Raj Persaud: A doctor's diagnosis - the NHS is not recovering

Managerial inefficiency is endemic and, as a result, quality of care continues to deteriorate
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The Independent Online

You would have expected those who work in the NHS like myself to be thrilled at the Health Secretary's announcement of 15 new NHS hospital development projects in England, together worth £4bn. John Reid describes this as "genuinely a renaissance in hospital building in this country". Well, we doctors are intrigued to be told we are working in a "renaissance", as we are flummoxed as to where all the new money has actually gone. We haven't seen any of it.

You would have expected those who work in the NHS like myself to be thrilled at the Health Secretary's announcement of 15 new NHS hospital development projects in England, together worth £4bn. John Reid describes this as "genuinely a renaissance in hospital building in this country". Well, we doctors are intrigued to be told we are working in a "renaissance", as we are flummoxed as to where all the new money has actually gone. We haven't seen any of it.

Not only do we not notice any positive improvements in our working conditions, or the service we can provide for our patients, the system seems to lurch from bad to worse with each passing day. As I write this I have just been called by the Liaison Psychiatric Team for the local acute hospital to be told there are no doctors in its unit today. Both consultant and junior doctor are on leave and medical staffing has not provided a junior doctor. There is no consultant in the team because the trust has historically never provided a locum to cover consultant leave.

Last weekend I was the consultant on call covering the whole of Croydon for psychiatry - a population of some 300,000. I was rung late on Friday night to be told that medical staffing had been unable to provide either of the two junior doctors meant to be on call with me. This experience of a service constantly stretched to the limit and beyond is a daily reality for most staff and patients around the country.

I know of two parents whose son was acutely psychotic and looked after as an in-patient in another trust. After having improved on medication, the child began to deteriorate mysteriously. The staff were perplexed by this downward turn, but it was only when the parents accidentally saw the drug chart that they discovered to their horror that the medication had been omitted, by an administrative oversight, for several weeks. From then on, the family themselves had to check the drug card (with permission) each week, as the only way of guaranteeing their son received the treatment for which he was in hospital.

When I tried to draw the attention of a medical staffing department to the fact that they were frequently leaving clinics and wards without any doctors manning them, they filed a complaint about me for daring to suggest that one of the chief reasons a patient might come to a hospital was the expectation, of seeing a doctor.

The horror stories, which go on and on, would turn your hair grey (they have done so to many of my consultant colleagues). But the recurrent patterns are there for all to see, and yet the Government remains reluctant to tackle the real problems at the heart of the NHS, which is no longer a pure funding issue, but centres on profoundly outdated and inefficient management structures that relentlessly seek to exclude doctors from shaping the service. For example, the management has recently taken away my - and my consultant colleagues' - ability to admit those patients we feel require (expensive) hospital care.

As the NHS is a monopoly supplier of health care for the vast majority of the population, it suffers no consequence for failure, and managerial inefficiency is endemic. As a direct result, quality of care continues to deteriorate. While the Government is obsessed with targets and figures, few if any of these refer to actual quality of care - they are hoping the electorate won't notice the sleight of hand.

Dr Reid recently declared that, compared with 1997, there are 67,500 more nurses working in the NHS and 19,000 more doctors. And there are 258,000 fewer people on the in-patient waiting list compared with March 1997. None of this tells us is anything about the actual quality of care being delivered - an issue much more pertinent to a patient' s experience and wellbeing, but also more difficult to measure.

Official figures suggest that the annual increase of nearly 10 per cent in the cash budget of the NHS, in the five years to 2003, has brought only a desultory 2 per cent annual increase in output. The figures are so appalling (and therefore politically dangerous) that one of Britain's top economists, Sir Tony Atkinson, of Oxford's Nuffield College, has been asked to investigate.

Controversially, the solution advocated is to incorporate "new" ways of including quality; and lo and behold, the revised figures for productivity, which have benefited from this new massaging, recently released from the Office for National Statistics, have shown that annual NHS output is up nearer 4 per cent compared to the previous 2 per cent figure.

The danger is that quality of care could become the next WMD issue for the Government. If ministers repeatedly assure us that quality is improving in the NHS, then it must be, even if no one can find it. Most consultants and doctors will keep their heads down, rather like the intelligence community did just before the war. We all hope not to become yet another acceptable casualty on this new front on which the next election will be fought.

The writer is a consultant psychiatrist at the Maudsley Hospital in London

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