So. According to all the media reports, and the scaremongering from professional bodies, the NHS is in crisis and falling apart because it is significantly under-funded and a political football. It is barely “muddling by” [1,2,3].
Well maybe.
It cannot be denied that the NHS is in crisis. It is badly organised and badly managed. And yes it is a political football.
I’ve written about this before [4,5] and I make no apology for doing so again.
It cannot be denied that some sectors of the NHS are woefully under-funded. This is especially true of GP services where funding has fallen from a high of 11% of NHS budget in 2006 to around 8.3% today against a background of significant increases in the number of consultations and demands from politicians [6].
However overall I cannot believe that the NHS is under-funded. It seems to me the NHS has shed-loads of money to do everything you and I could reasonably want it to do. But that money is badly used, in large part because of the appalling level of wastage.

The NHS employs way more managers and administrators than it needs. That in itself is a huge waste of resources. Just take a look next time you visit a hospital at how many staff are wandering about apparently aimlessly. What do they do? Is it useful? How many are doing nothing but moving pieces of paper from A to B? In this day and age moving pieces of paper around by hand is an inexcusable waste. Do it electronically! Use email, or on-line documents, or database systems.
Yes, to get the NHS using pervasive electronic communication is going to take time, and will need an up-front investment. It will also need the Civil Service and government not to cut corners on cost by being constrained to choose the cheapest bidder, to understand how to manage a big IT project (like don’t keep changing the project scope) and to listen to advice from their trusted suppliers.
The NHS also has far too many managers. Their lives seem to be predicated on bullying staff and chasing meaningless government targets. If we could get rid of the pointless targets and teach the managers how to manage people the NHS would need far fewer of them. In doing this it will take the NHS quite a long way towards trusting and empowering its employees. Trust them to do their job. Trust them with the empowerment to do it efficiently. Empower them to change things sensibly if they can see a better way. In other words, act like a good private company.
Somewhere else the NHS wastes money is in the sheer waste of supplies. One hears stories of hospitals where Ward A needs supply Y but can’t buy it because there’s no money; yet Ward B has a cupboard full of the same supply but has to throw it away because it has gone out of date. In one instance I know of where this happened, and it was pointed out to the top brass by a junior nurse, just changing the procurement policy saved the hospital several million pounds in the first year. Practices like this are not uncommon.
And let’s not talk about hospital food. If patients were fed properly, not only would there be a lot less food waste but the patients might actually get better quicker so they could be discharged sooner.
This is all well and good but I fear it will never happen. For a start politicians, almost by definition, have to keep meddling. Not only is it ideological but it is the only thing they can do to try to show they are doing something.
The other reason it will never happen is that there is no-one at the top of the NHS who has the ability to grasp the whole organisation and energise it. That is not the Civil Service way. But without this there will be no change. The NHS needs someone highly skilled, robust, no-nonsense and bloody-minded to head it up. Someone who will energise the employees, from top to bottom. Who will empower from the top and support empowerment from below. Who will give his or her henchmen a job to do and expect them to get it done — or get out. And most importantly someone who will tell the politicians to butt-out and stay out.
Names like Richard Branson, Alan Sugar and Digby Jones come to mind. You may not like them, but they are the type of people who are needed. Badly needed.
Without someone like this, and without government getting a proper, business-like grip, the NHS is indeed going to go nowhere except, as predicted, down the tubes. And that is something the country cannot afford!
——————————
References:
[1] Observer; 28 June 2014
[2] Daily Telegraph; 18 June 2014
[3] Independent; 29 June 2014
[4] https://zenmischief.com/2014/02/transforming-the-nhs/
[5] https://zenmischief.com/2012/08/reforming-the-nhs/
[6] Royal College of General Practitioners; 27 June 2014

This is an absolutely classic example of why NHS — no actually not just NHS, but all government — IT projects fail so spectacularly.
There are a couple of telling comments in the report on the NHS decision to quietly close the “Choose and Book” outpatient appointments system.

During a recent investigation … MPs were told by NHS staff that while some GPs liked Choose and Book, many did not, and that not all outpatient appointment slots were available on it, limiting its usefulness.

Whether GPs like it or not, that’s the process they have to use; so get on with it and then get it improved. But not having all the appointments there is inexcusable. And the appointments aren’t there; I’ve recently had the run-around getting an audiology appointment because Choose & Book can’t get their act together. (And to be fair my GP went ballistic because of the inefficiency.)
But then it gets worse …

NHS England said … the new e-referral system would use different technology, but it was unable to say how much the scheme would cost.
(Emphasis mine.)

This is the crux of the matter. If you don’t know how much a project is going to cost, then you do not have a project because you cannot commit funding. There are three prerequisites to running ANY project: a sponsor (ultimate responsibility), a coherent defined and documented set of requirements (the job) and committed funding (ability to pay). Without all three there is no project. Ever.
And government never provide any of the three. They are totally unable to define, specify, cost and manage projects (and they will not take sensible advise from their suppliers). The right level of funding is therefore never committed. And no-one takes overall responsibility.
So things either never happen (because suppliers won’t accept rubbish contracts) or they go tits up (because what is specified either can’t be delivered at the agreed price or isn’t fit for purpose).
So it seems likely that this new project will either be stillborn or will fail within three years. And that is our money — our taxes — down the drain. Again!
Why is there no-one in government, the civil service or parliament with any teeth?

In a widely reported impending announcement David Cameron is allegedly to pledge £50m to fund 1000 GP surgeries (roughly 1 in 8) to open 0800-2000, 7 days a week. See for instance here.

Yes, these extended GP hours are something we, the patients, are asking for. And there is a need because currently there are people (just how many is really debatable) who can’t (for lots of reasons) go a GP appointment but unnecessarily clog up A&E.
But yet again the UK government has proved it doesn’t have a clue about how to actually run the NHS. Cameron doesn’t stand a hope in hell of achieving what he’s pledging, because $50m by my reckoning will pay for a quarter of that for just one year.
Here’s why …
Opening 8-20, 7 days will mean around an extra 34-40 hours a week to be covered. (It’s 34 hours if the practice is currently open 0800-1800, 5 days a week; and many aren’t.)
This means every GP practice which is going to extend their hours, as demanded will need to employ at least one extra full time equivalent GP.
And to cover the extra hours they will also need at least one full time extra member of reception/office staff.
Leaving aside where they are going to find all the suitable, spare GPs, let’s look at the cost. Here’s a very broad brush, back-of-envelope, estimate:
Assume that a GP costs the NHS £150K pa (that’s salary plus pension contributions, plus employers NI contributions, plus other benefits like holiday etc.).
Assume similarly that a full time trained receptionist costs £30K pa (again salary plus benefits package). (Yes you do need trained receptionists; medical work is not something anyone off the street can do, and certainly not safely.)
And then remember that the extra hours will also incur costs for heat, light, hot water and other services — let’s assume that’s £25 per week per practice.
Which means each practice would need funding of around £181K a year.
Dividing that into £50M would provide enough funding for around 275 practices, or about a quarter of what is proposed. And 275 practices is little more than 1 for each NHS area (CCG) in the country (by my count there are 211 of them in England).
So even if the “reorganisation” also provides 100% efficiency savings (which would be a world first!) that still means we’ll achieve only 50% of Cameron’s pledge.
So not only will Joe/Josette Public not realise that this may mean his/her GP isn’t open (and they have to go several miles across the borough to find the practice which is open — on a Sunday when there are no buses), but it is going to go nowhere near meeting Cameron’s pledge.
And that’s without all the fancy gizmos, like Skype video consultations, which are being promised. They have to be paid for too!
Oh and if you read the articles don’t be deceived by all the twaddle about the over 75s. That’s been in the plan for a long time; it isn’t new. Just as I suspect the £50m isn’t new money either.
How do we get these people to understand that healthcare is expensive, that the available funds are being misallocated and mismanaged, and that GP services are hugely underfunded compared with 10 years ago? Because they really don’t have a clue how to fix things.

As regular readers will know, transforming the NHS so that it can provide excellent healthcare to people in the UK at an affordable cost is something which has exercised my mind for a long time (see, for example, here and here). And I am involved, at a local level, in trying to help unlock this.
Now don’t get me wrong. Many parts of the NHS are excellent. In an emergency they generally work brilliantly, at least in the short-term. And many of the doctors and nurses care deeply about looking after the patients.

However whenever I walk into any NHS hospital, clinic or office** there are several things which immediately strike me:

• the obscene level of waste
• the absence of appearing professional
• the number of staff who seem to spend their lives wandering around doing little or nothing
• the appalling environment
• the apparent lack of both money and the will to put any of this right.

And that is despite the fact that the NHS should already have shed-loads of money to do everything we would want it to do if it used it wisely.
The other day I had to visit a local private hospital, and the contrast with the NHS was almost as stark as it has always been. No, it wasn’t perfect. For a start it was far too hot, but it was clean and looked professionally welcoming. Yes, there were plenty of staff around, and they all appeared to be doing something with a purpose. You had a degree of confidence that everyone knew what they were doing and why and that they cared about their patients.
This is more what the NHS should be like. But how to get there?
I keep thinking about this and here’s my three step plan for the paradigm shift which the NHS requires, from top to bottom.
Step 1. Get someone at the top who can successfully run a large, quality, profitable corporation and who is able and willing to tell the politicians to butt out and stay out. Someone like Richard Branson, or perhaps Alan Sugar (no, I don’t care that you dislike them; they’re good at what they do). Someone who will have a vision of how the organisation should be and will implement it regardless of push-back from any level — if you aren’t going to do the job, get out.
Step 2. Tackle the appalling level of waste. This includes finding efficiencies — improved ways of doing things — at all levels. And that means everything from reducing bloated layers of managers and administrators, through cupboards full of medical supplies which have to be thrown out because they go out of date while other departments can’t order the very same thing, to turning down the heating.
Yes, really! Turn the heating down! NHS hospitals, clinics and offices are always far too hot; when people who are usually cold tell me it’s too hot then you really are wasting money! Just this one thing could save the NHS millions.
And while you’re saving money, fix the buildings: even if you can’t build new hospitals (because of time, money or space) you can at least make the ones you have into a habitable environment. Fix the leaks etc. Stop the draughts. Buy some paint. Because they will save you even more money in the long run.
Do those two things and you will start to see a culture change. But to complete the paradigm shift you need to do something just as fundamental the the outlook and attitude of all the staff — from the most world renowned consultant surgeon to the lowest lavatory cleaner. So that means …
Step 3. Everyone needs to take on board four basic beliefs and habits:

1. Cherish the patients. They are why you are doing what you do. They’re not just important they are your whole raison d’être. They deserve the best.
2. Put yourself in the other person’s shoes, whether they’re a consultant, GP, patient, nurse, administrator or ancillary worker. Think what effect things will have on them. And then treat them as you would like to be treated.
3. Work as a single team. Everyone is equal but everyone has different skills. It doesn’t matter if you’re a patient, the most renowned surgeon or the ward cleaner, everyone has an important role which has to be valued as important to the patient’s recovery. (And part of that means valuing people and paying them decently.)
4. Be empowered. If it is right and needs doing, do it. This has to come from the top by giving everyone freedom (not bullying), and it has to come from the bottom with people grasping that freedom. Unless there is an over-riding reason not to do something, just do it.

No, I don’t pretend it will be easy. That’s why you need the right person, with the right attitude, at the top. Without that one person it will never work because the politicians will keep meddling and the all the vested interests will see the top as weak and keep playing their own games. And then the patient (remember him/her?) is forgotten.
Yes, initially there will be a lot of scepticism and probably a morale hit. But as time goes on, as it begins to work and people start to buy-in, morale will increase and you’ll win lots of crusaders.
But it will take time. I went through this in a multi-national corporation in the 1990s and it took the best part of a decade, lots of head-banging, a lot of people being retrained and several rounds of redundancies for those who couldn’t or wouldn’t adjust. So I’ve seen it done; I was looking up from the bottom wondering WTF was happening; after a couple of years the penny dropped and I too changed. I know it can be done.
So David Cameron and Jeremy Hunt, do you have the balls to do this?
I’m not holding my breath.
____________________
** This also applies to some GP surgeries although most are better as they are small stand-alone businesses which have to keep afloat.