NHS - tribes at play
13 Oct 2011 - The Care Quality Commission today reported that a significant proportion of hospitals are doing an appalling job of looking after old people. It seems it's not the clever whizzy bits that are going wrong, but just the simple tasks of caring that aren't being done - keeping people clean and fed. This isn't new news - so why does it persist in an organisation whose very purpose is care and restitution?
One of the points that seemed to amaze the CQC and the various commentators was the variability in standards - good hospitals have bad and good wards on the same floor, and some Trusts are good, some are bad. Why so?
Here are some thoughts as to why it's not such a surprise:
Don't be fooled by the name
Whatever else it is, the NHS isn't national, about health or a service. To my mind it's actually a regionalised treatment delivery network.
- Regionalised, not national
The operating units are deliberately left to their own devices to do what they think is best - the recent revelations on purchasing practice prove that, with hundreds of different types and makes of rubber gloves and bandages being bought from loads of different suppliers, with no attempt to use the natural purchasing weight to improve performance and cost.
- Treatment, not health
It's not about health. The record of the NHS and indeed all government bodies in the UK for improving health is poor. They are simply not skilled at changing behaviour - at least, not nearly as skilled as the private companies seeking to increase sales of leisure foods and couch technologies, which worsen diets and reduce exercise.
And the NHS isn't really that bothered about these initiatives - the focus is on training experts in delivering increasingly complex treatments in larger and ever more centralised buildings. Some GP's try to get their patients to eat a better diet and exercise more, but these obviously beneficial changes in lifestyle are not the focus of the NHS at large.
Being healthy isn't the same as not being ill.
- Network, not a service
A service serves you. It is set up to look after you, whatever transactions you need to do and whoever you need to talk to in dealing with this service. The NHS does none of these things - experts work in a network of individual silos, and you are an entirely new customer to each of these. There is no attempt to make it a seamless service.
At least, there wasn't until Labour's lunatic IT scheme came along. The national computer network was supposed to speed us all along a healthy data highway, linking the whole enterprise together. But the ignorance, lack of business experience and general naivety of professional politicians was the undoing of the project from the start. They believed that sprinkling computer technology on a system that doesn't work in the first place will put it right. It didn't.
Surprisingly, the consultants hired to do the work didn't point that out. Instead, they carried on accepting large amounts of money from all of us - and keeping the fact that it wasn't going to do what the politicians (and the equally-ignorant civil servants) hoped it would do a big secret, known only to anyone who took a passing interest in what was going on.
A tribal culture
What is a hospital? I think it's just a place where tribes of experts gather. They each have their own tribal grounds, camp followers and culture. Occasionally they come up against each other, but essentially they have their own territories and they stick to them. The elders are revered by all the subordinates, with a class-consciousness that I recognise from private industry of the 1980's but not now.
Each tribe has its own structure, with its own national professional body being the holder of the keys of culture, history and defence against other tribes. So the surgeons and the psychologists and the ophthalmologists all live as distinct and separate entities.
Of course, they need patients to provide raw material to work on, and to bring money into the tribe. And I'm sure they care about us to some degree, too.
Professional nurses
But I'm less sure about the nurses. It seems the idea of nursing as a caring profession is dying out. Perhaps they collectively see themselves as above the basics, now, since the move to increase the qualifications required and turn it into an academic trade on a par with doctors and consultants. The lure of status has apparently undermined the whole point of the nursing arm of the business.
It's a business, just like any other
And this is the part where I'm most likely to part company with many readers. To me, providing healthcare and educating people is just like any other business. There's an end result to be gained by following some kind of a process - that's all.
Doctors and teachers who complain that there job isn't like 'making a tin of beans' are quite wrong. Invariably, they have no idea of what's involved in making a tin of beans - how you have to cope with a variable raw material, control complex processes to turn out a predictable end product, do research to find out what sort of beans people want, make sure your consumers are happy and talk to them when they aren't. Healthcare and education are both susceptible to the same processes of improvement and control as manufacturing and other service industries.
They're not angels and it's not the best in the world
But as a society, we seem to want to cling to the idea that our nurses are angels, our doctors are pillars of the community, and the NHS is the best health service in the world. None of this is true. Yes, establishing the NHS was a singular achievement in a country wracked by war and debt - but it didn't work from the start.
Overspends are as old as the NHS itself. The doctors only joined because he 'stuffed their mouths with silver'. And the consultants have retained a status and private working perks from the beginning. We really shouldn't pretend that it's perfect, without parallel and the only way to arrange things.
My debt to the NHS
I wouldn't be alive without it. My life was saved by a doctor and a big dose of penicillin when I was a few days old. So I owe the NHS everything.
But I've also been let down in life-changing situations since - so I don't stand back from criticism.
These are just my thoughts - I'd be happy to hear yours.