Tuesday, 19 August 2014

NO and the NHS

At first look the tile looks a bit Buddhist and philosophical but I hope you will find what I am about to relate interesting, if a bit long. I have worked for or with the NHS in the UK from 1984 to 2008 initially as a clinician and latterly as a quality assurance auditor and consultant specialising in health care and related sectors for a Norwegian based company.

I have put clinical governance / quality assurance systems into a range of NHS sectors as well as overseas in South East Asia. I have used my quality system audit skills to trouble shoot problems within the NHS in England and on a couple of occasions in Scotland. One of my professional articles published in Quality World on the problems in the NHS was used in the training and examining of ISO / Quality System auditors across all scopes by IRCA for many years. I mention this to reassure you I am not going on a rant about the No campaign (the NHS is too important for that) but I am going to highlight the operational problems the current Labour and Tory NHS reforms have caused in NHS England, how this impacts on the service provided and inevitably has knock on impacts for NHS funding in England and therefore the rest of the UK's NHS provision.

The problems in NHS England date back to 1990 and the first round of market reforms introduced by the then Thatcher Government. The Health Minister of the day, William Waldegrave, made clear he was going to tighten the valve down on NHS funding in England until something broke.

The first part which 'broke' was NHS dental provision with dentists across England terminating their NHS contracts and 'going private' on the grounds they could no longer justify or afford providing a second rate service for a third rate fee. The Tories mounted their standard attack in papers like the Telegraph and Daily Mail to embarrass dentists into staying but this failed and across England there was a sudden crisis in NHS dental provision as Health Authorities had thousands of patients they were responsible for providing NHS treatment to and no dentists. In England in 1990 97% of all courses of dental treatment were NHS by 2013 the figure was barely above 40%; reducing the funding required for NHS dentistry in England by 50% and therefore impacting on the funding share awarded for NHS Dentistry to NHS Scotland. My friends in South West England are telling me NHS dentistry in England is on the verge of collapse as the current generation of NHS dentists are now also saying enough is enough and dumping their NHS dental contracts after the latest round of Tory real time NHS dental contract cuts.

The 'marketisation' project in the NHS in England carried on apace during the Tory years with 'Foundation Hospitals', private public funding partnerships (PFI), GP commissioning trials and much else all causing declining morale amongst the front line in health care who did not know whether the budget or the patient was more important. these professionals were often lead by management promoted from the medical ranks on the basis 'can not do' so make them a 'care manager' to reduce the danger to patients, Since the mid 90's the NHS in England has been cursed by a management system which is all about do not rock the boat, we need to hit DoH targets to keep our funding and little to do with patient care delivery. Many in the health care profession hoped the arrival of a 'Labour' Government would see change, a more patient focused NHS England, less political micromanagement from Whitehall, yet all that changed was the name of the Tory marketisation systems to make them seem less like privatisation by stealth but carry on the process. 

By 1999 it was clear, even to the DoH, something had to happen in the light of the Bristol Royal Infirmary infant cardiology scandal and the unnecessary deaths of so many new born infants at the hands of incompetent surgeons, in the future. It was on the basis of the judicial review of Bristol RI that Liam Donaldson, as he was then, was appointed CMO (England) to sharpen the NHS up. Sir Liam called in Quality Assurance specialists to a meeting at Harrogate in 2000 and explained what he was seeking to achieve and how he would require us specialists to help him put it in place. The meeting was informative, as was the brainstorming session held afterwards, and with the support of the QA world he felt he could now take his plan to the DoH for ministerial approval. The plan was based on best QA practice which revolved around the simple idea that clinical decisions had to be made at the patient level and the NHS system's responsibility was to ensure the resources were in place to meet the patient's clinical and care needs - a patient centred process, bottom up, with interlinked responsibilities between care staff, NHS management and politicians all the way to the Minister of Health themselves.

This proposal immediately threatened the status quo between the vested interests at the top level as they would be responsible for resources going down but responsibility for failure to meet patient's needs would be coming up the chain. This could not be allowed, NHS empires were threatened, vested interests were at risk, politicians of all stripes would become where the buck stopped - NEVER!

Sir Liam Donaldson's plans were watered down by the vested interests to the point they were unworkable. Instead the politicians and vested interests in Westminster, medical academia, BDA and the BMA put in place a plethora of layers via quango's, new levels of management and non-patient focused 'targets' which would make the politicians look good even as NHS England fell about their ears. Patients? - Pah! - This was all about avoiding responsibility and accountability.

The QA World predicted the systems invented for this new NHS clinical governance system were destined to fail because they only paid lip services to the quality delivery of any services and were not patient focused in their measurement of service delivery. We predicted that the systems put in place would not prevent a re-run of the Bristol Royal Infirmary debacle as has been proven to be the case in Mid-Staffs (twice) Tonbridgewells Trust, Luton General and most recently at Musgrove Park in Taunton (the list of disasters is much longer than this with out adding in the failure of outsourced elderly care and other private contracts - ambulance, NHS 24, GP out of hour services - by NHS Trusts across England).

As the clinical governance systems failed then the DoH, Trusts and Health Authorities started buying in the specialist help they should have had from the start to try and turn things round as patient dissatisfaction turned to legal dispute and an ever growing cost of settling compensation cases for poor or inadequate treatment. Identifying what was wrong with the system, for people like myself, was not a problem, it screamed out at you:  lack of resource (people and kit), lack of direction from management, incompetent or no leadership and constantly changing political goal posts which ignored patient's actual needs, expectations and concerns with regards the NHS care being provided.

Up until 2007, the NHS in Scotland was suffering increasingly from these failed reforms as Jack McConnell aped his bosses' in London's line on the NHS. Amongst the worst Trusts in Scotland during this period was Tayside who seemed to be in the news on a weekly basis as yet another failure at Ninewells or else where in their system added another half a million or more to the their compensation pay outs. There was the attempt to close down Monklands Hospital to save North Lanarkshire Health Trust running out of money as a plethora of PFI schemes they had embarked on began to empty their coffers and impinge on their ability to meet care needs.

The election of an SNP Government at Holyrood has not prevented the ill thought through health policies inherited from New Labour from having a serious impact on NHS Scotland and its ability to meet patients needs. PFI contracts still have to be paid out on, they still hit Scottish Trusts who engaged on PFI contracts hard, even though the SNP Government has sought to ameliorate the impact to some extent. NHS Scotland still suffers from vested interest groups protecting their academic and NHS empires and fiefdoms so we can not pretend all is rosy in the NHS Scotland garden but things are improving as the changes instigated by Nicola Sturgeon and her team take effect. NHS Scotland is becoming more patient focused but still has a long way to go and a lot of thinking amongst the medical and political hierarchies and vested interests has to change before we can have an NHS Scotland comparable to our Scandinavian neighbours.

A 'No vote' can only have negative impacts on NHS Scotland and sow the seeds of its destruction, this is the observable message coming across the border from England where things are now so bad the GPs and DGPs are walking away from their NHS England contracts. Young, UK trained doctors and dentists are emigrating to Australia, New Zealand, the USA and Canada for a more equable career rather than seek an NHS career in England. This is the side of the Tory and Labour 'reforms' you will never read about in the London media - medical emigration - no, it is only coverage of greedy doctors, dentists and other health care professionals betraying the NHS.


  1. It is disgraceful what has and is happening in England. Hopefully with independence our NHS can continue to improve and once again become the envy of others. As it was in my day. Thank you for helping highlight this.

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