 | | |
| Quote: http://www.theguardian.com/commentisfree/2013/aug/08/nhs-market-impossible-expecations The NHS will fail us so long as we look on it as a market The latest report on the lessons to be learned from the Mid Staffordshire hospital scandal begins with a statement of mind-boggling banality. The NHS, writes the report's author, Don Berwick – a Harvard paediatrician and adviser to presidents Clinton and Obama – should "place the quality of patient care, especially patient safety, above all other aims". Yes indeed, and the clue should be in the name. What other aims could a "health service" possibly pursue? That the core mission of the NHS should need re-stating in this fashion by an American – alongside other platitudes, such as it being better if "pride and joy", not fear, "infuse" the workforce – is an indictment of political leaders of all parties during the past 30 years. Politicians have saddled the NHS and other public services with impossible expectations. They promise perfection and, when it is not achieved, decide that more reorganisation, more competition, more centrally determined targets, more consumer choice and more private-sector input are required. Tony Blair said "monolithic provision" in the public sector should end, so people got individual services at a time of their choosing from doctors and teachers. This goal is beyond most providers of gas, electricity, broadband and cable TV. Now David Cameron demands "zero harm" in the NHS for which, with the tact of a man accustomed to dealing with politicians, Berwick gently chides him. The scientifically correct goal, he says, is "continual reduction". The battle for patient safety, he points out, is never "won". Since it isn't always clear why someone is sick or what treatment will make them well, healthcare is bound to involve risk, as does everything else in life. The NHS is, above all, a triumph of old Labour collectivism. The health policy pundit Rudolf Klein called it "the only service organised around an ethical imperative". Aneurin Bevan himself thought it made society "more wholesome, more serene, and spiritually healthier". Collectivism came naturally to people who had emerged from a devastating war that required patience, stoicism and personal sacrifice for the common good. It sits uneasily with a world of instant gratification, consumer power and demands that every service offer "value for money". In striving too hard to adapt the NHS to that world, politicians have lost sight of its central objectives. Two things have contributed to the loss of focus in the NHS and the sense that it is always in crisis. The first is cash limits. Until the mid-70s, governments planned staffing, equipment and other resources around estimates of need, and found the money accordingly. Then public resistance to high taxation alongside exponential increases in costs of treatment – caused partly by medical advances, partly by rising longevity, partly by growing public intolerance of even minor ailments – demanded more rigid control of budgets. Almost every top-down reorganisation of the NHS has been driven not by patients' needs but by the imperative to control costs. Choice, competition and outsourcing to the private sector, according to some opinions, improve medical outcomes. But that has not been at the forefront of politicians' minds, nor the minds of managers running the services. Their priorities have been to keep costs down. The second problem is the drive to reduce and even abolish waiting times. On the NHS's first day, some doctors barricaded themselves in their offices, expecting an overwhelming rush for free treatment. Patients simply formed an orderly queue. Waiting is integral to the NHS. Medical care is a scarce resource and, when not rationed by price, must be rationed by queueing. But time being the most precious of commodities to the 21st-century consumer, waiting is regarded as intolerable. Politicians, therefore, promise to bring down waiting times, which provide tangible measures of performance not only for Whitehall bureaucrats and NHS managers but also for NHS patients who, lacking sufficient knowledge to assess the quality of medical treatment, tend to judge it by how long they have to wait for it. The focus thus switches from quality of care to the speed at which it is delivered. It is in trying to cope with those competing demands – for whatever treatment the patient demands at maximum speed but within budget – that politicians have lost their way. Managers, as always, pass the problem downwards. Fewer staff are told to provide more at lower cost. They are monitored and harassed. Managers' focus shifts from patients' needs to control of staff. Staff focus shifts from care of patients to keeping managers off their backs. If staff fail, they must be lazy or incompetent. If they convey bad news – resources are insufficient to achieve a certain goal, cost-cutting is endangering patients – they must lack corporate loyalty and commitment. That is the blame culture that Berwick identifies in the NHS. At the root of it all is a category error. Public services, free at the point of use, cannot work as goods and services offered through the private sector market do. They provide to all at low public cost what would otherwise be available only to some at high private cost. Treating everybody alike, rich or poor, powerful or not, is what they are supposed to do. Nobody expects a bus to turn up at a time of their choosing as a privately ordered taxi would. You can always get a porter in a posh hotel, because it will have several standing around doing nothing – reflected in the hotel's prices and expected tips. Taxpayers cannot support similar slack in the NHS or education. To suggest they can is to raise expectations that cannot be met, and to demoralise medical staff or schoolteachers. The first duty of the NHS is to make patients well – or, at least, less sick – not to pander to "consumer preferences". Almost all would settle for that, just as most parents would sacrifice school choice for a decent school in their neighbourhood. The miracle is that Berwick's report can conclude that the NHS is not "unsound in its core". The vast majority of staff, clinical and non-clinical, are dedicated to helping their patients, he says. And in a passage that I do not expect to be quoted in any ministerial speech or the Daily Mail, he writes: "Leaders and opinion formers … (including national and local media … ) have a crucial role to play in shaping a positive culture." In other words, instead of abusing staff for their failure to meet impossible goals, politicians and commentators should support them in restoring the true aims of equitable public service. | |
| | |
