A new philosophy, what I believe: allow Trust Board members to use the language of rationing in media press releases

“Human Beings cling to their delicious tyrannies and to their exquisite nonsense like a drunkard to his bottle and go on until death stares them in the face.” Sydney Smith.

I am not sure I am right, but to me the NHS closely resembles a tyranny.

“To live a creative life, we must lose our fear of being wrong.” Joseph Chilton Pearce

A reader of these pages can see that my overall intention is to get a more honest debate on the principles and the philosophy behind the RHSs (Regional Health Services – There is no NHS). There have been over 340 postings, and 6 interviews in less than six months. I and many others do not believe it is founded on a rock, and sustainable. If it was to remain “paid for by taxation, universal (cradle to grave), comprehensive, free at the point of access,  and treatment based only on clinical need, and without reference to means” (Andrew Lansley on BBC News 31st Jan 2011) and these criteria were written in stone, then we have to address the issue of “everything for everyone for ever” which is not sustainable. In addition the regionalisation warned about by Aneurin Bevan is already upon us.

Almost all the medical professions understand this, and increasingly expensive technology improvements for rare conditions, and demographic changes, are challenging our ability to deliver. The philosophy needs to be clear: Is the (N)HS utilitarian and should the state encourage autonomy for individuals and families whenever possible, and if so will it encourage the Information Age? The need for change is clear: but not how to change it. …..Polly Toynbee disagrees with the changes.

The original document, “In place of fear” is the starting point for all readers who wish to understand the (N)HS as originally formed. Aneurin Bevan did not have any truck with regional variations which he felt would be the beginning of the end. ( Wales, Northern Ireland and Scotland all now have different systems to England.) Is the regional health service about encouraging autonomy for small/cheap health issues and services – or not? Is it about a paternal state which claims it can be universal and comprehensive? Is it about fairness overall (eg for cancers) or only regionally?

The recent headline about a new attitude to GP training indicates a government in fright/panic. A shortfall of 16,000 GPs is threatening.. along with a £30bn budget deficit. Politicians will of course blame their successors when they need to recruit (again) from other countries in 2-3 years time. But then its much cheaper to have a Dr trained in Africa and appointed here… Forget the linguistic and cultural issues – its another seat occupied. But then…

“The only good government is a bad one in a hell of a fright. ” Joyce Cary, The Horse’s Mouth, 1944.  David Cameron (and The Coalition) is in a mess about the NHS and he is beginning to contradict himself.

Interviews with impending or retired Specialists and GPs and other professionals are very useful, truthful, and so far seem to give a consensus response – give the professions charge of their departments and units, and ask the managers to implement the decisions taken by their professional leads. These interviews are not inhibited by “gagging” threats. I just wish more people would come forward. to bear witness.

We need to legislate to allow Trusts to dispose of staff who have bad sickness and absence records, and ensure a full working week. (weekend deaths should be no different to the working week) If this requires breaking up the health service further in order to reconfigure it might be worth it. Trusts allowed to go bust and be taken over will ensure the loss of staff with poor work records, and reconfiguration of working practices and timetables. We should measure follow-up rates for consultants against their peers. Every letter which asks a patient to return should say when, why and what is to be done which could not be done in General Practice. The return should involve an examination of the patient: so many Out Patient appointments could be done with a phone call… This should be universal…

We should override the GPS right to decide their own IT system of choice, and start by inducing them to, and then punishing them if they don’t, conform to the local/regional system. Bring this IT system into locality A&E and OOH services and then allow it to spread like a cancer throughout the Trust. Get all GPs involved in the management of OOH, and if they wish the operating of both A&E and OOH. Measure GPs on continuity of care – a long negotiation is needed… Measure their crude referral rates relative to their peers (this happens now), and then the appropriateness of those referrals (do the surgical referrals need surgery? Could another GP have handled the dermatology referral?)

Take on the media, and encourage open debate about pragmatic solutions. Bear in mind that “Any philosophy that can be “put in a nutshell” belongs there. Sydney J Harris, Leaving the Surface, 1968″ The media love Information and facts and will support the change from Industrial to Information Age Medicine. It’s their NHS as well..

Increase Medical Student recruitment to British Medical Schools so that a small excess is produced in years to come. (It will take 10 years from the implementation to produce new GPs) Encourage and facilitate a period abroad during their training, with exposure to a different system. Review medical student places, finances and debt at the end of training. Some specialist training may need a “rebate” or a debt write off on qualification (possibly Psychiatry, Venereology, Community Paediatrics and Epidemiologists at present, where recruitment is difficult).

Reduce the number of criteria in the QOF (Quality and outcomes framework) for GPs and the equivalent Management Information Systems (MIS) for nurses, giving them back some “space” and choice in the shape of their jobs.

Make Health Care Assistants into Nurses, (despite criticism of the Nursing Times) and then Train nurses to be “hands on” again, and accept that for good care we need to give them good pay.

Bring back “choice” in regions where it has been lost. Then act immediately to decide what services are important enough to insist on equal access and choice across the nation, ignoring regional boundaries. These might be cancers needing chemotherapy and other treatments, and heart diseases needing surgery in the first instance. Then, some treatments will need co-payments, different in people’s different situations, and some will need part payment and some will be excluded. If regions/practices are aware of the excluded treatments/services, they can be induced to make general savings so that these might be made available the following year… but some might never be.

Politicians need to decide whether the information age for patients is to be encouraged – or not. There is no point in providing information if you don’t believe in choice.

Leave NICE to clinical excellence. Form the British Equivalent of The Dunning Committee. (see page/post on rationing) which might be a virtual committee, and would encourage feed in from Trusts, Charities and the Public.

GPs as the gatekeepers are the most efficient part of the NHS, seeing 90% of the consultations with 10% of the budget. GPs should be allowed to remain the advocate for their patients, and the conflict of interest of GP commissioning should be removed. The RCGP published “What sort of doctor” back in 1982, before all the current perverse incentives were created. The report should be revisited. My prediction that more and more Trust Chairmen, Board members and CEOs will resign is coming true. They are finally appreciating that they will become the scapegoats for the politicians’ cowardice and “head in the sand” behaviour. NHS staff resignations tell a story, as do lack of exit interviews.

Readers might be interested in the INVESTIGATION IN TO MANAGEMENT CULTURE IN NHS LOTHIAN (N.b. see summary chapter 2) which is mild and would be repeated all over, where it would of course be covert. Full marks to Lothian for bringing this forward, but what is omitted from their report and beneath the surface?

We cannot ignore the politicians – unfortunately – they hold the purse strings. Many don’t actually believe in the (N)HS and use private providers. They are cowards when it comes to public debate about rationing along utilitarian lines. Because their mandate is from a small locality they, like Claire Gerada will oppose change, and they will not discuss a change of philosophy or principal. The religious dedication of the people to the (N)HS was revealed by the reaction to the recent exposures in Mid Staffs – this is classic communal denial of an inconvenient truth.


Regarding rationing which politicians call prioritization, limiting and restricting:

“Since a politician never  believes what he says, he is surprised when others believe him.” Charles de Gaulle, 1962.

Regarding honesty:

“The most distinctive characteristic of the successful politician is selective cowardice.” Richard Harris in the New Yorker Magasine, 1968.

Regarding principles:

“The effectiveness of a politician varies in inverse proportion to his committment to a principle.” Sam Shaffer, in Newsweek Magasine, 1971.

Regarding speaking out:

The (N)HS has been likened to the most modern religion, but religions don’t change and don’t have to address new technologies, and failure does not lead to deaths.

“Religion is excellent stuff for keeping the common people quiet.” Napoleon Bonaparte.

I believe the people will get increasingly vociferous as the Health Service fails further. There may be a stampede, of those who can afford it, to leave the “religion” which has no clothes. The result could be increasing inequality and civil unrest, and an early sign will be private hospitals running casualties, and patients using these more and more, particularly at weekends and in August after staff changeover.

P.S .There are about 25 website followers but a lot more through Facebook and Linked In., I have no idea how many through twitter. Please e-mail me if there is a burning issue you wish put on NHSreality.


8 thoughts on “A new philosophy, what I believe: allow Trust Board members to use the language of rationing in media press releases

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