Friday 16 August 2013

How to grasp the NHS nettle

I have huge respect for the NHS blogger Roy Lilley and follow his blogs avidly, almost the only one I read every time it is published.  He is extremely influential, by virtue of his enormous readership, and rightly so.  In recent weeks, he has been asking rhetorically how the NHS needs to change.

This is an important question.  There have been a string of high-level NHS reports saying non-specifically that the NHS has to change, and warning of imminent system breakdown, but there are precious few answers to the question: how?  Few of them dare do more than tweak.

Even so, the recent CQC report into the hospital at Whipp's Cross is embarrassingly familiar and it does crystallise the problem - inadequate staffing, food put out of reach of elderly patients, not enough care or consideration.  There is a problem out there, and although it isn't exactly clear why the NHS is facing a crisis now - its funding is ring-fenced after all - something is going on.

Partly the situation is politically confusing.  There are elements where the last government is clearly to blame (the failures of the CQC and the PFI debt crisis) and there are elements where clearly it is the fault of the coalition (benefit changes, or fears of benefit changes, which emerge as extra demand on primary care and A&E).  There is too much positioning, not enough prescription.

So I've been asking myself what I would do, and - since my family tells me that my blog is too filled with middle-aged complaints - I thought I would share the ten-point Boyle plan:

1.  Consolidate the ruinous PFI loans: they are the looming public sector debt crisis, five years after the private sector debt crisis, and they need to be dealt with the same way - taken off the books of the trusts and put into a special financial vehicle designed to re-negotiate them and remove them.  They may otherwise cost over £300bn, a huge drain on services.

2.  Abolish the centralised inspection system: Roy Lilley is absolutely right that the CQC must go and its duties be handed to local Clinical Commissioning Groups.  Monitor is still required: it needs to take charge of failing trusts.

3.  Share the work with patients: the time has come for major investment in people-powered health and co-production, which Nesta believes will save at least £4.4bn and maybe considerably more.  It is extraordinary that this is happening so little.

4.  Take rights in new drugs: the government invests in health research but gets none of the financial benefits, while the drugs bill  (now £11bn a year) spirals.  Pricing according to the financial benefits of drugs, the current strategy, is not adequate (more on this another day).

5.  Sack boards of failing trusts: there must be some sanction against the boards who allow their hospitals to end up inhumane places of care.

6.  Hand back out-of-hours care to GP practices: easier said than done, I know, but the present system is a disgrace and a blot on the reputation of GPs.

7.  Hand over patient records to patients: they should own their own data and give access to professionals that need it, rather than the present wasteful system of parallel agencies asking patients endlessly for permission to share (see PKB for example).

8.  Do most follow-up appointments electronically: there is huge spare capacity in the system just because consultants have a rigid system that requires face-to-face follow-up appointments every six months, whether people need one or not.

9.  Encourage hospitals to invest in primary care: they have the motivation to invest in prevention.

10.Investigate the perverse incentives: too many patients are being given the runaround because hospitals can charge more.  All gaming behaviour that wastes resources for the system as a whole must be defined as 'anti-competitive'.

By which I mean that we will have an NHS which is not leaching money to PFI contracts, which is delivered partly by other patients and which is a great deal more flexible.  I hope it will also fulfil Roy Lilley's claim this morning, that kindness is more important than technology, skills, drugs or investment.

And when you've done all that, I have a few more up my sleeve...

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