A junior manager once asked a senior vascular surgeon why he did so many fewer day case aortic aneurysm repairs than his colleagues. Surely it would be so much more efficient and save hospital costs to do more of his cases as day cases?
The surgeon's answer is thankfully not recorded. What the manager had not appreciated was the difference between elective aneurysm repairs (which need recovery time in hospital afterwards, and have a good chance of getting home) and ruptured aortic aneurysm cases admitted acutely (usually rapidly fatal.)
Now let us assume that the manager was intelligent, and well meaning. And that he didn't want to ask a foolish question. His question still shows a deep lack of knowledge of what he is supposed to be managing. He can count figures and categories, but he has no idea of what they mean either in terms of the medicine or patient experience involved. The surgeon understands the medicine well, and hopefully also his patients.
This example of mutual incomprehension can be multiplied up throughout the health service. What we see is a mishmash of misaligned policies and incentives that are actually inimical to good patient care. We see glaring gaps between rhetoric and reality.
In my own area, for example, the district nurse teams have been reconfigured. Existing DNs have been moved to new teams so that rather than working with people I have known and trusted over many years the patients and the doctors will now have to meet a whole new group of district nurses. A structure that was working well has been needlessly disrupted, and will be less functional for some time to come. DN morale has dropped significantly.
In medicine we are taught Hippocrates's great instruction, "First, Do no harm." As a doctor I wish NHS managers would learn to understand its wisdom. This change has been entirely management-driven, for no discernible clinical reason, and done with no reference at all to doctors or patients who will be intimately affected by these changes. Meanwhile, in a parallel universe, NHS management prattles on about "clinical engagement".
At the highest levels we get endless talk about "patient centred care", "reconfigured care pathways", "seamless services", "choice", and "high-quality care." But at a practical level we need to remember that local NHS trusts have three main survival goals – to stay within budget, to make it appear that government targets have been met, and to avoid any major clinical incidents or other adverse publicity.
Meanwhile, at a structural level, the financial drivers of the NHS are now Payment by Results (PBR), the "tariff", which pays hospitals for activity; World Class Commissioning (WCC) by Primary Care Trusts (PCTs); and Practice-Based Commissioning (PBC) by GPs. As you can see, acronyms abound. The focus throughout, however, is on costs and activity, not on patient care.
Money is easier to count than outcomes. No one fully understands how it will all work, either in theory or practice, though many, particularly in management consultancies, pretend to do so. So the result of this tariff system is that the care of patients get broken up into ever smaller segments of care. These segments can then become the focus of a tendering process between competing providers.
Unfortunately, this drive to itemise medical care into smaller and smaller segments mismatches the practical needs of most modern patients. Very few patients now have just one specific problem to fix. Most of the patients I treat are older, and have several concurrent illnesses, as opposed to one single problem and need complex balances to be struck between treating one illness whilst not making another one worse. Medicine has been moving away from an acute problem model for several years towards a chronic disease management model.
The McKinsey report underlines the present drive in the NHS to present hospital care as bad and expensive and to present primary care as good, cheaper and local. We are increasing the gap between primary and secondary care, leading to gaps in care as patients move through the healthcare system. Little wonder there are so many patients left unhappy by their treatment in the NHS.
The NHS – which is a national system, after all – has an opportunity to be an integrated care organisation that gets its parts to co-operate with each other smoothly to achieve good results for patients. This is the target that we should all aim to meet. Instead, what we see at present is a drive to fragmentation. The result is an NHS that while good in parts, is always less of a whole than it could be and should be.
Peter Davies is a Yorkshire GP and author with James Gubb of 'Putting Patients Last: How the NHS Keeps the Ten Commandments for Business Failure'Reuse content