The joy of state services

guardian.co.uk on NHS\" href=\"http://www.guardian.co.uk/society/nhs\">NHS care is under renewed scrutiny after a damning new report on Wednesday highlighted how some patients were denied pain relief, told by nurses to go to the toilet in their seat and left without food and water.

The NHS is ignoring patients\’ needs because of \”a systemic problem\” which requires an overhaul of hospital procedures to eradicate neglect by staff, warns the Patients Association, an influential campaign group, in a study which details 16 cases of appalling care inflicted on people who were already very unwell.

The Department of Health responded by pledging to \”root out\” poor treatment wherever it occurred and work with the NHS until the problems identified in the dossier were resolved.

The association\’s report follows a series of critical reports about standards of NHS care in some areas, especially of elderly patients, by watchdogs such as the Care Quality Commission and charities such as Age UK.

The report said: \”In the 21st century, in one of the most developed countries and health systems in the world, patients should not be left starving or thirsty, they shouldn\’t be left in pain and they shouldn\’t be forced to urinate or defecate in their bed because the nurse designated to them says it\’s easier for them to change the sheets later than to help them to the toilet now. Yet this is what is happening around the country every day.\”

One of the things that a little competition would cure, isn\’t it?

A restaurant gets a reputation for serving up slop then word soon gets around and everyone goes elsewhere.

A hospital gets a reputation for insisting patients sit in their own faeces and word seen gets around and everyone goes elsewhere.

Medical treatment, qua medical treatment, might not change all that much. But the lived experience of patients would most definitely improve. That alone is a good enough reason to do it, no?

32 comments on “The joy of state services

  1. This is where the good intentions of the people who care have led us to.

    But please don’t sack anybody, don’t change anything, don’t experiment with other ways of doing things, don’t make anybody responsible, it’s not their fault.

  2. Well yes, but there is a reasonable left-argument that competition doesn’t work so well in healthcare. The real problem is that the NHS provides large numbers of people with something they can’t actually afford.

    Healthcare is pretty much out there on its own as something that doesn’t scale with income. In fact, it tends to have an inverse relationship (poor people do more dangerous jobs and have less money to generally pamper themselves, leading to more health problems). Poor people can live in smaller houses and pay less insurance, less fuel bills, and so on. But cancer treatment costs much the same whether you’re a duke or a dustman. So the only realistic way to scale healthcare costs is to, er, provide crappier facilities for the poor patients. That is, toffs get a private room with a widescreen TV and free blow jobs, and poor people get a dormitory with shit on the walls and a mad woman in the next bed singing The Roses Of Picardy.

    And even then, you’re not actually scaling anywhere near as much as you’d like, unless you’re going to give the poor people a cheap crap surgeon with the DT’s and a low survival rate. So it’s not really a simple problem. It always is going to come down to the problem that, at this stage of human development, healthcare costs more than most people can reasonably afford. So either you’re going to just accept that some people don’t get it, or get a very limited version (the US model) or you have to have the State do a forcible redistribution of some kind.

    But then, once you’ve got the State involved, the patients cease to be the clients of the healthcare providers; the State becomes their client. And the State wants to save money. The last thing the State wants in that situation is people shopping around for better health provision, with other peoples’ money, since of course they are going to want the very best. Somebody else is paying after all, aren’t they?

    It’s a basic problem. People will only be thrifty with their own money. Give them somebody else’s and they will become very discerning customers indeed, and all rush off to the widescreen TV and blowjob hospital, and then the costs will escalate.

    So I don’t think there’s really an answer here; plus, the reality is that even if the Radical Libertarian Tendency were swept to power in some kind of bizarre electoral accident, it would still take them decades to dismantle the hard core of the welfare state.

    So, I dunno. Like I said, don’t think there’s an answer really. My guess is we may as well bumble along with what we’ve got until science can solve the Ageing Problem and we can actually start bringing the costs down; we just live at an unfortunate time in history where medicine is pretty good at repairing faults, but it’s rather expensive, but hasn’t yet got to the stage of repairing the major design flaws inflicted on us by evolution, that getting old and breaking down bit by bit and then dying thing.

  3. “But the lived experience of patients would most definitely improve. That alone is a good enough reason to do it, no?”

    Surely the only reason we need to do it is basic humanity?

  4. I bet it’s actually against the (criminal) law anyway, wouldn’t it count as some form of abuse?

    I mean, it’s certainly illegal to do this kind of thing to animals. Have they got around to extending it to humans yet?

  5. The Department of Health responded by pledging to “root out” poor treatment wherever it occurred and work with the NHS until the problems identified in the dossier were resolved.

    Again.

    The difference with the private sector is that they don’t wait for things to get this bad. Take call centres… they randomly monitor staff calls. Someone gives out the wrong information or gets rude with customers and they sort it out, one way or another.

    It strikes me that government doesn’t refine. It throws money at say, an NHS IT system and it just gets worse and worse and eventually someone realises that it’s completely broken as a project and cans it. Someone in the private sector would have intervened within a few months on that project (at worse, and assuming they’d done the project in such a stupid way in the first place).

  6. The difference with the private sector is that they don’t wait for things to get this bad. Take call centres… they randomly monitor staff calls. Someone gives out the wrong information or gets rude with customers and they sort it out, one way or another.

    Well there’s a data point; you don’t get your energy supplied by British Gas.

  7. Ian B,

    And even then, you’re not actually scaling anywhere near as much as you’d like, unless you’re going to give the poor people a cheap crap surgeon with the DT’s and a low survival rate. So it’s not really a simple problem. It always is going to come down to the problem that, at this stage of human development, healthcare costs more than most people can reasonably afford.

    That’s what lots of people thought about computers. Yet the £500 phone in your pocket has more computer processing than the £1m mainframe that a bank had 30 years ago.

    There’s a guy in Scotland called Mark Frame. He’s worked out a way to take a cat scan and build the model data for a 3d printer. Sends it off to a 3d printing company who send back a model. Cost? About £75 a time. Cost when the NHS used one of their suppliers? Thousands.

    To find out that Oxford had capacity to see me about my eyes, I had to phone 2 people… twice. How much did that cost, for something that’s little different to what Hilton have set up?

    Why are we not doing production line surgery, despite the fact that a surgeon in East Anglia and one in Bangalore have shown that it’s far more efficient than having surgeons waiting for anaesthetists?

    I’m sure there’s enough waste in the NHS that we could do the same things that we do now for half the cost.

  8. Tim, good point. But that’s not a specific of the healthcare system. American healthcare is phenomenally expensive, despite being private sector. There are all sorts of general problems; regulation, cartelisation, guild methodology. None of which is addressed by teh “competition” argument. A privatised system won’t be any better. It will have the same problems, as will any nominally “competitive” system as this article is proposing.

    Don’t get me wrong, I’m a libertarian. I profoundly agree with you. But I think that under the current regime, in which the “three sectors” have now reached a stage of virtual homogeneity (many people are now noting a new ruling class who wander from “private” to “public” to “voluntary” at whim) these kinds of comparisons are rather redundant.

    The remnant of a real “private” sector remains in smaller business, and blokes like the one you describe. They could certainly bring costs down a great deal, and I passionately would like to see that. But we aren’t going to get there with stale debates that don’t recognise current realities about the nature of our society.

    And I would argue that, even with all sorts of potential cost reductions as you describe, you are still going to be stuck with something very expensive that doesn’t scale with income, which is the problem with “caring” industries in general (e.g. non-medical elderly care). I do stand by my assertion that we’re just at a really shitty juncture in history right now. I tend to say this too much, but we do live in the middle of history, not at the end of it. Sometimes it’s worth just waiting a bit.

  9. So Ian, what you are saying is that Tim’s point would work in a true free market but that we are so far from a free market in healthcare that “competition” (that isn’t really) will have no effect?. Is that right?

  10. Mr Ecks-

    Pretty much, yes. I increasingly think our society’s structure has moved far beyond that which was initially analysed by classical liberalism, particularly that the old clear division between private and public no longer in practise exists. There’s now just this big sort of governance spodge. It’s a bit like arguing about whether something should be the province of the church or the state when you actually live in a theocracy where they’re both basically the same thing, kind of thing.

  11. “That is, toffs get a private room with a widescreen TV and free blow jobs, and poor people get a dormitory with shit on the walls and a mad woman in the next bed singing The Roses Of Picardy.”

    For me he was a mad man singing Daisy, Daisy, but other than that it was identical. Even when the pretty Ukrainian nurse offered me a bed-bath she was stopped by the boss-nurse because I could, “walk to the sink”.

  12. Whatever system you employ, it will require better nurse:patient ratios than we currently have – especially on general wards.

    I’m not optimistic that the ConDem reforms will improve the situation.

  13. Ian B,

    But I think that under the current regime, in which the “three sectors” have now reached a stage of virtual homogeneity (many people are now noting a new ruling class who wander from “private” to “public” to “voluntary” at whim) these kinds of comparisons are rather redundant.

    I’m not sure I entirely agree. There’s definitely strong links between public and voluntary sectors, but parliament has very few people who’ve been through the more open parts of the private sector (I’ll rule out people who worked in law, television or consultancies as they don’t have much competition for public money).

    And to some extent, medicine is always going to have a higher barrier to entry than someone running a graphic design business because medicine does need more regulation.

    But, couldn’t you also say that about airlines? There’s a stack of regulations about maintaining planes, pilots have to be licensed. Yet since Open Skies we’ve seen the arrival of Easyjet, Ryanair, GermanWings and Jet2, and the destruction of Sabena.

  14. Fair comment. I’m sure you could get better care if you had an oversupply of care homes, with patients and their relatives able to choose between them. And I’m sure it would cost a lot more.

    I’m also sure that you could get much better care in the state sector if you gave the care homes more money in exchange for better staffing levels.

  15. As I sort of said above, it comes down to this particular problem at this moment in history, that we’re very good at curing illnesses and keeping people alive, but lousy at curing The Illness, which is ageing. So we’re ending up with this bigger and bigger “what to do with the old folks” problem. Including of course, ourselves, eventually.

    Although the shortness of life in the past is exaggerated- old people were not as rare as we like to think- there certainly were fewer of them who didn’t last as long, and elderly care was thus less of a problem. We’ve now got very many people being “old” for as long as they’re “adult but not old yet”, and that’s steadily getting more extreme. However you care for them, private sector or state, it’s unlikely that any such system will have enough money, especially with the economy in total shreds all the time. I just don’t think any more that the State vs. Private dichotomy is much of a useful argument. It comes down to whether a “Death Panel” is going to ration your care, or whether the fact you didn’t make enough money earlier on in life is going to ration your care. What we do know from GDP, crap as it is a statistic, is that there isn’t enough income for everyone to pay for a nice old age, not at current production levels. So how you decide who gets what treatment, and whether you level everyone down to “hopefully bearable” or have some people getting luxury and others getting beaten up and sitting in their own shit, that’s pretty much a matter of taste.

    Presuming the Greens don’t actually pull civilisation down as they hope, we can expect that this problem will be sorted, almost certainly this century, by arresting the ageing process, the one “illness” we are all doomed to suffer, and which causes most of the rest of the problems with healthcare and care in general. But right now, bad time to be alive, just like every other time to be alive so far in human history.

    I daresay the future will be grand, though. Wish I was going to see it. Sigh.

  16. “I’m also sure that you could get much better care in the state sector if you gave the care homes more money in exchange for better staffing levels.”

    Yeah, cos more money always makes people behave more compassionately.

    Haven’t we just seen one of the largest sustained increases in spending on the NHS ever, from 2001-ish onwards? Including paying everyone lots more money? And has it made the quality of care any better? Or do we constantly hear, both from official reports, and the evidence of our own eyes if we have to use the NHS, that patients, particularly vulnerable ones such as the elderly, are continually treated worse than animals?

    Indeed if I forced my dog to lie in his own faeces I suspect the RSPCA might prosecute me for cruelty, and rightly so.

  17. Sorry, I forgot for a moment that whereas CEOs work better if you give them more money, care workers work better if you shout at them.

    Yes, increased spending on the NHS has improved the treatment it offers. But long-term care of the old and incompetent is not where the funding has gone. If a carer ignores a patient who needs help, it’s usually for the same reason that a waiter ignores you in a restaurant: they’ve got too much to do. That could be fixed by improving staffing levels. And if the problem is that the carer simply doesn’t want to do their job properly, that can be fixed by paying enough money to attract better staff.

  18. Paul B,

    “Fair comment. I’m sure you could get better care if you had an oversupply of care homes, with patients and their relatives able to choose between them. And I’m sure it would cost a lot more.”

    This is just the same old Marxist argument all over again. It’s the same reasoning that was used to claim that government-owned and planned industry would eliminate inefficiencies caused by over-supply. The problem is that it completely ignores a couple of the most important economic findings:
    1) incentives matter
    2) creative destruction

  19. @PaulB: the report in question deals with NHS hospital treatment of patients, not care homes. The NHS has definitely had more money to spend over the last decade and it hasn’t improved things.

    The behaviour of nurses detailed in this report has zero to do with money, pay or overwork. It has everything to do with people behaving in a manner that suits them rather than the patient because they know they can. How many nurses have been sacked for such negligence? None I’m sure.

    If a member of staff from a private business treated its customers in such a manner (and it does happen yes) and they were discovered, then they would be disciplined and possibly dismissed. This does not happen in State run enterprises. Enquiries are held and ‘lessons are learnt’ when something goes wrong, and no-one carries the can. And the result is old ladies left to sit in their own sh1t.

    My mother was a nurse in the 1960s, and was a ward sister. She would have been mortified if anyone were treated in such a manner on her ward. The very thought of it would be inconceivable. She had less staff to manage her ward than they do nowadays, but they managed because they were 100% dedicated to their task – caring for sick people. It wasn’t a ‘career’ it was a vocation. They were paid a pittance by todays standards but the care they provided was second to none.

  20. @PaulB: I’m glad you used that quote because I looked it up, and you omitted a very important part of it:

    “He asked a nurse to assist him, but was told that she was too busy and that it would be easier for her if dad relieved his bowels in the chair”.

    A decent human being does not tell an old man to sh1t himself because that would make life easier for them.

  21. So you agree that she was too busy, but you think she made the wrong choice of which patient to neglect? Or you think she was right to neglect this patient, but wrong to tell him so?

  22. I do think this comes down to a fundamental matter of human decency, that you just don’t tell people they’ll have to shit themself. There are few things more degrading.

  23. Paul B,

    there are more ways at ensuring that people are not too busy than throwing money after them. Y switchboard operators were busy connecting X phonecalls per hour back in the days whereas the same or a higher amount can now be done with substantially fewer staff (at a lower cost)

  24. @PaulB: she ‘said’ she was too busy, which could mean anything. It could mean she was rushing to administer the kiss of life to someone, but I suspect if that was the case she might have mentioned it. It could mean she couldn’t be arsed and wanted to chin-wag with her mates outside while having a fag. It could mean she was about to go off shift in 5 minutes, and if she left the patient, someone else would have to deal with him. We don’t know. But I’m pretty sure that if there was a real reason for the nurse to be unavailable (ie another patient dying at that very moment and needing urgent attention) it would have been shouted from the roof tops.

    What we do know is there is no evidence the person involved has even been disciplined let alone dismissed. Which is par for the course for of ‘Envy of the World’ health service.

  25. I agree that what happened was disgraceful. And I agree that we know nothing about the reasons for it. I am puzzled that without knowing the details, you and others have been to solve the problem with such confidence. Tim knows that privatization is the answer, and Emil knows that despite what we see in the USA, privatization wouldn’t increase costs because we could automate the switchboards and, presumably, the bedpans. Bilbaoboy knows that we need to experiment with the system, whereas you know that the system worked fine before we experimented with it. And above all, you know that the problem was definitely not overwork.

    Me, I don’t know what lies behind this outrage, so I don’t know the solution. I am sympathetic to lost_nurse’s view that we need more nurses on the wards. You could try reading some nursing blogs and see if you agree.

  26. Apropos of this comment thread I thought I’d ask my Mother about her nursing experiences back in the day.

    In 1968 she was a a ward sister, in complete control of a 40 bed ward. At any one point she had no more than 12-15 nurses available to keep all those 40 patients (there were very few empty beds at any time) cared for. The very idea of telling one of her patients to defecate in his clothes made her very cross when I told of the report detailing what had happened. Such a thing would never have been allowed to occur. At no point in her NHS career did she earn more than £1000 per year, even when she was ward sister. The modern equivalent of her job is paid on NHS grade 6, or £25-34K pa, so anywhere from 25-34 times as much as she was. Average earnings have gone up in the same time by about 25 times, so no-one doing her job today would be paid less (in relative terms) than she was, most likely more.

    So it is absolute nonsense to suggest that staffing levels and pay are responsible for the current malaise. If people earning less in the 1960s could cope, so can those today. The fact that they don’t is entirely down to the system that controls (or rather doesn’t control) the way patients are cared for – a State run monopoly.

    And as is the case with all State run monopolies, they end up being run for the benefit of the staff, not the person using the service.

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