Swimming against the tide

shutterstock_415481728-(1)The current commissioning model for the NHS has become part of the problem, Kevin Lewis says.

This column is like a magical mystery tour through the good, the bad and the ugly.

For starters, we have a black hole in the NHS that was recently quantified by Simon Stevens as £2.45 billion in the financial year just ended (2015-2016). More interestingly, we are told that a deficit not too far short of that mindboggling sum had been quietly expected and discreetly budgeted for – but the overshoot ended up £500 million more than planned. As discussed in this column on many occasions, a significant and recurring part of this problem is the cost of employing agency and other locum staff.

Black holes in the NHS, rather like their namesakes elsewhere in the universe, are the very antithesis of a little pocket deep in space with nothing much in it. On the contrary, black holes are massive, jam packed with super-compressed ‘matter’ and stuff happening. It’s just that we can’t see it. So in a sense the NHS itself is the black hole, not its budget. The NHS is jam packed with people, infrastructure, equipment, non-stop activity and it exerts a gravitational pull of colossal proportions. The result is that nobody outside the NHS can see or understand what’s really happening. Those closer to the action come away shaking their heads in disbelief.

The current commissioning model and ‘internal market’ approach with competitive tendering was an attempt made to square the impossible circle to end all impossible circles, and to seek maximum value for money. But many, both inside and outside the NHS, are coming to believe that this model has become part of the problem itself rather than a potential solution. They may well be right given that the cost of the process for procuring goods and services, negotiating contracts etc is believed to account for somewhere between 10 and 15% of the entire cost of the NHS. Given the scale of the NHS this is staggering and it is little wonder that those whose salaries depend upon the clunkiness of these processes, would prefer things to remain as they are.

Do you come here often?

With well over 200 clinical commissioning groups wrestling with a clunky and time consuming process, that is a lot of precious healthcare resource generating copious documentation and attending meetings, spending their time with other precious healthcare resources, instead of with patients. But they can always be back-filled with agency staff of course, so that’s OK. Well speaking as a taxpayer and potentially a consumer it’s not OK actually.

But as with every model that the NHS has ever spawned in its (almost) 70-year history, the internal market and latest commissioning model has created winners and losers. We have heard a lot about a postcode lottery in the NHS, but you can also win or lose according to how old you are, what condition you happen to suffer from, how healthy you are at the moment you become ill and your socio-economic circumstances. It’s a harsh truth and an uncomfortable one.

FIGJAM

There is plenty of evidence to support the premise that the least experienced and least competent people tend to believe they are a lot more competent than they actually are.

The cricket season is upon us so I make no excuses for borrowing the FIGJAM acronym, which is the nickname that the Australian media (and players) unkindly bestowed upon the former England test cricketer, Kevin Pieterson. It stands for ‘F*** I’m good – just ask me’.

There is nothing wrong with the concept of procurement being recognised as a specialist skill and it would be insufferably arrogant for healthcare professionals to suggest otherwise. But it is also insufferably arrogant for procurement specialists to believe that they possess some kind of magical skills that enable them to obtain the same thing for less money.

When procuring professional services this is nonsense. Actually convincing yourself that it is true is dangerous nonsense. But when the only people you mix with and speak to are people who share the same delusions, there is no limit to how much you can over-estimate your competence.

When comparing alternative providers, price is an obvious differentiator but quality is not – at least, not before the event. In healthcare, most quality differences become apparent during or after the event either in terms of the outcome or the way in which it was achieved. By that stage the procurement specialist/commissioning manager is invisible and it is the professional and the patient who come to appreciate the true cost of the money saved.

As it becomes increasingly obvious that our present NHS-centric healthcare model is unsustainable, attention naturally shifts to what the alternative might be. With an ageing, more demanding and quickly growing population, is it still possible to swim against the tide?

It’s been done

UK primary care dentistry is living proof that alternative models can work, and work well. Until 2006, successive governments wrestled for years with their inability to contain and control the cost of NHS dentistry. What has evolved – by accident as much as by design and putting aside the UDA shambles for a moment – is a workable mixed economy model where those that can afford to do so make a contribution every time they access dental services. There is plenty of protection for those who cannot afford such a co-payment and for identified priority groups.

This already very different-looking NHS model sits comfortably alongside a flexible and vibrant private sector offering choice between pay as you go, capitation schemes and private health insurances.

There is too much purist and ideological bashing of the private sector and the contribution it makes to UK healthcare – but far too much NHS bashing too. We should celebrate the amazing things that the NHS and its staff achieve every day, but in doing so we should not be blind to the need for change. A compelling letter to The Times in mid-April, for example, pointed to the fact that the very existence of waiting lists costs money, and also that most of the successful healthcare systems in continental Europe ‘have much less micro-management from on high and rely more on responsibility and accountability being shown by the medical profession.’

It is not going to be easy to re-engineer the NHS and carry the British public along with any change, but even now the task is far from being impossible. It was Francois Duc De la Rochefoucauld who unwittingly pointed us to the real obstacle to getting on with the job of radical reform when he observed that: ‘We have more power than will; and it is often by way of excuse to ourselves that we fancy things that are impossible.’

That seems a bit rich coming from someone whose name is so unpronounceable and if not impossible, at least implausible and unnecessarily long. But he certainly has a point.

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