Polly\’s guide to change in the NHS

Until now care was bought mainly from NHS hospitals, community trusts or independent GPs (not companies running GP services). But the purpose of CCGs is to bring in maximum competition. NHS services will find themselves bidding against the likes of Virgin Care or the American giant United Healthcare, which are likely to cherry-pick easy and profitable services – diagnostics, routine pre-planned surgery and simple treatments – leaving behind A&E, the frail, the old and anything that is unpredictably expensive.

That sounds sensible. Let market competition work where market competition can and not where it cannot.

If they succeed, more hospitals will go bankrupt.

So we are therefore admitting that NHS hospitals are less efficient than the private providers they will be competing against then? After all, you don\’t go bust if you are more efficient, do you?

That\’s scaremongering, the government protests, and yet the government\’s own figures show what\’s already happening: NHS Financial Information 2013 reports that private patient income earned by UK NHS trusts rose by 5.3%, and London specialist hospitals\’ private business rose by 15%. On a different ideological path, Scottish NHS private practice fell by 18%, and Welsh by 8%.

Market segmentation through product differentiation. Standard business practice. You make sure that you\’re offering more than just one level of service. Thus you can shake more money out of those willing to pay while keeping the custom of those not willing to pay extra. VW does it by building the VW Touareg, the Audi whatever and the Porsche Cayene on the same basic platform. Starbucks, famously, did by offering for the barista to stir your sugar into your iced tea for an extra 50 cents. You get more cash out of those willing to pay more cash by offering them something perceived as being different.

So, NHS England is managing to squeeze extra cash out of the rich for exactly the same health care (even if a better bed or nicer food) that the poor are getting. This is good isn\’t it? More cash for the NHS? As opposed to that different ideological path where all must be equal therefore there is less total cash to pay for health care?

What works has been integration and co-operation across silos, as in cancer or coronary care. What works is washing hands, bringing cleaners back in house, collecting evidence, sharing best practice, not wasteful turf-war competition.

Health is not a market.

And Polly still doesn\’t get the most basic point about markets. They are a coordination, cooperation, mechanism.

We all actually agree that it would be lovely if you could take 1.4 million people and £100 billion and more a year and just \”make it work\”. But you need a system to do that. Stalinist top down control simply does not work in an organisation of that size. It works just fine in a family of course (although note that it\’s very rarely the paterfamilias who exercises the power. Mater always has much more) but as we scale things up such direct control just does not work. Even voluntary, communal, cooperation (as Elinor Ostrom found out) begins to fail once you go above a few thousand people.

Setting targets leads to those absurdities like ambulances waiting outside emergency rooms so that the 4 hour target is met.

At larger scales you simply have to bring markets in. Their incentives, their prices, become the great calculating engine which informs us about who should be doing what to whom where and when. We humans just have not found anything else that operates at such scale.

It\’s not all about enriching the private sector. Not all about allowing the capitalists to run off with the peoples\’ money. It is simply that we do not know any other method of running such a large \”thing\” with any semblance of efficiency.

Which is, of course, why France, Germany, Sweden, Norway, Denmark and all the rest run their health services on pretty much the model that the Bastard Tories are bringing to the NHS.

58 thoughts on “Polly\’s guide to change in the NHS”

  1. Her argument about competition is madly confused.

    If there’s lots of competition, isn’t that going to reduce profitability for those companies? Where then, does she get this idea that they’re going to “cherry pick” those services, when cherry picking implies picking the stuff with the most money in it? These companies are going to be supplying the things they have the capacity to supply, the low-profit, run-of-the-mill stuff.

    The NHS is simply going in the direction of many corporations: the organisation is a shell, managing the contracts with numerous suppliers, with you pulling it together. Google has a €75m data centre in Dublin that employs 30 staff. Which means that nearly all the comms, power, cleaning, server installation and air con is being managed by contractors. Those 30 people are mostly just making sure that those suppliers are doing their job.

  2. It really is all about the ideology with Polly and her mates. It’s psychologically extremely hard to admit that you have been wrong about almost everything, and that the beliefs you hold dear have cost thousands of lives and ruined millions of others. Hence the useful idiots of the USSR.

  3. less efficient than the private providers they will be competing against then

    You really don’t have a clue what’s happening on the ground – not least given that all these all-oh-so “efficient” providers are actually passing the buck on anything complex or messy – whilst profiting from NHS infrastructure, workforce training and acute capacity.

    A&E is increasingly overrun – and things are getting worse, & fast. Platitudes about competition are going to sound increasingly hollow.

  4. @ lost_nurse
    You’re really great at telling us how suggestions to improve the NHS are a disaster.
    The last government tried the throw money at the problem solution without success & there isn t any more money to throw.
    So, rather than criticize, what s your suggestion?

  5. Surely thats down to contracts then? If a company has the contract to do something, and does not, is there a clause giving penalties?

    Plenty of private involvement in the NHS already. More than a few trusts lease their ambulances and fast response cars – someone else takes care of the fleet for them. Why? Because its cost effective perhaps? Because buying a vehicle is expensive?
    The public already support private involvement in health. Hospices. Non-NHS involvement in end of life care.

  6. Surreptitious Evil

    More than a few trusts lease their ambulances and fast response cars – someone else takes care of the fleet for them. Why? Because its cost effective perhaps? Because buying a vehicle is expensive?

    Because recurring costs are much, much easier to manage in a UK public finance style budget than capital costs.

  7. Hi All

    This is where the financial economist agrees with lost nurse. We cannot have competition in hospitals in the way that Tim describes. We don’t have prices. The NHS has no idea about costs – because it really is insanely complicated. The NHS accounts are not designed to provide true costings. This then means that the NHS has approximate costs for most operations.

    Imagine the fee for hip replacement is 10,000. This is the average figure – in fact some operations are simple and cost 5,ooo, others because they include a stay in ICU cost 20,000. A private provider can agree to do ops for 7,000, but they only do the simple operations – netting them 2,000 in profits. The NHS hospital still bears the cost of the difficult ops and falls into financial difficulty.

    In order for competition to work the private provider would need to be bidding 5000 for the easy operations. In practice this is going to be nightmarish, who bears the cost of transferring patients who have complications midway through the private hip replacement to ICU?

    Some things can be costed properly and thus can be subject to contract. Others are far more difficult – and the Management Information Systems are not available to help cost stuff. I think it is far more likely that this reform will end badly.

  8. Ken
    What you’re describing there is no different to a host of other service industries. You price for a job. Sometimes the job comes out easy & you make a packet. Sometimes it turns out a pig & maybe you make a loss. It s swings & roundabouts. If you price correctly, overall you make a profit & are also competitive against other providers, who have to make the same judgement. There’s no reason a contractor for the service could not farm out the complicated jobs to a specialist, absorb the extra cost & still come out on top in the long run.

  9. ken,

    1. “We don’t have prices” because we don’t have competition. It’s a circular argument. I can go to a dentist, get a quote for work, and go to another dentist and get a quote for the same work.

    2. Your hip replacement example ignores the fact that the NHS hospital is also a bidder. If there isn’t anyone offering to do the

  10. ken,

    what bloke in spain says + who says that prices should always be related to costs? In the case of health care there are e.g. a very large amount of shared and common costs (admin staff, waiting rooms, building security, storage, cleaning staff, etc, etc). No economic theory says that there is only one way of recovering these costs. On the contrary it is very possible that the welfare maximising way may be to recover them based on price elasticity and to do that we need a market, not a cost system

  11. BiS and Tim A.

    The commissioning authority has one existing data point – the 10K they are charged at the moment. This is used to cross subsidise other service elements such as ICU. What you are suggesting is that the NHS should unravel all the prices and cross subsidies and then charge the correct amount for each. In practice this isnt what is being done, they will ask for bids on a number of hip replacements. Since the existing internal price includes the cross subsidy, it will be possible for the NHS hospital to bid 5000, but this will leave them out of pocket. Instead they are more likely to bid 10,000 as they do at the moment and find themselves underbid by a private provider that will not provide the ICU.

    I like the idea of allowing private providers controlling an entire trust – so that al the costs are internalised, I am far less convinced of asking for tenders for limited types of ops. At the moment the NHS pays for education, emergency services and the more difficult ops via the uniform price, I’m just not convinced that it will be easy to get the competition that you envisage. You get ever more complex rules as different contingencies are contracted for.

    Go back to my example, say that the private provider contracts for hips at 5k a pop. They can then refuse to do difficult ones (driving their cost below 5k) or cut corners increasing costs to the rest of the NHS.

    Note that in your world, we would find prices through competition for all services. In practice the delimitation of each service is unclear – helping to explain why the US system spends so much on admin – battling clerks fighting out the allocation of costs of different ops.

  12. Ken>

    Depends on the terms of the contract. If the bid is per-op, then presumably the low-bidding private provider won’t be bidding on the complicated procedures, allowing the NHS to bid a cost-reflecting price. Or, alternatively, if the simple procedures cost less than 5k, another simple-procedure-provider will come along and do it.

    If it’s genuinely cheaper to provide the complicated procedures when you also provide simpler ones, then the private providers will have a reason to do so – or the NHS could bid cheaper than them for such jobs, and make back the difference from the reduced costs on complicated stuff. If it’s not cheaper, then there’s no reason to do it that way and we don’t lose by having simple and complicated procedures shared amongst different providers.

    The alternative is that the contracts will be for all hip-ops in a given area, or some such.

    Really, you could just look at how this works in every other country that does it.

  13. ken

    1) if contracts are written properly then the private provider cannot refuse to do difficult ops or cut corners

    2) it is not only the us having more market in healthcare than the UK but just about any other place in the world

  14. I really wish this “the private sector can t cope with non routine” argument would propagate outside the NHS.
    By the same logic, airports wouldn t need to provide crash teams, ships lifeboats, commercial premises fire extinguishers & sprinkler systems… None of these are regularly used, are they? mostly they re never used, nor intended to be. So why have them? Company s could save a fortune.

  15. Surreptitious Evil

    I really wish this -the private sector can t cope with non routine- argument would propagate outside the NHS.

    I read the argument somewhat differently. From my pov it the interconnectivity between different bits of the NHS (lost nurse’s obsession) and that the govt are so crap at agreeing outsourcing contracts (partly because they don’t actually understand what they are doing and how much it actually costs – which is essentially how I read Ken’s point), the only things they are going to be able to outsource are the very simple things. And they’ll get fleeced even on those. This is Chris Dillon’s best point – managerialism. Not all things are susceptible to being managed. And managing things solely through contracts and reports is rarely the best way.

    I made the same argument for a very large company that didn’t actually do much out-sourcing (outside professional services and facilities management) and was considering it. My advice to Group Risk – poach somebody brilliant from one of the outsourcers and get them to run the programme.

  16. Well you could ask then, SE, what exactly is the NHS for? The NHS is the management structure. Nurses, doctors, hospitals would exist without it. The only thing the NHS itself actually does is manage them.

  17. BiS.
    It is quite correct that the private sector can cope with the non-routine. The main problem is that the NHS as it is presently set up is not in a good position to divide up costs between different aspects of its operations. I’d also point out that Heathrow failed miserably to meet its responsibilities with snow clearing.

    Emil
    Complete contracts are impossible. The rail privatisation led to ever longer more complex contracts as the bureaucrats tried to deal with every contingency.

    The point I’m making is not that competition is not good. It’s that the NHS as presently constituted is unlikely to be able to take advantage of competitive tendering for many activities and that this reform is more likely to result in supranormal profits for private firms and bigger holes in the NHS budget.

    Does this mean that I think the NHS is efficient? Far from it, just that having badly informed GP consortia buying in services will probably not result in the nirvana of competitive efficiency that some seem to hope for. As I said, a complete trust in the hands of a private owner would resolve many of the issues I can see, although there would still be the issue of what the target(s) would be.

  18. ken and others

    This is why railway privatisation didn’t work out the way it was intended to, well one of the reasons. The problem of apportioning costs has never been overcome, because it can’t be. You either have one company dealing with all the costs or you have a dog’s breakfast of trying to work out who pays for what and when and the organisation with ultimate responsibility, be it Network Rail or the NHS is left constantly trying to square circles and having to justify itself against artificial benchmarks. If you’ve got politicians and civil servants with their own agendas adding to the mix it makes it even more fun.

  19. SE,

    Not all things are susceptible to being managed. And managing things solely through contracts and reports is rarely the best way.

    Actually, Chris Dillow’s point about managerialism is about the decline of “autonomous professionals” in favour of hierarchy and how wrong it is. Unfortunately, he’s wrong.

  20. Thornavis>

    “The problem of apportioning costs has never been overcome, because it can’t be.”

    Have you never heard of an auction?

  21. Thornavis>

    Well, it’s a system for solving the problem of apportioning costs/prices to goods or services.

  22. Dave

    On reflection I think we may be talking about different things here. My point was that within the system that appears to be emerging in the health service I can see similar problems to those that have bedeviled the railways since privatisation. It’s all very well having an auction to decide prices in advance but if the system you set up to run things produces hidden costs late on or if the bidder underbids and then can’t pay you’ve got trouble,this was ken’s point I think about complications in operations. The railways aren’t exactly analogous to the NHS of course but it seems to me that’s there’s a good chance of things going the same way. Auctions work fine where everyone knows what they are buying and what the cost is, if they don’t then it’s a big guessing game, get it wrong and someone has to pick up the tab, in this case that means the taxpayer ultimately. There must be a severe danger of the NHS reforms actually increasing costs in the long run and without necessarily improving customer satisfaction.

  23. So, rather than criticize, what s your suggestion?

    Put a stop to these ridiculous, muddle-headed reforms & concentrate on core functions (esp providing joined-up acute care). Preserve the co-operative working relationships that exist across the NHS (e.g. stroke, trauma, cardiac networks). Keep ‘er steady thru the existing programme of efficiency savings – and have a sensible debate about what we want from a healthcare system, & how – if it is to be comprehensive – we are going to fund and regulate it. Do not include any fcukers from McKinsey, in any part of the process. Do not reduce the complexities of healthcare provision down to cute platitudes about buying coffee.

    As it is, I think things are going to unravel pretty fast. The fragmentation of services and the resulting pressure on acute care is going to make for some grim headlines….If anything, it makes Mid.Staffs-style meltdowns more, not less, likely.

  24. Be kind to Polly.
    She is facing the knowledge that her specia self is not needed to run a bit organization. She is facing being an irrelevance.
    Now that cannot happen hence the squealing.

  25. Thornavis>

    It really depends how the auctions and contracts are structured. Done competently, it’s not only how the world does business, but also how most other (actually successful) national health systems are run.

    Of course, we should never underestimate the government’s capacity to screw things up.

  26. Oh and never forget, every GP in the land is a private business.
    Private business has been in the NHS for all of its life.

  27. There must be a severe danger of the NHS reforms actually increasing costs in the long run and without necessarily improving customer satisfaction

    In a nutshell, this.

    If you think the bureaucracy is bad now, just wait until the commissioning process (with lawyers in tow) really gets going. And if Joe Public isn’t seeing commensurate improvements in local healthcare, then we’ll have sold the whole bleedin’ show to Serco and Beardy for nuffink. The taxpayer will still be shouldering the risks – and the bill.

  28. I’d be interested to hear why you think that a system proven to work well in many other instances will not work here.

  29. will not work here

    Why? Are we going to fund it like our Franco-German cousins? Properly regulate it? Have a sensible debate about none-exclusion social insurance? Stop kowtowing to the corporate healthcare lobby? Have a sensible debate about anything healthcare-related? I mean, in these ‘ere parts, it’s pretty much verboten to make a link between alcohol and hospital admissions.

    Offloading the NHS to Serco, Virgin, United, Care UK, Circle and all the rest will not result in European style healthcare nirvana. It’s shaping up to be like every other piss-poor UK privatisation process. I’m standing on the actual ground – and it’s an utter clusterfcuk.

  30. Dave

    I think you answered that yourself when you said never underestimate the government’s capacity to screw things up. This is what happened with railway privatisation, the system as it was established had inherent weaknesses that weren’t entirely apparent at the time. Those of us on the inside were generally pretty sure that it wasn’t going to go well, there were a number of reasons for that feeling, some were due to fear of change or producer interest ( the latter largely turned out to be unfounded ) but generally we could see, even if we couldn’t always predict exactly how, that it was deeply flawed. Which is why I take note of lost_nurse and people I know who work in the NHS who are very pessimistic, it’s one thing to say how a reform could work, another entirely to insist that it will.
    By the way railway privatisation hasn’t been all bad by any means and much of the hostility to it is misplaced or politically driven but the railways were already well on the way to becoming a well run commercial concern, there had been a programme of reform within the nationalised structure that should have been built on instead much of it was undone. The NHS has not got to the stage that the railways were in in 1992, it hasn’t even started down that road, if it all ends well I will be very surprised.

  31. “it’s an utter clusterfcuk”

    Plainly. But it’s been a clusterfuck for years. I hate to tell you this, since evidently you’ve been under the opposite impression, but you and your colleagues have been _failing_ to provide an adequate service, and the failure has been ongoing for decades, under different governments and different funding regimes. That’s why we’re taking the job of running the NHS away from you.

    Frankly, nothing could make things any worse than they already are, from a managerial standpoint. Based on my experiences, those of everyone I know, everything reported in the news, and the statistics, nursing would require a significant change to bring it up to the ethical standards of ‘the corporate healthcare lobby’ about which you’re complaining. I’d rather trust my life to a competent, professional ethical nurse than either, but given the choice between trusting a company with a financial incentive to save it, or a typical NHS nurse, it’s a no-brainer.

  32. Thornavis>

    I assumed it went without saying that if we’re factoring governmental incompetence into the equation then the solution which involves less involvement from government, and more from private enterprise, is obviously superior from that perspective.

    The usual way politics works is to find something better than we’ve got, then horse-trade away almost all the advantages to give everyone a bit of the benefits until what we end up with is only slightly better than what we started off with – just enough to make the whole thing vaguely worthwhile.

  33. Dave

    I don’t know what the typical NHS nurse is like but the two I know very well are certainly professional, competent and ethical, those I have encountered as a patient are generally pretty good too. I wish I could say the same for the GPs I’ve encountered. This sort of blanket condemnation of an entire group of people is both foolish and part of the problem. If you assume that the workforce is useless then there isn’t much point in trying to reform the workplace.

  34. you and your colleagues have been _failing_ to provide an adequate service

    Judge away, pal. You know nothing of me or the service I help to provide. As for trusting my colleagues with my life, I’ll take my chances, thanks. A “typical NHS nurse” in my immediate vicinity is either emergency or ITU-trained, and a fair number of ’em have rotated through Camp Bastion. If I keel over, I want to be looking at their ugly faces.

    I’ve seen the NHS at its best and worst, and plenty of it. And far from your belief that nothing could make things any worse than they already are, these bloody stupid reforms stand a very good chance of doing exactly that. Frontline staff aren’t opposing them because they think the NHS is perfect – it’s because they are an unworkable mess, with the potential to screw up things that are done well.

    That

  35. Sorry, cont. – comments seem be disappearing…

    That’s why we’re taking the job of running the NHS away from you

    I’d be most interested in who, exactly, you think that ‘job’ is being given to.

  36. Thornavis>

    If we reform the workplace, we can do something about the incentives that have served to attract the unusually workshy and unethical to nursing in this country for quite some time. In some cases, like the Mid-Staff scandal, the incentives worked so strongly that the kind of complacent evil we associate with concentration-camp guards managed to crop up in this country.

    Yes, I’d say there’s a damn good reason to condemn the nursing profession as it currently stands.

    The nursing unions reflect everything currently wrong with the profession, and you can be sure the first thing a market-based system would do is break the unions. That alone will go a long way to cleaning up the mess.

  37. “A “typical NHS nurse” in my immediate vicinity is either emergency or ITU-trained”

    Well then, they’re not typical NHS nurses. BY colleagues, I meant the much wider pool of nurses in this country, not your immediate co-workers.

    “I’d be most interested in who, exactly, you think that ‘job’ is being given to.”

    A market. That’s the whole damn point.

  38. Well then, they’re not typical NHS nurses

    I’d say they’re pretty typical of acute care nurses, as found in most major city hospitals.

  39. A market. That’s the whole damn point.

    There will be no ‘market’ as a result of these reforms, ferchrist’s sake – not in the purest, most competitive sense of the word. There’ll be superficial notions of patient ‘choice’, plenty of buck-passing – and insanely busy A&E depts.

    Anyway, enough.

  40. “I`d say they’re pretty typical of acute care nurses, as found in most major city hospitals.”

    And what percentage of the nurses do they make up?

    “There will be no ‘market’ as a result of these reforms, ferchrist’s sake”

    So you’re saying they need to go much further in the reforms? Perhaps you should stop pushing them back, then.

  41. I’m not a fan of the unions. But in this particular case, I’m not convinced that this is a union problem.

    Indeed, I’m fairly certain that the problems in the NHS as a whole and Mid Staffs are down to similar issues to the ones I have with the proposed =market= reforms.

    The NHS has MIS that allow lots of target monitoring: financial targets at the hospital/trust level, waiting time targets, targets on whether you put the right rubbish in the right bins. It comes from a belief (fostered by the McKinsey fcukers) that ever more central ccommand and ontrol will result in better performance. What these systems dont do, is tell you what costs are associated with particular operations (explaining why we have the insanity of cancelled operations at fiscal year ends).

    The ethos within the NHS is all about management targets and not enough about patient care. It isnt the unions. It is the way systems have been set up.

    On top of this crap system, the idiot government now want to introduce a =market= when the costs are unclear and we dont have a proper system to allocate them. Markets work well when there is perfect competition – lots of small providers, no barriers to entry or exit and the products are easily defined.

    In an ideal world, we would be able to put all the NHS services out to tender and low cost high quality providers would bid. In practice, the government accounting system will reward commissioning consortia that =reduce= costs by paying less for their hip replacement surgery, while leaving the local NHS hospital responsible for providing ICU. The private healthcare company will do well from offering to do routine surgeries at 7K, less than then 10K that the op cost under the NHS, but more than the 5K it actually costs.

    People keep saying the market will solve everything. It is true that eventually we will be able to work out the costs – and we will only pay 5K for the hip surgery, but it will take years – and in the meantime NHS services will be seriously degraded. And the problem of defining what constitutes a contracted service will continue. Anyway, well before then some new government plan will be rolled out.

    None of this is to say that there are no bad nurses or doctors. It isnt even that the managers are bad. (athough some undoubtedly are). But the system is seriously flawed and we are about to add a whole new level of idiocy to it.

  42. Lost nurse is quite right, there will be no market in the sense that people seem to want. Instead we will see commissioning panels =saving= money by dumping costs on one part of the NHS (the A&E departments and other acute care), whilst enriching management consultants and private consortia.

  43. Having been through some of the commissioning of services locally (not NHS) there are always elements that cannot be planned for.
    So are budgeted for instead. If that means setting prices high enough to both provide a profit and cover unexpected higher expenses then so be it.
    Can we at least agree that at a minimum a company or NHS should in a bidding process cover its expected costs – x amount of staff, y amount of equipment, portion of management costs etc?
    If as an example that works out as

  44. lost_nurse,

    I mean, in these ‘ere parts, it’s pretty much verboten to make a link between alcohol and hospital admissions.

    No it isn’t. I’m sure that Timmy would love to hear about the costs of alcohol to the NHS, as we could then consider it in terms of whether we have sufficiently taxed alcohol to cover the external costs

    But if you’re going to do it, find a methodology that actually tries to measure alcohol-related admissions, rather than the current guesswork ofcounting the number of operations and assigning a factor of what percentage are alcohol related, which produces the sort of data quality that most people working in operational management would put into the shredder as utterly worthless.

    Unless you’re looking for symptoms of alcohol consumption when someone arrives at a hospital, you are not measuring alcohol-related admissions.

  45. Martin Davies

    Yes, this is absolutely true. In an ideal world, we would commission hip replacements and start from a baseline of 5k keeping the remainder for other services. We would be able to specify the details of the services contracted for with sufficieny accuracy so that there would be no gaming of the system, whilst still keeping the cost of negotiation down.

    Even with incomplete contracts, some price discovery would help with cost reductions – but given where the commissioning groups are starting from, I expect a loss of resources to the NHS as private sector groups game the system . I expect this loss will far overshadow any gains in efficiency.

  46. Offloading the NHS to Serco, Virgin, United, Care UK, Circle and all the rest will not result in European style healthcare nirvana. It’s shaping up to be like every other piss-poor UK privatisation process. I’m standing on the actual ground – and it’s an utter clusterfcuk.

    I’m with Lost Nurse on this: reforms are desperately needed, but I fear any attempt by politicians and the inadequate jobsworths which infest the UK to create a European-style healthcare system out of the NHS will be an utter clusterfuck. I have vast experience of sensible projects being managed by the completely wrong people, and I have no confidence this will be any different.

  47. I assumed it went without saying that if we’re factoring governmental incompetence into the equation then the solution which involves less involvement from government, and more from private enterprise, is obviously superior from that perspective.

    The problem is that outsourcing in the UK usually takes the form of government functions being outsourced to private companies, with the government being the customer. This is *vastly* different from the government getting out altogether and private companies taking over with the end users as the customer, or the function being abolished altogether.

  48. Lost nurse writes:

    I’d be most interested in who, exactly, you think that ‘job’ is being given to.

    And I say, Pretty much anyone, really….

  49. @Ken

    “and in the meantime NHS services will be seriously degraded”

    Again, exactly this. In acute care, we are pretty much adopting the crash position in preparation for what’s coming. Your point about Mid.Staffs is also most relevant. Whilst there has – rightly – been focus upon clinical neglect (including some glaring errors in emergency care, as well as the crating-up of elderly patients) & overstretched wards, attention should also be paid to why management took their eyes off the ball – e.g. caught up with the push for foundation status, and how that itself fuelled target mania. My fear is that these reforms are going to greatly amplify such dysfunction.

    @The Stigler – I was being rather tongue in cheek. I resent the State interfering with my pint of bitter asmuch as anyone. But Tim’s attacks on the public health worthies do sometimes suggest that he doesn’t really think there’s a problem. And in terms of avoidable admissions (whether in-yer-face trauma or lingering liver death), there certainly is a problem.

    @Dave – I understand exactly what a market is, and how it functions. That’s precisely why I remain deeply unconvinced by both the justification for these reforms and the current DOH rhetoric about what is – basically – a yardsale. It says much about the reigning confusion that the ConDems seem to need Nicholson to stay on as chief-enforcer (much as he helped to enforce previous topdown, pseudo-market reform). Personally, I think we are heading for the worst combination of worlds – and there may be political ideologues who welcome the fragmentation of services, but they generally ain’t the ones trying to deal with the fallout.

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