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.