“Why do you keep mentioning the NHS, Alun?”

“Why do you keep mentioning the NHS, Alun?”

Is one of the questions that I am asked. Main answer: because I have a longish memory and have read a lot about the evolution of the organisation that, to quote the Tory ex-chancellor of the exchequer Nigel Lawson’s memoirs, “the nearest thing the English have to a religion”(google it for a day well spent reading opinions in support and otherwise.)

I started work in general dental practice on April 2nd 1981. There had just been an NHS patient fee contribution increase from £8 to £9 for a routine course of treatment; the principals in the practice thought this would deter patients from attending but, apart from the odd “I see you lot have another pay rise” comment, nothing changed, or so I gathered. The NHS reforms and the, Mrs Thatcher led, assault on professionals and their status was just gathering strength. Soon would come the abolition of the hospital consultants’ dining room, seen by some as an exclusive club but in many cases used as a secure and confidential place to exchange ideas, clinical opinions and get advice on patient care. Through the 80’s in dentistry came repeated maximum patient fee hikes until Kenneth Clarke’s introduction of a “percentage” of the total changed the model significantly so that dental charges were no longer the “prescription charges” for teeth but reflected the cost (tho’ not always the value) of the treatment delivered.

Enough of history.

The words of advice I was given in 1981 were:

  • You’re a self-employed professional,
  • You happen & choose to contract out to the NHS for each and every course of treatment,
  • Never forget that you are an independent,
  • Only you decide what you will do and under what model you choose to work,
  • You studied a subject at a university to be used for the benefit of individual patients,
  • Don’t make the treatment fit the system,
  • Listen to these rules and you’ll keep your own sanity, your soul and you’ll be a success long term.

I never forgot those words especially the first couple of lines, and when the model offered by the NHS became unbearable for me to work with in the early 1990s I chose not to take their contracts and stood on my own two feet as a business. I think UK dentists especially the younger ones need to be reminded of their independent status before it has slipped away from them entirely. There is no such thing as an NHS dentist or an NHS doctor they are dentists and doctors, nurses, midwives etc etc all independent trained to be professional first, second and third.

This long preamble is in order for me to quote in full Roy Lilley’s blog piece today. He sums up a lot of my present thoughts. In Margaret Heffernan’s book Wilful Blindness she argues that our biggest threats are not the things we cannot see but those that we can. But choose to ignore.

“You already knew that!

Last week was another action packed week on the road.  I found a clean BP petrol station loo!  Thank you, everyone, for your warm welcome.  At one event I was taken to one side by a very elegantly dressed lady of a certain age (Gucci Soho patent leather shoulder bag, Eleonaro black riding boots, Thomas Pink raspberry gingham shirt, Tyrwhitt black crepe suit… you know the type) a very experienced business woman and non-exec… she asked; ‘Do you know what’s going on… really?’

She laughed, I laughed and said; ‘It’s complicated!’

What is going on?  I think this is what she meant.  The NHS is in the SH-One-t:

  • At the end of July 2013, almost half of non-FTs forecast a deficit for 2013/14. The collective position for all these trusts?  A forecast deficit of £232 million for the financial year.  Ouch!
  •  Crucially, margins for earnings before interest, taxes, depreciation and amortization (known by finance types as ‘EBITDA’) are nose diving across all Trusts, except specialist FTs. This is a crucial indicator of whether a hospital is financially viable.  Double ouch!!
  • Nearly half of non-FTs ended 12/13 below the 5% margin Monitor would normally require to grant FT status. A further 40 FTs were also below this benchmark!  Translated; this means about a third of all trusts are financially flaky and bluntly, there is not enough money and there are too many hospitals.  This is beginning to look like a melt-down.  Triple ouch!!!

The solution?  Trusts could up their game.  However; the Nuff’s Trust research on 110 Trusts suggests that the rate of productivity growth has not improved since the beginning of QIPP in 2010/11. Better productivity won’t get anywhere near the savings at the levels planned.  Forget it.  More ouch!

How many governments have tried to provide better care for less, by treating people outside hospital?  Sorry; it’s not happening. Spending on the secondary care continues to rise while GPs have seen real terms cuts. Reducing emergency admissions has been a key priority… I’m sorry to report… the most recent figures show that they are increasing.  Even more ouch!

Shifting care out of hospital to GPs and primary care isn’t working.  A number of evaluations show very limited evidence of these schemes reducing emergency hospital admissions in the short term… ouch.  Just ouch…  ouch… ouch.
Source The Fabulous Nuff’s latest report.

Got all that.  It’s really code for; we have too many customers and not enough money and crucially, no idea what to do next.  It’s, sort of, the private sector equivalent of over-trading and the road to hell in a hand-cart.

The Nuff’s fabulous Chief Economist, Anita Charlesworth said:

“The NHS faces an unprecedented challenge in finding savings of 4% per year. This will be difficult to achieve through productivity improvements and there are no clear signs of initiatives so far making savings by reducing emergency admissions to hospital.
 
Meanwhile, although pay restraint and management cuts have created large savings, these cannot close the long-term funding gap without threatening the quality or sustainability of care services.
 
We need to monitor the signs that this challenging situation could lead to an unsustainable financial squeeze on hospital trusts. Recent figures show that smaller hospital trusts and those which still have to become foundation trusts face particular difficulties. The weakest hospital trusts appear to be getting weaker but will still face pressure to increase spending following the Francis Inquiry and initiatives such as “seven-day” working. Policy-makers need to think about how they can deal with the situation.”

I don’t know why everyone at the top of the politico-policy food chain is so mealy-mouthed.  Trusts are too busy dealing with demand on inefficient services that are very busy and can’t become more efficient because they are too, very busy… dealing with demand.

If the NHS was a business it would be broke, bankrupt and skint.  If you bought it you would have to plunge a massive amount of money into efficiency-gains and hope to get a return in 40 years.

Last week I picked up palpable concerns that the wheels are coming off.  In the meantime Le Tache and other NHS bosses run around like headless chickens saying ‘the NHS has to change’.  My guess is they have no idea ‘into what’ and if they did they’d not have the cajones to say.

So, that’s what I found out last week… but I guess you already knew that! “

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