Was there ever a better case for de-politicizing the Health Services, and indeed, in order to achieve fairness and equality, for restoring the “National” part of the pre 2001 NHS? This would of course mean a review of the Scottish and Welsh assemblies. Non functional mutuals of 3 0r 6 million are much worse than a functioning one of 65 million, if we can achieve this.
Prof. John Oldham, of Imperial College has written an interesting summary of the last 30 years in the BMJ 2013; 347:f6716, and the evidence supports his contentions. The last time the title was used was in The Telegraph in 2007.
I have attempted to list these below and I attach a copy of the whole article. (Reform Reform Oldham J bmj.f6716) and then an interesting response….
Oldham adapts the change cycle to a (cynical) reform one:
1. A system built on body parts and top down – rather than holistically looking at the whole patient, and bottom up. (Not providong good transport links in deprived areas while there was the opportunity from Objective One and Community Fund monies meand that managers cannot sell the centralisation of expertise, even though it will save lives.)
2. Harm from competing demands. “Policy generating mechanisms unwittingly conspire to create a scenario of competing, and sometimes conflicting, demands on the NHS, at both the financial/managerial and the clinical level….”
3. Bias to status quo. “There are substantial stakeholders in the health-care system whose power and prestige is secured if things don’t change very much…” (not least Politicians who wont look at philosophy or agree to ration care, and are “gagged” by their central party structure. They always want change and nationalising care to centres of excellence, but never in their own patch.)
4. Death by research. Since advancement in most branches of academia depends on publication, bogus and duplicative, non-contributory, and micro-section research abounds. (Political nous achieves promotion, and often it is not medical talent or ability)
5. More effective reform: “physiology not anatomy”. (The focus on hospitals at the expense of primary care despite protestations to do the reverse for years… has meant that it is very difficult to sell the changes needed in rural areas. If General Practice had been stronger, and there were more GPs providing a greater variety of services, this would have been much easier.)
In has last two paragraphs, Prof Oldham says ”
My basic tenet is that few reforms have truly transformed the delivery of healthcare as it is experienced by patients in the NHS in England. They have often been the wrong sort of reform—focused on organisational structure not the way organisations work or what drives organisations to work that way—and do not reflect the multimorbid complex needs of most patients. Fundamental elements of the healthcare system not only remain untouched by reforms but create a self regenerative cycle that impedes true transformation. Although I have focused on the NHS, similar problems can be seen in the health systems of many other countries.
The next iteration of reform must not focus on structures but begin the rebalancing needed: rewarding longitudinal population care, prioritising and narrowing the focus of system-wide demands, creating equivalent generalist and multidisciplinary input to policy generation, and placing as much emphasis and reward on implementation as there is on research, in both training and career advancement.
Most importantly, the health and social care system experienced by citizens will be bettered by a deeper understanding of the nature and holistic needs of the patients and users that are the main drivers of activity. Professions and organisations should reform their functioning around those whole people, and not around body parts. Multimorbidity and complex patients and their needs are the new frontier of healthcare.
one of the BMJ responses
Why aren’t patients at the centre of health care?
A theme running through the print edition of the BMJ of 23rd November was how patients are not, despite the rhetoric, at the centre of health care. In addition to the professional factors,including those described by Oldham(1), three powerful trends in the last thirty years have made this less, not more, likely.
The first is the neo-liberal ideology of competition, that health systems will work best if made to behave like competing businesses. A major fallacy in this is that to a business, customer service is a means to the end of profit, not, as it should be in a health system, the end in itself. Businesses cannot be expected to do things that do not contribute, directly or indirectly, to profit. If healthcare organizations are to behave like businesses, they too will first look after their own interests, not necessarily those of patients.
The second is the cult of management that has dominated us since the 1980s, entering the National Health Service with the Griffiths Report, with its creed that all problems have generic managerial solutions. This has given us our never-ending stream of reorganizations: to a man with a hammer, every problem looks like a nail.
The third is the abuse of industrial analogies for health care. While industrial models of defined processes can be applied to some healthcare activities such as elective surgery in fit people, such processes depend on standardized and quality-controlled raw materials – the very reverse of the raw material of medical care, people in all their variety and increasing complexity as they age, with freewill and feelings of their own.
Reference: Oldham J. How NHS reforms go round in circles. BMJ 2013:347;f6716
Competing interests:None declared
Edmund J Dunstan, Locum Consultant Physician
Royal Orthopaedic Hospital, Birmingham,