hamish dibley

Home » 'Front-to-back' thinking » Time for a dose of healthcare heresy

Time for a dose of healthcare heresy

Help WantedRather predictably, the political debate over the latest crisis afflicting the NHS is generating more heat than light. Superficially rules. Discourse reduces itself to a reverse Dutch auction over who can promise more cash whilst at the same time compete to declare unconditional support for the NHS. Stephen Dorrell, former Health Secretary and Chair of the Health Select Committee is on to something when he was quoted in The Economist magazine last year saying that anyone who tries to introduce knowledge and understanding to the issues ‘quickly finds out what it must have felt like to be regarded as a heretic in a more religious age’.

Fast forward to the begininng of a new year and we see numerous acute hospitals triggering ‘major incidents’ in response to ‘unprecedented levels of demand’. Their response is often to hold ‘extraordinary meetings’ that occur with such regularly they lose their original connotation. Hopes that periodic cash injections like the multi-million ‘winter bed pressure’ funding or ad-hoc ‘urgent summits’ will resolve the current predictable morass facing acute NHS hospitals is a fool’s paradise.

In fact, we have worn out all the possible tinkering approaches: from restructuring and merging hospitals to only achieve bigger problems; deliberately fragmenting the healthcare system so that no one reliably knows who is doing what, why, when and where; successive bouts of IT-led change that cost more than the benefits derived by both patients or professionals; imposing arbitrary targets that distort behaviour (such as the ubiquitous 4-hour waiting time indicator or referral to treatment times) and lead to ‘gaming’; increasing capacity which makes performance worse to rationing care (particularly in community and social care settings) that results in a false economy.

Indeed, the belief that we can simply talk or spend our way of trouble is indicative of a paucity of understanding. It is worth remembering that since 2000 we have tripled public expenditure on the NHS but not experienced service improvements consummate with such investment. Years later we still feel the need for calamity talks and emergency bailouts.

Such inertia and belief in extra expenditure is a costly distraction from consideration of the real problem facing the NHS; namely that we have an outdated model of healthcare that is capacity-constrained not demand-led. The current crisis of increasing attendance and admission rates (not the same thing as increasing numbers of people) to A&E is one consequence but not the primary cause of the turmoil.

It is possible to achieve the holy grail of healthcare: better care at less cost but this will require a complete resetting of how we intelligently manage, lead and apportion expenditure across the whole system. The only way that will work is to understand the nature of patient demand that appears and then develop a coordinated healthcare response (through redesigning broken systems, processes and payment mechanisms) that meets local needs – no more, no less.

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