spends most of the first year learning how local services and local variations of national services are provided. They also raise the expectations of their "clients". Then the funding runs out, or there aren't enough staff because demand was underestimated, or the carer, navigator, advocate, matron, or whatever has left and "we're recruiting a replacement soon".

I like to think that sooner or later, Whitehall will realise that asking those responsible for the poor execution of health delivery (which means the poor management of health delivery) to deliver new and different services is as daft as asking the Child Support Agency to help single parents - and how daft is that?

Creeping Policies

Rarely does a week pass without me being required to absorb and react to some new policy or other. The variety is bemusing and the volume is breathtaking. Being an awkward sort of sod, every now and again I ask:

"Why?".

If an answer appears (sometimes), and if it makes sense (rarely), the usual justification is "Standards for Better Health" which is a government White Paper. This justification is almost inevitably unfounded. Here's a typical example: Last year we were instructed by our PCT to obtain Criminal Records Bureau (CRB) checks on all our employees. "Its a new policy".

"Why?"
"To protect children and vulnerable adults and anyway, it's part of Standards for Better Health. We're checking all our staff; it's best practice."

"Please show me where it says that."
(Six months later) "Um, er, it doesn't but it's good practice and that's why we're doing all our staff."

"These checks cost £36 a pop. Why should I do this for my caretaker and the lady that hoovers reception?"

(Three months later)"Please answer the last question"
"Um, actually we've stopped checking everyone because we're short of money and it doesn't make sense to do everyone."

"Now please tell me what I do if someone has a criminal record. Your policy doesn't mention that!"
"Well, it all depends"

I won't go on. It's too painful but it is the typical approach of our so-called managers. They are quite happy to spend the best part of £20,000 of someone else's money rather than think something through. When challenged, they waffle on about putting patients first when what they mean is avoiding acting like a competent manager and making sensible decisions. If there is a micrometre of doubt, they'll spend the money. After all, it's not real money, is it? It's certainly not theirs.

Good for You Patricia

The dust has settled and they've swept away the debris from the annual conferences of Nurses and Unison (the health workers' union). The Secretary of State survived her "ordeal" of heckling, jeering and slow handclaps. Everyone can be pleased and none more so than Her Secretaryship. Frankly, anyone who has shimmered her way so far up the greasy pole would find being politely heckled by nurses about as awful as not having the correct change for a newspaper. In the meantime, her Macmillan-like "best year ever" attack served its purpose.

Imagine that it's you sitting in Health HQ, knowing that the nurses and the unions are going to make, and the press will be delighed to print the headlines about how bad it all is. Attack is still often the best means of defence and that's exactly what the Mem Sahib did. She set the agenda and no matter how much ridicule her attack generated, it still took the wind out of the sails of her opponents. Now that's what I call effective senior management!

The Deputy Prime Minister's troubles also wiped the debate completely from the public's low-capacity consciousness too. Who say's "It's an ill wind ..."?

How Many - Deja Vu?

I thought I would get ahead of the game. Everybody tells me that the Avian Flu pandemic is a matter of when and not if. Some time ago those that carve the stone tablets sent me a sample "Flu Pandemic Information Pack" containing a range of publications. Some were aimed at clinicians, some for patients, and there were nice big posters inviting patients to "ask for further information". Well, thinks I, since I have 14,000 patients and a "churn" of 20% in our transient community, I'd better ask for 5,000 of the patient stuff and enough of the clinical stuff for our fifteen health care professionals (a new Labour phrase that always leaves me wondering who are the health care amateurs?).

On to the NHS order line.

I want 5,000 of these please.
maximum order is 1,000.

I want 15 of these please.
maximum order is 2.

I want some of these and some of these
both out of stock. contact us at a later date.

The "how to communicate effectively about the pandemic " recommendation is to "let the patients know early". Someone, somewhere is Healthquarters is sitting back thinking that they have got the information flowing. I think the word trickle might suit?

I'd swap a tonne of management

It is fashionable to complain that the NHS has spent much of the extra funding provided over the past few years on recruiting loads of managers. Like most "well know facts" there is some truth in it. I should know since I am one of 'em. Irrespective of the 'new vs old' chestnut, one feature of most NHS management that does get me down is how little leadership they provide. It is a difficult time in the NHS. This government says it is transforming the way everything works through its major Payment by Results and Practice-based Commissioning programmes. There is a veritable avalanche of new stone tablets coming down from the Department of Health mountain. Changes and budget restrictions, new ways of working, breaking down established pathways from primary to secondary care; all these challenge staff at every level. It all cries out for positive leadership; someone who can inspire the team to rise to these challenges and achieve these ambitious goals.

From my lowly position, I can see none. I don't mean "not much" or "not enough". I mean NONE.

I'd settle for a few kilos of real leadership. Oh, I get lots of memos. I get loads of papers (usually cut and paste jobs from a DoH circular). I get deadlines and funding floors. I suppose I ought to feel pleased to be consulted (usually about how I feel about a decision that has already been made) and yet I'm not. Instead I feel that those that should be inspiring, motivating and making it happen, are behaving like any dictator worth his salt. They're hidden away down in the bunker sending out orders with no real idea what their troops are doing or if they're succeeding or not.

One thing's for sure; if we get it wrong, it won't be their fault. After all - they didn't get involved.

No it isn't difficult. It's simple.

Gaby Hinsliff is a journalist on The Observer (a UK Sunday newspaper). She was told to ring her hospital to arrange an appointment to see a consultant. Read how she got on here.

Don't think that this is unusual because it isn't. Whenever I challenge our local hospitals over their appointment booking telephone facilities (from the latin facile which means "easily, without difficulty") they patiently explain that it is very complicated and they receive lots of calls and they're awfully busy. It is delivered as though it explains why the service is so awful. Well actually Mr ever -so-patronising hospital grandee, it isn't difficult at all.

Lots of calls is lots of demand.
Lots of waiting equals no supply.
You're in charge of supply so do some.

If you don't know how, then get yourself a clipboard and (a) count the calls; (b) measure the average call duration and divide (a) by (b). Tweak the number for holidays and assumed sick leave and abracadabra. This is how many people you need answering the phones at any one time.

Drip by drip

In my current role, I am for the first time responsible for maintaining a fairly sizeable building and surrounding land that isn't my home. Looking after 'bogs and drains', fixing dripping taps and redecorating is time-consuming, fiddly and, not to put too fine a point on it, dull. Even worse, occasionally I have to deal with the Scarlet Pimpernel of English tradesmen - builders ("They seek him here ... "). It is ever so easy to do something more interesting, more intellectually challenging and involves finding or making money rather than spending it. Maintenance can so easily be deferred, ("if it ain't broke. don't fix it") especially when the same work will cost double the price that would be charged for"domestic" customers. But I buckle down and do it, reminding myself that the building is a huge financial asset and the cost of repairs will eventually come to those who wait.

Then there is the question of the appearance of the place. It may not need painting to maintain structural integrity, but high-use buildings soon start to look shoddy and tired. Aesthetic priorities are almost certain to be ignored when the finance director comes a'prowling to balance his books. These matters always come down to "balance".

What does frustate me greatly though, is the lavish expenditure on capital projects. When a new building is constructed, there is plenty of money for landscaping and stocking the gardens. There is no minimalist cost approach to fixtures and fittings so it seems fair to assume that these things are of merit. After all, there is plenty of second-hand furniture and office equipment around from whatever was closed to make way for the new build. Yet it seems that only new stuff will do. Clearly, "balance" doesn't quite extend this far. There is no money for flat screen displays for the waiting rooms in most of the estate; yet all the new build gets them.

"Ah, but that's Capital" say the wise people. "Ah" say I. In a commercial world, a company's freehold is a significant part of its capital and an important one to keep in good nick.

Look around next time you're visiting your local health facility. The state of deterioration is a straight-line function of the years that have passed since it was built. It needn't be so but bogs and drains just aren't the sort of thing that gets the local MP to cut ribbons or Chief Executive's their OBEs.

How Many?

For a year or more, the Department of Health has been touting Choose and Book as a good thing. In many ways they are correct. As a patient, I too would be impressed that, on being told that I am being referred to a consultant for a specialist opinion or for specialist treatment, I could "leave the surgery with an out-patient hospital appointment convenient to me". This post isn't about the merits or otherwise of "Choose and Book". It will happen and it's all our responsibility to make it work. To help us to do this, our local "lords and masters" have published a handy booklet for us to give to those whom we refer using the new system. It's jolly nice, informative and comprehensive. It will be a great help to patients. We are supposed to give one to each person whom we refer. For us, that's over 4,000 booklets each year. How many did they send us?

Ten.

Can't get any more: out of stock... No idea when there'll be any more... Not sure who ordered them... Try again in a month or so.

Can You See Me?

General practitioners (or GPs as we say in England) are some of the most advanced users of software to support them in their day-to-day clinics. Many practices use their computer-based medical record as the primary source of information about the patient sitting in front of them. An ingenious system of coding every sort of ailment, disease and unfortunate event that can befall man means that all sorts of useful data can be extracted and used to help better manage each patient's health. In fact they're so good, that our lords and masters want us to do more and more with them, mostly more good stuff. As with so many good things, there is a trade-off. Your doctor can't be looking at you if he is busy typing in his consultation notes and looking at patients is still an important part of any consultation.

My son had to visit his new GP for the first time recently. On being summoned, he entered the consulting room and held out his hand to shake that of the doctor. The doctor never looked up from the screen on which he was reading my son's summary. Instead he asked: "how are you?". Luckily my son was in one piece. Nothing was hanging off, exuding pus or bleeding over the floor so he didn't look as foolish as my son felt.

We should all remember that it is as important to look as to listen. Body language can tell much about the person that the words won't reveal on their own. If a patient limps in and sits down with a grimace, it wouldn't take much medical skill to see that there is something amiss, even if it isn't what the patient has come to talk about.

Then there is the question of plain good manners.

More of the Similar

Yesterday we reviewed with a number of your performance directors and choice leads, the best means of assuring readiness is genuine and reaffirmed the expectation that this is captured in a written form, practice by practice.

or ...

We met yesterday to decide how to make sure that you were all ready, and to agree what written evidence we will ask you to submit to prove it.

You couldn't make this up

Extract from a report by a Strategic Health Authority into progress made in implementing "Choose and Book". Ready?

"The key concern is that the added resources funding implementation teams expire this March, while local communities need to move from 2% electronic booking to the December target of 90%. Communities are at various stages of identifying funds to continue implementation, but credible plans for managing the trajectory have not yet been submitted."

For those of you who aren't quite into "healthspeak" I add this translation:

"We've almost run out of the extra money we were given to do the work although we still have a great deal of the project to do. We're looking for more funding to enable us to plan and complete the project but haven't found any as yet."

I think I will go and sit in the corner for a while ...

The Devil is still in the Detail - It Always Was!

Next time you hear a politician on the BBC Radio 4 announce a new initiative, may I ask you to stop and ask yourself: "How will that be implemented?" You might be forgiven for thinking that the answer is not only straightforward but reasonably obvious. There are thousands and thousands of health service managers so the one thing we're not short of is people to actually "DO IT".

If only it was that simple.

The two primary ingredients for doing "it" are ability and money. That's not any old ability like the ability to whistle with your fingers (a skill I covet but to no avail). It's the ability to turn intention into effective action which delivers the benefits that have been promised. The money side is also fairly useful, otherwise it's a bit like saying "you can have a new car" when you know there isn't any money to buy it. Spend a day with NHS management and you will realise that their implementation skills are poor and their grasp of controlling money is poorer.

You are thinking I am being harsh? You may be thinking that it is easy to heckle from the cheap seats? OK then, consider the following: most financial targets are set well in advance of the financial year but the money needed to implement the action plans for these targets is usually quantified several months into the year. Quite often the actual budget is much less than managers were led to expect and the action plans have to be cut down. Why is there no resistance to such poor leadership? What would you do if your spouse/partner sent you out to buy the ingredients for a lunch for ten people and then, when you returned home with the shopping, told you that there was only enough money for five people? It's only possible in my world because for most NHS managers, it isn't real money. Their actions have no impact on there being enough cash in the bank at the end of the month to pay their salaries.

It is this same ethos that enables so many plans to be written that are quite simply unworkable. Timeframes that rely on staff working at a rate that is never achieved. Training made available when there isn't the staff to do the training nor staff to release to attend it. Tasks delegated to people who are somewhere else (e.g. seconded to some task force or other, or on long-term sick leave). It doesn't seem to matter, since after all, the plan was written and the box can be ticked. It's all a bit like the final days of Adolf Hitler down in the bunker, sending non-existent troops to defend land already lost.

The Balance of Power

The latest political wheeze is to campaign on the promise of giving local people much more direct control over the management of their local services; from bin men to hospitals; from where to put the local library to changing bus routes. It all sounds jolly democratic and something that could only be opposed by the "Daddy knows best" brigade.

I hope that this shift in power will mean that we can sack all the people that are supposed to be making these decisions and getting them right! After all, it seems only logical that if the "people" want to make different decisions, then either the existing planners are wrong or it's the "people" who don't understand the question. I am not holding my breath.

Wouldn't it be nice that just now and again (actually I'd settle for just once) when a public service doesn't work properly, those being paid to get it right were forced to do it properly instead of changing how it's done. Then "people" wouldn't need power since they would not feel the need to change the service.

After fifty five years, shouldn't we be asking why the Secretary of State for Health needs to hold a consultation exercise to find out what her managers ought have known in the first place. The one question she doesn't appear to have asked is why her senior directors and managers didn't know already.

Go on. I dare you.

"The money will follow the patient" is one of the new fashion phrases amongst senior healthcare planners. In essence, it is supposed to mean that having given patients the choice of where they can obtain hospital care, the hospital will then be paid by the number of patients it "attracts". There is a national tariff (price list) which ensures that all hospitals are competing on a level playing field (except for the foundation trust hospitals which can set their own prices). If a hospital cannot fund its current operations, the government thinks it will be able to say "it isn't our fault; you aren't attracting enough patients or you are performing the work inefficiently".

So, the day will come when some hospitals will start to "implode". They will start to lose services which will make them less able to fund the overheads of their buildings and services which will require them to save even more money by reducing their services further, and round and round it goes.

Earlier this month, the government lost a by-election in the constituency where lives our Prime Minister in waiting. One of the principal reasons given for this loss was the "downgrading of the local hospital".

So one question: how long will it be after the psephologists calculate the "health effect" in government marginal seats before the local hospitals suddenly find a bag of cash at the front door?

The Triumph of Forms Over Substance

Public Inquiries into failures in the caring services seem to lead inevitably to new layers of procedures and paperwork. The aim is to prevent whatever went wrong from going wrong again. The recent biggies were Shipman and the death of Victoria Climbie. In both cases it was people who went wrong and the system didn't work in such a way as to prevent them. As a result, there are now more restrictions, more forms and more procedures. However, in both cases, it seems to me that the signs were there and visible to people who should have recognised them for what they were: symptoms of something seriously awry. I am not sure that changing the procedure will open the eyes of those who failed to use their experience and professional competence in the first place.

My main worry is that over time, staff will change and the reasons for the procedure will be forgotten or not understood by their replacements. It will be just another lump of bureaucracy.

If you don't believe me, consider the chages that we had to implement following the Laming Inquiry (into the death of Victoria Climbie). We have to fax our local social services with the details of any child registered for treatment by any adult other than a parent or someone with official "parental authority".

I telephoned our local social services to ask what they did with the fax......

Nothing.

I am not surprised. Social workers have a caseload that would tip most of us over the edge in a week or two. Everyone knows this to be the case but still the procedures are established. Someone, somewhere can then tick the box that says they have done what was required by the report. It looks good on paper but really nothing has changed.

Can You Spot the Join?

Today's "strange but true" entry is presented courtesy of Newham General Hospital and is about their management of their out-patient appointment system.

They plan their out-patient clinics weeks and weeks and months and months ahead. When you make an appointment, it might be for a clinic in sixteen weeks time. OK, you might not like the wait, but at least you're on the way. So, in the diary it goes and you get on with the day job.

Meanwhile, back in the hospital, the doctor you are supposed to be seeing is only required to give six weeks notice for his leave application.

Notice anything odd??

A Rose by any other Name

The government has decided that the best way to conceal the cracks in their healthcare strategy is to generate enormous amounts of paper. (Paper ... cracks ... OK??) For the past few weeks we have been the recipients of a blizzard of spin from Patricia (a.k.a. Mummy knows best) Hewitt, the politician who is supposed to be in charge of it all.

This weeks classic was the announcement of the new "health campus" plan. Groups of health professionals will work together in purpose-built facilities so that the public can enjoy all the benfits of a "one-stop shop". The rationale is that many relatively minor conditions can be treated much less expensively in smaller and less specialised clinics. Now where I have I heard that before?

Fifty years ago, this sceptered isle was covered by health campuses where local doctors could send patients for the routine operations for a hundred-and-one minor-ish ailments. They weren't called anything quite so sexy. We knew them as "Cottage Hospitals".

Starting in the 50s, the big-is-best brigade eliminated them because it was so much more efficient to group everything together in jumbo hospitals. You know them; they're the ones that the goverment have decided are too big, too inefficient and too expensive for treating "ordinary" illness.

Death by a Thousand Changes

It's 2006 and our government has thrown enormous amounts of money to "solve" the NHS' problems. The trouble is that near the top of the problem list, is the fact that NHS management skills are generally not very good. Giving poor managers lots and lots (and I mean LOTS) of additional cash is like trying to fill up a leaky bucket by pouring in more water and hoping that you can fill it faster than it is gushing out of the holes.
We're now in the early stages of panic. The money has been poured in and the results have been underwhelming. Now the money is running out and all the chosen metrics: waiting times, productivity, are moving in the wrong direction (i.e. back to where they were). Time to micro manage and decide policy half way through a speech in parliament.
I feel like a sheep in dire need of a collie. One that will gather us all up and at least get us running in one direction. Preferably the right one at that.