The NHS is not broken. It is a large ramblings house. An army of itinerant plumbers have been at work; tutting as they remove vast organs, replacing them with incomprehensible new pipework: the gurgling continues. Various wings have been sold off, re-emerging as smart incongruous glass-clad boxes. A general air of tender dishevelment pervades. Cleaners gather around a cafe table, playing cards, Doctors in blue pyjamas strid the corridors, stethoscopes draped round their neck denoting status.
An American psychotherapist joined our out-patients clinic. She took one look at the plastic covered hotchpotch of low slung chairs, and spent most of her budget converting her consulting room into a set from a Woody Allen film. I imagine an exasperated Allen sitting up from the analyst's couch exclaiming "you cannot be serious".
Lucy eventually retired, and items from New York clinic gradually spread themselves round our building. Now I walk into a room full of an eclectic mix of furniture. I enquire "shall we put your mum in the chippendale high-backed chair, or on the moth-eaten waiting room chuck out?"
The land where I used to park was converted into a new Public-Private Partnership (PPP) GP surgery. The day before the building opened someone sprayed across a bright azure blue painted wall, "stealing from the people". It was quickly covered over, but I noted that the tone of the erasure paint was slightly too light. leaving a shadowy scar.
The NHS is supposed to be a 'service', but as we all know, the population now appears to 'serve' the beast. The only way to change this is for the power balance to shift. This is a mighty challenge, because some of the most powerful people and interests in the land are tied up in this enterprise.
Research showed how illness and calamity during a weekend (especially one with a bank holiday) results in a much higher rate of fatality. The government moved towards a 7 day a week NHS. But this was very problematic. No one wanted to work at the weekend. The only way to archive this is to use highly paid locums. Locums are the people who prefer to live on the edge of the system. They are modern day peddlers.
The other thing that people do not know about the NHS is how the private sector lives off the main body of the NHS. The private sector could not exist without the NHS. If any emergency occurs during a private procedure, it's off the local A&E. Private hospitals employ NHS staff. They are essentially a 'queue jump'. You get the same service from the same people, but quicker. People think they reduce the burden on the NHS. But private staff are all subsidised by the NHS. They trained in the state system. When the insurance runs out, the patients get shipped back to the NHS. The private sector is far more likely to invest in commercial products that are not really essential. If they were essential, they would be in the NHS already.
So what do we do to 'fix; the NHS? The first thing will be to set a charter that defines how it is to be run. The NHS has a constitution (with many fine words). The first line is "The NHS belongs to the people." However, if you wanted a plumber to do urgent work and got the response, "sure, I'll be with you in six months", you would say, "sorry no, I'll get another plumber."
My Constitution for the NHS
1) To remain free at the point of use. No money to be exchanged. The act of collecting the money in the first place will cost more than the benefit accrued. This includes the threat of fines for non-attendance. And also so called NHS tourism, which again is not as significant a problem as is made out to be.
People who miss appointments are likely to be elderly. A significant proportion of NHS services are used by the elderly, and quite sophisticated reminder systems are in operations to get them to appointments. Some appointments are clearly not needed if forgotten. Much NHS admin time is dependent on people not attending appointment.
2) Be open and honest about the resources available. Elect regional juries to help the specialists allocate these resources to mitigate against powerful commercial interests.
3) Define functional waiting times for all disciplines. Waiting times are part of very well known 'demand- capacity' economic formulations. There are three things that affect waiting times. the first is increase the resource. This works when the need and capacity are very close. The second is work with greater efficiency, which also includes 'cutting corners', such as admin/ letters and reducing 'belt and braces' assessments (such as MRI scanning). Increasing tolerance to 'risk' will need public approval, because the system is very averse to risk.
4) Redefine the nature of liability. Much of what the NHS does is governed by the fear of litigation. This means it is constantly 'looking over its shoulder', rather than looking forward. With a new partnership formed with the public, financial recompense can be seen as insurance, rather than redress.
5) Weed out people in the NHS who are there for the wrong reasons. As with all industries, there are parasitic behaviours that are not healthy in any organism. The NHS needs to be more welcoming to the good people who work in the system, and show less tolerance to those who abuse the system. Since I joined the NHS I have seen a greater level of what I see is counterproductive harshness to staff. New starters have to argue about their starting salary. They begin in the system with a bad taste in their mouth. There is a fear that management in soft, so no time allowed for a Christmas lunch, when across the whole country is relaxing together. A bit of discretion is allowed. Let's call it team building.
6) Ensure that the NHS works on the basis of equity. This means that equal access incudes ensuring that people who will find access difficult has their pathway eased. The NHS is good at providing an equal service, but we are not all equal. Equitable means that these differences are accounted for.
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