I’ve just spent 3 weeks on a trauma ward in a northern hospital after a nasty accident, and coming from an industrial background, here are some thoughts on the NHS and a Lib Dem approach.
First and most importantly, hospitals are large, high tech and high skill businesses. They are continually investing in equipment, and the best hospitals will have motivated doctors, nurses and managers who take ownership of their jobs and are part of the process to continually improve the clinical excellence and effectiveness of the hospital. Hospitals share many of the challenges of excellence with manufacturing businesses.
What are the barriers to excellence? I will give just one: capacity.
I know of no business that can be excellent while running at maximum capacity most of the time. A business running continually at 100% capacity is fire fighting, lurching from one crisis to the next, lacking strategic direction and usually having a stressed and irritable staff.
A business that runs at, say a capacity between 70 and 100% will be under pressure for short intense periods, but will normally be under control and will be able to follow the right clinical path for every patient nearly all the time. A hospital can provide excellent care on this basis.
For most of my time on the ward, every bed was full. I don’t know what happened when new patients were admitted through A & E. They couldn’t come on to my ward. Some inefficient compromise will have had to take place, wasting staff time and reducing clinical effectiveness. In contrast, when a bed or two became free, they were sometimes taken by patients like me in for a while. On other occasions, patients with fractures were given a bed overnight so the fracture could be monitored and subsequently x-rayed. The free capacity allowed for clinical excellence.
I identified two structural reasons for the lack of bed availability. The first reason was that the patient, having finished their clinical care, had nowhere to go. It is a compelling argument for joined up interlinked NHS services like a business supply chain. Norman Lamb wrote on this subject on LDV on 14th May.
The second reason was the attitude of some patients. I was, frankly, appalled by the way a minority of patients treat the NHS. For them it is a 5* hotel, where they can walk in and out of the ward as they please and expect instant attention. The result of this attitude was that the clinical care that the hospital wanted to give was undermined and drawn out by the failure of the patient to cooperate. A patient who should be in for a couple of days would be in for a week. When I asked the nurses about this, they made it clear they were pretty powerless. And a reading of the NHS Constitution (and particularly page 11) gives about as clear a message of entitlement without responsibility as it is possible to give. The Labour Party has indeed hijacked the NHS. A Lib Dem NHS will always be about the rights of a completely universal service AND the patient responsibilities that go with it.
One last thing: competition. In my recent experience, competition was largely irrelevant. It was clinical excellence that was critical. Excellence exists in both the public and private sector. The NHS isn’t a monopoly in the way the water companies are, and there is clearly a role for innovative excellent private companies within the NHS supply chain as part of a dynamic culture of an excellent health service.
* William Hobhouse lives in Bath and is co-founder of the Lib Dem Campaign for Manufacturing.
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4 Comments
You missed out one barrier to excellence; the lack of individual accountability in the NHS. There’s a culture of shared responsibility which serves to hide individual incompetence and negligence. I look no further than my own recent experiences in hospital.
– the nurses refusing to dress my wound because it wasn’t their job. For a fortnight I had to do it myself. This while I had a life threatening infection that nearly killed me.
– dirty sick bowls being left for 2 days at the weekend because it wasn’t anyone’s job to tidy the ward on a Saturday or Sunday.
– My father being given an overdose of morphine. Twice. After waiting 18 months for an operation after a cancer diagnosis (and having the operation cancelled three times, once because of no instruments being available)
– My 80 year aunt being sent to the VD clinic for chiropody! Then being called at home (she wasn’t ill) to come and collect herself because she was ready to come out of the ward now.
– Last month, being sent an appointment for an urgent cancer scan – for someone else.
– Being given 5 other peoples’ prescriptions folded inside my own. Then being told it wasn’t their fault.
– Taken ill at my mother’s house and being told to go back home if I wanted a doctor because they weren’t allowed to travel 2 extra miles to see me. I had to get a taxi to the hospital where I was admitted for 2 weeks.
These are just one year’s personal experience of the NHS in my city.
On the other hand, my stay in hospital was of the highest quality, despite my bad behaviour. They were polite, courteous and utterly professional, remaining concerned about my health even though I was, to say the least, trying.
William makes the same mistake as many industrialists, that of taking industrial practices and norms and trying to force them into areas where they are not appropriate. So with operating at capacity. In industry this can only be done in short bursts because the profit motive promotes having the minimum staff to do the job. In, for instance, the NHS, capacity should (note the should) be sustainable because staffing should (again, take note of the caviat) be such that capacity can be sustained for prolonged periods.
Now we come to the rub, and where our health service is falling down. Not only are wards NOT staffed to run at capacity, many wards are not staffed to their planned establishment. Just as with the Armed Forces, the government expects, no – demands, that NHS staff punches above it’s weight.
The reason for this is obviously funding. Worse, it is because of the savings being forced on the NHS. Administrators are being cut, that administration still has to be done and so the NHS has to rely on already overburdened nurses. That wards are running at capacity without appropriate staffing will result in the NHS falling into crisis (if it hasn’t already reached crisis point).
The solution? Economic liberals are not going to like this, but there is only one way to solve the problem and that is to fund it adequately, and to do that we will have to raise income tax
In response to both comments from Meg Crosby and ‘A Social Liberal’: inefficient, ineffective or just plain bad care in the NHS isn’t just about how much money is thrown at the problem. If a hospital can operate under control at a sustainable capacity with steady procedures and structures, the level of care should be consistent.
Where care goes wrong is when the staff are lurching from one crisis to the next. Resolving this is a management issue, and if got right, doctors and nurses can get on and concentrate on providing the excellent care that is our aspiration for the NHS.
The NHS has plenty of unused capacity because it virtually shuts down at weekends. Expensive equipment and operating theatres are left unused. This is a management issue but clearly also a funding one.
I have had to take my partner through A&E on several occasions including once over a New Year when the beds were fully occupied, with patients ‘ sleeping out’ in the wrong places and doctors running around looking for them. He passed through two ‘ wrong’ wards before ending up in the right place. This did affect his care because the drug trollies are supplied with ward-specific drugs which were not what he needed. An recent emergency admission during the week was much more efficient ( and indeed life-saving) .