Stronger and more accountable Foundation Trusts needed to avoid “Staffordshire 2”

At least 400 died needlessly

“These patients were not simply numbers: they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.”

The enquiry was published this week on deaths at the Stafford Hospital part of the Mid Staffordshire NHS Foundation Trust between 2005 and 2009.   It should be required reading – all 455 pages of it -  for commissioners and Trust board members everywhere. What happened in Staffordshire could happen elsewhere unless governance and clinical behaviour are drastically improved.

Don’t just read the recommendations or you will miss the outrage you should feel at the recurring catalogue of systemic clinical, governance and above all individual failings (nurses but also doctors and managers) that resulted in the untimely deaths of some 400 people (maybe up to 1200 according to some accounts).  If a train crash killed 400 people, there would be an immediate public enquiry and Ministers would be front and centre.  But that’s not what happened here.

No openness: no challenge: no change

The Francis enquiry report  is not strong enough on improving Foundation Trust governance. It largely ignores the role of the Trust’s owners – the Members of the Foundation Trust and their elected Governors.   A Foundation Trust is after all defined in law as a “public benefit corporation” – a species of social enterprise -  but what that means in practice has been deliberately fudged by Ministers and Monitor since FTs were first created. Now we can see what that sort of “governance neglect” can lead to.  Francis could have made a big stride forward to rectify that, but instead it made a rather bland recommendation to empower members and governors.  Much, much more needs to be done about ensuring there are stronger public and service user Governors and – crucially – about empowering staff governors elected from the Trust’s own workforce.

Then there is the role of the Local Involvement Network (LINk).  Why was there not a functioning LINk locally?  Why were there no unannounced visits to these wards under enter and view powers and reports made to the local authority and the PCT about obvious care shortcomings?  I cannot image a Community Health Council (CHC) pre their abolition in 2003 failing to respond vocally to the first reports of failing standards.  This is a measure of what we have lost in local accountability.

Closed enquiry

In Staffordshire theenquiry led by Robert Francis QC was closed and so most members of the public and the media outside the region were not even aware of until it reported this week.   To its credit the Francis team produced a good report, concluding that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care in a headlong pursuit for Foundation Trust status which it achieved in January 2008.

But however good its recommendations, this process isn’t the same as a robust enquiry held in the public and media eye and it falls far short of assigning responsibility for these failings to individuals.  Only individuals can be held to account for this magnitude of institutional failure.  Think casino investment banks.   The Trust as a corporate body and its culture are only the reflection of the sum of the behaviours and attitudes of the people who comprise it -  the clinical staff, managers and board members in particular.  Some of them did try to raise the alarm, but most did not.  Some were cowed into silence, but it seems that most chose to look the other way. Or maybe they just could not believe it was happening to them.

Where were the nurses?

Most worrying of all is the question “where was the voice of professional nursing as the patients’ champion?”  The Trust’s diverse nursing team are the most numerous group of employees and always will be. They are  everywhere and they see everything.  Had nurses taken a united stand and made their collective voice heard, the care failings of the Trust would have come to light much earlier. Where were the letters to MPs that the hundreds of nurses working in this hospital should have written?  Where were the local nursing clinical leaders? Where were the nursing trade unions and professional bodies?

Does the buck stop nowhere?

If people knew and did nothing, that must be culpable if not criminal.   If some senior people at the Trust are not personally held to account for this, then the message is “the buck stops nowhere” and accountability is reduced to a cipher.   Relatives are demanding responsibility at this level and so too should the public because this outrage took place at a time when the NHS has never been more regulated and this Foundation Trust was – on paper – rated a good, and safe, provider of services.   But no one challenged the failures.

Governance matters

The enquiry recommendations could have clarified that the governance of the Foundation Trust must be rooted in the membership community and its elected representatives whose role is to hold the Board to account and who must be supported to carry out that role.   This seems to be what the Secretary of State Andy Burnham is now talking about in his reported views about strengthening the Governors of FTs .  Will he translate these words into action?

This Foundation Trust’s board meetings were held in private.  That was wrong and Mr Burnham has now declared in a parliamentary answer that FT Boards must meet in public and Governors must have access to all Board papers. There is still some wiggle room in that which needs clarifying.  It is welcome, but in itself it will not solve the problem of a culture opposed to openness and challenge.

It is an indictment that without the persistence of “Cure the NHS” -  a local group of patients and relatives who knew that things were going wrong within the hospital, who raised complaints and whose members kept shouting despite efforts to silence them –  the magnitude of this scandal would never have come to light.  Their contribution is praiseworthy, but they should not have had to make it alone.  The Foundation Trust is after all “owned” by its Members who elect a Council of Governors to hold the directors of the business (the Board) to account for delivering safe, effective services and fulfilling their strategic plan.

Stronger Governors needed now

Should FT Governors therefore have a role in the complaints process?  That is one option raised by Francis, along with the possibility of the Governors electing their own chair instead of sharing a Chair with the Board as currently.  Both suggestions have merit and need serious consideration. Governors could be effective scrutineers of the complaints process (which could do with improving its performance in many Trusts), but should not as individuals get directly involved in complaints handling.  And Governors deserve their own, independent chair.  Having the same person chair the Board and the Governors invites conflicts of interest as was obviously the case in Staffordshire.

FTs at a crossroads

The Mid Staffordshire scandal shows Foundation Trusts at a crossroads. We must learn from this and quickly because all other NHS Trusts are headed for Foundation status or else franchising from an existing FT.   These “community benefit corporations” must be made to behave for the benefit of the community and be accountable to its representatives.  They  must be directed by Government down the road of greater local accountable to their Membership communities through stronger, more effective Governors – public and staff.  If this does not happen, then it is just a question of waiting for “Staffordshire 2” to happen.

Dear President Obama, build US healthcare on what works already

No Place to Hide from Healthcare Debate

In between dodging blizzards and snowdrifts flying around the US from coast to coast for three weeks earlier this month for work and to see friends and family, there were lots of opportunities to soak up what the media and individuals were saying about the debate  on health care proposals from the US Congress and the Obama administration.   Actually you couldn’t avoid it if you tried.  CNN, FOX, MSNBC and all the rest of the rolling news services are pumped into all airport gate waiting areas and there is no escape as it seeps repetitiously into the brain.   To say there was no consensus in the broadcast media is putting a polite European gloss on what is without doubt an increasingly strident and partisan political shambles for which the prognosis is poor unless something is done to reverse it quickly.   The tragedy is that it doesn’t have to be like that because the US has elements of a healthcare system that are reasonable building blocks on which to construct something much better.

Remember Rule Number One

I came away from our three week jaunt across America convinced – and rather saddened given the scale of the obvious unmet need for primary healthcare in particular – that the US debate started in the wrong place.  I have some sympathy with those –  the majority? – who say the are confused at best by the competing proposals and anxious that they might lose something which – if they are lucky enough to be employed and live in the right place – just might entitle them to  a reasonable service (though at a high cost).

I was reminded of my “Rule Number One” in health promotion  – you have to start with where people are if you want to enable them to move to another place.   Sadly – and due in no small measure to the mega bucks of ubiquitous lobbyists in Congress -  government figures seem intent on creating a highly complex debate which ordinary people out on Main Street USA simply cannot follow and therefore distrust.  Which is when the shouting, demonising and teabagging really starts to ramp up.  Judging from the National Tea Party Convention in Nashville last week, these people are just getting into gear with their volatile alienation from conventional politics.

Build on what’s in place already

Most Americans, to my surprise, are not aware that the United States already has a National Health Service of sorts.  The US National Health Service Corps, part of the Surgeon General’s Department,  aims to have over 8,000 primary care clinicians caring for some 9m Americans by 2011.  Since 1972 National Health Service Corps primary care doctors, dentists, nurse practitioners, nurse midwives, physician assistants, dental hygienists, pharmacists, therapists , mental health professionals and others have mainly worked in small towns, isolated rural areas and deprived communities of all sorts across the US where accessible or affordable health resources are scarce.

The American NHS Corps is a reasonable and well-established model of grass roots primary care. It could be generalised across the country. Primary care is in dire shape in many places and GPs as we know them are beyond being an endangered species.   To the NHS Corps could be added the hospital and rehabilitation services of the extensive, and recently much improved in terms of quality and safety, Veterans Health Administration health system.  Beyond that, of course, are the mega bureaucracies of Medicare (for the over 65s) and Medicaid (means-tested for low income groups) which provide ample learning of how to – and sometimes how not to – run comprehensive(ish) single payer, insurance-based, mass coverage programmes.  No one is arguing that these programmes as they exist now are fit for purpose for a country-wide unified health service.  But they are generalisable and capable of considerable improvement.  Most importantly, they were invented in the US and well-understood in the American political context.

Taken together the NHS Corps, Veterans Administration, Medicare and Medicaid could form a large nucleus  of publicly funded healthcare services around which pragmatic politicians could weld a system of single-payer, universal access health care.  And they could start with primary care which is in such short supply in most locations and which – as we know in Europe – is the key to grappling with the manifold problems and costs of the acute sector.   So why isn’t this happening?

Keep it simple stupid

This motto ought to hang by law on the office wall of all Members of Congress and every room in the White House.  Healthcare reform and complexity are a lethal mixture.  The title of this week’s online editorial in the New England Journal of Medicine sums it up: “the complexity that killed health care reform (again)” Just as with the Clintons’ ill-fated attempt at healthcare reform in the 1990s, history seems to be repeating itself.  President Obama and the drafting committees in Congress have reached too far and tried to accomplish too much all at once, ending up pleasing no one and leaving the “debate” wallowing in a slough of complexity.  The healthcare bills emerging from Congress are themselves strictly for chronic insomniacs and legislative masochists — 1990 double-spaced pages for the House bill and 615 pages for the Senate bill.  President Obama has yet to produce his version – and the big question is why did he let slip such an opportunity to capture the heights of the healthcare agenda? Let’s hope it’s a snappier read when it does appear.

Remember Rule Number Two

My “Rule Number Two” in health promotion-  don’t let striving for the best get in the way of achieving the merely good – applies to the US dilemma about healthcare reform in a big way.  Specific provisions, passed by Congress one by one if necessary, should be used to create a new, comprehensive system by welding the existing parts together with general principles.  An omnibus leviathan piece of legislation to do everything at once will not pass (as the Clintons should have realised).   That way ends up pleasing no one and plays into the hands of the (many) enemies of publicly funded care.  The devil is in the detail remember.

What is happening this time is doubly sad.  The current proposals actually seem to alienate many of the very people who would benefit.  Perhaps this is understandable in a time of recession, foreclosures, fear of higher taxes and job losses.   Starting to build on what already exists, therefore, would be a better (because less threatening) tactic and “keep it simple” should guide the legislative output.   Primary care has to be the right starting point.  Get that right – as we know from struggling with the issues around the NHS in Britain – and everything else will fall into place.

I wondered in all of this what Americans who use the NHS Corps services think about them and are they involved with planning them?  That’s something I would really like to know more about if any readers of this blog can point me towards some evidence of user engagement with them. It will be interesting to see what emerges from a research project by Involve and Consumer Focus seeking to quantify the benefits of public engagement.  A post on the Public Decisions blog in the US from Involve in the UK announces an ambitious project with Consumer Focus England. The project is seeking to develop an equation for identifying costs and benefits associated with public engagement structures and processes and is asking for examples from the US.

NHS User Action Research – Choosing, Booking, Sampling and Giving

The headline says it all really. Log in and choose the appointment and wait while it whirrs away and does it. All very simple and hi-tec. But not the whole process – my referring GP wrote the details down in a big notebook first and the paper work reached me about 5 days later. Some productivity gains yet to be made.

Some concerned blog readers contacted me  as a result of my mentioning the bowel cancer test. Thank you for your concern but no need to worry – it was just a screening test programme and the results were fine. I just wonder what the take up is like on this particular exercise. Collecting the sample challenged both motor and organisational skills and doing it all involved confronting certain of my own (and most other people’s I would guess) established personal behaviours and attitudes. Is there a medal to be awarded?

The next participative saga involving the gift of my state of being and medical history as the NHS UK BioBank project tracks me to my grave is yet to come – watch this space.

Getting My Sh*t together and other belated New Year resolutions

Faecal occult blood has a certain fashionably vampire ring about it. It gives the right air of spooky mystery so encouraging us all to get engaged and involved in our own health by sending in our samples for the bowel cancer screening programme. The instructions for collection are admirably brisk and matter of fact and we need not go into the detail here – the main point to remember is not to put the cardboard sticks down the loo. The collected goodies are then to be consigned to the post where we must hope there will be no recurrence of industrial action and postal delays. Anyway resolution one – to take more interest in my health – is  being put into practice although it may take a moment to get beyond the instructions in the leaflet. (Sound choice of communication channel – not one for You Tube.)

So I was already  in the right engagement frame of mind when a couple of days later I got an ‘invitation’ to join  the UK Biobank research project inviting me to come and be what – cloned in Croydon? Well something is happening in Croydon that  the distinguished researchers signing the letter assure me that while it will not help me directly, future generations will benefit from the data gained from tracking me and my health (are they separable?) into my grave.  This is one – positive – demonstration of how electronic health records make our addresses available to the passing researcher. They even offer to pay parking and travel expenses.

Add to this, the Tribunal action with other residents of my block of flats and the cup of public involvement rather over-runneth. But I and the other MAC Partners busy contributing as parents, members of the friends of the local park or in the GP practice patients group, do find that active engagement means that any advice we may offer others on how to engage people is all the better for having seen it from different perspectives – researcher, organiser, participant.

This gives us lots of stuff we can blog about on our new and improved website. We have brought together the public involvement blog and the main site and given it a new and lively look. We hope you enjoy it and feel free to give us some comments on how it looks and feels for you.

There have been a couple of blogs already this year. What do you think of the NHS Constitution? We give our views. The other blog is an inspired piece of photo journalism showing how a Kenyan hospital near Mombasa goes about getting its vision and service commitments across – they have not yet embraced the label ‘Constitution’.

2010 is looking good already and Partners enjoyed a Chieftain Haggis from MacSweens of Edinburgh. And if you thought Chieftain was the name of a tank, take another look at both haggis and monster vehicle and wonder which was named after the other. Memo to self – engage in own health and eat fewer tanks in 2010.

Belated though our resolutions may be as this letter emerges at the beginning of February, that does mean that they were not forgotten by 2nd January. To all our readers working on their 2010 plan, we hope that your resolutions are similarly durable and do not vanish like snow off a dyke.

Health Act rag bag delivers part of the real prize

Health Act Rag Bag

Almost unremarked in the rush of bills getting  the Royal Nod on Friday  the 13^th was the rag bag of measures collectively known as the Health Act 2009. Tucked away among new powers to strengthen tobacco control; to place a duty on all NHS bodies, private sector and third sector providers of NHS services to have regard to the NHS Constitution (more on that in a later blog); to deal with (whisper it) failing Foundation Trusts; to require (largely meaningless) “quality accounts” from NHS bodies and to reform pharmacy services is the provision to give money directly to certain patients so they can obtain their own health care.

It’s Getting Personal

But it isn’t as simple as it looks – the consultation on the regulations and guidance is pretty daunting.  The real problem is that this will deliver only half of the prize that should really be on offer:integrated health and social care individual budgets reflecting the real level of user and carer need.  This is going to be big in coming years given an ageing population and more people with long term conditions surviving for longer periods with better quality of life.  How many?  The think tank Demos At Your Service report estimates 1.5m people in five years will be controlling personal budgets for health and social care.    When this happens, public services will never be the same.

The progress in freeing up NHS money so it can flow direct to individuals for this purpose is welcome (NHS money can already be handed to third party organisations to spend on behalf of individuals) and it evens the scorecard with what is increasingly common practice in social care. In fact, the consultation on the health care budget regulations largely proposes to mirror existing good social care practice.  If this is a hint that the two channels of care services are converging then we welcome it.

If our public services could just get their acts together about this we might see some progress towards the real prize.  David Cameron had the right idea in his recent statement on health priorities earlier this month when he included as part of a reform of long term care that “budgets combining social care and health care funding for people with long-term conditions will be rolled out.”

People Powered Public Services

The latest report from NESTA*  The Human Factor provides the evidence about moving to “people powered public services”  which could save billions. It should be required reading in PCT and Local Authority boardrooms as well as by political party strategists. The word is that Andrew Lansley likes this approach.   Both parties are making noises that the boundaries between health and social care services are going to be intentionally blurred in the near future.  In that light, keeping separate budgets for healthcare and for social care is simply perverse and discriminatory against the very groups who are meant to benefit.  It perpetuates an impediment to integrated services which goes back to 1948.  It really is time to come into the 21^st century with how we commission and provide public health and social care services for our increasingly complex and diverse population.  That’s the challenge MAC would like to see all parties grasp as the election temperature starts to rise.

*NESTA is the National Endowment for Science, Technology and the Arts

Telling it like it isn’t: the language of the NHS

I always like it when the newsletter of NHS Networks pops into my inbox with its cheery “ping”.  Not only does it save me lots of time finding out things, but occasionally it brings a dose of real wisdom coupled with wit.  Today’s was no exception with its offering of a front page mini essay on the problems of language in the NHS.  I can think of no better way to share this with our blog readers than to quote it verbatim below, together with a “thank you” to its anonymous author whose frustrations about NHS communication MAC shares and whose humour in the face of frustration we can but admire.

“Language matters. If you want to get people on your side or avoid turning them off, choose your words with care.”As the railways have learnt, promoting mere passengers to customers does nothing to mitigate a poor service. If anything it deepens the irritation. Similarly, having a more elaborate and cunningly worded excuse — “lack of availability of a train crew” or “delays caused by the failure of an earlier service” — does not fool anybody. The facts are as follows: the driver didn’t show up for work and the train broke down; the station is draughty and crowded and you are going to be late for work.”

“The NHS is not like this. There is a genuine desire to communicate, to clarify and to explain but for one reason or another, the harder we try, the less sense we make. We can’t even talk about talking without lapsing into a strange language that sounds like English and even uses English words but in other respects is clearly not English.”

“For example, we insist on “engaging” people, giving them the disturbing impression that either we want to offer them a job as our butler or that we want to marry them, settle down and have children.”

“We refer to people as stakeholders, a meaningless term soon to be adopted by the railways – “stakeholder under the train at Chorleywood” – and which implies a much greater sense of ownership than anybody really wants. We all know it’s our NHS, just as it’s our Inland Revenue, our BBC, our national sewage network and our Parliament, but frankly there’s only so much stakeholding we can do if we’re to leave time for involvement, engagement and consultation.”

“The NHS mistakes its internal language for universal currency. Just as the British Empire was founded on the belief that the world would be better place if it spoke English, worshipped a Church of England God and played a lot of cricket, so the NHS believes that if it speaks loudly and slowly enough and keeps peddling the same dull linguistic tokens to the natives they will eventually sign up to the programme.”

“Like any large organisation, the NHS has a language of its own. The jargon may or may not promote understanding among those who speak it. For everyone else it is completely baffling. The sooner we realise that, the sooner we will start making sense.”

Next week’s instalment is on polyclinics, billed as ”where to take your parrot when it becomes unwell”.  I can hardly wait.

Early Apples – an early harvest after a glorious summer of posts

Boundless Blogs

We may not have published a newsletter since June but the blogs abound. Over the summer, the creativity and productivity of Partners ( and one in particular – the indefatigable Andrew Craig)  has produced a bumper crop of posts addressing the topical, the public and the personal at home and abroad – all active issues in the world of public engagement, healthcare costs and reform and good old complaint handling.

Who are you going to call?

Back in June we were reminded of the power of the personal anecdote – link – and picked up on what remains the most used way of contacting health services – 999 is now embedded in the national consciousness as the number to call. Can we be weaned off 999 in favour of numbers such as 111?

Find out about ‘Thought Bubbles’

Telephone access and response was not on the list of comparators in the recent row about comparing NHS and US health care – cost was the main bone of contention. Rachel Piper (Caroline Millar’s daughter) pointed us in the direction of a great website where the US debate about healthcare is summarised wittily and pithily. Take a look – short and fun which is more than you can say about most of the interventions in the health debate especially when national pride is involved.

Forget Global Warming – Prepare to get cold

Undaunted and perhaps indeed inspired by this technological tour de force, Andrew’s blog about future NHS financing floated off in a cloud of meteorological and geophysical images – what happens to the NHS climate when the warm Gulf Stream of funding is switched off? Answer: the NHS becomes Labrador. Not a dog but that chilly island unvisited by the Gulf Stream. This makes making the health service more efficient even more important – there is money that can be saved not by firing and closing but getting all in the NHS to perform as well as those in the top quartile. Beyond that, it is time to address the fundamentals:

• what is a health system for?
• who should own it? and then and only then
• how should it be paid for?

Best Practice Customer Recovery

If you are feeling that you may drown in this sea of debate – be it warm or or be it freezing – Caroline Millar’s piece about the modern art of customer recovery as practised by Eurostar will be straightforward and encouraging. Read all about how Eurostar complaint handling turned her into one of the company’s greatest fans.

They do things differently in Wales

The NHS is notorious for not paying much attention to what other people are doing and for its slowness in absorbing best practice from elsewhere. For all those engaged in user representation in health and social care, there are lessons to be learned in Wales where Community Health Councils have survived to become a key ingredient in the future development of NHS Wales. Andrew identifies the key ingredients for success for “CHCs Mark 2″ in England. .

Leadership is one theme that recurs frequently in any discussion of successful change and improvement. So we finish by raising a question asked by Colin Adamson prompted by the regime changes at both the Office of the Information Commissioner and the Financial Services Ombudsmen where both Richard Thomas and Walter Merricks have already or are moving on.

New Leaders Needed

Under the heading ‘Ubi Sunt?’ we wrote in July:
Just a few weeks ago, we blogged about Richard Thomas throwing off his crusader cape as the Information Commissioner and now Walter is handing in his SuperOmbuds costume. Last week I attended a leaving party for Allan Asher ex-head of Energywatch and chair of the BSI’s Consumer and Public Interest network just before he headed back to Australia. Ou sont les consumer heroes d’antan? More to the point. Ou sont les consumer heroes d’avenir?

If you know of any, we would be interested to hear who they are. Self-nomination is fine.

England needs a Welsh lesson

The Conservatives created them in England and Wales without appreciating their full potential.  Labour neglected, belittled, callously fragmented their functions and then destroyed them in England as an afterthought in the NHS Plan, despite widespread agreement that they could and should have been reformed and refocused. But in Wales , Community Health Councils (CHCs) survived.  

It’s time England learned a lesson about this. As Carol Jones, Director of the Board of CHCs in Wales wrote recently in the Cardiff Western Mail, CHCs have never been more vital as that country embarks on a new approach to its heath services .  

A Welsh lesson would be timely with a new Government on the horizon.  MAC believes now is the time to recover our inheritance, dust off the organisational memory and move on.  In effect reinvent CHCs for England. This isn’t a homage for just doing things as before.  First and foremost, we must keep the expanded health and social care remit of LINks, which is the one good thing to come out of Labour’s chaotic “reforms” of patient and public involvement.  

England needs unified geographical authorites to integrate local commissioning of health and social care.  We also need local statutory consumer bodies mirroring the health and social care commissioning spectrum.  Their job would be to co-produce, enable, articulate and advocate based on the views of the public, users, clients and carers.  To start fleshing out this role, we’ve identified the following chacteristics of “CHCs Mark 2″: 

• comprehensive strategic and collaborative remit with NHS and local authorities balanced with attention to quality and detail of service delivery which matters to patients, clients and carers
• professional staff to continuously engage with their communities, co-produce intelligence for action and support their members
• sufficient real budgets including recognition and reward for lay people’e time carrying out public duties
• access to all premises and services where publicly-funded patients and clients go
• one stop complaints and redress advice across health and social care
• visibility on the high street as well as the web
• national operational standards and an independent regulator and auditor to ensure probity and compliance
• independence in governance and funding from the services scrutinised
• democratic control and accountability to local people for their policies and actions
• access and rights of referral to overview and scrutiny bodies and ministers when issues cannot be resolved locally.

Rights and influence are the trade off for responsible and accountable behaviour.  We want new-style CHCs in England to be the informed and critical friends of the statutory services.  Too often in some places in the past they were allowed to become the neighbours from hell in confrontational relationships with local services.  A governance approach reflecting the suggestions above would go a long way to ensure that did not happen again.

MAC would like to see people elected to new-style English CHCs as independent members without party affiliation for the individual contribution they could make because of their knowledge, skills, local networking and other attributes. Public money should fund election hustings and “town meeting” type events where candidates would be voted on to CHCs and where on a regular basis reports would be made back to the public about the body’s activities.  It is good that the NHS in England now has a statutory duty  to listen and engage, but without a stronger voice the listening ear is just an appendage.  Let’s try some real localism for a change, because centralism doesn’t work when it comes to getting things down “down our way”.

As Carol Jones rightly observed, “If we want to avoid another Mid Staffordshire catastrophe, learning from the Welsh experience and building on it for the English NHS and social care system seems an obvious way to go.”  Let’s not quibble over names; it is roles that matter. Whether it is called “Healthwatch”   or something else, a new-look English CHC rose by any other name would smell as sweet, so long as it was up to the job.

The painful truth

“Text cloud” for this post below, created by www.wordle.net

US scaremongering is a distraction

“The painful truth about the NHS” as Marjorie Ellis Thompson said in a thoughtful Guardian comment piece recently,  is that scaremongers in the US are distracting us from the real debate about British healthcare:  “What is important is that we acknowledge the need for adaptation and change without sacrificing the central principle of equal access to healthcare, an argument that apparently terrifies those who are lucky enough to be insured in the US.” Quite so, but how to do it?

This is a stiff challenge for citizens to get to grips with because it has got harder recently to have a serious discussion about the NHS without tripping over some politician or other trying to shout louder than the rest.  If it isn’t a maverick MEP hurling vitriol about the NHS being a “60 year mistake”, then it is the Health Secretary’s sanctimonious rebuttal to such talk as “unpatriotic”. Did no one forewarn Mr Burnham of Dr Johnson’s pungent observation “patriotism is the last refuge of a scoundrel”?

Caught in the crossfire

All in all, this is not a pleasant crossfire to be caught in. The big guns are out for points and the sniping isn’t likely to die down much between now and upcoming election.  Most people will keep their heads down.

Donning my tin hat and venturing above the parapet nonetheless, I too see a painful truth about the NHS -  in the form of the shackles that bind it to party politics of all persuasions.  There will be no resolution to what passes for “the debate on the NHS” as long as political parties still have breath in them.  To have a proper debate, we need to separate “health” from “health systems” which are about delivery.

Health is not delivery

“The NHS” is just a delivery system, albeit one that has assumed the position of a surrogate national religion.  It was created out of a now-vanished post-war context to address issues like communicable disease (think TB and diphtheria, not swine flu) and the debilitating effects of grinding poverty on large sections of the population.

To be fair, it has delivered quite a lot in its 60 years – far more in fact than Beveridge, Bevan and the other founding fathers could have foreseen. But continuing to tinker with its basic design has little impact on the underlying factors - economic, educational and behavioural - largely determining the health of individuals and communities.

Outcomes matter for health

What we really need to be debating is not another ratchet of system reform, but something which is more fundamental: what do we really want in terms of health outcomes? Once that is clear, and no one should pretend it is an easy question to answer, then the job is to build new systems to encourage, incentivise and deliver those goals. Politicians should be facilitating that conversation rather than indulging in quasi-patriotic sloganising – or worse “twittering” – about who is better at loving the good old NHS.

Sadly, the 1948 model however much we flash it up in contemporary livery and lavish love on it is never going to deliver enough of what is needed. Other models in other countries have feet of clay too, so this isn’t a paean of praise for any one of them.

Thinking about ends is hard work

As informed citizens we should be addressing three questions: “what is a health system for?”; “who should be its owners?”; and only when there is a consensus on the first two, “how should it be paid for?” These are mainly questions about ends not means. It is our almost universal preoccupation with “means” that keeps the real issues in the background. Until they come centre stage, expect confusion and frustration to be the main outputs from the current “debate”.   And expect the politicians to shout even louder.  Ear defenders anyyone?

Climate change warning for the NHS

“Text cloud” for this post below, created by www.wordle.net

A latitude lesson

We may not think much about it, but in these islands latitude should be a big issue. Get a map out and see what else lies between 50 and 60 degrees North. The British Isles are on a parallel with the Labrador Peninsula in Atlantic Canada (think long, cold, hard winters and migrating Polar Bears).

Despite our national propensity to moan about the weather, the British Isles generally enjoy a much more temperate, even occasionally balmy, climate than it otherwise might thanks to the benign intervention of that miracle of Nature called the Gulf Stream wafting a bit of the Gulf of Mexico to our shores and skies. Should it ever desert us, a climate more akin to our high northern latitude – Labradorean winters even – would not be far behind.

That climatic change image came into my mind as I scrolled through the recent publication from the Kings Fund and Institute of Fiscal Studies laying out scenarios for “how cold will it be in NHS finances after 2011“?

Aesop had it right

We’ve had a financial version of a beneficent Gulf Stream in the English NHS recently with unprecedented investment during the current Comprehensive Spending Review  – nearly 7% real additional funding each year since 2000.   That level was always going to be reduced substantially at the end of the current funding round, but the global financial situation makes it likely the effects will be more severe.  If the “investment Gulf Stream” departs, what will financial climate change in the NHS be like?  To answer that question, the Kings Fund paper lays out three scenarios:  “tepid”, “cold” and “arctic.”   Don’t expect politicians to talk much about this because the next decade’s pain has to be faced no matter who will be in power.  So why not swallow hard and face it now before the chill really hits us?  Aesop’s moral lesson about the grasshopper and the ant cannot be postponed: “It is best to prepare for the days of necessity”

Bracing but not perishing

Locally our PCT is facing a likely “zero growth” scenario post-2011.  I don’t think that means we will freeze. My personal view is that this will be “bracing” – remember the LNER Skegness holiday poster? – but not “perishing”.   It will be an incentive to us as commissioners to keep moving briskly along the road to more efficient use of our resources and send a message to our providers to get better value for money from what they do and where they do it for our population.

Some of the anticipated funding gap can surely be closed by increasing efficiency, but we need to scrutinise things now before the big chill starts.  Recently Niall Dickson CEO of the Kings Fund was quoted as saying as much: “There is enormous scope still to redesign services and reduce variations in performance – such as making sure all areas are following best practice and investigating why areas with similar populations appear to spend widely varying amounts on services such as mental health and cancer care. “

Invest like the best

This week’s HSJ takes this theme forward by claiming, based on comparisons between high spending and lower spending PCTs, that up to 20% savings were possible if we all spent as efficiently as the best.

Yes, as critics of this approach have pointed out, there are clinical and population variations in these figures and, yes again, it’s improved health outcomes that matter not levels of investment per se.  Despite these things, however, there must be something worth investigating in this spread of expenditure related to results which the DH’s programme budgeting data throws up.  If we want to be smart health investors we can’t ignore this.  I’d like to see our PEC devote a special meeting to this.

Even if it only helps us to make a start on understanding what value and outcomes we are getting for our commissioning ££££s it should be worth it. In Nigel Edwards’ graphic phrase: “We have to use this data as a tin opener and then burrow underneath.”

Part of that burrowing must be about talking to the users of current services and getting their views on what could be done better for less.  I would like to see GPs sit down with patients who attend out-patients and clinics and find out what could be done more conveniently, quicker or not at all. Commissioning clusters of local practices need to get their teeth into real change in the acute sector. Some of this happens, but not enough.  PCTs and their local government partners must work ever more closely together to address what really matters about improving health.  They must work in tandem to clear away barriers to seamless services that actually address real inequalities that are lifestyle-related.  It’s not as if there isn’t plenty we could and should be doing right now before the thermometer plunges.

Avoiding the arctic scenario

We have a choice of course: either do things better in a sustained way with the same or, preferably, fewer resources, or, as in The Winter’s Tale, prepare to exit stage left pursued by a (polar) bear into an arctic funding scenario.  I don’t fancy our chances with the latter.

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