Not Waving But Drowning

Apologies for lack of posts. Denham Senior has been hospitalised with a serious heart condition and blogging has therefore moved to the back seat. But today's report from the Royal College of Nursing just has to be clocked.

According to their latest survey, NHS nurses are still "drowning in a sea of paperwork". Nearly one day in five is spent filling in forms, ticking boxes and ordering supplies. RCN general secretary Peter Carter says:

"These figures prove what a shocking amount of a nurse's time is being wasted on unnecessary paperwork and bureaucracy. Yes, some paperwork is essential and nurses will continue to do this, but patients want their nurses by their bedside, not ticking boxes."

Yes, indeed. And visiting Dad in two NHS hospitals over the last several weeks we've been able to study the process up close and personal.

The first stop was a large acute hospital just beyond the M25. It suffers all the usual problems: decrepit buildings, huge financial deficit, and a chronic - and I do mean chronic - lack of parking for visitors. Admission even for blue light emergencies like Dad is via a 12 hour plus trolley wait in A&E, and once finally admitted, care is in the hands of those overstretched uncontactable doctors. The nurses spend huge amounts of time behind the counter filling in forms rather than being out on the ward with patients, and you virtually have to book an appointment for one to stop by your bed. The whole impression is of an operation struggling barely to keep its head above water.

The second stop was one of Britain's top specialist heart hospitals, and it is much more impressive. What's done there in terms of heart surgery is truly world class, and its clinical staff are the business. The doctors are top notch, and the nurses do real nursing (Dad even attempted to take one home with him). Morale seems high, with junior nurses actually on first name terms with the top consultants. True, it's clear that staffing ratios are higher than in the general hospital, but much more striking is the excellent attitude and commitment of staff members.

Yet even here, the nurses told Dad they have a complaint. It isn't the hours, or the inconvenient shifts, or the stressful sometimes stomach-churning work, or even the pay. Their number one complaint is excessive paperwork. And even though they don't let it interfere with patient care, we watched them filling in great piles of paper in every spare moment.

So what's it all for? Why do we need all this paper?

Back in the dark days of the Commissariat, much of it was to satisfy the central planners that patient pathways were being rigorously followed, that prescribed risk assessments were being fully documented, and that every bedpan could be duly accounted for. Or rather, to provide a full audit trail which could be filed away to protect bureaucratic backsides in the event of a system malfunction.

But surely we're now three years on from all that. Surely we don't need all that now?

It's not that Jezza Hunt isn't aware of the problem. He's told us before of the million nursing hours a week spent on form filling rather than caring for patients. Of the nurse who had to fill in a 22 page form and 10 additional forms to get a desperately ill patient admitted to a trauma ward. And of the Hospital Trusts who have to report to, and comply with, 60 different regulatory, licensing, commissioning and public scrutiny authorities. Why, he's even ordered a review of NHS bureaucracy.

But he's attempting to tame a monster. The NHS is far too big, and the bureaucracy far too entrenched, for one single weedy minister to prevail.

The only way of getting on top is to break it up, give us choice and competition, and allow the hospitals themselves to find ways of managing their own affairs. They must be held accountable for results, not for how many boxes their nurses have ticked.

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Problems With The Roller

This may never turn into a Rolls Royce

Now don't laugh, but there used to be a theory that the Civil Service was a finely tuned Rolls Royce. Ministers had only to point it in their chosen direction, settle back in the plush leather seats, and leave the purring giant to convey them effortlessly down the road.

Of course, it was never actually like that in practice, but for politicians keen on expanding the scope and reach of government it was a useful and comforting myth. Attlee's New Jerusalem government reckoned Civil Servants were capable of managing everything from the commanding heights of the economy right through to the allocation of bedpans in their newly nationalised health service. Wilson's government pushed up the proportion of our economy under Whitehall management from 35% to 45%. And we all know what the Blair/Brown government did.

But if your base your approach on a myth you end up with a disaster. And far from settling back in the Connolly leather, ministers spend most of their time flat on their backs under the car wrestling with the transmission.

And this week we've got two very good examples.

First, the latest attempt by a Health Secretary to stop the dysfunctional NHS killing so many of us. The bureaucrats at the Department of Health having failed to come up with anything other than more paperwork, Jeremy Hunt is issuing his own Orders of the Day.

Order Number One. All hospitals and care homes will be officially rated by a the new Chief Inspector of Hospitals.

Order Number Two. Any state healthcare operative who fails to freely confess his own shortcomings will be shot. Well, maybe not shot exactly... but their employing organisation will be given a jolly good talking to.

Order Number Three. Before they qualify, all student nurses must spend a year... well, let's say "up to a year", actually doing some nursing with real patients.

Mmmm... no matter who's sitting in the big leather chair, the NHS just goes on fighting the Battle of Stalingrad. As we've blogged many times (eg here and here), running a huge organisation through top-down orders and fear may have worked for Stalin in 1942, but he wasn't trying to save lives (other than his own of course). In the NHS it's been a total flop: successive Health Secretaries have tried it, and it simply doesn't work.

As for the new Chief Inspector of Hospitals, he's only being introduced because Labour's Care Quality Commission has failed. And the Care Quality Commission itself was only introduced because its predecessor, the National Patient Safety Agency, also failed. A government regulator regulating a nationalised industry is always going to be the public sector marking its own homework. And while the Government Inspector may strike fear into the hearts of employees - witness the hatred of Ofsted among many headteachers - that's because the regulator becomes an instrument of Commissariat control rather than an objective assessor of standards.

And who ever thought it was good idea for nurses to qualify without having a hands-on apprenticeship of feeding and washing patients? When my Mum trained as a nurse back in a flagship pre-NHS hospital, one of  her duties was to make sure the patients in her care were eating and drinking properly: years later she still recalled being pulled up by matron for not cutting the crusts off some old boy's sandwiches. It was the Department of Health - miles away from the sharp-end of patient care - that later ruled that wasn't part of a nurse's duties.

Meanwhile our energetic Home Secretary has announced that she's breaking up Labour's useless £1.6bn pa UK Border Agency. The UKBA has become a byword for ineptitude, with among other things, an immigration case backlog well in excess of 300,000 cases.

According to Mrs May, creating this gigantic immigration super-quango may have looked neat on paper but in practice it was disastrous :

"First, the sheer size of the Agency means it has conflicting cultures, and all too often focuses on the crisis in hand at the expense of other important work. Second...UKBA was given agency status in order to keep its work at an arm’s length from ministers. That was wrong. It created a closed, secretive and defensive culture. The new entities will not have agency status and will sit in the Home Office, reporting to ministers."

This echoes two points we've long made on BOM - one, that bigger is almost always worse, and two, that delegating power to arms length quangos means rule by bodies unaccountable to anyone, let alone us poor schmucks out here paying for it all.

So good for Mrs May.

But not so good for Mr Hunt.

Because although both of them are attempting to fix the broken old jalopy of of Civil Service management, Mr Hunt ought to be trading it in for a superior model.

With border control Mrs May has little choice but to somehow get her Civil Servants working better: protecting our borders is an essential function of government, and she can't turn it over to others. She has to make it work, however hard that is.

But healthcare is something else entirely. It's not an essential function of government, and Hunt should be learning from the workings of superior systems elsewhere. The European Social Insurance systems put customers in charge via their freedom to choose between competing providers. In all likelihood their Civil Servants are no better than ours at running things, but it doesn't matter because they're not required to do so.

Unless we can shrink government back to its core functions we will never enjoy the standards of service we're already paying for. No matter how hard ministers may try, you simply can't build a Rolls Royce from the bits off an old Austin Allegro.

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Our Scary NHS - 3

Maybe he should have a crack at the NHS

According to government health adviser Professor Sir Brian Jarman, ministers and officials could have saved at least 20,000 lives had they listened to his warnings over dangerous NHS hospitals.

Jarman is the co-founder of the Dr Foster company, which provides comparative information on health and social care services. Among other things it produces statistics on hospital mortality rates (Hospital Standardised Mortality Ratios - HSMR) that flag up hospitals with significantly higher levels of mortality than the average. Jarman says their stats identified the problem at mid-Staffs long before any official action was taken, and similar issues at other hospitals now finally being reviewed by the government. He says:

“Those hospitals which had persistently high death rates over all those years and have now been listed for investigation should have been investigated earlier, because it’s quite possible we would have had fewer deaths in those hospitals... [there] must be at least tens of thousands of avoidable deaths in those hospitals alone, when we should have been going in and we should have been looking at them”.

In just the 14 hospital trusts* now being reviewed by the government, he reckons excess deaths number "a bit over 20,000".

This is bad enough. But even worse is the fact that even when Jarman flagged up his concerns directly to Labour Health Secretary Andy Burnham, nothing was done. In March 2010 he sent Burnham a list of hospitals with significantly high death rates and nothing happened. Nothing.

It's not hard to see why. Because March 2010 was just two months before the last election. No way would Burnham - or any other Health Secretary - have wanted that blowing up during the campaign. With politicians at the controls, patient safety must always come second to political imperatives.

Not that Burnham ignored Jarman outright. According to Burnham's own account, he referred the matter to the Care Quality Commission, who "did not find that there was anything to worry them". Further, Jarman's HSMR data was "new" and "the government could not put it's full weight behind it".

Hmm. Here we have an officer of the state, warned that his state owned industry is going seriously off the rails, and relying on his own state commission and own state statistics to check it out. Does that sound like a recipe for customer safety?

Now, nobody's saying Burnham's a bad man. True, he's a politician, but just like every other Health Secretary in living memory he found it impossible to manage our huge NHS to deliver as he (and his customers) would have wished. He found himself as one against one-and-a-half million staff, staff who know far more about their business than he could ever hope to find out. And if his managers choose to tell him there's nothing to worry about, how can he possibly hope to find out what's actually going on down at ward level? As always, information is power.

Which is why the current Health Secretary, Jeremy Hunt, is now making it a criminal offence to fiddle NHS stats. In future, anyone cooking the figures for hospital mortality, or waiting lists, or anything else in the NHS, will face a jail sentence and their employing trusts will be fined millions. Hunt says:

“This is about a transparent, honest and accountable NHS. Patients and the public should be confident that they can trust information about how hospitals are performing, and a culture of honesty and accuracy will help those organisations drive up standards of care."

A new culture, yes, that's what we need all right. But can criminal sanctions deliver it? Out East, they have plenty of criminal sanctions to support the right culture - and we're talking sanctions that are a tad more bracing than three months in Ford Open Prison. Yet their new management team inherits a state behemoth with all the NHS problems plus a few more besides.

"President Xi Jinping told the nearly 3,000 delegates gathered at Beijing’s hulking Great Hall of the People that his government would “resolutely reject formalism, bureaucratism, hedonism and extravagance, and resolutely fight against corruption and other misconduct in all manifestations.” Shortly afterward, freshly appointed Premier Li Keqiang said the central government would slash its payroll and freeze spending on overseas trips, guest houses, office buildings and new vehicles in response to falling revenues. “The central government will lead by example and all local governments must follow suit.”

Formalism, bureaucratism, hedonism, extravagance, corruption, and other misconduct in all manifestations. Well, maybe the NHS hasn't quite ticked all of those boxes yet, but on my count it's done at least four out of six.

Good luck to the reformers, both out East and here in the NHS. But meaningful reform in big organisations whose customers have no choice is next to impossible.


*Just so you know, here are the 14 hospital trusts now under review for having significantly higher than average death rates:

• Basildon and Thurrock University Hospitals NHS Foundation Trust
• Blackpool Teaching Hospitals NHS Foundation Trust
• Buckinghamshire Healthcare NHS Trust
• Burton Hospitals NHS Foundation Trust
• Colchester Hospital University NHS Foundation Trust
• The Dudley Group NHS Foundation Trust
• East Lancashire Hospitals NHS Trust
• George Eliot Hospital NHS Trust
• Medway NHS Foundation Trust
• North Cumbria University Hospitals NHS Trust
• Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
• Sherwood Forest Hospitals NHS Foundation Trust
• Tameside Hospital NHS Foundation Trust
• United Lincolnshire Hospitals NHS Trust

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Our Scary NHS - 2

Postponing our appointment

"The UK has had universal free health care and public health programmes for more than six decades. Several policy initiatives and structural reforms of the health system have been undertaken. Health expenditure has increased substantially since 1990, albeit from relatively low levels compared with other countries.... However, the UK performed significantly worse than the EU15+ for age-standardised death rates, age-standardised YLL rates*, and life expectancy in 1990, and its relative position had worsened by 2010."

Today's report in the Lancet is a timely companion to yesterday's blog. Not that it tells regular BOM readers anything particularly new about the under-performance of our nationalised healthcare system, but the facts need to be known much more widely, and this Lancet study has certainly grabbed the headlines.

The study focuses on premature death, and as we've blogged many times, compared to its counterparts just across the Channel, the NHS is pretty poor at keeping us alive. In the BOM book we summarise the key figures on premature death, including our low survival rates for cancer and heart disease. In fact, every year around 50,000 of us - the population of Salisbury - die from diseases which should in theory have been treatable (so called Mortality Amenable to Healthcare). Of course, no healthcare system manages to prevent all such deaths, but the European social insurance systems do much better.

And although our life expectancy has increased hugely under the NHS, nobody can seriously argue that's down to the NHS itself. While life expectancy has increased by around 13 years since the NHS was founded, in the previous five decades it had increased by 20 years. These are worldwide trends, and they reflect improvements in medical knowledge and diet much more than the efforts of our underperforming NHS.

However, despite the headlines, the Lancet article did not set out to be an NHS hatchet job. Rather, it puts the blame for our poor showing on our own unhealthy lifestyles - too many horse burgers and not enough press ups. And the report's authors clearly want more state intervention to control our unhealthy lifestyles. More public health programmes, more booze taxes, more fat taxes, more sugar taxes, more indolence taxes, etc etc.

You can certainly see how you get there - if we could all be hassled or forced into living healthier lives, we'd almost certainly live longer and probably save the NHS a shed-load of cash. It's exactly the kind of thinking that drove Labour's anti-obesity programme, although somehow they never did get round to fat and sugar taxes.

Except of course, that's not how the better performing countries do it. Although France, Spain, and Italy all outperform us in this study, my own extensive research suggests that their booze taxes, at least, are an awful lot lower than ours. The issue is rather more complex than comparative tax rates and public education campaigns.

What this study really highlights is that when it comes to health, we have a lot to learn from our neighbours. None of them have a nationalised health system, yet most of them enjoy longer healthier lives than us. Instead of pretending our healthcare system is the envy of the world, we should have the humility to look and learn.

PS I've just been listening to Sir David Nicholson being grilled by the Health Select Committee. I must say I admire the guy's sheer nerve. Yes, he says, terrible things happened at mid-Staffs while I was in charge of the regional health authority, but I knew nothing about it. Barclays tried that one, but Diamond still had to walk the plank. And even if Nicholson didn't know, he surely should have done. As we've said many times on BOM, you can delegate authority, but you can never delegate responsibility.

*YLL is Years of potential Life Lost

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Our Scary NHS

The bald facts**

Two years away from blogging, and it's time to check how the NHS is doing under its current consultant Mr N.H.S Cameron.

We have to start with mid-Staffs. It ought to be old news - we started blogging it in 2009 - but last month's Francis Report has shone an even more scary light on how an NHS Foundation Hospital (yes, a Foundation Hospital!) managed to kill as many as 1200 of its patients.

I've been reading the report, intending to quote some of the many personal accounts of horrific standards of care meted out to patients: loved ones left lying for hours in their own urine and faeces - their cries for help ignored by staff - left without food and water, illnesses made worse rather than cured, and bed sores, broken bones, gashes, and hospital infections just a routine part of the grim patient experience.

But the more I read, the more upsetting it became. These are real people talking, and to use their anguished accounts merely to make a blog point feels grossly intrusive and disrespectful. So let's simply quote Robert Francis's own summary:

"I heard so many stories of shocking care. These patients were not simply numbers they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives."

As for management claims that the original press reports had been exaggerated:

"A number of staff and managers at the hospital, rather than reflecting on their role and responsibility, have attempted to minimise the significance of the Healthcare Commission's findings. The evidence gathered by this Inquiry means there can no longer be any excuses for denying the scale of failure. If anything, it is greater than has been revealed to date. The deficiencies at the Trust were systemic, deep-rooted and too fundamental to brush off as isolated incidents."

The harrowing events at Mid-Staffs highlight many of the critical NHS failings we've blogged in the past. In fact the Report sometimes reads like an excerpt from BOM:

• target-driven priorities – a high priority was placed on the achievement of targets, and in particular the A&E waiting time target. The pressure to meet this generated a fear, whether justified or not, that failure to meet targets could lead to the sack.
• disengagement from management – the consultant body largely dissociated itself from management and often adopted a fatalistic approach to management issues and plans. There was also a lack of trust in management leading to a reluctance to raise concerns.
• low staff morale.
• isolation - not as open to outside influences and changes in practice
• lack of openness - One particular incident concerning an attempt to persuade a consultant to alter an adverse report to the coroner
• acceptance of poor standards of conduct – an unwillingness to use governance and disciplinary procedures to tackle poor performance... incidents of apparent misconduct which were not dealt with appropriately, promptly or fairly.
• denial – In spite of the criticisms the Trust has received recently, there is an unfortunate tendency for some staff and management to discount these by relying on their view that there is much good practice and that the reports are unfair.

The management of the Trust clearly bears a heavy responsibility for all this, and the Report shows how they made a series of ill-informed and ultimately catastrophic decisions about resourcing and organisation. It also shows how they routinely dismissed and suppressed criticism, even when confronted with the cold hard statistics of rampant death on their wards. 

Ah yes, those cold hard mortality statistics. BOM always tries to support argument with stats, but when it comes to public sector performance, the stats so often turn out to be damned lies, fabricated to hit targets and tick boxes rather than illuminate the truth. And so it seems to have been with hospital deaths.

The problem is that not all hospital deaths have been counted in a hospital's official mortality stats. For example, hospitals were allowed to exclude the deaths of those receiving palliative care (ie terminal patients who were merely being given pain relief while they died). So at the Wolverhampton Hospital, deaths recorded under palliative care were bumped up from 2% to 20%, double the national average; deaths from other causes - the ones that did count in the official stats - were correspondingly reduced. The Royal Bolton Hospital seems to have pulled a similar stunt with septicaemia deaths, which are also excluded from official mortality figures. And there are probably countless other examples around the country.

Now of course, all of this took place under the previous regime, so we can't blame Mr N.H.S. As a Conservative he fully understands the disastrous consequences of the old Stalinist regime, He's pledged to abolish targets, stop box-ticking, and enforce accountability via the criminal law if necessary.

Well, er, he kind of suggested that's what he'd do. What he's actually done seems to fall some way short.

Most extraordinarily, he has not fired the Chief Executive of the NHS - Sir David Nicholson - even though at the time of mid-Staffs disaster Nicholson was first in charge of the local Strategic Health Authority, and then CEO of the entire NHS. Long-time readers may also recall that when we first encountered him at a Public Accounts Committee hearing in 2006, we were somewhat less than impressed. He should be gone.

And then there are those targets. I've perused the Department of Health website desperately trying to pin down what's actually happened to them, but I'm blowed if I can work it out. It's possible they've largely been abolished, although I'd need to do much more digging to find out for sure. And on the ground - ie down in the hospital wards - personal experience just before Christmas suggests the nurses are still spending just as much time ticking boxes and filling in forms, rather than caring for patients.

Besides, even if the targets and the tick-boxes have gone, there's a much more fundamental problem with the NHS. And it's one that bubbles just under the surface of the entire Francis Report: the insidious effect of unaccountable institutionalised power. 

We've recently seen how corrosive this can be in other organisations, from the Catholic Church to the Liberal Democrats: powerful men abusing their positions, and even when they're discovered, continuing to enjoy the protection of an institutional cover-up. And in the case of mid-Staffs, Francis spells out how staff felt intimidated by management, making them reluctant to report problems, still less blow whistles. From the disassociated fatalism of the consultants through to the cowed cowering nurses, nobody was prepared to stand up for fear of losing their job.

But most striking of all is what Francis has to say about the complicity of patients and their relatives:

"Patients’ attitudes were characterised by a reluctance to insist on receiving basic care or medication for fear of upsetting staff."

We all recognise this. We've all been there. If you complain, are you just going to make things even worse? You or your loved one are in an extremely vulnerable position, entirely dependent on the service provided by staff. If you piss them off, who knows what might happen? You are stuck, and your only hope is to schmooze and nudge them into doing the right thing.

Being a member of the sharp-elbowed middle class, I like to think I'm fairly good at doing that. Disgusting myself, I'm prepared to use every trick in the book - crawling, sympathy, flattery, the works. Often that does the trick. But it shouldn't be necessary, and what if you're no good at it? And what if it fails? Personally, I've developed a technique of suggesting escalation to higher authority without actually threatening  to do it: more along the lines of "look, I can see you're doing your very best, but you're obviously stretched beyond the limit, and I've got to consider my sick child. I'm seriously concerned and I can't just stand by... who would I talk to?"

Of course, if this was Tesco, you wouldn't need to do any of that. You'd just take your business elsewhere - no fuss, no schmooze, no problem. Or rather, there is a problem, but it's Tesco's not yours. And either they ensure there can never again be horsemeat in their value meals, or their biz nosedives.*

The power of choice and competition. The power of simply being able to take your custom elsewhere. The power of a paying customer rather than a helpless supplicant. So much more direct and effective than hoping Mr N.H.S can somehow sort the problems before we get killed.

* Apologies to Lost Nurse for getting back on the Tesco worship so soon. We do realise that healthcare is not quite the same as groceries, and we will try to limit our grocery sermons.

** Excellent graphic from MHP Communications.

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Sick Up To Here

Lost Nurse has been an active commenter on BOM posts for a long time, and he/she's had more than enough of our Tesco worship:

"I'm just bored of hearing the Tesco worship. Antibiotic resistance? No problems, Tesco will sort it. Paediatric cardic surgery? It's just like running a cheese counter, you know. MRSA, C.Diff? All this will vanish under private ownership. Even the mounting demographic challenge of elderly care will be eased by two-for-one offers. Apparently."

Now unlike most of us, Lost Nurse is on the frontline. He deserves a properly considered response. Especially since Tyler suspects, at root, we probably agree on the broad thrust of NHS reform.

The first thing is for Tyler to admit that he may be prone to the odd bit of simplification here and there. So yes, Tesco can build a store in 13 days, but no, we don't really think they could build a fully functioning hospital on anything like that timescale. The Tesco vid is brilliant testimony to just what can be achieved, but when it comes to major construction projects we're not really comparing apples and apples. Fair comment.

The second thing is that Tyler's criticisms of the NHS are not meant to be criticisms of everyone employed therein. As we've blogged many times, Tyler's mum was a nurse and he has the utmost respect for the difficult and often stomach-churning work healthcare workers undertake.

It's the NHS Tyler has a problem with - the outdated state monopoly approach to healthcare that delivers Stalinist disasters like Mid-Staffs, where at least 400 people died (back in the news this week with the opening of the public inquiry). Or the Kent and Snuff It where another 300+ died.

For most of Tyler's life, the NHS has been projected as the envy of the world - a shining British success story that brought modern healthcare to all, irrespective of income. There's always been room for improvement of course, but fundamentally we should all thank our lucky stars we weren't struggling with the kind of patchy overpriced healthcare available to Johnny Foreigner.

It's only more recently that we've come to understand how misleading that image is. For one thing, there was healthcare available before the NHS - indeed, Tyler's mum worked in a flagship pre-NHS hospital largely funded by local ratepayers and charitable donations.

More seriously, it turns out that the NHS achieves significantly inferior results to most healthcare systems in other developed countries. Take cancer treatment. Until a few years ago, Tyler had no idea your chances of survival after diagnosis were so much lower in the UK than elsewhere. But they are. Here's a recent summary of the proportion of patients surviving at least 5 years after an intial diagnosis of cancer:

As we can see, the UK has the worst overall survival rate in Western Europe, and is only just a bit better than Eastern European countries, which spend much less than us on healthcare.

Ah, yes, spending.

The traditional NHS defence to criticisms like these is to say that our health outcomes are worse because we don't spend as much money. And in truth, even after the big expansion in NHS spending over the last decade, we still seem to be a tad below the OECD average. When last sighted (2007 figures), average spending on healthcare across the OECD was running at 8.9%, against 8.4% in the UK. And even if we discount the US (on an astonishing 16%), all of the major Western European countries still spend more than us.

So you'd have to say that money could well play a part in our worse health outcomes.

But what does that actually tell us?

It tells us that if you leave healthcare in the hands of national government, you get a system that's resourced not according to what the customers want, but according to what the commissars decree.

Which means the kind of thing we've had for the last 50 years - a destructive stop-go cycle, with alternating periods of feast and famine. Obviously the famines are difficult, but even the feasts are not that great, with vast swathes of cash getting wasted on cost escalation and declining efficiency.

That clearly happened during the Blair/Brown NHS splurge. As we blogged here:

"In Labour's first 11 years, they increased health spending by 138%. But 43% of that disappeared immediately in ludicrous pay deals and other cost increases, and the ONS reckons the volume of inputs only actually increased by 67%. Against that, the volume of outputs only increased by 55%. So excluding those mooted quality improvements, productivity (ie outputs divided by inputs) fell by 7%, or 0.7% pa."

Look, we all accept that in healthcare there is no magic bullet. We all accept that.

But as we've blogged many times, the European social insurance systems do seem to deliver consistently better health outcomes than the NHS. Yes, in the past they have cost more, but what they also offer is choice and competition - the best driver of efficiency yet devised.

Take the highly regarded Dutch system. There, everyone is obliged to purchase health insurance, covering primary care and most hospital care (the poor are state subsidised). The private insurance companies providing the cover cannot refuse to insure anyone on health grounds, and must offer a defined minimum standard package. But they can compete on price, giving them a strong incentive to drive good deals with healthcare providers, and to keep costs low.

But what about Dutch emergency care? As Lost Nurse points out, there's not much profit in that, so how does it work? The answer is that Dutch emergency care is essentially tax-funded. So on that LN is right - emergency care probably has to stay with the taxpayer. Similarly, long-term care of the elderly probably has to remain funded by taxpayers - nobody has really cracked that one yet.

But for everything else, the Dutch system seems to offer a compelling way forward. Choice, competition, and efficiency on the one hand, but universal coverage on the other (ie no US-style dropping through the net).

And our guess is that there are far fewer lost nurses in Holland. Far fewer victims of commissariat blunders and middle management bullying. And there are certainly far fewer inquiries into deaths from hospital acquired infections.

PS In deference to LN we intend to lay off the Tesco comparisons for a while. But we can't promise to stay away for good.

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NHS Reform - How Will The Money Work?

Keep your eye fixed firmly on the money

Tyler has now read Lansley's white paper, Equity and excellence: Liberating the NHS. An ambitious title, but then again, Health Secretaries have never been lacking in the ambitious titles department.

To start with the positive, there's lots of good stuff about putting patients first, more choice, better information, clinicians in charge, and an end to politically driven micromanagement. All problems we have blogged to death, and all problems we are glad to see Lansley promising to tackle.

In fact, we'll go further. Lansley has surprised us by just how radical he is apparently prepared to be. Abolishing the wasteful bureaucratic PCTs and focusing authority in the hands of practising clinicians is a big step, beyond anything we'd expected. He's also going to encourage more private providers into what is clearly the basis of a real market system - all good. Even more encouraging, judging by his punchy appearance on yesterday's Newsnight, Lansley suddenly looks like a man reborn and spoiling for the fight.

But as always, the key question for BOM is how will the money work? And there, the white paper is worryingly vague.

Let's start by reminding ourselves how the money works in the grocery market.

You the punter have the money, and you choose whether to go to Tesco, Sainsburys, Asda, or whoever. You are very keen on getting good products at good prices, because, hell, it's your hard-earned money. Which doesn't mean you cross-check products and prices every week - life's too short. But all the supermarkets know that if they start taking the piss, sooner or later you'll rumble them and you'll start shopping somewhere else.

Now, the supermarket doesn't produce the goods itself. It commissions suppliers to produce all its msg potato wedges and trans-fat pizzas, and it screws those suppliers hard on price and quality. Both are determined by head-to-head negotiation. You the customer don't get involved in any of that, both because you haven't got time, and also because you know absolutely naff all about producing pizzas let alone pricing them. You trust Sir Terry Tesco to make those calls for you. And Sir Terry only survives if he gets those calls right enough for you to go on giving him your custom.

So how does the Lansley NHS model compare?

To start with, you won't have the money. The money will still come from the big black pot up in Whitehall (see Lansley's wiring diagram above). Which straightaway weakens your role in the entire process.

Yes, Lansley does talk about giving we punters "personal healthcare budgets", but in truth, that's never going to work universally and he admits it (no, you can't have that critical second operation because you've already used up your personal budget).

Instead, the "money will follow the patient". How? Lansley is not yet sure:

"... the Department will start designing and implementing a more comprehensive, transparent and sustainable structure of payment for performance so that money follows the patient and reflects quality. Payments and the ‘currencies’ they are based on will be structured in the way that is most relevant to the service being provided, and will be conditional on achieving quality goals."

Hmm. Talk of "currencies" rings a rather loud alarm bell. We already have a perfectly good currency, and it's called the pound sterling. It's simple, clear, and relates directly to the real world outside the NHS. You can bet Sir Terry insists on the real thing, and so should Lansley. The last thing the NHS needs is an outbreak of Funny Money.

And also, how much money will follow the patient? Apparently it won't be the same for all patients:

"Our principle is that funding should follow the registered patient, on a weighted capitation model, adjusted for quality. We will incentivise ways of improving access to primary care in disadvantaged areas."

"A weighted capitation model, adjusted for quality". Riiiight. WTF does that actually mean for the average punter? And who decides what the relative weights are for different types of punter? Will someone with Tyler's chronic conditions get more capitation than an A1 specimen? And if not, what's to stop a profit maximising GP refusing to take Tyler, should he move to Eastbourne? There are an awful lot of dots still to join up.

Then there's the issue of pricing. Whereas Sir Tel sorts out prices mano a mano with his suppliers, in Lansley's reformed NHS, prices for specialist treatments will still be mandated by the same old Commissars in Whitehall. The only difference is that prices will now be set on the basis of "excellent care", rather than bog-standard care:

"We will rapidly accelerate the development of best-practice tariffs, introducing an increasing number each year, so that providers are paid according to the costs of excellent care, rather than average price."

In Tescos, their excellent care range is called "Extra Special" and it's more expensive than the standard range. So does excellence mean the NHS tariffs will be increasing? Or does the word "excellent" actually mean excellently cheap? Again, there are an awful lot of dots still to join up.

But look, let's not carp. Lansley has made a reasonable start, and he is sounding a lot more radical than we'd ever expected. He seems intent on creating a market-based system, intent on broadening the range of providers - including private for-profit providers - and intent on getting those in the NHS to learn the new skills and responsibilities they will need outside the Stalinist world of state monopoly healthcare.

Let's give the man a chance.

Oh, and let's hope Cam gives him the time he needs to implement his plan. The NHS has had more than enough revolving door political masters.

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Dr Croesus I Presume

Andrew Lansley might be about to make our family doctors rich. Very rich indeed.

Because according to this morning's reports he's going to hand over control of £70-80bn pa of NHS cash to them. He's going to abolish the Primary Care Trusts and give their responsibilities for commissioning hospital treatment to our GPs.

What massive spending power they'll have. What huge potential for boosting their own modest stipends. Even the riches they got from Labour's bonkers new GPs' contract (up the £380 grand pa - see here) will seem like small potatoes in comparison. Out-of-work investment bankers (and we know a few) will be queuing outside Guys to retrain as GPs.

To be clear, we agree with Lansley that the NHS is in urgent need of reform. Bloated quangos like the primary care trusts (PCTs) certainly need to go. And the NHS certainly needs to become far more efficient.

For example, according to recent research at the OECD, despite Labour's spending splurge, Britain still has the 8th worst record for preventable deaths among all its members - right down there with Mexico, Poland, and the Czech Republic. And we have the 7th highest potential for efficiency gains in our healthcare system - ie the potential for improving health outcomes without spending any more money. Here's their key chart (the higher the bar, the greater the scope for increasing life expectancy from improving system efficiency):

So yes, the scope for big efficiency gains is definitely there. The burning question is how do you achieve them?

As regular readers will know, we have long favoured putting the customer in charge - just like he/she is when it comes to buying car insurance. Choice and competition to drive efficiency just like it does in other areas.

True, we don't want the US private insurance system, where many have no insurance, and costs are very high (largely driven by so-called information asymmetries and moral hazard - standard problems in private insurance markets everywhere). Which is why we favour a system of compulsory social insurance of the kind they have in most European countries. Everyone has to have cover for a mandated minimum bundle of risks and treatments (premia for the poor being subsidised by the state), and the competing licensed providers cannot refuse to accept customers on the basis of medical screening. The new Dutch system looks like an admirable model (see this TPA blog).

Unfortunately Lansley's reforms do not achieve this. Although he talks about greater patient freedom to choose consultants, in reality few of us are equipped to do that. We will rely on, yes, our family doctor to guide us. The same family doctor who may well in future have a direct financial interest in steering us one way or another.

Fine, OK, you could always switch your family doctor. But have you ever tried it? Not that easy. And what's to stop rascally GPs selecting patients on the basis of medical history/lifestyle/address?

Bottom line?

In breaking up Labour's centralised command and control system, Lansley is definitely moving in the right direction. But putting this vast amount of commissioning authority with GPs will bring problems of its own. And we very much doubt that the customers will get much of a look-in.

PS Cards on the table, Tyler has private health insurance. Why? Because he suffers from not one but two potentially serious conditions that require regular hospital monitoring (no flowers please), and frankly he doesn't trust the NHS to provide either the monitoring or the immediate knife action if required (yes, he's very lucky he can afford it - fair comment). Anyway, just recently there has been a somewhat unwelcome development. The local anesthetists have got together and refused to do the biz for the price laid down by the health insurer. Which means Tyler now has to pay an excess direct to the anesthetist - either that, or opt to undergo the procedure biting on a stick. So what to do? One option might be to switch insurer. Bad idea. With Tyler's pre-existing conditions no other private insurer would touch him (or they'd quote a preposterous premium). Another option would be to can the private insurance altogether and self-insure (ie pay the fees out of his own pocket directly). But although right now, in terms of annual costs, Tyler would roughly break even, who knows what might be required in the future. So that's not appealing either. Of course, if we had a system of social insurance, both of those problems would be resolved. Tyler could shop around for another insurer who had managed to agree rates with the local anesthetists, and who would have to take his biz. And he simply wouldn't have the option of self-insuring - ie if he was lucky enough to have A1 health, he could not self-select himself out of the system. He'd be an active participant in the health insurance market, switching his biz around and driving efficiency.

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Pathways To Hell

Nearly there now

As the Doc has described many times, Labour's NHS is a huge Stalinist meat processing factory through which patients are transported on a series of conveyor belts.

The belts are picturesquely known as Patient Pathways, and alongside five year plans, mandatory organisational protocols, and do-or-die output quotas, they are central to the way the Bureau of State Health Production directs its massive industrial empire. That, and summary execution for managers who fail to deliver their published quotas.

And just so you know, here's what an NHS pathway looks like (click on image to enlarge):

Well, it now turns out that the entire empire has been on a pathway of its own. According to State Health Commissar my Lord Darzi:

“The NHS is continuing a journey of improvements, moving from a service that has rightly focused on increasing the quantity of care to one that focuses on improving the quality of care."

A journey of improvements - aka Marxist-Leninism. The Dictatorship of the Proletariat is a necessary but temporary stage on our journey to a workers' paradise of plenty and fairness for all.

What my Lord was trying to explain away was the latest evidence that organising healthcare as a Stalinist meat packing factory is a shocking idea. Patients get treated as lumps of condemned offal, staff get deskilled and demotivated, managers... but look, don't listen to me, listen to the government's own assessment report - a report they tried to suppress:

“The patient doesn’t seem to be in the picture... We were struck by the virtual absence of mention of patients and families ... whether we were discussing aims and ambition for improvement, measurement of progress or any other topic relevant to quality... Most targets and standards appear to be defined in professional, organisational and political terms, not in terms of patients’ experience of care...

The GP and consultant contracts are de-professionalising, and have had the peculiar effect of simultaneously demoralising and enriching doctors. We’ve lost the volitional work of the doctors and far too many of us are now just working to rule...

The risk of consequences to managers is much greater for not meeting expectations from above than for not meeting expectations of patients and families.” 

And that's the entire problem with Big Government - the needs and preferences of individuals no longer count, and our public services end up serving a bunch of arrogant ill-informed commissars closeted miles away from the action, who in many cases don't even use the services they are inflicting on everyone else.

Yet despite manifest failure right across our public services, the so-called Progressive Consensus still seems to think that Big Government is the best way forward. Just like Stalin, they are prepared to accept as statistics the deaths and broken lives that result from Big Government failure. They are prepared to accept the costs and inefficiency that Big Government always entails.

Why?

Well, because they believe they're on the side of the angels.

Take Michael Foot. Obviously he was a deeply flawed individual, who held fellow travelling views repugnant to most of the British population, and who would certainly have bankrupted us had he ever become PM. But both he and his Prog Con supporters honestly believed he was A Good Man who intended only to do good for the proletariat. And those good intentions somehow absolved him from responsibility for his dangerous and deluded ideas on how to realise them.

And that's the thing about good intentions. They've paved no end of hellish pathways. From the Mid-Staffs NHS Trust all the way to the Gulag Archipelago.

There is only one path to better public services. Which is to break up our top down commissariats, to have providers compete for customers, and to put the spending power into the hands of the individual customers themselves. And as we face a decade of spending cuts and low growth, it is more important than ever for us to get onto that path.

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Inspectors On The Non-Job

Labour's huge and incompetent government inspectorates are worse than a waste of money - they are downright dangerous. Take today's scandal:

"Poor standards of care at an accident and emergency unit in one of the country's flagship hospitals may have contributed to the unnecessary deaths of over 400 patients, an official NHS investigation has concluded. Dirty equipment and an absence of leadership contributed to a death rate almost 40 per cent above the national average among emergency admissions to the 770-bed Basildon and Thurrock University Hospitals NHS Foundation Trust, inspectors said.

The unit had blood stains on the floor, dirty curtains, stinking mattresses and soiled equipment; nurses who failed to monitor, feed and give drugs to patients correctly; and a rate of pressure sores almost twice the national average. Instead of the national four-hour maximum waiting time for A&E, the trust was operating a 10-hour waiting time."

That's scandalous enough of course (especially as the description sounds all too reminiscent of various other NHS hospitals we could mention).

But the real scandal of Basildon and Thurrock Hospital is that it's literally just been rated by government inspectors as "Good", with a 13/14 mark for "Safety and cleanliness" (see here). And those inspectors - the Care Quality Commission - are the very same inspectors who've now discovered the hospital is in fact unsafe and filthy.

So WTF is going on?

On BBC R4 Today this morning, Evan Davis attempted to find out from the Commission's head, serial quangocrat Baroness Young (Environment Agency, BBC, etc etc). She made virtually no sense.

First, she said the scores on the Commission's website were out of date, even though the scores relate to 2008-09, ie the recent past. She reckoned they'd only published them because the Secretary of State had a duty to so. Then she said the Commission's inspection methods had changed and that they now involve... er... inspections. Then she said the Commission is brand new and can't be held responsible for the rubbish produced by the previous inspectorate - even though it's been published by the Commission on the Commission's website.

Obvious questions arise. If the scores on the website are useless, why should we punters believe them? What's the point of them? What should we believe? How do we know any hospitals are safe?

But when Davis tried to ask those follow-ups, the Baroness slipped into a kind of gibberish that Tyler cannot report because he simply couldn't follow it (like virtually all members of the modern commissariat, Young is immensely articulate without actually making any sense).

So there we have it - another large government inspectorate churning out screeds of rubbish that is much worse than useless.

And what does the Quality Care Commission cost us?

The Commission is another of Labour's superquangos, established in March 2009 as the amalgamation of three existing quangos - the Healthcare Commission, the Mental Health Act Commission, and the Commission for Social Care Inspection. Summing the 2007-08 spend of those three gives us a total annual spend for the new Commission of £214m (see latest TaxPayers' Alliance quango book). Let's call it £230m for this year.

The combined staff is 2700, which you might consider more than enough. But the Commission clearly wants more, and is currently advertising the following attractive new posts:

• Head of Learning - £75k pa
• Head of Culture and Performance - £75k pa
• Head of Change Management - £75k pa

Amazingly, they are not advertising for a Head of Tying Up Your Own Shoe Laces, but we get the general idea.

We've blogged these hopeless government inspectors many times (eg see here). They have a long and shameful history of rating killer organisations as perfectly safe and fit for purpose - Oftsed rated Haringey Social Services as good at the very moment Baby P was dying under their watch (see here).

Things are so bad, even the chief inspectors no longer have confidence in the ratings. Baroness Young clearly thinks her organisation's ratings are useless, and earlier in the week the head of Ofsted said the same thing about their school ratings.

In Ofsted's case, it turns out that when they rate a school as "satisfactory", what they really mean is that it is failing to provide its pupils with a proper education. Which right now means that a shocking one-in-three state schools is failing.

Ofsted's Annual Report also illustrates another key weakness with these inspectors - they keep changing their minds. So nearly one-in-five schools judged to be good at their previous inspection are now rated as no longer good - ie merely "satisfactory" or inadequate. Who can place any faith in ratings that slide around like that?

So what to do?

First, abolish these massive inspectorates - they have expanded way beyond their original remit of making sure taxpayers' money was not being squandered, and they now do more harm than good (especially to the organisations they terrorise).

Second - yes it's that same old song - put power into the hands of the customers, and let the market decide who's doing a good job and who isn't. School vouchers and competing social health insurers are the only way we can seriously expect to achieve improvement.

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Earning Your Pharmacist An Honest Crust

May I tick your boxes?

As we may have mentioned before, Tyler is a major league drug user. And not all of them are for recreational purposes: he routinely ingests an amusing cocktail of prescription drugs to keep a lid on his wayward immune system.

So the other day he's visiting his local chemist to pick up the latest crateful, when he's accosted by the pharmacist (see here for previous pharmaceutical encounters). Would Tyler care to enter her consultation room for a quick word?

Consultation room?

"Yes, yes, it's a bit more private in there."

Private? Why private? Is she going to break bad news? Has there been some horrible mix-up? Has Tyler inadvertantly been taking those drugs they use to chemically castrate elephants? No wonder he's been feeling a little lacklustre of late.

"Mr Tyler, we've noticed that you've never had a medicines use review." The keen young pharmacist brandishes the form she's holding. "If I just run though this with you, we can make sure you're getting the right medication."

"But I already have an annual review with my GP, and I'm also under a consultant."

"Ah yes, but they look at your body - we look at your medicines. We can advise you on them."

"Hmm... well, OK."

"Fantastic! Now, these first pills, how do you take them?"

"I... er... swallow them."

"Fantastic!" She ticks a box. "And how often do you take them?"

"Well, once a day, like it says on the instructions."

"Fantastic!" She ticks another box. "And do you have any side effects?"

"No... otherwise I'd have gone back to my consultant."

"Fantastic!" Another box ticked.

I could go on, but you get the idea. By the end of my 3 minutes, she must have ticked a dozen boxes. And what advice did she have for me?

"Well, you seem to be taking all your medicines correctly, and there's nothing I can suggest in terms of lifestyle to help your condition."

So no advice.

Fantastic.

But what was really going on?

The pharmacist was earning herself - or at least her company - £28 from the NHS. Which for 5 minutes work isn't bad (£336 per hour). That's what she gets paid for conducting a Medicines Use Review (MUR) under a scheme set up by the NHS to make sure patients comply - yes, that is the word they use - with the instructions they've been given.

You can sort of understand how the commissars dreamed up the scheme. After all, they spend well over £8bn pa on prescription drugs in England alone, and that bill has doubled in ten years. The last thing they want is for we punters not to be taking them properly.

But is 5 minutes with Sharon ticking boxes in her consultation cupboard really going to help?

Seems unlikely. In fact from what Tyler saw, it looked more like money for old rope.

And what does the whole exercise cost us?

According to the official stats, the number of MURs is soaring. Between 2006-07 and 2007-08 MURs roughly doubled to over a million. Which at 28 quid a pop comes in at around £30m - a considerable sum in these straightened times. Especially when you remember that pharmacies in England and Wales already earn getting on for £1bn pa from the NHS just for dispensing fees (ie not including the cost of the drugs):

Which is presumably why the commissars have imposed a limit on how many MURs an individual pharmacy can conduct - 400 pa.

But how does that work exactly? Who decides which punters are going to get MURRED? Sharon told Tyler she could tell immediately he didn't really need a MUR because he wasn't a batty old lady. But she went ahead and did it anyway.

And come to that, isn't the whole shebang open to massive fraud? How can the commissars possibly tell that the MUR has actually taken place? Tyler signed nothing, and Sharon retained the tickbox form.

Oh, guess what - the whole shebang is open to massive fraud. And it turns out there is a massive fraud investigation underway. The NHS's own Counter Fraud Service (oh yes, the NHS needs one of its very own) is on the case, and has already discovered that the payment system was set up by a particularly unworldly four year old:

"Pharmacists declare to NHS Prescription Services how many MURs they have performed during the month when they send their monthly FP10s for processing, and they are paid £28 for each one. They do not submit MUR forms or disclose patient names in support of their declarations, although they do send GPs lists of patients whom they declare have received MURs."

There is no procedure for checking that the claims marry up with what the GPs have been told. Still less is there a procedure for checking whether the MURs have actually taken place. Fraud is almost certainly rife.

Needless to say, the pharmacists are squawking. It seems they don't want to be investigated, and they reckon the case cannot proceed because of "patient confidentiality concerns". So the entire investigation is now on hold while m'learned friend is consulted - no doubt at further considerable taxpayer expense.

Now, just imagine you're a pharmacist. You'd probably be knocking off as many of these £28 "consultations" as you could possibly manage, before the opportunity disappears. You'd also be ticking patient boxes like fury to get some kosher records on file ahead of Inspector Knacker's forthcoming visit.

Let's hope they still have time to make sure Tyler doesn't get any more of those elephant pills.

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Thursday Morning Blood Boil

Mind how you go

Is this government the worst we have ever had? Surely it must be. Yes, OK, they introduced gay marriages, and they stopped us going into the Euro. But apart from that, we can't think of anything they've done that hasn't turned into a disaster. And this morning we're treated to a rash of reminders.

1. Immigration

Labour has lost control of our borders. We all know that. In just 12 years, they have permitted more than 3 million foreign born migrants to enter, 5% of our entire population (eg see this blog). Some of these migrants have undoubtedly made us richer, but most have not (eg see this blog). It has produced dangerous social tensions, boosted now by mass unemployment, and there is absolutely no way of stuffing the genie back into the bottle.

Things are now so desperate, that even the arrogant clowns who rule over us realise there's a crisis. Unfortunately the crisis they see is not the one we're all so worried about. The one they're concerned about is that the immigration issue might lose them the next election.

So they've decided they'll admit to a few mistakes.

Today, Brown himself stood up to "admit ‘mistakes’ on immigration after BNP TV furore". Well, that's what the newspaper headlines said he was going to do before his speech. But when you actually read the speech itself, you don't find any such admission. All you find is a statement about how he now "gets it", and how it isn't his fault anyway because previous governments left him a shambolic immigration system that he is now valiantly fighting to sort out.

And the migrants he actually picks on for his draconian fuzzy new controls are not the low-skill alien culture type migrants everyone worries so much about. Instead, he says "we no longer need to recruit civil engineers, hospital consultants, aircraft engineers and ships officers from abroad - and so these and other jobs are being taken off the list." It's a classic shimmy - these highly skilled workers are not the people we're worried about. Most of us want people like that to be able to come in.

He tells us we can't have a fixed annual limit like Australia's because it would be too inflexible. Too inflexible for whom? We all know that employers want unlimited immigration because it depresses wages. But the rest of us want a clear limit because of all the social and public spending pressures mass immigration brings with it (see previous blogs).

And as for his argument that imposing a limit would "overturn our obligations to our EU neighbours", why not just have a limit applying to non-EU citizens? It's non-EU citizens who have made up more than 80% of the inward migration over the last decade (eg see this blog).

Brown still seems to think we're all stupid.

Gah!


2. Cost of Nanny

On one level, Labour's nanny state is a source of harmless national amusement. But as soon as you realise it's costing us a ton of money, the joke falls kinda flat.

Here's the latest episode from the Sun:

"POLICE chiefs faced ridicule last night over plans to give cops guides on how to ride a bicycle.

The potty pamphlets, running to 93 pages in TWO volumes, tell cops how to balance so they do not fall off.

The official Police Cycle Training Doctrine - the cost of which is estimated at thousands of pounds - gives full instructions on how to stop and get off a bike safely.

Officers will be taught how to brake and avoid obstacles such as kerbs and rocks. They are warned not to tackle suspects while they are still "engaged with the cycle"...

Officers are advised to wear padded shorts for "in-saddle comfort" and reminded to eat enough food and drink "adequate liquids" - because cyclists get hungry and thirsty.

Undercover cops are told they may need to go without a helmet to avoid being rumbled. But the guide warns: "This lack of protection must be noted and a full risk assessment of the required role to be undertaken."

No, no, stop it. I'm starting to get asthmatic.


3. Bonuses for catastrophic failure

We've blogged the issue of bonuses for public sector staff many times (eg see here). And today we hear about the latest bonuses being paid to the buffoons who run the catastrophically awful MoD. Despite all the equipment shortages and all the procurement cock-ups we read so much about, £47m has been paid out so far this year:

It makes you want to spit.

"The bonus figure covers just the first seven months of the financial year. The MoD said yesterday that the bonuses would average less than £1,000, but a senior civil servant could pick up £8,000. Last year, the department had 95 employees who were on a salary of more than £100,000. A private in the Army can be paid as little as £16,681 a year"

As we've said before, bonuses in the public sector are a farce. Unlike the private sector, the public sector is not targeting profit, or any such clearcut objective. There is no bonus pool driven directly by the money available. Indeed, there is no transparent and robust linkage back to any real world objective. Just another pile of box ticking commissariat wibble. The practice should be stopped.

And as for the BBC paying for its execs to stay in glitzy £647 per night Las Vegas hotels, I can't even bear to read the story.


4. Too posh to wash

The government is about to insist that all nurses now have a degree.

Why?

The health minister says:

“By bringing in degree-level registration we can ensure new nurses have the best possible start to meet the challenges of tomorrow. This is the right direction of travel if we are to fulfil our ambition to provide higher quality care for all.”

The minister obviously lives on an entirely different planet to those of us who've visited real NHS hospitals.

The Doc long ago tore out his few remaining wisps of hair over the fact that many essential nursing jobs like washing patients no longer get done by nurses. They are too posh to wash or to ensure patients are eating and drinking properly: upgraded beyond such menial tasks they instead now spend their time studying patient protocols and pathways. A fact not unconnected with the huge upsurge in hospital acquired plagues.

As we've said before, just make sure you keep up your BUPA payments.

And try to forget that state healthcare now costs each and every household nearly £5 grand pa.

I think I need to lie down.

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Oink

With a cheep-cheep here, an oink-oink there, and a total confusion everywhere

For reasons we needn't go into, Tyler is what the NHS describes as immunocompromised. No, it's not what you think, but it does mean he received a call today from Sharon at his GP group practice.

Sharon informed Tyler he was in an at-risk group, and therefore needed to come in for the Swine Flu jab.

"Wha!" said Tyler. "The new experimental quatermass vaccine... but, but... is it safe?"

"Oh, yes," said Sharon, "it's under the government vaccination programme. It's all been tested and it's perfectly fine. And actually I see you haven't had the normal seasonal flu jab - we'd better do that at the same time."

So what to do?

Clearly, you'd be mad to say yes just because the government wants you to.

For one thing they're a bunch of serial incompetents, and for another, they are proven liars.

Why would they lie about the safety of swine flu vaccine? Well, because this is one of those public health issues: the more people they can get vaccinated, the less likely it is that we'll have an epidemic. And as we've blogged before, when it comes to public health, governments follow traditional Stalinist principles: "one death is a tragedy, a million is a statistic". In other words, they're not bothered if a few dozen Tylers go down under the needle, as long as the herd gains immunity.

This calls for an urgent consultation with Dr Google.

Now let me see... "swine flu vaccine"... yikes! Google immediately suggests "swine flu vaccine deaths" with 13.1 million results.

So... "Swine flu jab link to killer nerve disease: Leaked letter reveals concern of neurologists over 25 deaths in America... The letter from the Health Protection Agency, the official body that oversees public health... tells neurologists that they must be alert for an increase in a brain disorder called Guillain-Barre Syndrome (GBS), which could be triggered by the vaccine. GBS attacks the lining of the nerves, causing paralysis and inability to breathe, and can be fatal." (Daily Mail)

Gulp.

In Sweden there have been four vaccine-related deaths. Or is it six? Accounts seem to vary. And come to that, how do we know the deaths don't run into hundreds, and there's been a cover-up? The bodies could easily be stored in a cordoned-off frozen fish factory - they must have loads of them up there. Obviously they'd keep that pretty quiet, so how are we supposed to find out?

Or what about this in Time Magazine - Time Magazine! - "...the vaccine is tainted with antifreeze or Agent Orange, causes Gulf War syndrome, has killed U.S. Navy sailors... the vaccine is an "evil depopulation scheme."

Jeepers! That's it! No way is Tyler getting pumped full of Agent Orange.

Oh, wait. Time goes on to say "these claims are nearly pure bunk", and that "the crop of falsehoods about the H1N1 vaccine... are potentially... dangerous, since they encourage the credulous to avoid vaccination at all costs."

Hmm.

OK, so what does the NHS itself say about vaccine safety?

"The swine flu prototype vaccines have been clinically tested and shown to produce good immune system responses, and have an acceptable safety profile. The insertion of the H1N1 strain into the vaccine should not substantially affect the safety of the vaccine in the same way that annual modifications to the seasonal flu vaccine do not."

There they go again. What exactly is an "acceptable safety profile"? Acceptable to whom? Stalin's Commissar for Collectivised Health?

In a complete muck-sweat, Tyler finally turned to the one man he could trust to cut through the doublespeak - the good Dr Crippen. What should Tyler do?

Unfortunately, the Doc is himself now under heavy medication, having gone down with a nasty bout of H1NHS gravis.

Apparently he was exposed to a whole series of confusing and largely incomprehensible circulars from the Chief Medical Officer at the Department of Health, believed to have been triggered by the recent outbreak of swine flu vaccination fever.

So at the Doc's suggestion, and suitably masked up, Tyler examined the latest of these circulars, the one that gave the order for Sharon to ring Tyler. Under the Stalinesque identifier of Gateway 12870, it orders NHS operatives like the Doc "to maximise the level of uptake of the vaccine amongst the priority groups". Operatives are further instructed to access further vital campaign plans at Gateways 12241 and 12781.

Unfortunately, when you actually try to access those vital further Gateways, all you get is this:

"Error page

We are sorry but the page you are looking for cannot be found. It may have been removed, had its name changed or be temporarily unavailable."

Is it any wonder the Doc is a wreck. After months of trying to follow this kind of gibberish, the poor fellow's immune system is shot. Jabwise, he has no more idea what the Commissars are asking him to do than you or I. Only Sharon seems sure.

Although, now we come to think of it, what about Sharon? Is she going to have the jab herself? According to recent polls, roughly half of nurses (and GPs) are going to refuse. They obviously know something the rest of us haven't been told.

Which leaves Tyler in a quandary.

You see, although now immunocompromised, Tyler is old enough to have picked up some of the natural immunity oldies seem to have to this swine flu. For example, he got very ill in the 1957 Asian flu epidemic.

So is it worth risking a shot of Agent Orange now?

Tricky.

But one thing's for sure: all the guff so expensively pumped out by the Department of Health is not going to help him decide one jot.

PS What will the vaccine cost the NHS? Needless to say, the government refuses to tell us, but according to the World Health Organisation, the cost per dose is $20. So if, as the government apparently expects, three-quarters of us get the jab, it will cost $900m, or around £0.5bn.

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