I suggested that the NHS and education both suffered 'hopelessly inappropriate' management structures yesterday and was asked to justify that claim. I am happy to do so.
The art of management is to ensure that tasks are appropriately identified as necessary, are then done effectively, once only wherever possible, and by those best able to do them. You might call that a somewhat brief theory of management, but for the current purpose it will do.
Let me put this in the context of these two national, free at the point of delivery activities whose primary aim is to make available to all services that might otherwise be unaffordable for many. Implicit in their mandate then is not just the service, vital as it is, but the social and economic consequences of its delivery in this way.
Given these facts (and I think they are facts) the management structure of the NHS and of education has to be chosen with three objectives in mind. The first is that the decision making unit has to be big enough to deliver the social and economic goals of these services. In other words, social and economic impact has to be possible as a consequence of the decisions made in addition to services that are excellent in their particular field. This, then requires that strategic decision making for both must cover significant swathes of the population that cover all the likely social spectra that it is intended be impacted by the redistribution implicit in the supply of services in this chosen way.
How big must those units be then? Some cities will be big enough. So will a few counties (Yorkshire, perhaps). Scotland, Wales and Northern Ireland are. Almost no other counties will be. And nor, to be blunt, is the regional difference in demand for these services so different across the U.K. that localisation can ever be justified for that reason.
In other words, both health and education have to be managed across very large regions of millions of people. Given the goals for the service no other management structure will do.
Given the need for integration in service supply in both cases it is also true that fragmentation within those areas will be antithetical to effective supply. Health and social care need integration. So to do physical and mental health. Sub division can only create inefficiency. That's also true of education where cooperation to ensure a balance of services to meet deeply varying needs is what is required. The over emphasis on academic results is the opposite of that at present.
There is also cost to consider. That is the cost of duplication. And the cost of accounting between organisations. As well as the inefficiencies that lack of scale bring. Local spells expensive in every such process if too many boundaries are put in place. That is what is happening now. A bonfire of the boundaries is needed.
That is because these boundaries are in any case not required: one pot pays for these services. It's not local financial accountability that any such service requires: it is the setting of appropriate key performance indicators to suit local need that is necessary. This may be ensuring education to meet the particular needs of the local economy is available. It maybe healthcare to suit the particular age, gender and ethnic needs of a local population. These are the performance indicators that matter. And they aren't measured financially. But they do target resources.
Of course there are financial constraints: these have to be considered in service supply. And in the representations the major health and education authorities I suggest we need could make on government decision making based on their on-the-ground observations of the success or failure of service targeting to meet need. But do any of these things below the scale I suggest and neither the scope of the decisions that can be made or the scale of the impact that can be measured will be large enough to make any difference to service outcomes, and in health and education these are the criteria for management decision making structures that truly matter.
So we need big, regional, service delivery, although empowered local managers matter, of course. But local management in these services can never be strategic. The result is that we don't have effective strategy now because decision making units are far too small to deliver it. And that matters, enormously. It's why I hate to say it, but top down reform is essential. But the outcome will be services focussed on what matters, which is not management and budgets, but patients, students and service supply in the broadest possible sense.
I hope Labour is thinking this way. It needs to.
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Sensible post, as usual. Unfortunately whoever pays the piper always wants to call the tune; with the present bunch of inadequates, it’s always the Free Market Blues, of course. As a party member, I don’t see Labour yet switched on to regional management of key services – John Prescott went down that road, but was rebuffed by the electorate (or vested interests). We have to get rid of the ‘command and control’ dogma whilst making sure that the regions don’t opt for discriminatory options like grammar schools. Or would you allow your regions to make “bad” choices?
” Or would you allow your regions to make “bad” choices?….”
I think that is probably an important question, and one that requires some serious consideration.
At both (extreme) ends of the political spectrum choice disappears for the majority.
Communism is claimed to deny choice because of the centralised command and control structure, but a laissez fair Capitalism, which purports to offer consumer choice, only allows choice (ultimately) to those who can pay for it whilst simultaneously restricting the ability of the majority to pay, and therefore have the option to choose.
Getting the balance right between those extremes is what politics is about. There is no infallible blueprint (can’t be or we’d all be using it and living happily ever after) so we have to experiment and some experiments ‘fail’. Although in truth an experiment can’t fail – it produces results and it is for the experimenter to evaluate the results.
In the case of health service provisions we have lots of experimental evidence to go by and seem to keep ignoring it. That, I think, smacks of collective stupidity.
There is a much more fundamental management problem in the NHS that I have been trying to interest people in for many years. So-called demand for health services is actually the product of previous treatment and interventions but this is never tracked or assessed. It is assumed that the medical silos are entire unto themselves whereas over the decades this has become untrue in the majority of cases. Basically all opportunities to manage future demand are thrown away.
There is also a corrupt system at the heart of prevention where dietary advice is the opposite of what it should be. This is creating a level of “demand” big enough to sink the ship on its own: diabetes and Alzheimers, CVD and cancer.
I agree with all that
Maybe I am over-exposed to the NHS!
I read your piece with interest, looking for the kinds of practical solutions I’d favour, but I’m afraid your ideas seem to be just as woolly and thinly thought out as the ideas that landed us in the mess to begin with.
I could go through each point and take issue, but I will spare us both that and simply say your definition of management is indicative of the difficulty you would face in making any meaningful change.
“to ensure that tasks are appropriately identified as necessary, are then done effectively, once only wherever possible, and by those best able to do them”
In my experience of working for 40 years in the bureaucratic swamp that is the civil service I can say that such a description would indeed sit well with current managers, who I would describe as people who lack the skills to identify tasks, don’t know what effective delivery would look like, are happy to duplicate and overlap processes as long as they are left sitting on top of their own wee ivory tower, and who have no idea about who is best suited to carry out those tasks.
In my experience it is the staff who effectively do all of those things, with management just getting in the way. All whilst the things the staff really need to do their jobs (waste bins, sympathetic lighting, enough desk space, phones that work, modern heating, computer systems fit for purpose, strategic thinking that understands the organisations’ purpose, inclusion and visibility on the shop floor, etc etc etc)
I have lost count of the number of times “experts” (sometimes even academics) or consultants have been brought in to “fix” the problems. Hired by managers who don’t have a clue, and so working from the start with the premise that managers know best, they have ALWAYS failed to make any significant progress, and in these days of austerity and cutbacks many parts of the civil service have been rendered unable to efficiently and effectively do their jobs (ref HMRC, DWP et al).
If you want to fix health and education then start not with managers and strategic thinking, but with the people and the staff and LISTEN. Then meet those needs as budget and practicality will allow, using whatever resources are available.
We could start by culling managers. I reckon we need one in ten?
You can only cull if you change the system
The change comes first
“You can only cull if you change the system”
Culling is almost certainly what is required. This is where I worry about your top down prescription.
I think there is an argument for culling upwards. Everybody who has ever been employed knows whether their line manager is any use. They can also frequently see where their own line manager is being stymied by the next tier up.
Trickle down management is about as effective as trickle down economics.
Strange how often, when a system doesn’t function well, it is because we have it upside down.
But there has ti be a new structure in mind first of all
Adding more managers, or shuffling around the ones you have into new shapes, will not help you deliver more effective management. Don’t you know there is an inverse relationship between managers and efficiency?
I disagree with your solution, in so far as it is described at all. I think what you offer is more of the same mess.
Efficient delivery has spare capacity within it. Yes, you can always crunch a number and find duplication of effort, but whereas to you that looks like inefficiency and waste, to me it looks like effective service provision.
It is not efficient to have a single MRI scanner working flat out with a waiting time of several weeks, if you could have two scanners with one of them operating only part time, and no waiting list. If you look at only the pounds and pence of course you’d cut the service down, but in health care efficiency should not be equated with money, but with service provision. Rather than ask, did we get value for money we should be asking, did we deliver the service quickly and effectively?
Similarly, education within an inner city is a very different thing from the same provision on a small Hebridean island.
Actually, it’s interesting that you would lump health and education together, because the indicators for success are radically different, and the kinds of management structures you need are not at all equivalent.
In health, assessment of the success of a strategy is seen almost immediately in patient care outcomes and individual health, whereas the results from an education service may not be seen in an individual or a community for years.
We need leadership not management. To do that we need to change the structures for sure, but if we do not address the problem of “scientific bureaucracy” and the stratification of our public service management structures we will continue to get the same unsatisfactory outcomes.
Since your article was short on detail here are the changes I would put in place –
1) Staff representatives on the board of every public body.
2) Greater moves to workplace democracy.
3) Leadership roles.
4) 360 degree reporting.
5) Ditch competency based promotion and recruitment.
6) Localisation.
7) Pegged proportional pay rates for senior management.
Anyway, it’s a good discussion to have, but I do wonder if we will ever see things done better.
If we don’t imagine it then it cannot happen
I have a lot of sympathy for Peri’s position. I worked in the public sector for 20 years and was always amazed at how quickly those promoted to management positions assimilated into management.
That is, they quickly forgot they had once been “ordinary workers” and in doing so they forgot the the large amounts of useful experience held by “ordinary workers” that could be brought to bear in many areas where problems needed to be resolved. Consequently, they would quite happily spend hours in meetings with the great and the good or involve outside consultants before arriving at “solutions” that were inadequate and which any “ordinary worker” would have identified as unsuitable immediately as, often, the “solution” took no account of how processes/systems actually worked.
An example from my wife’s workplace in the Scottish NHS. The whole department was being refurbished and an extension built. Once the new accommodation was about to be opened it was discovered that it was going to be all but impossible for my wife and her co-workers to deal efficiently with the volume of patients coming through because nobody had thought to ask them how they actually carried out their work. As a result the workmen had to be recalled to strip out cabling and re-cable the computer system and the departmental public-facing desk had to be restructured. Hardly the end of the world, I know, but a typical failure to give even a nod of recognition to those at the front-end.
Gordon, I’m sure Richard means well, indeed all the people who mess things up mean well, but they still mess things up. Look at his terse responses here. He doesn’t like what he is hearing, because in his mind he had it all figured out, what with strategy and reviews and so on. There’s only one way to fix it and that’s to LISTEN to the staff and to the public, then respond as if you can actually hear what is being said to you, rather than picking a response that suits the pre-set agenda.
I could regale you for hours with tales of mistakes made and lessons never learned, but I have a feeling I don’t need to.
Hey hang on….
I have nothing worked out per se
All I said was culling without another structure in place is a crass idea bound to lead to chaos
I know: I’ve seen it
You are making stuff up
Gordon McAdam says:
“I worked in the public sector for 20 years and was always amazed at how quickly those promoted to management positions assimilated into management.”
This effect of ‘changing sides’ from ‘worker’ to ‘management’ is not confined to the public sector. It’s endemic. (It’s camp guard syndrome, barely disguised)
It’s predicated on the curious idea that industry consists of two sides in conflict. I would blame Marx for it if it were not that all he was doing was observing and commenting on what he saw as the clash between the interests of capital and labour.
I’ve been fortunate to work in sectors, both public (Nhs specifically) and private, and third sector too, where I’ve experienced management culture rather more enlightened than that.
What I regard as an ‘enlightened’ manager is a manager who understands the aims of the organisation and makes strenuous efforts to support the ‘coalface’ workers in achieving them, notably by ensuring they have the resources necessary to do the job.
If you have a good enough management you don’t need trades unions. The company mission statement that comes out with bullshit along the lines of ‘Our most valuable asset is our workforce’
does so because the mission statement is the only place where that sentiment appears.
Coming from a manufacturing background it strikes me that many of the problems in the NHS could be improved by further application of Lean techniques, as most notably championed by Toyota but now replicated in most blue chip manufacturers and gaining a foothold in the NHS in some ways. Lean could help in a number of ways. For example, so-called tiered reviews happen at various levels in the organisation and at the shop floor level this will capture the small but important annoyances such as you mention. If KPIs at this level are not being met then the problems are escalated to the next level up and so on. In that way not only are problems captured and addressed at the right level, but also there exists a mechanism for escalating problems which cannot be solved at shop floor, in the clear expectation that they will be solved higher up. Another benefit of this process is that the thousands of minor mistakes (lost documents, miscommunication, delayed discharges and so on) that happen every day across the NHS can be identified and the root cause addressed in real time.
Finally, the Lean process fits the NHS because it is primarily about flow. The NHS is in many ways like a manufacturing plant. There are varying inputs (people), inventory (waiting), processes (treatments, admin) and outputs (treated patients leaving), and the opportunities for continuous improvement in that flow is truly vast.
Of course rhere’svthe human factor
And the NHS needs second opinions, often
But broadly I agree
If as much effort, energy, education, training and money was invested in sickness PREVENTION as is in the NHS, the latter’s problems would at least be more manageable and the nation would be healthier at a fraction of the cost.
The NHS has its roots in the post 1991 internal market reforms which did not represent an evolution of the service’s until then highly fluid organisational and planning framework but were, through the damaging trust system shifting from proper strategic planning. They also cut the link between funding and provision…the change that should have taken place was, as Calum Paton has argued dependent on expanding the Regional Health Authorities remit to include the planning- distribution of community-GP services and specialist Hospitals, coordinating Health and Social care, improving performance management at the district level and tackling other issues such as achieving clinical consistency and deep seated health inequalities…The post 1991 changes took the NHS in the opposite direction…
sorry, I should have said the ‘NHS crisis has its roots’ above
I think you are going to struggle to manage all schools and all hospitals from one office in London (or Birmingham). Inevitably you are going to need different levels of management, at the local and regional level as well as centrally. It is absurd to expect clinicians to manage hospitals (ordering dressing and arranging staffing rotas) when they should be treating patients, or to ask teachers to manage schools (maintaining stationery supplies and arranging the lunches) when they should be teaching. Proper, professional, management is what is required. A good manager will pay for themselves many times over in saved time and cost.
You really are confusing issues here
Of course there is a need for local micro management to ensure effective delivery
That’s a world away from having local strategic management, which is what the government has tried to create
Your argument is akin to saying a multinational corporation cannot function because the Stoke-on-Trent store can’t order photocopier if the global HQ is in Frankfurt
Have you any recent experience (in the past say, 5 years) from the inside in either the NHS or local authorities (at least the counties or unitary authorities)?
Your post comes across as quite theoretical, with little practical grasp of the politics and culture of both the NHS and local authorities (and the differences between them, and the difficulties in bringing about change). It suggests you haven’t really seen it from the inside yourself.
I’m a local authority officer closely involved in some of the activities. We have no shortage of arm chair critics who haven’t been there, done that.
I have been actively engaged with both in my time
Not I admit as much in the last five years
But I have certainly been engaged with education
And sure I know about change, and politics and the resistance to anything happening. Much of my career has been about that.
What’s your last comment meant to mean? That you know change is not possible? If do, I beg to differ. I am under no illusion that it is hard. But impossible? That I doubt.
And I would add, you may not like theory but it is what shapes the NHS and local government. You might as well chose the best one
Thanks
The direction of travel as I see it (in the north and parts of the midlands anyway, may be different in other parts of the country) is for more decentralisation and for closer working between local authorities and the NHS (with the mood being they’ve got to become more like us than the other way around).
Is there a DASS or a DPH who disagrees with this? I haven’t met one. Do you know any?
When working with NHS colleagues, it is striking how hamstrung they are from London. Councils have a lot more freedom. Our NHS colleagues almost appear envious at that freedom.
If you were asked to persuade any DASS or DPH of your ideas (which are against the flow of traffic), you’d need to give them a more substantial description of your experience than the one you’ve given me.
I really do think you need to out things bin context
First, I float ideas. Without ideas there is no change.
Second, I expect mu ideas to change: they do, and often.
Third, that is because I listen to others, who have better ideas.
Fourth, I very much doubt I will deliver this change: others with more experience will (although I have more experience than most cabinet ministers)
I do not for a second suggest I am putting forward a complete blueprint. The whole aim is to provoke thinking. Why aren’t you joining in instead of seeking to play the man and not the ball?
One of the problems with the UK is the attitude that we have nothing to learn from experience elsewhere – the “it wouldn’t work here” syndrome. More recently we have had the imposition of “market-think” on institutions such as the NHS and Education as if they were businesses competing for customers. We’ve also had chronic government initiative-itis – ministers come in for a year or two and feel they have to something, anything, or get sacked, which they do anyway. That has to change. These institutions need some stability, not constant interference and tinkering from political dogmatists.
Re Education, I would start by looking at experiences elsewhere and see if we have anything to learn. Then government could set the broad strategic parameters and principles, such as, inter alia, comprehensive education based on local catchments, scrapping all selective, fee-paying and private schools, faith schools, and religious observance in schools, investment in teacher training and re-training (including management), suggesting broadly the core curriculum, (but not the content or how it should be taught and certainly nothing to do with “British values”) then leave it up to the “administrative units” (mentioned above) to work out more of the detail and then leave it up to schools to develop and implement an education appropriate to their students. But never forgetting that “education” is not about producing cannon fodder for business – business should have its own training role to play – nor is about gearing everything towards university entrance.
School management should be about empowering all staff and giving them a role in its development and direction. Remembering that most managers are ultimately promoted beyond their competence I would democratise the process so that managers are voted into office for a fixed term by the people who know – the staff. If they want a professional manager to order the jotters then they can decide that for themselves and appoint one. But that manager will be part of the team, not the leader.
We’ve had top-down for centuries and it’s failed; time for bottom-up.
G Hewitt says:
January 29 2018 at 7:33 pm
“One of the problems with the UK is the attitude that we have nothing to learn from experience elsewhere —”
Without wishing to deny that point I would add that we don’t seem capable of learning from our own experiences.
Thank you. That’s the first intelligent critique of NHS management structures I’ve read, but is anyone that matters listening? That’s a genuine question.
I have another question. If your advice were taken, and a top down revision of management structures implemented, do you have any feeling for how much additional resources might be available at the front line? I’m thinking primarily of the NHS, but my questions apply equally to the education sector.
Sorry – I have not got that far
But, this will save a whole tier or two of local management – most well paid and ineffective
It will save considerable accounting cost between far too many NHS organisations
And all the contracting
And more
I am not saying performance data will not be required, but make it clinically focussed
I find it impossible to think there won’t be savings
And scale saves money too
I agree that money can be saved, and substantial amounts at that, but my gut feeling is that the savings might not be significant in the context of what is spent on front line Services.
But the change in focus would be transformational
Lots of relevant stuff in this post that could be used to make the NHS better.
As I see it, THE biggest problem in public sector management is the confusion between public policy and management.
This exists because centralised politicians (who really should only develop policy) take their role too far into the management sphere and end up trying to be responsible for the service – for example for performance.
Politicians can have all types of backgrounds – but they are politicians first – not managers. Politicians also increasingly ‘manage’ services (or at least want to be seen doing so) that they have never had to use or have no experience of managing.
And so what happens is that these experiential voids are filled with ideology instead.
Yet another problem is NPM – New Public Management – where we are expected to have dynamic management but the truth here is the over centralising of budgets to Westminster or stupid performance targets from politicians tend to undermine the promise of such leadership whose main aim ends up only to cut and cut because of central budget constriction as well dealing with political fads like ‘internal markets’ or cheat the system of performance measures. NPM just becomes a conduit for bad ideas from the centre at worst and at best – well, people resign.
From what I know about my time in business and business strategy is that a ‘business unit’ ( a local point of service delivery within a national framework of service provision) should have the local freedom to meet local and unique market conditions (demand) in its own area.
When I worked for Tesco and Sainsburys for example, stores that say were near a large Jewish or Muslim population had the same core range of food as any other store, yet the store manager had discretion aided by the central office marketing team to make provision for kosher of Halal foods that were not in the national core range. Simple – but effective.
I think that what needs to happen for our public sector to be better is this:
1) Fund the services adequately from the centre. Including prevention work.
2) Lets have a new deal for all public services based on the ideas of the Courageous State. A revised
statement of intent and commitment and principal. Why it is GOOD to have these services this way.
3) Legal reconnection of the Government’s responsibilities to these services on behalf of its Citizens.
4) More local discretion given to management to provide a service that meets need (also connected to 1).
5) More emphasis on quality than cost. Tessa Jowell’s speech had a serious message. Never mind
cheering and bloody crying about the speech – lets get it done.
Can I also mention Professor Paul Spicker’s Book ‘The Welfare State: A General Theory’ (2000) which I would also use to rebuild the State and society’s relationship with public services. Spicker reminds us why it is good to do these things that were set up post-war and why we need to keep doing them.
Spot on
Local effectiveness and discretion
But within a much higher level strategic framework
Right now we comepletely confuse the twoandvthe wrong people do the wrong things as acresult
Pilgrim Slight Return says:
January 29 2018 at 10:11 pm
“Lots of relevant stuff in this post that could be used to make the NHS better.” (Improvement would not be confined just to the sphere of the Nhs operation.)
“As I see it, THE biggest problem in public sector management is the confusion between public policy and management.
This exists because centralised politicians (who really should only develop policy) take their role too far into the management sphere and end up trying to be responsible for the service — for example for performance.”
Spot on to a great extent, PSR
This is why we are doing Brexit in my opinion. Because the EU has spent far too much effort on micromanagement issues and not nearly enough in getting the foundational structure right. (I think we’d ditch our Westminster government on similar grounds if we were given the option. In fact, I’d argue we did that last June and were ignored and overruled.)
Political, and managerial ‘control freaks’ don’t espouse the principle of subsidiarity. On terms of (crude) efficiency every decision in an organisation should be made by the lowest paid worker capable of making it.
There are multiple benefits to a subsidiarity culture, not least is that people ‘own’ the decisions they have to live, and work, with. They are highly incentivised to get those decisions right.
Thank you but I disagree with you about the EU. There are darker motives here and I would argue the managerialsim present is different – it is financial rather NPM.
Problems with the EU have come about because of what we call ‘mission creep’. The EU has its fair share of Federalist dreamers no doubt. But there others who benefit from this too.
What was just a trade treaty framework started to become something bigger that it was intended to be. Not always a good sign. And rather than NPM mangerialism interfering at the coal face, it was instead just creating limited and arcane rules further up stream at the money producing level about what its role is (which no one had even consider pre-2008 it seems).
Maybe too many Goldman Sachs advisors got involved? Maybe it was because the US wanted to do to the EU what it had done to Japan and SE Asia and use the ECB as it had used the central banks there to open up economies whilst ECB sat back saying they they could not help? Maybe this helped US companies to come in and use their over valued dollars to snap up failing EU businesses and assets at fire sale prices? Who knows?
As Werner teaches us, Central Banks are very powerful – especially when they do the wrong thing or do nothing. The ECB has relented. But is it too late? And will it withdraw its current stimulus prematurely? Do we need an ECB?
The ECB should be wound up – it was just a bad idea from day one. Just like BREXIT – which is just predicated on lies and an over done relationship with Britain’s past as I’ve tried to illustrate here before so here’s yet another view on that subject:
https://www.theguardian.com/politics/2018/jan/29/german-ambassador-peter-ammon-second-world-war-image-of-britain-has-fed-euroscepticism
Pilgrim Slight Return says:
January 30 2018 at 12:11 pm
“Thank you but I disagree with you about the EU.”
Not entirely you don’t.
What you point out as the problems with the EU are symptoms in my opinion of the foundations being insecure.
The EU is broadly speaking a social-ist project which is being managed by ‘neoliberal’ paleo-conservative market capitalists. That essential contradiction is why neither of our main political parties can dream up a coherent policy to either leave or remain.
It’s not that the ECB should be scrapped it’s rather (I suggest) that it shouldn’t have been set up the way it was within a structure that was flawed. If the economic foundations of the Euro were sound the ECB would be necessary. The ECB without the foundations is a bit like building a huge cathedral spire before you have the cathedral to put it on. We’ve even got gargoyles, minarets and all manner of rococo adornment, but the walls are cracking and there’s no coherent congregation of believers.
The whole EU venture has suffered from putting carts before horses (and the Euro is the most egregious manifestation of that).
I don’t think we disagree, except in the way we interpret and choose to describe the mess and its causes.
The one small shred of rationality in the Brexiteers position is to view the mess as something they can’t fix. They’re damn right about that, because the evidence suggests very firmly that they don’t know how to run a national-scale economy let alone a supranational one. Their solution is to jack out of it regardless of any collateral damage that might result.
The costs are well worth it to them because as individuals they won’t be picking up the tab.
Thank you. And good night!
https://flipchartfairytales.wordpress.com/2014/01/15/is-the-nhs-really-over-managed/
https://flipchartfairytales.wordpress.com/2012/03/29/the-nhs-its-a-system-stupid/
https://flipchartfairytales.wordpress.com/2012/02/10/you-dont-need-to-be-a-lefty-to-think-the-nhs-reforms-are-mad/
Basically; this is about people. All the NHS does, is about people.
Left to its own devices, when I became ill I would have gone to the local hospital.
Easier, cheaper and closer.
It would have been fatal.
I was given a choice: I chose a 25 mile trip to a specialist hospital.
Obviously, it was the right choice. Very expensive diagnostic machinery, very expensive technicians, very expensive laboratories. None of which are at my local (other than a few MRI scanners)(used for pets at night). I noted a comments about MRI machines…as a matter of interest…they are never turned off! Other than breakdowns/maintenance, they are 24/7/365…
JohnM says:
“Basically; this is about people. All the NHS does, is about people.”
Left to its own devices, when I became ill I would have gone to the local hospital.
Easier, cheaper and closer.
It would have been fatal. [Because the resources you needed have been purloined by the private sector]
I was given a choice: ”
I think you mean you were able to afford to make a choice. And good luck to you, I expect you believe you earned your luck and maybe you have. Your good fortune however is at someone’s expense because there is no rational reason why the level of service you were able to buy couldn’t be available to everyone. And much of the resource you were able to access is underpinned (paid for) by massive amounts of public sector spending in education and training, medical research, social and material infrastructure and directly or indirectly in allowing you the affluence to make (and pay for your choice).
If my health were at stake I expect I’d chose to use my surplus wealth in a similar way to your choice (if I had any), but I hope I would be still be supporting the Nhs principle of universal delivery that is being willfully destroyed by this government on the phoney grounds that there isn’t enough to go round and that’s just tough because nothing can be done about it.
I don’t accept the truth of that proposition. I’d go so far as to say it’s a lie.
No Andy…
I was given the choice at my NHS trust hospital.
I could stay there, or go to another NHS hospital which specialises in lung and heart problems.
Having relatives working at both helped a lot, as their opinion was to go to the specialist hospital.
Said hospital also does paying-patient treatment as well, but then all do now to complement their revenue.
Effectively, the choice was to stay in a one-small-ward treatment facility…or to a hospital that only treats people with my type of complaint, and treats them exceptionally well. AND is NHS, AND is world-renowned.
For the record, private treatment centres are a poor second best. Their doctor-to-patient ratio is, at the point of treatment, worse than the NHS, with stories (true) of 1-doctor to 50 patients…and I know from friends and relatives who work in the local NHS hospital of private patients who suffer a relapse in private care, and then get transferred to NHS acute care facilities. Acute care is labour intensive, equipment intensive, and very EXpensive. So private stays away from it.
The private sector costs the NHs several tens of millions every year, with no evidence it is ever paid back….
JohnM says:
January 31 2018 at 12:07 am
No Andy…
“I was given the choice at my NHS trust hospital.
I could stay there, or go to another NHS hospital which specialises.”
Totally missed the point of your original posting. My apologies.
I had a similar experience when I had my hip replacement op. done. Same surgeon, but better back-up facilities at the big, further away, hospital. In fact I’m not sure whether that was because I was assessed as likely to throw up complications or whether it was more a matter of scheduling convenience to get the job done in timely fashion, but I have no complaints either way. Nhs (Scotland) did me proud.
My earlier reply as you can see mistakenly assumed you had opted for a private provision.
I should have been more clear..
I should also point-out that the consultants in private hospitals are highly likely to be the same ones in the NHS hospital.
You get more IMMEDIATE service in a private hospital, and better room service, but not a better medical service.
I also note, from conversations with the staff at the (NHS) hospital, that many private patients are sent there for specialty healthcare provision…because it is the best available.
I don’t know who Steve T is but it seems to me his suggestion is not as innovative or perhaps as innocent as it might appear. The Toyota Lean system is in place in the NHS. It pervades every Sustainability and Transformation programme. Indeed its theories are present in Whitehall to an alarming extent. The Virginia Mason Hospital in Seattle is currently being paid £12.5 million over 5 years to come here and teach Lean to 5 NHS Trusts. The outsourcing of large ‘back office’ contracts across groups of Trusts is very much the vogue as is the use of Referral Centres to double check the cost-effectiveness of GP clinical referrals for tests and specialist treatment. Who runs the back offices and Referral Centres? Optum (UnitedHealth of America), Capita, KPMG, PwC… Need I go on? Plus the use of Lean in human facing and personal services is very much a contentious issue. Cleaning – outsourced in the 80s in large contracts across multiple sites – led to MRSA and c.difficil becoming serious problems. Where they have been taken back in house costs have dropped and standards have risen. The idea that manufacturing productivity objectives hold true in the NHS is badly mistaken. When you introduce technological innovations into factory production lines you speed things up and reduce your staffing. That means increased productivity. When you introduce technological innovation into healthcare you increase the potential for diagnostics and for new treatments. That means more conditions, more patients, more staff. And most of us are very grateful for that. But in terms of productivity? It’s a decrease.
Thanks for contributing
Lallygag,
Sounds a lot like paying the foxes to consult on chicken farm management.
From what I’ve been told Cuba has stunning medical provision. It might be more instructive (if indeed it is true) to find out how they achieve that standard whilst under the cosh of US economic sanctions for decades.
The weakness of outsourcing is the loss of control. Witness Carillion. Government helpless because it’s ‘only the customer’. And a gullible customer at that as far as buying public services is concerned.
Hi Lallygag,
Be assured I’m merely a career engineer with substantial experience of the Lean system and have no other interest in this than wishing to improve the NHS.
I certainly agree with you that like all tools, Lean can’t be applied to all areas with equal effectiveness. Some of the concepts like waste elimination are certainly universal, but others are not. Where it has been shown irrefutably to work is in reducing wasted effort and non-value added activity, improving flow and reducing inventory – in this case waiting patients. I think it’s universally accepted that a reduction in wasted time and effort would benefit the NHS, as would a reduction in the time spent by each patient in the system (including time on waiting lists) and a reduction of the many small but irritating avoidable errors.
There is nothing about Lean that says the result must be fewer staff and I personally would not advocate for this. You can choose any care based or flow based KPI you want.
John Seddon and his Vanguard consultancy are the people to listen to. Also, another like mind consulting company called ‘Perfect Flow’.
Seddon’s take is that successful service provision is one that is able to deal with diversity – different needs – rather than shoe horning those diverse needs into ‘standard operating procedures’ (making the customer fit the service – not the other way around). This – and the use of too much IT – means that people cannot actually get what they want and end up using another channel of the service to get what they are after. He calls this ‘failure demand’. You could also call it ‘waste’.
To me failure demand in the NHS is the increase in elderly people we see in our A&E departments as adult social care slowly breaks down.
What is important in this sort system thinking is that the person delivering the service is empowered and has discretion to meet people’s needs – this would include the option not to close wards or a decision at a DWP office to give someone money to tide them over if there was a benefit claim problem (not punish them by holding back cash).
The Toyota system is the same. It empowers workers to stop the production line to deal with variances in production quality there and then – ‘Kaizen’ – making running improvements to performance and processes. The just in time principle avoids holding large inventories of unused materials which lie there doing nothing.
Doing nothing is what closed wards do whilst people die in hospital corridors instead.
The Toyota System and Lean have not been used on the public sector – they’ve been abused by what we call ‘tool heads’ – people who just take these models and use them unthinkingly, ineffectually and selectively but also inappropriately.
Seddon is truly feared by Whitehall BTW. And he has no time for Tory ‘shared back office services’ or New Labour’s previous obsessions with targets which he evidenced just encouraged people to cheat.
Those of us on Seddon’s distribution list get a newsletter about his latest travels in public services via an email. He encourages us to pass them on if we care but I’m not sure how I’d link an email to this page. They are a good read and offer a better way of doing things as Richard does too.
Services and management outsourcing:
http://www.ekklesia.co.uk/node/25053
(Following two years of operation of the Primary Care Support Service England (PCSE) by the private company Capita on behalf of NHS England, a new survey of practices and GPs by the BMA provides clear evidence of continued serious failings that are impacting patients and practices)
Twitter:
(((Frances Coppola)))
â€Verified account @Frances_Coppola
14m14 minutes ago
(((Frances Coppola))) Retweeted Sean Farrington
It’s the same financial model as #Carillion – mostly intangible balance sheet, highly leveraged, extremely sensitive to cash flow variation. Needs more equity, less debt and a lot more free cash.
(((Frances Coppola))) added,
Sean Farrington
Verified account @seanfarrington
#capita:
Outsourcing company – provides lots of govt services (eg. welfare assessments)…