Recently I’ve been looking at the NHS as an outsider and a user. This has led me to think about the organisation, it’s shortcomings and whether anything really can be done to improve it.

The Health Service is something that we all want, and for which we all pay taxes. So we expect that when we need it not only will it be there, free at the point of use, but we will get the best possible treatment, speedily, in a good environment, from professional people and a professional organisation.

Sadly one or more of those elements are nearly always lacking, often conspiring to make patient care less than optimal.

Don’t get me wrong. Many parts of the health service are excellent. And in an emergency they generally work brilliantly, at least in the short-term.

Recently Noreen and I attended a Patient Participation Group which our GP practice has started. Everyone there was self-selected and had volunteered; they were not “yes men” hand-picked by the practice. And everyone there had nothing but praise for our excellent GPs, nurses and admin/reception staff — indeed we found it quite difficult to come up with anything major we thought they needed to improve. The only significant thing we homed in on for improvement was some of communicating with the body of patients as a whole. But our doctors are lucky; they have excellent staff throughout the practice and new-ish purpose-built accommodation. Nevertheless they are now short of space to do all the things they want to do.

Many parts of the Health Service are not so lucky. Visit the average NHS hospital and you’ll find a run-down building containing a large number of staff many of whom (especially at the lower levels) appear poorly paid, poorly trained, poorly managed and demotivated, giving off an air of being oppressed and disinterested. One suspects there may also be bullying by both management and unions. They seem ground down and struggling to do a good job against a background of inefficiency, waste and the awfulness of the people (mostly patients!) they have to deal with.

And that’s a two way thing. Staff (and an organisation) that don’t care about patients encourage patients to not care about how they treat the staff.

This has to lead to an attitude of unprofessionalism. As an example I am continually horrified by the awfulness of the communications I receive from all parts of the NHS. They are written in poor English (GOK what their Gujarati translations are like!); poorly typed; poorly designed; poorly printed. One recent letter I received was offset such that the right hand edge of the text was missing, it was faintly printed, poorly worded and covered in printed-on splodges of toner. It looked slapdash and unprofessional; the work of a not very careful 10-year-old. Frankly I would have been ashamed to even put it in my rubbish bin, let alone send it to anyone. And yet this was an important communication.

Go to a private hospital and you generally find exactly the opposite of all this: personable, helpful, interested, caring and motivated staff at all levels and good communication.

Why does the NHS have to be this way?

The simple answer is that it doesn’t.

Whilst bringing the whole of the NHS up to the standards of the best private hospitals may be neither achievable nor affordable, it should be possible to achieve a 500% improvement. (And this doesn’t mean US-style healthcare where one has to pay for everything or go without.) It won’t be easy; but if there’s a will I believe it could be done. In broad terms this is how I see it being done …

• The NHS always maintains it is short of money. It isn’t; it has shedloads of money to do everything it should (and we want it to) sensibly do. But …
• It also has too many meaningless, politically imposed, targets.
• In consequence there are also far too many managers.
• It probably also has too many (non-productive) admin staff. There always seem to be lots of people walking about carry pieces of paper but apparently doing little else. I’m not saying they are all unnecessary, but does anyone really know?
• On top of this there appears to be an especially corrosive and pervasive culture; a culture of mistrust and of doing the minimum necessary; a culture which generates unprofessionalism and a couldn’t-care-less attitude.

So what can/should we do about it?

• Well first of all there has to be a real will to do something and act sensibly, not just out of short-term political expediency or protecting one’s backside.
• Then the budget has to be maintained at least at current levels, in real terms.



• In doing that there has to be a vast improvement in cost control (yes, drug spend does need to be monitored, but hopefully not rationed), which means good stock control and the reduction of waste.
• Scrap all but the most essential of targets and have what targets there are set by the clinicians for it is they who really understand what the patient needs. One target which must remain is to ensure the service is the same across the whole country; there must be no postcode lottery.
• That should mean a reduction in the number of managers required, which will free large sums of otherwise non-productive money for patient care.
• Then we need to look very critically at the number of non-clinical, non-managerial staff required. Reductions, where sensible, should be achievable by streamlining much of the (still largely paper-based) admin. That doesn’t mean an all-singing-all-dancing ginormous IT system; it means a large dose of analysing what really happens, what needs to happen and lots of common sense.
• Much of all of this can be achieved by empowering all NHS staff to make the right decisions for the patients (both individually and collectively), empowering the staff to help improve their environment (why shouldn’t they repaint a wall or fix a door handle? — they’d do it at home!) and take pride in what they do.
• All of this will only happen with a major change in culture to one which cherishes and values both the employees and the patients; a culture in which the staff treat the patients (and each other) as they would wish to be treated themselves. That has to start at the top: the top of each hospital/practice and the top of the NHS, ie. with the politicians and Civil Servants. Lip service won’t do; management have to demonstrate that they mean what they say. It also needs the staff — and the unions — to engage with, and believe in, the process and have an element of trust in it.

None of this will be easy. I’ve worked in an organisation where it has been done. It is difficult, painful and takes time. It needs a determination from everyone to make it work. Heads will have to be banged together. It almost certainly means shedding staff: if nothing else the non-believers have to be encouraged to change or move elsewhere — for their good and that of the organisation. It needs good, no-nonsense, management at the top; management with a long-term vision, a determination to make the right things happen and the charisma/skills to be able to fully engage with their staff at all levels. It also needs the unions to be willing to embrace the change (or be sidelined).

What is not needed is what we currently have: short-termism, poor management, bullying and continual change driven b
y political expediency.

Someone has to get a grip. Sadly I don’t see who that someone is.