Be Careful What You Wish For!

I guess everybody now knows the "old Chinese proverb":

Be careful what you wish for;
it may be granted.

A fair number of people must be hoping that the Tories do win the election that can be no more than six weeks away. Let's just suppose they do. Then what?

Trouble, that's what!! Big trouble.

The present lot have presided over and implemented the most right-wing policies ever experienced since the NHS was founded sixty two years ago. They have done so consistently ever since Tony Blah "discovered" health in 2000 (when a junior minister lost a "safe" seat in Kidderminster to a doctor who campaigned solely on keeping the local hospital open).

Now think of Charlie Whelan (a.k.a. Charlie Marx) running the Unite trade union and close fried of Gordon (you know ... "the safest pair of hands we've ever known as a Chancellor" - that Gordon).

Add these all together and you may understand why Labout have got away with it; the biggest privatisation of healthcare and lots more of it already signed and sealed if not delivered. Now fast forward to the second week in May ..

David Cameron walks into 10 Downing Street.
Andrew Landsley (presently shadow health sec.) walks into Richmond House, 79 Whitehall.
Guess who will be walking out?

• nurses
• porters
• technicians
• cleaners
• maintenance people
• drivers
• etc

The "free ride" enjoyed by Labour will be over. Any cuts will be an immediate political cause celébre.

I know several people who will vote Labour not because they admire them but because:

• the country cannot be ungovernable at such a time;
• they should be forced to have clear up the mess they've made.
  

Care in the Community - Been There - Got Nothing

The sudden burst of posts might lead you to think that I have suddenly become more agitated of late but you'd be wrong. It's just that the year end in public accounting is when we all get inundated with requests for "stuff" - I won't bore you with the trivia that is much of my working day. The worst of the storm has passed, so I can attempt to benefit from the catharsis from shouting at the world-wide webosphere.

The current DH obsession with "moving secondary care into a community setting" brings back both some sad memories from my own childhood and also my own view of the last time we heard "care in the community". This was a dominant mantra of the Thatcher years. Why sad?

Well, my elder sister was born brain-damaged and remained a young child for the twenty one years she spent on the planet. At the age of twelve, in the early fifties, she was sectioned and sent to St Lawrence's Hospital in Caterham. She wasn't a danger to herself or to anyone. It was simply because my parents couldn't care for her due to my mother's failing health. Every other Sunday, we visited for two hours (having to queue outside the main gate until precisely 2pm). The journey was bus, train and then bus again and it took two hours each way. The wards were crowded and the nurses were amazing. Most of the inmates were there because that was the only structure in place at the time to provide such care. Once admitted, the "patients' " chances of leaving alive were almost nil since there was no rehabilitation; just detention. You might think then that I would be "Care in the Community's" greatest fan? If only!

The reality was different to the hype. Who can argue that my sister and most of the other 2,499 prisoners would have been better off if the vision of Care had been delivered?

Instead, the whole strategy was used by central and local government to leech money from the system to meet their short-term financial imperatives. St. Lawrence's was closed the government pocketed the proceeds of selling prime Surrey commuter belt development land. Local authorities were left with inadequate budgets and insufficient experience to absorb a wholesale shift to them of people who had spent their lives in such institutions with complex health needs and no clue of how to even help in their own care. It was ten shameful years of waste, unnecessary bewilderment and confusion.

The problem was not the intention. it was its implementation. If I could lay my hands on the mandarin that executed this appalling act, I would cheerfully throttle him.

Polyclinics - An Elegant Summary

George Monbiot writes for The Grauniad. his article on polywotsits is a standard of writing to which I can only aspire with little confidence of achieving.

Do read it here

Don't Confuse Me with the Facts

In our neck of the woods, "polysystems" are the flavour of the moment. They are the result of Lord Darzis's major review that in far too many words and way, way too much money, concluded that:

1. London has too many hospitals;
2. Lots more care should be delivered "locally" (which is healthspeak for "not in hospitals");
3. GPs should work in polyclinics (but we'll call them something else because polyclinics don't work).

I attended a meeting last month at which I said (yet again) that the wholesale disruption of existing referral processes can only work if the communications infrastructure is in place.

The director chairing the meeting agreed.

I then said that this would be especially true if the Darzi model is implemented (it is happening right now).

The director chairing the meeting agreed.

Then says I, but the current infrastructure is not in place; it's years behind schedule and billions over budget.

The director chairing the meeting agreed.

So, I went on, if you agree that it will only work if the comms are in place and you agree that the comms are not in place, the only logical conclusion is that it won't work???

The director said it was too early to say that!

Mmmm... now there is a good idea. let's wait until the system isn't working and patients are transferred from here to there, and then somewhere else, whilst their notes move from anywhere to nowhere.

Makes perfect sense to me.

Meeting Targets and Failing Patients

Our local general hospital shares with our own primary care trust a DH target of "eighteen weeks from referral to treatment". Laudable? Oh yes.! Achievable? Mostly! But ...

If you make an appointment but then, due to unforeseen circumstances have to change it, you can't! Your referral is cancelled and you have to go back to your GP and start all over again. There is a reason (although "reason" is the last word I would used) as explained in the hospital's standard appointment letter:

"PLEASE NOTE: To avoid delays (sic) you may only be able to re-arrange your appointment once as we aim to complete your treatment in 18 weeks from your referral."

It is reasonable that, if a patient delays their treatment because they have chosen other priorities, the hospital doesn't then suffer the opprobrium of the bean counters. The hospital's way of ducking under the bar is ludicrous.

It is even more ludicrous when the reality is that they do not allow even one change of appointment, even when it was the hospital themsleves that cancelled the original appointment made by the patient and the replacement appointment offered is not suitable.

Where else would "the customer" be treated like this?

If Only Patients Were Apples

On telly the other evening was an article about how farmers are able to deliver "fresh" apples to us all year round. The answer is that they store apples in reduced-oxygen cooled storage units. Similar things are done with the humble potato. The way in which Tesco et al monitor the growing, storage and packing of everyday food items is astonishing. Consider the following the next time you are holding a bag of spuds in the supermarket.

Mr Sainsbury or Mr Morrison can tell you everything there is to know the batch of potatoes in that bag:

• What day it was originally planted and the weather conditions (wind, temp, etc)
• What chemicals have been applied to it (batch number, date, weather conditions, etc)
• What day it was picked (weather, blah, blah ..)
  
• Where it was stored and all the records of temperature, location, etc.
• When it was removed from store and packed
• Which lorry delivered to where and then the same for final delivery.

It is an amazing system and it hasn't cost twenty billion quid!

Into the valley of death

Many, many years ago, I was a military chap. I look back on my ten years defending Queen and country with fond memories and an ever-increasing amount of nostalgia for an organisation that was just that - organised! Quite often I resort to military metaphors to try and get across what I see are some of the things our senior NHS dafties get up to.

Time to bring on Connecting for Health.

CfH is a big plan. No, bigger than that. It's bloody enormous! Conceived as a "let's do away with these little systems and get big companies installing massive systems across whole regions". Multi-million pound contracts that now have a couple of extra noughts on the price tag. A completion date that is moving away so fast you'd have the warp drive from the USS Enterprise to keep up with it. The functionality is poor. The user interfaces are "clunky" and the speed of the system often reminds me of telex. Apart from that, it's a winner?

It feels like a battle where the plan was to capture the enemies' gun emplacements on the hilltop so the infantry could advance in safety across the valley and engage the main enemy force. Good plan. However ...

The attack on hilltop fails. When told, the general realises that the main body of troops has already started advancing. "Well, they've started now so I guess we'll just have to let them carry on. It would be just too embarrassing to admit defeat before the main event!"

Delays to right of them, cost overruns to the left of them,
Into the Valley of Financial Death rode the 600 ... um ..milllion
nope make that 2,4 billion
ooops, I meant to say 12,6 billion
or should that have been 16,billion

for an electronic care record to be delivered in 2005,
2007,
2009,
2011,
2014 .....

Organisational Dementia

I have been in in my current job for over seven years. In that time, at my PCT I have seen the comings and goings of four chief executives, four directors of finance, seven directors/managers of primary care, two directors of commissioning, three finance managers, three directors of clinical governance and three directors of human resources. Not one of the heads of the major departments was in post more than three years ago.

This need not be a bad thing. indeed, for these individuals, it's usually a very good thing. New appointments usually mean promotion, more cash and new interests. For those of us left behind, it is often a source of irritation and frustration.

Why is it frustrating? Well, because quite often we find that the useful suggestions (and accepted as such by the management), we made about improving services fall by the wayside. The replacement arrives at the next meeting with a clean sheet, fresh start, and other manifestations of the lack of an effective handover. The good idea has to emerge all over again and the clock is reset. As far as the new incumbent is concerned, there is no delay because the count has just started.

Then there's the irritation. We negotiate an agreement with a director and do whatever the agreement requires of us. A couple of directors later, the new leaner, meaner, "we must reduce costs" senior gunslinger calls us in and says we're not doing it properly. Our response that "we are doing what was agreed" is brushed aside. "I wasn't here then" which is intended to mean: "that agreement doesn't count and we can and will ignore it".

Efficient organisations learn from their successes and their mistakes. The NHS doesn't seem to learn. I cannot see any evidence of any determination for our PCT to retain a clear view of who did what, when, and the outcomes. The process of finding a replacements for a departing senior executive usually starts after his or her departure. Frequent reorganisations mean the shifting of some duties from one person to another and departments are broken up and re-established with the energy of a Scottish country dance. In amongst all this organisational musical chairs, knowledge and experience evaporates.

Never mind, a new director will soon be here, brimming with "fresh" ideas.

Tidy processes but untidy outcomes

General Practice is managed by its local Primary Care Trust. Our PCT has a population of 330,000 patients and spends hundreds of millions of pounds of your money and mine. They are responsible not just for ensuring we are performing our duties properly, but also for introducing new services and the procedures to support them. They also commission new buildings; they modify and adapt the complex arrangements that are involved as a patient moves through the system from GP to hospital or to a specialist clinic, and then back again. From a general practice perspective, virtually everybody with who we come into contact is a "manager".

It may come as a surprise to you that so many of them have no specific previous relevant experience that they can apply to the tasks for which they have been recruited. The important essential criterion seems to be the ability to produce impressive word-processed reports with lots of tables accompanied by a multi-page spreadsheet with lots of colours. Too often, it is the triumph of style over substance.

Don't believe me? Then consider the following:

Yesterday I attended a meeting of a group meant to be steering an important screening service for people suffering from complaint found frequently in our population. There were seven of us managers and we all like to think we have the best interests of patients at the heart of everything we do. We were discussing the local hosptials failure to achieve a fourteen-day target for seeing urgent referrals.

Nice manager from the hospital: "We have a high rate (40%) of non-attendance in clinics."
Nice assistant director of PCT: "What are you doing about it?"
Nice manager from the hospital: "We're recruting a locum consultant to work thought the backlog".
Nice PCT service manager: "That's good to know. How long will it take?"
Nice man from hospital: "We are recruiting now and we believe it will soon make a signficant improvement".
Nice assistant director: "That's good to know."
Me: "Hang on a minute. If two in every five people aren't turning up for their appointment, why get more capacity when the capacity you've got sits unemployed for 40% of their clinic time?"
Nice man from hospital: "The consultants won't let us double book clinics".

Apart from the inherent nonsense of the consultants' stance, nobody else seemed the least bothered. They had dealt with the problem i.e. they had pushed and prodded it a bit (but not too hard) and had a response to write in the minutes.

Meanwhile, patients are still not getting urgent appointments within two weeks, and there is no date given at which it is forecast that this entirely avoidable situation will improve.

Their process is nice and neat but the outcomes which were poor are no better.