Blog 2023 Malcolm Blair-Robinson

Not yet anyway. Meanwhile it is strikes, the NHS, collapsing concrete, passing the buck, high interest rates,  falling house prices or a government of musical chairs unable apparently to get a grip or exercise control.  All of this unending bad news stems from two related ideologies. One is that the individual is greater than the state and the other is that the state is subject to market forces. Both of these are said by believers to be the highest examples of freedom when in fact, for the vast majority, they devour it.

Add to that cuts, economies, efficiency savings, project postponements and austerity over very many years and you end up with a deformed economy which cannot deliver. That is what we have now. Hunt and Sunak can tinker at the margins to effect marginal improvement, but in the end there will be only marginal recovery, nothing sustained, no great leap forward. At the first adverse event, and there are many coming down the track, the decline will return.

What is needed is a complete overhaul and restructuring of our system of government, our economic model, our economic management, our control of money and our social and strategic priorities. We need an industrial policy, a housing revolution and direct delivery of energy to business and households. Quangos, regulators and apologists engaged in scattering responsibility to avoid direct ownership must be consigned to the dustbin.

None of this will happen because we have  a political class of the utmost incompetence and mediocrity. Hidden within it, eclipsed by the lies and broken promises of their peers, lie waiting a small number of sharp minds with the capacity to do something worthwhile. To empower them something has to blow. When it does, the bang will be big. Make no mistake about that.

Only then is there any chance of a fresh start. Without it, it’s down hill. All the way.

There is an unwelcome culture now embedded in the English structure through which the State and its outsourcing satellites runs our public services. Or responds to unexpected emergencies and events. Late or never delivery, cover ups, buck passing and warnings ignored are no longer the exception but the rule.

This has to change because while in the past these things caused a short term storm, it passed and people forgot. Except for those whose lives had been  affected, often ruined. But now public attitudes have very much advanced through social media and platform sharing, to the point where their information is more up to date and accurate than the official line. Once they spot a problem they cannot be bought off with platitudes nor will they let go.

A properly researched list would be almost endless and way beyond the resources of this blog. But into most people’s minds spring Contaminated Blood, Bloody Sunday, Weapons of Mass Destruction in Iraq, The Post Office Horizon scandal, Grenfell and the ongoing small boats. Current news dwells, quite rightly, on the outrageous Michaelson miscarriage of justice and the horrific Lucy Letby serial killings.

It is always the same. Warnings unheeded, the problem ignored or if revealed covered up. Then when it bursts into the open, nobody owns it, nobody is responsible, nobody goes, an inquiry comes to indecisive conclusions long after the event, when public consciousness has moved on.

Well that has to stop. Or else the people, in a convulsion of anger and despair will stop it. That would traumatic and the collateral damage vast.

Time is running short.

NHS Reports of using spare capacity in the private health sector to help deal with backlogs in the NHS make sense. In the short term this is the obvious route to improvement, as it does not require massive reorganisation of the NHS. To be effective it needs to be disciplined and working to a programme, rather than ad hoc here and there. The situation demands something like 70% of private sector capacity being used to treat NHS patients. The other positive in the headlines is talk of diagnostic centres separate to hospitals.

NEW OIL DIG LICENCES Net zero campaigners are justifiably outraged by such a retrograde proposal. There is however some logic in this, although the government has as usual been cack-handed in its messaging. Even if we proceed with renewable energy development at pace, including power lines to distribute it, we will need a run off of fossil fuels, currently mostly imported. If we can reverse that, use only home dug and get it into the national grid, not only will we be reducing our carbon footprint by avoiding imports, but we will be creating real new money as well. For a financial model addicted to relying on borrowing and printing this is good news.

INTEREST RATES Up again, but softly with an 0.25 rise rather than the bolder 0.5. The trouble with this steady as we go approach, now in its 14th attempt, is that it puts off the moment of recovery so far into the future, that flatlining for not just months, but years, is seen as a good outcome. This is very not so. At the moment it is beginning to look as if the fifteen years it took to deal with the last bout of inflation illness maybe what we are in for this time. Meanwhile all the other major economies appear to be doing much better, with the US where the latest figure is under 3%, very much better.

As I said in my last post, the organisational structure of the NHS, both medical and administrative, is dysfunctional. Unless you are addicted to queues, waiting lists and  needless suffering. Failure to actually deal with these issues, apart from tinkering, promises and announcements, now threatens the very future of the NHS as a public service. Handing over to the private sector to set up an insurance based US style model is a real threat. Yes it would be political suicide, but with the state of the national financial model on the edge of serious failure, there may suddenly be no alternative.

So to avoid disaster there must be a plan.  Here is an outline of one to get the debate going.

Let us first deal with what has to go. The entire GP system, with separately contracted self-employed doctors trained and paid for by taxpayers, yet increasingly unavailable to most of them, goes. As does the the hierarchical structure of  of the medical profession.  Care, cure, remedy and repair are about teams not ranks.

Hospitals that close at night and at weekends, on the model of a department store, when only emergencies are accepted out of hours, must end. Not least because it costs more to shut them than to keep them open, but primarily because it hobbles outcomes and is nectar to lists.

Finally junior staff, over-worked with very long hours and so underpaid many leave, will stop. As will doctors currently ranked as ‘consultants’ working limited hours for the NHS and moonlighting up the road at a private clinic, mostly treating patients recruited from one or other of their bulging NHS lists.

First what we will call Family Healthcare. This is where it all should start. The initial call and consultation with a doctor. The tests. The diagnosis. The ancillary services and treatments. Scans, blood tests, biopsies, x-rays. The pharmacists, physios, counsellors, therapists. Referrals to specialists at hospitals only when diagnosis certain. Initial consultations with doctors from family to senior level, all at this single Community Health Centre open 24 hours for accident and  emergencies and fully operational for  12 hours each day. Trauma requiring admission would go to the District General Hospital, which would have no A&E department open to the public. Specialists would hold clinics in the health centre and family doctors would always see ill patients, for example with a fever, in their homes.

Next comes the District General Hospital which would be open 24/7 fully staffed and operational, running three 8 hour shifts for everybody. Senior doctors would lead teams in which each member, from the most junior nurse upwards, would be seen as a critical and important contributor. Of course there would be respect for all and experience would be valued and rewarded, but the hierarchical pyramid of today’s NHS would be gone. All doctors would be doctors. Surgeons would be doctors, not Mr or Mrs because they were once barbers or butchers of whatever the tradition is. We need timely treatment, not tradition.

The specialist and teaching hospitals would remain the most advanced destination for the most serious conditions, as they are now. Nurses and doctors would continue to study and qualify as now, but additional intermediate qualifications would be available over a shorter learning time for assistant physicians, either as an end in itself or as a stepping stone to full qualification later. All medical training would be free but those who receive it would be debarred from private practice. Any switch later would require a payment to taxpayers of then cost of training a replacement.

It is obvious that most of this, even as a sketchy outline, is way beyond anything being discussed or planned at the moment. Much of it would be impossible under the current funding model anyway, so it must be read in conjunction with my earlier post on NHS funding.

But if nothing is done except a little of this and that, the days of any return of the NHS as we once knew it, are gone. Moreover the current creaking, decayed national treasure, with its lists and queues and suffering, will finally fall over. So the choice is getting a grip or political oblivion for the government in power when it topples. All politicians should be worried, but the Tories should be very worried indeed.

I have discussed in previous posts the bewildering systems of managing and funding the NHS, including the broad outline of a better financial model. Today it is time to look at an outline of a way a rejuvenated NHS can be built and managed.

We start with the general structure of control and direction. From 1995 governments started to tinker with the system of regional and local health authorities running the service. Independent trusts were introduced and later commissioning boards, watched over by independent regulators and quangos of various kinds. Hobbled within this spider’s web of management are the over worked and mostly underpaid medical staff of the NHS, who daily dedicate their lives to making better, and yes saving, the lives of others.

Priority is given to due process as the track upon which everything has to run, ensuring a continuous litany of failure at every level. Nobody appears to be finally responsible for anything. Outcomes vary, many from disappointing to non-existent. Nobody owns these failures, so nobody falls on their sword. If the failure escalates to a disaster, a judge led inquiry is the standard remedy. Overseeing all this chaos is the vast Department of Health and Social Care, which is itself under the political direction of no less than six ministers.

So I would start by sweeping the entire agglomeration described above, away.  We begin with scrapping the Department and returning to the old idea of a Ministry with the specific function of running the NHS. The Ministry of Health. The Minister would politically own the NHS and fall if it failed. They would have reporting to them the NHS Director General, below whom would be the Regional Directors, followed by District Managers. There would be proper interface at each level with emergency responders and other public services, but there would be no trusts or advisory boards. Nothing would be independent of anything else. This is a joined-up state service paid for by public money gained through taxes. There is no autonomy nor is there any escape. It stands and delivers on its promises or it falls as a concept.

So what are those promises to be?

If you need a family doctor you will be seen that day. If you need to be referred to hospital you will be seen within 5 working days. If you need more tests they will be completed then and there. If you need surgery or other procedures it will be done within 3 working days. If you are caught in a health crisis or an accident and arrive at A&E you will be seen immediately. There will be no such thing as waiting lists, ambulance queues, treatment on trolleys, a famine in GP appointments and all the unforgivable chaos which is now the new and accepted normal. Idiotic targets of four hours for this and six months for that are a cruel confidence trick to disguise a river of gross mismanagement and incompetence, starting in Downing Street, flowing through Whitehall and seeping into the lives of every citizen.

To achieve this transformation will require a quite different medical organisation and care delivery system. That will be the subject of my next post.

In terms of its original blueprint the NHS has already failed. Delays, ambulance queues, waiting lists, vanishing GPs, strikes and so on, put timely care out of reach to millions. Meanwhile the nation has scarcely ever been more unhealthy with lifestyle and diet issues undermining the wellbeing of millions. How to stay healthy is left to influencers with little useful input from the very organisation whose vocation, very reason for existence even, is the health of the whole population equally, without privilege or favour.

In my last post we discussed the misshapen funding model and how to resolve it. Today we look at the misshapen structure and the byzantine organisation it has been mandated by government to operate. I deal with this in my 2009 book 2010 A Blueprint for Change, but I want to revisit this because fourteen years on the NHS in a much worse state.

It now boasts 200 clinical commissioning groups, which replaced primary care trusts. These are supposed to interface with over 200 hospital trusts. However, of the 200 hospital trusts, 143 are foundation trusts, allegedly operating outside government control. How anybody can imagine that such a system can produce a joined up health service is hard to fathom, more particularly when we consider that GPs are technically self-employed out-sourced contractors, not under the formal management of the NHS chain of command.  That chain of command is itself distanced from government by a network of quangos, but contains within it no less than 2,200 non executive directors. Yes really!

According to the Cabinet Office, Non-Executive Directors (NEDs) in the NHS have a particular duty to ensure appropriate challenge is made, and that the Board acts in the best interests of the public. They should bring independence, external skills and perspectives, and challenge strategy development. NEDs have a range of roles and responsibilities to fulfill within an NHS foundation trust. They play a vital leadership role in ensuring NHS boards act in the best interests of patients and the public. They bring different perspectives and provide constructive challenge from a strategic viewpoint¹.

Non-executives use their skills and personal experience as a member of their community to formulate plans and strategy. They bring independent judgement, external perspectives and advice on issues of strategy, vision, performance, resources and standards of conduct and constructively challenge and help develop proposals on strategy²

This is just absurd. A vacuous declaration of meaningless words and phrases. The goal of the NHS is outcomes not expressions. It does not need ‘independence, external skills and perspectives’. It requires  delivery of outcomes, responsibility and ownership of events. The three key words are delivery, responsibility and ownership. Who is the boss? What are they delivering? Whether they succeed or fail it is down to them. There is no need for committees, boards or wafflers.

My next post will offer a new NHS model which prioritises outcomes, pinpoints responsibility and abolishes not only quangos and regulators but infestations such as process before performance and reputation above responsibility.

It will also abolish targets and eliminate waiting lists. Watch out for it. Links will appear on Twitter, Threads and Facebook.

The NHS is probably the most comprehensive health service in the world. But it is now in crisis at every level and in every sphere. From time to time I plan expose what I believe are fatal flaws, which hobble its outcomes and frustrate both its selfless, overworked and dedicated staff as well as its suffering patients. Today I want to talk about money.

From the moment it was founded the NHS was launched on a mathematical impossibility. You cannot provide an infinite service on a finite budget. Yet it has always been the case that the NHS has had to work within the financial constraints or generosity (the latter not very often) of the government of the day. But the NHS, while planning large numbers of pre-booked procedures, investigations and treatments,  does not know for certain what any day will bring. Because its budget is fixed for the year and because it is paid out of general taxation, the more patients it has to deal with, the less it has to spend on each of them. That is plainly ridiculous.

The more customers who enter a supermarket the more they spend and the more the company stocks up to supply them. Imagine the fiasco if the owners were paid by the government a fixed sum to feed an unknown number of people in the district. Soon there would be hunger, shortages and queues.

The first thing we have to get straight is that the NHS is not free. We all pay for it. The problem is we are throwing money at the wrong business model. What is required is a funding system that expands with demand, so the more patients and procedures, the more the money. Not because the government allocates more, but because it is done automatically.

This is not a proposal to privatise the NHS. Nor does it, nor should it, involve the private sector for organisational reasons which I will lay out in a later blog.  The Government, or rather the State, should be the sole employer and provider, but instead of a fixed budget met from general taxation, it would be on the actual cost  paid by a universal insurance premium surcharged to income tax. Re-set annually, it would be calculated according to the current cost of the service and the  ability to pay, so the higher earners would pay more than the lowest. The State would be the sole insurer and there would be no exclusions from cover, as in private insurance schemes, which exclude existing health conditions or add surcharges to cover them.

The principle of the greater the demand, the greater the money, would be established and there would be democratic control of what was or was not free at the point of delivery. To make it work huge reform and de-structuring would be required to the byzantine structures and hierarchies which proliferate at the moment. These will be discussed in a future post.

The object is a health service without waiting lists, queues and cancellations, or such abuses as moonlighting doctors earning big money in private practice while others work themselves into the ground filling the gaps. What we need is an NHS, operating 24/7, giving  joined up care to those in need, which is all of us at some point in our lives,  with the money, staff and equipment to do the job properly.

That was the big idea at the beginning in 1948. It can be delivered, but not until we put the funding on a footing that meets the ambition.