Odd this really

The other will be much hand wringing about supposed inefficiency. So let me be clear: it does exist. It is an issue. I accept that.

But let’s not for a minute confuse the two issues. I am not an expert in addressing a culture of bullying. But I do know something about markets, quasi-markets and organisation structures and what I can say, beyond a shadow of a doubt, is that if there are buying and other management inefficiencies in the NHS then they can be blamed fairly and squarely at successive governments who have thought that introducing market practices would help its efficiency.

They were wrong. Markets do not drive everyone to efficiency, especially when NHS organisations cannot, ultimately, fail. All they can do is create division.

Certainly a stirring announcement of theory. But how does it stack up against reality?

NHS Scotland, NHS Wales and NHS England are different organisations. The third has, in recent years, had rather more market practices introduced into it than the first two. And the third has improved in productivity over that time period more than the first two.

It would seem that the theory fails when tested against the real world.

26 thoughts on “Odd this really”

  1. Oh joy. Ritchie’s trying to think again.

    “I am not an expert in addressing a culture of bullying.”

    He does now a bit about propagating them, though. Shouting people down, pressurising people publically, repeating lies til the become facts….

    “But I do know something about markets”

    Citation needed

    “I can say, beyond a shadow of a doubt, is that if there are buying and other management inefficiencies in the NHS then they can be blamed fairly and squarely at successive governments who have thought that introducing market practices would help its efficiency.”

    I can talk about buying inefficiencies at the NHS: I used to do this for PASA- that was nothing to do with the gvt: it was pisspoor civil servants who didn’t have the foggiest how to do it. And ffs: if the NHS has to buy something, how is it going to do that without interacting with a market? The bloc buying of the NHS caused so many market inefficiencies, but directly as a result of the incompetence of the civil servants and how they went about things. It wasn’t the fault of the market.

    “They were wrong. Markets do not drive everyone to efficiency, especially when NHS organisations cannot, ultimately, fail. All they can do is create division.”

    Markets drive competent people to efficiency. If someone doesn’t understand a market, they are unlikely to succeed in using one. Like a chainsaw, for instance.

    And the NHS fails all the time: clinical fuckups, shit policies (Liverpool care pathway) and financial disasters- it’s a disasterzone. And none of those things are caused my markets. Just simple incompetence.

  2. The much-missed “Burning our Money” blog devoted a large part of its output to the antics of the NHS and coined the label “The Simple Shopper” to describe them ( and the rest of the states dickless purchasing agents).

    .http://burningourmoney.blogspot.co.uk/search/label/nhs

    The above links to 100 NHS based posts if anyone is so inclined to peruse them.

    Murphoid is correct to the extent that bungling state-decreed “enterprise” is, while better than sovietism, not much better.

    An entirely private system is needed.

  3. “And the NHS fails all the time: clinical fuckups, shit policies (Liverpool care pathway) and financial disasters- it’s a disasterzone. And none of those things are caused my markets. Just simple incompetence.”

    Simple incompetence and the lack of any negative feedback mechanism for failure. What private sector organisation could have gotten away with killing hundreds if not thousands of is ‘customers’ and continue operating as if nothing had happened? A supermarket chain that killed tens of people through its direct incompetence would most likely end up closing all the affected stores and sacking all the staff, and face criminal charges. Railtrack faced corporate manslaughter charges for an accident that killed 4 people. The NHS kills hundreds in one location and continues there to this day, unaltered.

    My father is in hospital at the moment, having fallen and broken his hip. As ever with the NHS the initial response is brilliant, however once they have done the emergency bit the indifference and corporate callousness kick in. He’s slowly going backwards, entirely down to their failure to manage his specific needs or to implement any program of improvement going forward. Trying to get anywhere with ‘management’ is like fighting a jelly. No-one is responsible, its always someone else’s fault that X hasn’t been done.

    The whole NHS system is utterly disfunctional, and IMO downright evil in its indifference to human suffering, which of course it would be, being based on socialism.

  4. It’s interesting to compare with the railways. The state owns and manages the fixed assets, while private companies run the trains. A major component of their interaction is Delay Attribution. This means deciding who is to blame (and hence who pays) when something goes wrong. Despite being stuck with antediluvian union rules and decaying infrastructure, UK rail is a success story: passenger numbers have increased beyond all expectation.

    The NHS has no equivalent of Delay Attribution. When somebody screws up, they close ranks and cover their collective arses. If the government can achieve just one reform, it would be to better assign blame for errors in the NHS.

  5. Andrew M

    Rail isn’t quite the success story you claim. Network Rail is in severe financial and organisational difficulty, nothing to do with the unions either. The way that the modern railway is funded is a microcosm of the economy as a whole as the future is being borrowed from to pay the present. There are a lot of things to be positive about as well and the answer isn’t, as no doubt Richie would think, to re-nationalise but the increased state interference in the day to day operations of the railways that is inherent in the way the supposed privatisation was set up is not a good example to hold up as an alternative to the NHS way of doing things.

    Btw delay attribution, although it has improved somewhat from it’s early days, is still a constant source of frustration and blame shifting to those tasked with keeping the trains running.

  6. You & your father have my sympathy, Jim. If experience with my late father’s final illness is anything to go by, I can only recommend making yourself as thoroughly unpleasant as possible so you get some service out of people, just to get you off their backs. There was episode where I got the latest visiting District Nurse sat at the dining room table & explained to her, she was the third of her calling to arrive that day – all totally unaware of each other & with different & conflicting care plans – & it was about time they got themselves some f**cking organsition going. I mean. FFS! They eventually commenced his incontinence assessment the week he died. After us having 6 weeks of struggling to cope with it.. i can remember making the first entry on the report sheet they wanted filled in. Liquid taken nil. Urine passed nil. Remarkably effective cure for incontinence, death.

  7. Ian B

    I understand that productivity for things like the NHS = 100% – so the more state funded operations the higher productivity.( I may well have misunderstood this)

    Jim

    In 2001 the wondrous NHS had a go at killing my wife a couple of times, one of which was the fiendishly difficult diagnosis of a burst appendix which they failed over 5 days. Fortunately a transfer to a BUPA hospital led to emergency operation etc. I used the NHS complaints process & got the ‘not me gov’ and ‘it’s really difficult’ responses. All due to Tory cuts….oh wait.

  8. Jim

    When visiting your father and speaking to NHS staff, be seen to take notes – of dates, names, what you are told and your father’s condition. ‘Sorry, and your name is Nurse X, and how do you spell that?’ Word will soon get around, and service will improve. And if it doesn’t improve sufficiently, you will have all the facts you need for your complaint.

  9. “& got the ‘not me gov’ and ‘it’s really difficult’ responses.”

    I think this is the key failing in the NHS mindset. The conflation with “the caring profession” with the personal “giving a f**k”
    They’re all encouraged to regard themselves, individually, as wonderful people. Which they may well be. So when anything goes wrong, it can’t be them personally at fault. It must be someone or something else. Of course the someones are all wonderful people, as well. Big shrug.
    There’s something I used to say to the guys worked for me. “I never want to hear you say ‘I did my best’ No-one gives a f**k how well you personally performed. We get judged by the end result when the punter pays the bill. It’s your responsibility to ensure the people you’re working with perform as well as they can. It’s never someone else’s or something else’s fault. It’s your fault for not doing something about it.. We all work together to ensure shit never happens.”
    More than anything else, the NHS’s problem is lack of self criticism. It can’t improve because none of the individuals in it consider themselves capable of improvement.

  10. Bupa is fucking brilliant, but pricey. April is much cheaper and uses the same facilities/people. My wife had a cancer scare a few years back: 6 weeks wait under (Blair’s) NHS, Bupa saw us the next day. She ended up having an op on the day that the NHS were to have seen her for the initial consult

    I got full cover for my family with April for less than I was paying for just me with Bupa. Our broker pointed us to them: apparently they are well known overseas but less so over here.

  11. I suspect a major problem is that the patient isn’t the “customer”. If medical staff and others were directly answerable to the patient, they would probably admit to errors etc. far more readily. But what you probably have is a manager saying we can’t say that something’s gone wrong – some publicity seeker in the House of Commons will be trotting out the NHS isn’t safe in their hands line, so we can’t admit mistakes.

  12. I suspect a major problem is that the patient isn’t the “customer”.

    Indeed. The government is the customer. The patients are plebs who get in the way of them pleasing their customer.

  13. Yes, not admitting blame is a besetting sin of the NHS.

    And NHS markets? The clever part was copying the corporate sector, rather than the private sector (there is a massive distinction).

    On which subject, it’s nearly bonus time. I haven’t yet seen my targets for 2015, though there was a brief and vague conversation sometime in October.

    The targets have had to be delayed due to an unexpected and significant pair of write-offs at the end of the year … If proper remedial action isn’t taken, then 2015 bonus payments could be seriously compromised.

  14. Witchsmeller Pursuivant

    Managerialism is the problem. As soon as doctors, nurses and ancillary staff started to be measured and compared according to abritrary targets set by a management elite, they had to take their eye off the patient.

  15. Agree with most of what’s already been said but, in my opinion, there’s a further problem. Attitudes within the NHS.
    I worked for a large-ish state funded outfit (not health based) from 1984-2003. Very few of that particular organisation’s employees (junior or senior) ever gave proper consideration as to how expenditure was to be managed. Projects were funded without proper consultation, or altered without any consideration as to how the changes were to be paid for. The waste was endemic and shocking, because the view was always that plenty of public dosh was there for the taking and wasting, available now and for ever more. Nobody ever said, “HOW MUCH?”, when the shit hit the fan and another shed load of taxpayer’s hard-earned had disappeared on some wanky idea.
    Until public service employees are compelled to regard state funded money in the same way as one hopes they do their own dough, then I fear heads, banging and brick walls will continue.
    Anyone remember the telly programme that Sir Gerry Robinson did on the NHS a while back? He concluded, with a massive amount of obvious frustration, by saying that there was plenty of money available in the NHS, but it was being wasted and/or spent badly.

  16. Bloke in North Dorset

    It would be a start if the NHS set up something like the Aviation Safety Reporting System, but the antediluvian nature of the system means that any proposed change is seen as wanting to implement the US system.

  17. Markets do not drive everyone to efficiency…

    You know, I want to feel sorry for the Econ profs at City University, but you know what? They invited the bastard to join them in the first place. The deserve to shine in the reflection of Murphy’s stupidity.

  18. I might as well add here, as I’ve done before, that privatisation alone won’t help the NHS stop pissing money away and introduce a culture of accountability: these traits don’t exist in the NHS solely because it is state-run, they exist also because it is a giant, sprawling bureaucracy. As such, the same traits – pissing money away, unaccountability, managerialism, etc. – can be found in many a large private organisation (at which point I invite you to poke your nose into any oil company). If privatisation is to occur, the NHS needs to be broken up into dozens, possibly hundreds of competing enterprises, and not everything handed over to one or two gigantic corporations in the hope the managers will be any more competent.

  19. So Much For Subtlety

    Tim Newman – “If privatisation is to occur, the NHS needs to be broken up into dozens, possibly hundreds of competing enterprises, and not everything handed over to one or two gigantic corporations in the hope the managers will be any more competent.”

    As with the railways. Look at the growth, the efficiency and the reliability of the trucking industry. Compare with the privatised railway companies. The advantage trucks have is that any driver can save up enough money and go into business himself. The railways are more energy efficient but it does not help them. They have massive legacy advantages. Doesn’t help them that much.

  20. @Jim ” What private sector organisation could have gotten away with killing hundreds if not thousands of is ‘customers’ and continue operating as if nothing had happened? A supermarket chain that killed tens of people through its direct incompetence would most likely end up closing all the affected stores and sacking all the staff, and face criminal charges.”

    Tobacco companies?

  21. From my experience, the NHS is entirely market forces driven.Hospitals cuts their staffing levels at weekends to save money very efficiently in business terms .
    The thing is : it shouldn’t be trying to save money in the first place but to spend what is needed
    Cue braying donkeys: “But where’s the money going to come from?” Answer “Where the banks get it from: the stroke of a pen”)

  22. @DBC please tell us you’re not talking about People’s QE. And who defines “what’s needed”? The demand for health services of an increasingly geriatric (for very positive reasons) population is literally infinite.

  23. DBC Reed may have attained peak stupidity though I admit straight away that I might have misread the market.

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