The Editor's Blog
The First Post posted:
Monday August 4, 2008
(you are invited to vote on this post)
Since its inception in 1948, the unimagined advances
and costs of healthcare have seen the NHS decline from a world-beating
organisation to a hideously inefficient and bloated political punchbag.
But this is no ordinary organisational shortcoming, of little interest
to the public at large- the huge NHS machine is quite clearly out
And simply because the overwhelming majority of
Britons rely totally on the NHS for their healthcare, the
state of the NHS is of huge importance to the whole nation.
Whilst most patients have nothing but praise for the actual treatment
they receive, administering and funding the NHS has become a logistical
Forced to reconcile limitless
demand with limited funds, the NHS has become a tarnished
jewel and a minefield for successive
governments. Although generally demoralised by an endless stream
of centrally-imposed interference and change, the majority of staff
are nevertheless dedicated and loyal.
Clearly something needs to be done.
Equally clearly, but too much of a hot potato to address openly
and honestly, the available funds are too often spent unwisely.
Lets face facts - the NHS is a bottomless pit into which - for purely
political ends - successive governments continue to pour our taxes.
Quite rightly, we spend a very significant
proportion (currently approaching 10%) of our GDP on healthcare
and huge sums will continue to be poured into it.
Radical shifts of opinion and culture
within the body politic, the population at large and the NHS itself
must come about very soon if we wish to enjoy an NHS that serves
today's needs. The medical and social landscape has changed out
of all recognition since 1948 - the NHS also needs to change to
adequately serve current requirements at an acceptable cost.
We have to accept that unlimited demand for healthcare is simply
unsustainable. Healthcare rationing (and yes folks - it already
exists) will inevitably increase to a point where life and death
decisions based on financial criteria are both expected and, dare
I say it, tolerated if not accepted by the majority of us. It is
mathematically certain that, like it or not the time will soon come
Care and expenditure will be very
heavily skewed toward maintaining mobility, sanity, quality of
life and (within reason) the ability to maintain or improve the
individuals value to the community.
Treatments whose only certain outcome
is extending (or creating) a life that will be hugely expensive
to maintain and has little likelihood of benefiting the wider
community will have to be severely restricted.
We will have to respect the wishes
of those whose treatments are solely aimed aimed at extending
a painful and severely restricted life. An individual who has
already come to terms with death must, after due consultation,
be allowed to die with a maximum of dignity and a minimum of pain.
There will have to be very severe
restrictions indeed in areas such as fertility treatment (specially
where there is high risk of creating children with serious disability),
expensive surgical intervention where even a successful prognosis
is certain to be measured in weeks or months and geriatric care
beyond a certain point (related to quality of life rather than
Cosmetic and elective treatment
should only be provided free where there is overwhelming justification.
Any resource-hungry treatment that
aims merely to extend a miserable existence will have to be closely
examined on a case to case basis.
There is already some movement toward
these restrictions although the scale of change and the level of
frankness shown so far do not begin to approach requirements.
Unfortunately, harsh as it may seem,
the resources do not exist to extend life regardless of cost or
(again within reason) projected quality of life.
The NHS was never intended to provide
unlimited treatment with no regard to outcome or cost - it is not
a reasonable expectation now, and it never was.
We will all get old, creaky and eventually
die - get over it.
Quite frankly, the general quality of NHS management various from
mediocre to lamentable. I do not say this lightly. I have experienced
this at first hand and hear constantly about it from both staff
and patients nationwide. I also except that this is a generalisation
- there are of course exceptions.
This is not entirely the fault of
management itself, rather it is an unfortunate combination of many
The ever-changing (yet paradoxically
moribund) internal structure of the NHS.
The self-interested and suffocating
hierarchy which dictates against changing things higher up the
Constant pressure from government
to create good press.
Political correctness gone mad
- regardless of cost or effect.
The fact that poor performance
within the NHS (especially management performance) attracts little
or no individual sanction.
The fact that there is little movement
of management between the (accountable) private sector and the
(largely unaccountable) public sector. Incompetent managers in
private organisations pay the price.
Within the huge structure of the NHS there is normally a fairly
anonymous (and very well-paid) regional or national post awaiting
the senior failures.
It is a sad fact that the majority of middle and senior managers,
who have normally progressed from a junior post within the NHS,
are totally unsuited to the cut and thrust of the private sector.
Conversely, effective managers from the private sector who enter
the NHS soon find that the suffocating culture and lack of accountability
within the NHS is unacceptable at best, unbelievable at worst.
They leave and take their much-needed skills back to the private
The effect of this is to create a one-way filter keeping good
managers out and allowing bad managers in.
This dooms NHS management to become ever more introspective, incestuous
and ineffective. With no effective yardstick of excellence, mediocrity
becomes the norm, innovation is stifled and inertia becomes endemic.
When such managers have to negotiate with private industry they
go as lambs to the slaughter.
Changing this all-pervading mediocrity
will not be easy, yet without a change any money saved by the inevitable
healthcare rationing to come will be quickly swallowed up by a self-serving
management that is simply inadequate to create an efficient NHS.
I do not believe there are simple
or painless answers - but common sense dictates that fundamental
changes are needed.