Features

How to fix the NHS: a doctor's prescription

Competition – and ideology – isn't working

18 October 2014

9:00 AM

18 October 2014

9:00 AM

I’m a doctor, and I don’t care about the NHS. In this country, that’s an almost heretical statement — but it’s true. What I mean is that I have absolutely no interest in ensuring its survival simply because it’s a great national treasure. What I care about is making sure that we have the best possible and most cost-effective healthcare system. And as it happens, despite the strikes, panic and doom-mongering, I think the NHS — by which I mean a nationalised healthcare model — is the best option available, if only someone were brave enough to make the right changes in the right way.

Don’t expect this government to try. Senior cabinet ministers said this week that their attempt to reform the NHS (which culminated in the 2012 NHS Health and Social Care Act) was their ‘biggest mistake since coming to power’. As angry, beleaguered nurses and frontline staff begin striking, there is a cross-party consensus that the NHS can’t be touched: it’s just too toxic politically. So instead of making amends for the former health secretary Andrew Lansley’s botched attempts at reform, Cameron decided he’d rather ‘park’ the issue. That’s like a surgeon splaying open the patient, then realising he’s made a mistake and just walking away from the operation with a nonchalant shrug. The NHS has been left haemorrhaging on the table. Sorry, but that’s not good enough — there’s lots that could and should be done.

The Commonwealth Fund survey, which uses a range of measures to analyse healthcare systems around the world, has consistently found that the NHS is one of the best. But the attempts — first by the Labour government and then subsequently the coalition — to introduce more efficiency through competition have in fact meant an explosion of expensive bureaucracy. It’s quite clear that the more providers of healthcare there are in the system, the less efficient it becomes, and the risk of duplication, confusion and misunderstanding grows. I see this day in and day out in my own practice.

Research conducted by the NHS Confederation showed that clinical staff spend up to ten hours a week collecting or checking data — more than a quarter of their average week. It also shows that more than one third of that work was neither useful nor relevant to patient care. I frequently feel I am drowning in forms that demand to be completed, statistics that need to be gathered and boxes that need to be ticked. Every clinician I know feels the same. I work in a hospital providing tertiary care to people with complex mental health problems. I typically see patients for 30 minutes to an hour. For every patient I see, I have at least one hour of paperwork to do. Some of this has a clear benefit to the patient — for example, I write detailed letters to the GPs, providing in-depth history and giving plans. But the letters are only a small part of the paperwork. A manager pulled me aside to explain that if I don’t complete some forms, the service doesn’t get paid.

If it’s bad for doctors, it’s worse for nurses. Every admission triggers an avalanche of forms to fill. How have we got to the state in which, according to research by the Royal College of Nursing (RCN), the amount of time nurses spend away from patients, on non-essential paperwork, has doubled since 2008, with 2.5 million hours lost a week?

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Entire departments have sprung up in hospitals of managers writing bids and business cases to ensure that their department can compete in the internal market, instead of worrying about the quality of the service being given. It’s not cost-effective and it’s not good for patients. But the coalition doesn’t dare go back to the problem it created. The current political mindset is that further NHS reforms would be a vote-loser.

So what can be done to save the healthcare system from the wreck that the government has created? While it may be painful for those who are ideologically wed to the free market, there is no evidence of significant benefit to support the wholesale introduction of competition within national healthcare systems. Similarly, the tortuous, labyrinthine bureaucracy of commissioning, which sees NHS services being delivered by a host of different providers, all of whom must compete for business and contracts, must be brought to an end. It is grossly wasteful and drains resources, time, money and manpower and has no demonstrable benefit. The tendering process for contracts needs to be stopped and services brought in-house, so that healthcare services are provided by the NHS. That doesn’t mean that there must be no private involvement, far from it, but private companies must support the NHS, not the other way around.

We also need to centralise all the debt accrued by the private finance initiative (PFI), the absurd public-private partnerships that proved very profitable for a few companies but utterly disastrous for the public purse. Labour essentially sold off the family silver and we’ll never get back many of the buildings, resources and land that we gave to the private sector under ludicrously in-equitable terms. Sadly, there’s not much we can do about that now. We have to cut our losses and get out of these PFI deals.

The internal market model was brought in to answer concerns about ensuring innovation and quality within the service, and these remain vitally important areas to address. We need to adopt a value-based outcome model across the NHS. This idea, developed by Professor Michael Porter at Harvard Business School, may sound dry, but in fact it offers a clear way of assessing how much value for money each service provides. It is not based on targets set by politicians, but on what is important for patients. Porter’s team is in the process of developing a list of the most important outcome measures for all major conditions and treatments. So rather than slapping a blanket four-hour turn-around target on everyone coming into A&E with chest pain, hospitals can try to measure the time it takes to reduce that pain, or how long it took to carry out heart imaging to assess the seriousness of the condition.

By using specific, internationally agreed and academically validated measures for treatments or interventions, we can ensure we are properly comparing like with like. We can then quickly and easily analyse what trusts are getting right or wrong, and see which ones are doing things well.

The answer is not just to pump more money into the NHS. Again, the evidence suggests this doesn’t help unless the funds are highly targeted. There is a good argument for raising health spending so that it is in line with the spending of most other European countries, but that needs to be done with very clear objectives in mind. Increased spending on prevention and primary care makes sense. We should be spending a lot more on mental health, too. Where I work, the waiting list to have psychotherapy for an eating disorder — a condition which carries a mortality rate of 25 per cent — is more than two years. How is that acceptable?

More generally, we need to educate the British public about the cost of the service, drugs and treatments that they receive. I suggest that, as well as a national campaign to tell people precisely how much that course of antibiotics they didn’t bother finishing actually cost the taxpayer, they should also be sent an automatic message when they miss an appointment, telling them how much money has been wasted and the impact it has had on waiting times. Some trusts already do this, but it should happen everywhere. The suggestion that we charge for missed appointments will only lead to more administration, form-filling and litigation. It’s easier to use social pressures than punitive measures. ‘Nudge’ theory has worked well in other areas — such as tax collection — so we should apply it to the NHS as well.

An evidence-based healthcare system would be painful for politicians, because it would require them to put aside their ideologies. But the medical profession has had to embrace evidence-based practice, and although it was hard at first and doctors resisted because they felt comfortable in their old ways, the result was that patients have benefited enormously. Now it’s time for the politicians to take the same medicine.

Dr Max Pemberton is editor of Spectator Health, which has regular online coverage at blogs.new.spectator.co.uk/spectator-surgery

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Show comments
  • Doogal

    Yes, we need to measure the performance of the NHS with clinical outcomes. But “how long it took to carry out heart imaging to assess the seriousness of the condition” is not a clinical outcome. Further, the “value-based” outcome model comes up against the tricky problem of working out how much a treatment episode or procedure costs. This is more difficult than one thinks. In fact, the “armies of managers” currently employed by the faux-market would be needed to work this out.

    Let’s stick to simple, clinical outcomes that cannot be “gamed”. A measure ceases to be a useful measure as soon as it becomes a target (Goodhart’s law).

  • John Smith

    We need much more application of Behavioural safety, human factors in the NHS To stop the rash of Midstaffs, ABMU Wales being that latest one

  • Crag Face

    In total agreement.

    In 2001 had to leave the health services on the grounds of ill health after struggling for 18 months with over 86 patients in my care as a community mental health nurse, instead of the 15-20 I was supposed to have. This was due to the sudden influx of client referrals allowed from any source (including GP’s) directly to the CPN service, and the nursing process which increased paperwork beyond reasonable levels.

    I am old fashioned but the best working model we had was the iron rule of matron!

    • Terry Field

      Spankes eh? Now we understand your inner motivation – those nutcracker thighs and sever looks! Whooppeee.

    • red2black

      If ‘the iron rule of matron’ as you call it, applied from senior management all the way down to the ‘front line’, perhaps the NHS would be in far better shape than it is at the moment.

  • Mc

    “… a nationalised healthcare model — is the best option available, if only someone were brave enough to make the right changes in the right way.”

    In nationalized systems as complex as the NHS, the right changes will never be made. While privatized healthcare systems are imperfect, their key strength is that if they get things badly wrong for too long, they close down. Whereas in a nationalized system, the cost of their errors are passed on to the taxpayer.

    • Liberty

      Much of the admin can now be automated. For example. When a patient is referred to hospital the GP can log on to the hospital site and enter all relevant details and be allocated a time, to whom, admin has access to the same data, hotel services and reception readied.

      On entry, the patients identity is confirmed and the entry activated, medical, hotel and admin staff readied and can manage their days which was pre-prepared because the patient had been on the books since the gp put him/her there. All this can be on a hospital cloud based system so that all know the same info at the same time.

      Relevant data can be accessed locally, regionally and nationally and planning eased and all in real time

      Paper based collection of data should be eliminated as far and as soon as possible. All mobile staff should have a notebook computer only for data entry and information.

  • beenzrgud

    I have a relative who is a senior nurse at a large hospital, and about 10 years ago I asked about all the money being spent in the NHS. She said the only difference she had noticed was that there was now a shiny new admin building with lots of nice cars outside. This tends to back up the assertions of Mr Pemberton. On the other hand my personal experiences of the NHS have been very poor indeed, and can generally be summarized as doctors and nurses appearing to have little interest in their patients. It also doesn’t help that £billions is wasted because of mistakes that have to be paid for. I suspect that blame for poor performance can be laid squarely on all sides, the medical staff, managers, and the government, none of whom appear to live in the real world.

    • HJ777

      Derek Wanless, in a follow-up report in 2007 commissioned by the King’s Fund on how all the extra money he recommended in his original report for the government had been spent, concluded that over 40% had gone on higher salaries for existing staff.

      • beenzrgud

        I know that my relative was very well paid, although she didn’t think she was. She has recently taken early retirement but still does the odd shift for which she actually gets paid a lot more per day than when she was full time. All I can think is that virtually everyone connected with the public sector seems to think that money grows on trees.

        • HJ777

          Yes, my experience of people who work in the public sector is that they think that private sector workers are generally paid far more than they actually are.

          What is more, most of the public think that public sector workers are paid far less than they actually are. Nurses are a case in point. Most people think that they start at less than £20k, whereas even a newly-qualified nurse outside London gets nearly £22k basic (before overtime and other allowances) and the average nurse gets around 50% more than that. Nurses don’t even have to pay back tuition fees, unlike nearly all other students.

        • Terry Field

          Nurses have ipod apps that let them fix up drips with drips remotely from their sun-loungers on Eyebither. It’s tru! I read it in ‘The Moon’! (good, eh, Sun, Moon!)

      • Terry Field

        Exactly what one would expect from a Labour ‘government’ giving to centrally unionised soviet-type healthcare structure.

        • red2black

          A ‘soviet-type’ structure, as in where the unions act as a police force for management, and strikes are illegal?

          • Terry Field

            No, silly fellow, a system where asset control is state managed. assets are owned and supplied/planned by the State, the staff , doctors, consultants, etc are quantity controlled via the University system with quotas, etc, and where finance is cash-controlled from central precepts. A system therefore that is a queuing system. A system unresponsive to individual need, universally moderated by universal application of ‘group’ or ‘population’ standards and ‘protocols’.The staff are subject to national central pay systems, nationally unionised, nationally employed in large measure, and private supply is inconsequential. About as Soviet one can get. Bloody obvious really. Brezhnev would have designed this sort of codswallop.

          • red2black

            People object to private healthcare because making a profit is seen to be considered more important than the care being provided. People of almost all political persuasions believe that the principle of treatment when needed, regardless of personal circumstances, is very important.

    • Terry Field

      Pemberton is on Planet Tharg!

  • HJ777

    The problem with most UK medics, like Max Pemberton , is that they pontificate having had precisely no experience of work outside a nationalised system. That is one of the problems – we do not have people working within the medical system with a variety of views and experiences gleaned from working for different competing suppliers such as in private industry.

    He says: “The Commonwealth Fund survey, which uses a range of measures to analyse healthcare systems around the world, has consistently found that the NHS is one of the best.”

    This is a very selective view, to say the least. For a start, The Commonwealth Fund only compares 11 countries. What is more, it uses largely subjective assessments and does not look at any hard data comparing medical outcomes. It looks at things it thinks are important, but does not explain how these relate to the quality of medical services. Much of its inputs comes from the people providing the services, not from the users. It also has an agenda – the CEO of the NHS is on its board.

    More objective and detailed analyses, such as The OECD’s and the EHCI rank the NHS very poorly for performance and efficiency.

    http://www.oecd.org/eco/healthcaresystemsefficiencyandpolicysettings.htm

    “About average spending per capita”

    “The quantity and quality of health care services remain lower than the OECD average while compensation [pay] levels are higher.”

    http://www.healthpowerhouse.com/files/ehci-2013/ehci-2013-uk.pdf

    “The NHS urgently needs further reform if it is to match the services offered by Western Europe’s leading health systems. Both English and Scottish healthcare provision lags behind the performance of most Western European countries. The two UK systems sit ahead of the former Central and Eastern European countries but languish behind most Western European countries. Only those countries hit hard by the financial crisis – Italy, Spain, Greece, Ireland, Portugal and Cyprus – performed worse. These were the findings of an annual study published today, the Euro Health Consumer Index (EHCI) 2013, examining the performance of 35 national healthcare systems in Europe.”

    • beenzrgud

      Having had lots of experience of both the NHS and the health service in France I can say that the approach in France is a lot different to that in the UK. In the UK there seems to be a reluctance on the part of GPs to order tests in order to confirm a diagnosis. In France it’s the first thing they do. The upshot is that ailments can go on for years in the UK, never getting to the bottom of what the root cause is. This must end up costing a lot more in the long run than getting the tests done and sorting the problem out straight away. Incidentally I once ended up going private in the UK, just to get things moving a bit quicker, and whilst the consultant definitely behaved like he had a bit more time for me the nurses still seemed a bit off hand. Maybe there is something lacking in the training in the UK. Nowadays I always avoid the NHS if possible and use the French health service instead.

      • Terry Field

        I agree, I use the French, Dutch and American systems; all, EVEN the American, are much more careful, thorough and systematic than my experience of the chaotic NHS. In particular, the French system does exactly as you say – the GP and specialists treat first, count the cost not at all – that is a social decision to pay that is ALWAYS accepted.
        GPs in the UK are partly motivated to manage access – monstrous and evil.

        • Lydia Robinson

          “GPs in the UK are partly motivated to manage access”

          A GP practice is, essentially, a small business which is given largesse by the Government. This is why GPs act more like petty penny pinching accountants than doctors.

          • Terry Field

            I was trying to soften the criticism, but you are quite correct – the practices are stuffed full of conflicts of interest. Also, whilst we are on the subject of GPs, go and ask yours if the partners own the practices building, whether it was extended by state NHS funds via the then ‘health authorities’, and if the practices were given to the partnership. Furthermore, ask if the practice is or was in receipt if an open market rental subsidy for the value of the practice rental, irrespective of whether the ‘partners’ own the facilities; ask then if their proportion of the practice can be, and is, transferred for value to the incoming new partners?
            His or her indulgent smile may turn into a rictus when you ask that!

      • Terry Field

        I have extensive experience of NHS nurses. NOT a favourable impression, sadly. They think they are great; lucky them.

      • Lydia Robinson

        “In the UK there seems to be a reluctance on the part of GPs to order
        tests in order to confirm a diagnosis. In France it’s the first thing
        they do” Spot on. In private practice here they follow the same approach. The game with the NHS GP is to wait and see if it clears up and shoo the patient out of the door as quickly as possible. The onus is then on the patient to go back and fight their corner if symptoms persist. Unfortunately, not all patients are vocal or pushy enough to do that or they may be feeling too unwell to do so. I have been stonewalled by NHS GPs on various occasions now and have chosen to go private.

        • red2black

          I agree with what you say as regards some GPs, having been ‘stonewalled’ myself, which left me stunned. Even so, like millions of other people, I’m not wealthy enough to go private. If anyone tries to remove the core principle of the NHS, whatever the problems caused by it may be, they’re likely to end up with another ‘Poll Tax’ situation on their hands. Also, the way successive governments have allowed private drug companies to continue ripping off the NHS is unforgivable.

        • post_x_it

          Have you managed to find a decent private GP service? The ones in London seem to be mostly staffed by 25-year-old South Africans with very limited knowledge or initiative. They have swanky premises and appointments within an hour of calling, but I wouldn’t trust them with anything complicated.

          • Lydia Robinson

            I’ve been going to the same one in Harley Street for 10 years, run by very experienced doctors.

    • Terry Field

      And look at the value the ‘commonwealth fund’ gives to cheapness!

  • Hole_in_One

    The main problem is that almost the entire debate is supply-side based. Until we manage demand side with hard choices, the poor old NHS is on a hiding to nothing. Rampant antibiotics issue is a case in point, but I’m sure we can all identify other examples. Bottom line is that managing such a large undertaking must mean making choices, some of which may be unpalatable, but most other industries focus their activities where most impact can be made rather than “free everything at the point of delivery”.

  • http://ukip.com ukipifyouwantto

    ah the commonwealth fund. did you mention that the head of the NHS is on the board?

    if you spend time in an NHS hospital in 2014 (being this year), you’ll be staggered by the amount of literal paperwork. None of your fancypants computers here! Nurses carefully copying patient temperature data onto a little paper graph, like it’s 1945.

    NHS reform is a vote loser because Labour decreed that it shall be thus. Labour will twist any tory policy into an attempt to privatise the NHS, because Labour has spotted the NHS as the one wedge issue where they have a lead over tories. That is all.

    • Terry Field

      The report is not even-handed – it is propaganda

  • Terry Field

    “sure that we have the best possible and most cost-effective healthcare system. And as it happens, despite the strikes, panic and doom-mongering, I think the NHS — by which I mean a nationalised healthcare model — is the best option available, if only someone were brave enough to make the right changes in the right way.”

    What a seriously blinkered and stupid article, by a man clearly utterly out of his depth.He is long on arrogance; VERY short on world experience; a little local bloke dressed up.

    The NHS is at present simply a bad attempt to provide universal supply to all citizens; he attaches the word ‘nationalised’ with no justification, except by reference to a prejudice for ‘State good, private bad’

    Cretinous and untrue. No doubt the religion of the NHS will propel the Labour Party to power and the soviet style system will sputter on, will further degrade, will look and and be even more dangerous when compared to the best in the world – where systems are not ‘nationalised’, where massive capacity is privately supplied and fully integrated, and where a universal insurance hybrid / general taxation system provides usage and performance discipline unknown in the NHS and where out-turns are in many instances incomparably better than the ‘nationalised’ NHS.

    He refers to this government having wrecked the NHS.

    The system is far too large to be affected is a short number of years; it was a wreck that maltreated and often- as we have seen in recent years PRE coalition, – KILLED huge numbers. Its attitude to treating people over 75 has long been monstrous and plain evil – well before Brown became PM, let alone after Cameron arrived on the scene.

    Its service standards are dreadful and most of Blair’s financial incontinence went to the salaries and pension commitments of the ‘heroic’ staff.

    Is this stupid man a retard – is he unaware that ‘the ‘ Labour were going to fund the NHS MUCH LESS than the coalition? Dos he not recall the rigged market Labour introduced to favour private bidders? Does he think it is smart for a system to have no concept of, or record of, the costs of procedures and activities.

    Only a man protected from reality and living in a medicobubble could write like this

    His ludicrous, naive, doctrinaire, political little article proves why medicos should be nowhere near designing a health care system. Managing doctors has been described as herding cats (unionised ones at that) – and he certainly is a moth-eaten old moggie

    He then says

    “More generally, we need to educate the British public about the cost of the service, drugs and treatments that they receive”.

    Typical attitude of a Soviet minded would-be ‘manager’ in a cash-funded cash-limited queuing-type system. He sounds like an egomaniac!
    His evidence base is a cover for ranking prior to rationing; plain evil in its deceit and foul results. particularly when the best of the world does no such thing and is FAR better at delivering good universal care, but this parochial bloke (Doctor!) would not stick his nose above the parapet to look-see.

    He sounds like Eric Honecker, telling the inmates what they can have – and the NHS is much more like a Wartburg than a Mercedes.
    He is an old Soviet in his social attitudes.
    He should not ‘educate’ any member of the public on any matter economic-medical, since he is the least knowledgeable person I have seen write on the subject in a very long time indeed.

    • beenzrgud

      I pay about €1500 a year for my insurance in France, that covers me and my wife. When we use the services in France it isn’t obvious which bits are private and publicly owned. It all works seamlessly. Most people used to the NHS wouldn’t believe how fast things get done in France. As an example the GP may prescribe a blood test. I immediately make an appointment at a laboratory, usually next day in the morning. The results are ready to pick up the same day. I’m back at my doctors the day after. Only 2 or 3 days from start to finish. Last year I started getting some abdominal pain so I went to see my GP. About a week later I had seen a specialist and had a surgical hernia repair. There is very little waiting for appointments etc.
      I spend a lot of time in France but even if I didn’t I think I’d still keep my property there and keep paying my insurance just so I could have access the health service. For a lot of things France really isn’t very good, but we could learn a lot from their health service.

      • Terry Field

        I agree entirey – and of course the premium is funded by the sate for the very poor. The system works as you describe.
        I only disagree about the rest of France – from the individual’s viewpoint, I think it is far superior to the UK, re housing, education, transport, food, climate, location to other lovely European places – can’t be criticised. A nut-land of a politic and a bananhead of a president, a fruitcake of an energy minister (nice legs, shame about the mind) but that is their problem; mad place to develop a business, but great if you want a non-commercial existence.Oh, and social welfare systems leave the Black Island for dead- sadly literally often.

        • beenzrgud

          Unfortunately I have to deal with French businesses a lot which often has me tearing my hair out, but for people like retirees who are just there to admire the view and enjoy the weather then yes it’s a very good place to live.

          • Terry Field

            Oui
            Merde pour le travail. Bon pour la retraite

      • ginger

        And their roads, and their rail system, and, and …

      • Lydia Robinson

        Exactly my experience in France too. The NHS is certainly not envied over there. Perhaps it’s envied in the third world from whence it recruits most of its staff.

        • Terry Field

          The NHS is looked on, rightly, with horror in France, and indeed in most advanced countries. The british attitude to the Europeans is held, increasingly, in complete contempt. I agree with them. Britain is desperate; snake -oil is not the answer though.

          • Gwangi

            The French are hypochondriacs – always have been always will be.
            The British NHS is superior to a system in France where their doctors will quite happily let you die by the roadside if you can’t pay them.
            I remember I once visited France with a relative who had a broken leg. The rubber heel of the leg wore down and needed to be replaced. So we turned up at a clinic and asked in fluent French for this, flashing our EU health card. NON was the only word these French fckers know.
            Fortunately, we were all over 6 foot tall and fluent French speakers, so told the Froggy doctors that if they did not replace the rubber heel on the plaster cast and give us the treatment we were entitled to, we would not only break their legs but we’d shove their gallic shrugs right up their hypocritical hypochondriac French prrrt-holes. Happily, the changes the rubber heel and did not charge us (though they wanted to).
            Why oh why do we give foreigners free treatment on the NHS? I think we should charge all foreigners and charge the French double, just for being so damn irritating and pompous.

          • Terry Field

            You are a deranged, insane madman. Your rant is a ludicrous joke. Go and see nursie and she will give you the drugs that you so desperately need, bongo-boy.

          • Tom M

            I agree with all the comments referring to the differences between France and the UK (see my post above). I would though question your point that the NHS is looked on with horror by the French.
            A good friend of mine is an anesthetist for a clinic in Rennes. He holds the competence of the NHS doctors in high esteem and quotes publications like The Lancet as works of reference. He tells me that he wishes the French hospitals worked to a financial budget like the NHS instead of being paid by a points system for procedures.
            Mind you he has never been treated or visited an NHS hospital.

          • Terry Field

            Thanks for the response. Do not misunderstand me; the doctors, clinical staff, support staff and managers are good in the NHS – no criticism there. It is the absurd structure and ridiculously constrained finance model that is the problem. The politics is the problem, not the people.
            I have the highest regard for the people working in the NHS
            The French system refers to procedure costs and this is measured; it has to be since there is an insurance system that is billed for procedures. The NHS has little idea of cost; this, obviously, is a problem, and would have to change if the system were to use private facilities as happens across Europe.
            Your friend is right about the imperfection of billing systems; but the resource allocation for procedures as measured by cost has to become much more sophisticated as budgets are more and more effectively controlled – that is NOT done in the NHS and its hospitals today. Systems really are quite primitive, because of the ‘bucket’ system of cash accounting.
            French hospitals operate on throughput, as any business does, sine the establishment costs are ‘sunk’ – the NHS budget system arbitrarily allocates fixed costs to procedures, and this makes no sense where activity can be arbitrarily constrained by allocated funding. That is why NHS hospital costs, when they were measured (on the only occasion an attempt to understand costs was made under ‘fundholding) can appear significantly higher than private UK hospitals, who, like French hospitals, accent through-put and high usage rates.
            Thanks for your intelligent reply, makes a change – so many idiots engage with this subject.

    • Baron

      A superbly enjoyable rant, Terry, and right you’re, too, on every point you make.

    • ohforheavensake

      He’s a doctor. Are you?

      • Terry Field

        Being a doctor obviously impresses you. I assume you would listen to sewage workers when designing a sewage system.
        Trust me, I am a Doctor.
        I am, you know.
        Trust me.

        • Shorne

          You’re clearly not a Doctor but when faced by a calm, reasoned article from somebody who is we get the usual rant full of over- the-top insults (you calling somebody else arrogant is hilarious), sprinkled with random exclamation marks and capital letters (which I always think of as the equivalent of somebody sitting on a milk crate in a shop doorway shouting gibberish at passers-bye.)
          Your ‘house style’ weakens what you say. I usually try and follow Mark Twain’s dictum ‘Never argue with a fool, onlookers may not be able to tell the difference’ but to pick up on just one thing The Commonwealth Fund mentioned in the article is, despite its name, a non-partisan American organisation, in other words based in the country where private medicine predominates. It is respected the World over and it rated the NHS as being the best in the World, set against that your opinions come nowhere.

          • Terry Field

            Your reply is pure propaganda. You say nothing of value. Goodbye.

          • Shorne

            I suspected you wouldn’t come up with a sensible response but your use of the word propaganda continues the hilarity your posts cause, propaganda can be partly defined as ‘using loaded messages to produce an emotional rather than rational response to the information presented’ I cannot of a more accurate description of your comments.

          • Terry Field

            Look little person, I do not care if you are a doctrinaire leftie who likes the dysfunctional NHS.
            I do not live there; Frankly my dear I don’t give a damn. But I have, as have many others, offered powerful ideas, experienced and put into practice in other countries, to alleviate the dreadful problems of the current NHS.
            Reject them, I simply do not care; it is your funeral, not mine.
            To hell with you.

          • Shorne

            Look folks this is a man who accuses others of arrogance. The thing is nobody outside of comment columns will ever take any notice of what he says while organisations like the Commonwealth Fund are respected and listened to and the thought of that infuriates him.

          • Terry Field

            You are naive as well as bigoted.
            The C Fund has been roundly criticised, and will be ignored.
            The NHS model will be reshaped along the lines I have indicated within five years.
            To quote the Blessed Margaret, there is no aliternative.
            And the ‘folks’ think you are a total idiot. They are laughing at you as I write this.

          • Shorne

            Dear me you do fancy yourself don’t you.

          • Tom M

            If you think that this report by The commonwealth Fund isn’t NHS propaganda (apparently the CEO of the NHS is on it’s board) then I suggest you visit some of the other EU countries and form you own opinion.
            To suggest that the NHS is in any way shape or form even close to the French health service is risible.

  • Big Mouth John

    maybe if the british NHS did not go to Gaza to bandage injured terrorist who had started a war this summer, there would be more money for the British people, you know, the ones who were born in Britain, worked in Britain, paid taxes in Britian……apparently muslim terrorists are the new ‘Brits’.

  • Caroline Molloy

    Great piece. For more detail on the multi-billion cost of the NHS ‘market’ (and how successive governments have tried to suppress it, see the piece OurNHS openDemocracy published last week. https://www.opendemocracy.net/ournhs/caroline-molloy/billions-of-wasted-nhs-cash-noone-wants-to-mention

  • neverbefrench

    I have had some first class treatment from the NHS which saved my life at least twice. I also have the advantage of being well educated, articulate and prepared to make a fuss which i believe to have been crucial to my survival. Surgeons have been brilliant, intensive care staff, especially the younger (and probably more idealistic) have also been first class, nurses, older staff in particular, on wards, are a different matter altogether and have given the impression that patients are generally a nuisance. Had I left it up to them I would never have even made it to the operating table.

    The French system is probably the best in the world in terms of availability of treatment, but it is excessively bureaucratic and thus expensive. It does, however, have the advantage that the patient gets the bill (even if they rarely are the one paying it) and all test results belong to the patient. You are never rushed and the total cost of a GP appointment is 23 euros (about £18) but the state pays most of that. The patient is king in France and selects their GP, District nurse, Test or X ray centre and hospital. If you are not up to scratch then you don’t get the patients.

    In the Uk we have to get away from the situation where the more money goes in, the more NHS staff take out. NHS managers are paid ridiculous amounts and is your GP (ok technically self employed) really worth £100,000 per year? This requires some element of competition but designing the best system to achieve this, in the face of public ignorance and political misinformation, has proven impossible up to now..

    • Terry Field

      I knew an NHS senior manager who smiled and said little – because she had previously been an HNS receptionist and the cerebellum had a very smooth surface indeed!

    • Lydia Robinson

      “The patient is king in France and selects their GP, District nurse, Test
      or X ray centre and hospital. If you are not up to scratch then you
      don’t get the patients.”

      That is the key. Over here, if you have the bad fortune as I have had to get stuck with an incompetent GP who makes a misdiagnosis, there is no option but to go private.

      • red2black

        If you can afford it. No option at all if you can’t.

        • Alastair

          The French state pays for the poorest in society 100% of their medical expenses. For the rest the state pays half and the other half must be paid by the patient in the form of compulsory medical insurance. So no it is not a case of if you can afford it, if you are working you are paying insurance – everyone can afford it. For once socialist France has made the free market and social services mix in one of the best ways in the world.

          • red2black

            Lydia’s choice to ‘go private’ refers to the UK.
            (Over here…)
            I agree with everything you say about the French system.

          • Tom M

            “….For the rest the state pays half and the other half must be paid by the patient in the form of compulsory medical insurance…..”
            That’s not true. In general the state pays about 75%. It pays all if the problem is life threatening. If it is a car accident then the car insurance pays up if an accident at work then the employer gets the bill.
            If you can’t afford it the state pays all.
            It is not compulsory to have insurance (many UK citizens here don’t think it is worthwhile, more fool them). Non-residents get asked how they intend to pay when they visit a hospital and the hospitals accept credit cards.

      • Sy Delta Parkertron

        “there is no option but to go private.”

        There are other options! Get a second opinion from another GP in the same practice, change to a different practice, you don’t have to go private just because you and one particular doctor don’t see eye to eye

  • Tom M

    Dr Pemberton you have said nothing apart from what is repeated daily by opposition politicians as to what needs doing with the NHS. And that has been repeated, by opposition politicians, ad nauseam all my life. THe NHS has been in crisis since it was created.
    The problem is the concept of the NHS. It is a political election tool beloved by the left wing and unions. Any suggestion of change is met by a wall of self interested protest. All the other state run enterprises suffered similarly. When you quote some Commonwealth Survey I laugh. You must be joking if you think the NHS is up there with the best.
    If anyone gets past the first sentence criticising the NHS they will be asked if they prefer something like that in the USA, with all it’s conotations. They never draw comparison with our nearest neighbour France.
    In France the health system is publically funded like the NHS. The French Health Service bears no comparison whatsoever with the NHS. My family and I have all some tale to tell of the NHS quite a few not very nice at all and those span some 60 years.
    For a nation wedded to revolution and Socialism it is strange that in France no one bats an eyelid at the private hospitals (as available to the public as state run hospitals) or self employed pysiotherapists, district nurses, ambulance drivers, midwives, speech therapists and of course GPs. When you visit the GP you pay (22€) that is his salalry. No patients no income.
    You plug your carte vitale into his computer voila! all your medical history. He writes a prescription and it is instantly on the (any) chemists computer. Of the 22€, 14€ is reimbursed and back in your bank account at the speed of light. Note the mutual respect created between the patient and the GP when a visit is paid for. People are made aware that it costs money.
    “……….I typically see patients for 30 minutes to an hour. For every patient I see, I have at least one hour of paperwork to do…….”
    I have seen two French consultants in the years I have been here and both wrote their report as I was discussing the case with them. The last time I walked out of the hospital with the report (copy e-mailed to the GP) and x-rays in my hand after a total of 1 hour and 20 minutes in the hospital (I only spent 5 minutes in the waiting room).
    The NHS was created in the same month and year as the French Health Service. Both countries have similar populations and GDPs so after some 60 years of trying you must be doing something very wrong and continually to be in the state you are in.
    I suggest Doctor you take a day off and visit some French hospitals as a starting point. When you are there ask them for a copy CD of their IT system whatever they ask as payment it will be cheaper than anything that our politicians and civil service could do.

    • RuariJM

      “Dr Pemberton you have said nothing apart from what is repeated daily by opposition politicians as to what needs doing with the NHS. ”

      I very strongly disagree.

      I was going to take the good Doctor up on his prescription that “We need to adopt a value-based outcome model across the NHS.”

      I agree with that, with reservations, and was going to point to examples of where the adoption of Lean principles from manufacturing have delivered huge savings, as well as dramatic improvements in service.

      However, if people are so ideologically bound-up that they won’t listen, there seems to be little point.

      PS – but I will mention that purchasing and supply functions somehow need 14 different agencies and prescription services, just in my local area, need seven. Dr Pemberton thinks this is because of the ‘internal market’ and he may be right – but I’m more inclined to the opinion that it is symptomatic of a bureaucracy that suddenly enjoyed a massive influx of money. Based only on experience and historical evidence of where it has happened elsewhere, as night follows day. But the NHS might be different, you never know…

  • Baron

    What will it take for everyone to figure that the NHS cannot be fixed anymore than the communist societal model could have been. The two are like brother and sister. The ‘free-at-the-point-delivery’ paradigm just won’t work, even if NICE succeeds curtailing demand here and there. The NHS will continue moving from crisis to crisis, no tinkering will help, the construct is doomed, the sooner we face up to it the better.

  • davidofkent

    Our NHS is not the best model. Because of our taxation system, an ever-increasing number of people are able to use public services entirely free of charge. They create an infinite demand. We must re-establishment the link between contributions and use of public services. Only those who genuinely are unable to provide contributions (the very young and the disabled) hold be exempt. A mix of private provision and insurance is the way for the future.

  • Terence Wilkinson

    A bizarre article full of passion but very little in the way of evidence. Also it highlights one of the problems of the NHS: the contempt in which the general public/taxpayer is held. Rather than bring in measures to empower patients thus doctor wants to bring in measures to punish them! Why not go the whole hog and return to the 1950s when ordinary people knew their place and were suitably grateful to receive the healthcare they had paid for?

  • peterooo

    If I ran the NHS I’d keep diagnosis free (ie, tax-funded) and any prescribed follow-on procedures covered by private health insurance – but only up to a maximum cover of £10k… after reaching this ceiling it would return to being free (ie, tax-funded).

  • Retired Nurse

    Has anyone performed one of those new-fangled Root Cause Analyses on the Department Of Health itself? Can’t help thinking having Lord Howe (Hereditary Peer and Banker with friends in the baccy industry), Jeremy Hunt (Queens cousin) and Norman Lamb (conveyancing solicitor) steering it is responsible for much of the trouble…

  • Lydia Robinson

    “The answer is not just to pump more money into the NHS.”

    The NHS receives more money than any other European country but its outcomes are poorer. Anyone who has lived anywhere else knows that the NHS is not “the envy of the world.” Certainly not in France or Germany.

  • Liberty

    Anyone can devise a system but the fundamental problem is that if it is a monopoly it will be exploited by those in control for their own interests. The only way so far discovered to counter this basic human motive is a market; that is, firms pursue their own interests in competition with others for customers/clients and so force improved value for money.

    Socialists everywhere and always have regarded the number of independent firms and advertising a waste of money but we have always found a centralised, single provider even less efficient and effective and singularly unattractive to the user. Consider the number of phone providers now – allowing for technological change – compared to a monopoly provider of BT. Health is now beginning a technological revolution – all industries are – so this is no time for a nationalised monopoly, we need innovation and cut throat competition to force out poor providers and replace them with the best.

    So It is better that we have GPs the gatekeepers and fundholders who buy services from any competent provider who then competes for his custom. The problem of administration will diminish when the providers [hospitals, etc] have more experience, use technology more and the government stops demanding political accountability for everything; let the market do its work.

    • red2black

      The ‘problem of administration’ won’t diminish. American private healthcare spends about a third of its income on ‘administration’ – a euphemism for chasing people for money.

  • Gwangi

    Yes, but I assume you mean the NHS in England – and not that in Wales which is different, or Scotland which is also different.
    It is really arrogant not to make that clear.
    We have no UK NHS. If you are talking of the English NHS, then say so. Failing to do that is bad journalism, for a start, and could be seen as ignorance (maybe you think the NHS in England, Wales and Scotland are the same eh?)

  • Gwangi

    The Royal College or Nursing is on record for stating, and I quote: “there is no such thing as a bad nurse, only a nurse who needs more training”.
    Imagine if the teaching unions said that? Or the bus or train drivers union – after a drive had just crashed and killed passengers.
    The RCN is the union for nurses. They are not impartial and often try to cover up bad things nurses have done – they will ALWAYS defend nurses.
    No angels indeed…

  • Margot

    The NHS is already well down the private provider path. Whether any treatment is private or ‘NHS’ provided the important thing is that there is someone who knows what the standard should be and ensures that that standard is kept. At the moment there is no-one able to call anyone to account. Everyone is looking to their backs and afraid to criticise. This means that bad treatment carries on without anyone with the ability to say anything. Independent assessors and monitors are needed. Private providers have the benefit of being able to dispense with ridiculous form filling and just get on with the job.

  • Margot

    A few more points:
    It would have been a good idea if from the start everyone had been told the cost of any treatment they were having. We have arrived at the point that too many are grateful for even the minimum ‘free’ treatment, good or bad, with others expecting an MRI at the first sniffle.
    A medical degree doth not automatically being ethics with it. One health service I had experience of had GPs forming cartels to send their patients to treatment facilities owned by their pals.

  • BritInAmerica

    This reads well. Until you mention Michael Porter’s conception of value based healthcare.

    Porter fundamentally doesn’t understand healthcare and his ideas enacted in the UK would cause massive problems. His work on health is based on the problems of the US health system and his ideas don’t stand up to scrutiny when looked at through a British lens.

    But virtually no one in the UK has properly read his work. And many seem to be happy to endorse the emperor’s new clothes without thinking critically.

    I wish we weren’t so gullible every time a US business guru thinks they can fix healthcare…

  • Swanky

    What happens to all the forms? Why are they needed? Who reads them? What would happen if everyone decided not to bother?

  • Sinceyouask

    We should remember that many studies have shown that doctors’ prescriptions often leave a lot to be desired. Pemberton’s is no exception.

    He skilfully portrays himself as caring, thoughtful and good at his job. He may be; but his solution, like the many which have preceded it, comes out of a familiar mould – top down, imposed solutions from clever people who have impressed politicians desperate for something, anything, to divert attention from their inability to effect meaningful change. This prescription offers nothing new, beyond a bit of contemporary jargon, and will go the way of all the others.

  • Matt Sharp

    There’s a lot of anecdotal discussion of the French health care system going on in the comments, and how it compares to the NHS.

    It’s worth pointing out each year France spends an extra $750 per person on health than the UK ($4260 versus $3495)(according to the World Health Organisation).

    So if the French system is better, how much of that is down to the way it is organised, and how much is down to the extra money spent?

  • paulthorgan

    It is impossible to extract the ideology from the NHS. So long as it remains under political control, it cannot be run well. While Labour MPs bypass all the managers and bait the PM about NHS failures, the NHS cannot be reformed.

    It needs to be abolished and replaced by insurance-funded private provision.

  • teapartydoc

    The problem of health care is the same in all of Western civilization: licensing. Read chapter 9 in Milton Friedman’s Capitalism and Freedom. Licensing of physicians began in Europe and the USA at about the same time and in both places was supported by the same groups of cognitive elites and organized medicine, probably the initial project of progressives. No, it did not happen because there were riots in front of every county courthouse with people demanding government licensing for their doctors because they felt unsafe as long as their physician did not have a piece of paper provided him by some bureaucrat saying he was an excellent physician who would never make a mistake. No, it was a massive regulatory capture that accomplished the formation of the most massive and powerful government sponsored monopoly in the history of the human race, affecting the lives of every damn one of us.
    You pay through the nose, either out of the pocket, through your taxes, or through your insurance premiums to support this monopoly. The only way to end it is abolition of government licensing.
    If you want affordable health care offered at reasonable prices in a competitive business climate this monopoly must be crushed. ABOLISH MEDICAL LICENSING.

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