Another Brick in the Wall

Parents' evening. A time to discuss your child's successes, failures, likes, dislikes and crucially, their potential. Alternatively you can drown the spark of educational enthusiasm in targets and performance measures. At one point my daughter's tutor went into a detailed explanation of the necessary sub-level improvement each child needs to make in their SATs. The aim is to show how a child's performance has improved, but we are mired in the details of sub-level data collection. What the measure can tell us about a child's performance is lost in the drive to list all schools in a league table.

The performance measure has become an end in itself. Education is being reduced to how far a child progresses up a scale, but only in as far as it helps the school. Once that level is reached on goes the parking brake, because the box has been ticked for that little darling.

For my daughter the necessity to show improvement has helped her Maths no end. She can dance through Maths problems, where previously it was a weary trudge to the wrong answer. English is her strong suit, so time to unlock her full potential? No, she's doing fine, but other kids need to be pulled up, so she can tread water. Especially as it is SATs year. All energy is focussed on getting enough points on the school board, and the children are a means to that end.

Teachers want to teach and the kids (mostly) want to learn, but we are hemming them both in through the need for teachers to understand how performance levels are measured and how many sub-levels each child has to pass through on the way to a good Ofsted report.

We need to get back to the goal of education, which I think is:

**Every child has the opportunity to realise his or her full potential.**

Victims

Politicians pontificate and shake their heads

Inquiries about inquiries are announced with a straight face

And still the victims wait for justice.

A grey faced middle aged man says he knew nothing 

Another grey faced middle aged man shuffles the chairs at the BBC

And still the victims wait for justice.

Every paper discusses the grey faced man

And what next for the BBC?

And still the victims wait for justice.

Other middle aged men continue to make decisions

About children and their welfare

More victims who will have to wait for justice?

Talent Costs

We are told that to have talent at the top of a bank or business costs a lot of money, but it is the best way to guarantee returns to shareholders and drive economic progress.  The revelations over the last few years of how business and media work, suggests that the system is now run completely for the benefit of the few who go to the top universities, work up through large corporations and award themselves huge pay settlements.  If these few choose the political route, then after setting in place light touch regulation and making the countries business friendly, they can walk into directorships at the very corporations that have benefited from such largesse. 

Now since the crash of 2008 we are propping up the banks and the ethical hole in the middle of the system has been exposed.  The system was about making returns for the holders of capital, if you look at the pension mis-selling, the insurance mis-selling, unsound mortgages, toxic derivatives, LIBOR fixing and loan mis-selling and even phone hacking, it points to a rotten ethos and culture of making as much money whilst you can at the expense of customers, shareholders, taxpayers et al.

The rotten foundations upon which the modern financial system seems to be based, are now being propped up by taxpayers to the tune of about £20,000 per household, that is the true cost of the talent we have running our banks and businesses.

Get A Grip

Lying bankers, politicians prostrating themselves before media companies, a double dip recession and the Bank of England shoving money into amoral banks as fast as it can print the stuff.  

What are the two most senior economic politicians in the country doing?  Indulging in a puerile slanging match about who said what to whom back in 2008.  Have they learnt nothing from the expenses scandal?  We don’t care who did what to whom, because almost NONE of them saw the financial crisis coming, and the rest were too busy sucking up to banks and big business in general, or switching their second home allowance to care.  So they are all culpable for the economic and ethical mess we find ourselves in.  None of our political leaders have shown the clear or rational thoughts and ideas necessary to start to rebuild the economy, let alone the ethical foundation of our political establishment.

We do need a forensic review of what happened to our banking industry, but that is a big question to answer.  A parliamentary inquiry will achieve very little if our Chancellor and his Shadow can’t even say “Good morning” to each other without throwing accusations across the corridor at the same time.

Our politicians are showing small minded, petty, dogmatic thinking at a time when objective, forensic and rational thought is required.

Trouble is the only person in the country who seems capable of doing that is currently busy making our politicians and media people look even shiftier than usual.

May I add to the clamour “Robert Jay for PM?”

Ethos vs Mechanics

 The recent NHS reforms have been accompanied by the mantra that services will continue to be free at the point of delivery. So that's alright then, well actually no. The key ethos of the NHS is that it is available to everyone when they need it. Being free at the point of delivery is only the corollary of this ethos. I pay for breakdown cover and, if my car packs up, I get towed home with no payment. The service is free at the point of delivery, but I only get the service I have paid for.

Introducing more private provision into the NHS weakens the underlying ethos of care being available when needed, because the driving force behind a company is to generate profit. There are plenty of examples where private companies have not put their customers first (insurance and pension mis-selling, Southern Cross care homes, breast implants).

The biggest issue is not necessarily that things go wrong, public organisations can provide poor service as well, but how quickly issues are put right. Private companies will fight to protect their profits (it's their reason for being after all), look at how long it took for the insurance companies and banks to admit liability over the mis-selling of various products. In the case of the breast surgery the main providers of the PIP implants have refused to carry out corrective surgery and the NHS has acted as the safety net. When things go wrong in the public sector, the politicians have more power to take corrective action.

The NHS is far from perfect and includes perverse incentives (too many targets, an obsession with structural change), but the ethos is that the patient should come first. For private companies that will only be the case whilst the patient generates a profit. The argument over how the NHS functions masks the real focus which should be on why the NHS exists – to provide healthcare to all. The only questions we should ask are:

1. What is the best thing for the patient?
2. How do we allow staff to deliver that care most effectively?

The market can generate innovation and necessary change, but it cannot ensure everyone gets the healthcare they need, when they need it.

Keep It Clinical

Saving money in the NHS is an age old problem. Even when there was money to spend there was still a cost improvement/efficiency/saving programme in operation somewhere in each organisation. The usual national approach to this conundrum is:

1. Promise to give more power over funding to Doctors (usually G.P.s).
2. Give lots of money to management consultants in sharp (expensive) suits to help the existing managers to find more savings.
3. Re-organise the bureaucracy by giving NHS bodies different names, so:
   1. Regional Health Authorities became Regional Offices, which became Strategic Health Authorities, and now they become Commissioning Boards
   2. Health Authorities became Primary Care Groups, which became Primary Care Trusts and now they will be Clinical Commissioning Groups

But despite all this heroic structural change people still get sick and medical technology continues to advance, and spending goes on rising. Putting G.P back-sides on the re-arranged chairs around the meeting table makes very little difference to the cost or type of services provided.

The way to reduce spending is to block book real expensive hotels a week at a time and make sure you put plenty of money behind the bar. Not to send the poor managers clutching their P45s on one last beano, but to gather the local clinicians together so they can really change services.

Put representatives of all the clinicians involved in caring for a particular patient group in a nice hotel a long with some high class...facilitators and give them a week to re-design how the patients receive their care and treatment. Let them at the A La Carte menu, and give them a free bar, the only provisos are that the result of the week's deliberations must be the most effective and practical care pathway they can devise in 5 days (or you send them the hotel bill) and no-one can mention money. You will not get an effective pathway if everyone is worrying about the money.

Rather than getting clinicians to play at being budget managers you will have them together where they can focus on designing the best way to care for their patients. With free reign of the facilities and the alcohol they will relax,which will allow everyone involved to have their say. This is not a new idea, the Persians would only finally agree on a battle plan if they all agreed on it whilst drunk. Hopefully our care givers will not plot to over-turn Western democracy under the guise of redesigning the Diabetes pathway. Instead, given the space and time to talk about their favourite subject, they will come up with radical change.

The other thing this radical change will do is save money. The most effective pathways will make sure the patient is seen by the right clinician at the right time more often, reducing duplication and waste which will save money.

So dig out the hotel directories and get booking.

The £20bn Question

The NHS has to find £20bn worth of savings over the next 3 or 4 years.  So everyone is asking how you save what is, even to an investment banker, a large sum of money.  Whatever way is chosen will have to lead to services being provided in radically different ways, as the savings target is so large.

I can think of two ways to find £20billion:

1)             Ask every member of staff in the NHS to look down the back of their sofa.  This would need an average of £20,000 per sofa; which is unlikely unless lots of staff are all living with senior banking executives.

2)             Increase car parking charges at every NHS property.  This would lead to hourly charges equivalent to the weekly wage of an average senior banking executive.

Or there is the Government’s preferred option:

3)             Give 80% of the NHS budget to GPs without formal training in budgetary control and cross your fingers.

1) &  2) are very unlikely to find you £20bn

Certainly 3) is better than either of the first two options, but not really a sound basis for reducing expenditure by 4% per year for the next 3 years.  As we have seen recently, GPs are not keen on being the Government's human shield when it comes to deciding where to cut budgets. 

It would be surprising if students queue up on their first day at Medical School and decide, “I’ll skip basic anatomy this term and take an introductory course on ‘Budgetary Techniques for Managing Cross Programme Finances’ instead.  After years of training in the medical sciences you can see why GPs are not keen to fill their diaries with contract meetings or spend time analysing over-complicated financial spreadsheets.

The taxpayer has spent a lot of money training doctors, nurses, radiographers, physiotherapists, social workers etc.  We then want them, and in this case specifically GPs, to work out how to save £20bn.  That is the wrong use of their training.  We should get them all to answer a completely different question:

What sort of health services do we want to provide in 3 or 4 years’ time?

That is a pretty big question and also one that all of our highly trained clinicians should be equipped to answer, if they can work together on the solution.  What we don’t need to do is throw finance in the mix as well, certainly not at the start of the process.  If you make money the question, you will get an answer that is built around spreadsheets and financial analysis, not one focussed on patient care.

We have a market structure in the NHS – Primary Care Trusts (soon to be GPs) buy services and hospitals, community services and mental health trusts provide care.   With any market you have the need to compete, so if you tell all these organisations that in effect the market has just got smaller (by £20bn), then Primary Care Trusts will try and buy less from the providers who will fight to maintain their income levels as best they can.  Organisations defending their budgets are unlikely to generate innovative solutions to the question of how we provide patient care.  We need to accept that the NHS does not act like a proper market. I can't pop into town and see if one GP will sell me their services cheaper or offer more frills than their opposite number across the road.  You can't get your hip replacement cheaper in Croydon than in Crawley.

We need to get clinicians out from behind the organisational walls and talking as equals about what is the best way to provide patient care.  You need to involve all shades of clinical and social care disciplines, otherwise the debate will be unbalanced.

Time to ask clinicians the question they are trained to answer, you never know it may unearth the £20bn we are looking for.

Next step how we get all the clinicians in one place….