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 of control.

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.

General

Whilst most patients have nothing but praise for the actual treatment they receive, administering and funding the NHS has become a logistical nightmare.

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.

Treatment

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 when:-

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 age).

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.

Management

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 things:-

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 organisation.

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 sector.
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.