The NHS empire builders

John Womersley

reveals an indictment of
top managers

Also on this page:

Bedtime Book
John Moorhouse

Am I satisfied?

Jill Stephenson
is infuriated by attempts
at ‘customer service’

Also on this page:

Rear Window
The life of a starving artist

Norah

Mark MacLachlan
is taken aback by a family resemblance

Also on this page:

Dharmendra Singh
on Coco Chanel

Bedtime Book

John Moorhouse

Tell us what you are reading at the moment – and what does it mean to you? I think they were expecting a just-published novel or one of the current crop of political memoirs.
     In fact my choice is a pocket-sized hardback called ‘The Contour Road Book of Scotland’.
     It is the 22nd edition, and it was published in 1951 – what a treasure trove it is. It contains 500 maps and plans. It plots in precise detail 498 routes in Scotland, each one with its own precise contour chart and details of road conditions and one of those triangular mileage charts plotting the distance between all the key points on each journey.
     The series is completed with three guides to England. Wales, interestingly, is not mentioned specifically but seems to be included in the West England volume. (for there were guides to all other parts of Great Britain). It must have been originally produced for cyclists, although by 1951 it was clearly aimed at the motorist.
     The book lists the 90 youth hostels which covered the country. How many of those remain today? It details the ferry crossings and the fares – which at around four shillings (20p) for a car must have made travelling a very expensive pastime. A gallon of petrol in those days was around four shillings and fourpence (22p) so the little chart which compares the distance by way of the Kincardine Bridge versus the Queensferry crossing would have been particularly useful.
     There is a marvellous Recommended General Tour of 1,047 miles from Kelso to Carlisle by which ‘the finest scenery in Scotland, as well as the most noted points of interest can be visited with comparative ease’. When undertaken other than in the summer months, the Lamp Lighting Tables, which catalogue the precise times of the switching on of street lights in each separate town, would have been an essential source of information.
     The loose Supplement, which still remains in the book, warns, however, that ‘the roads in the North of Scotland have not had regular attention for many years, and are liable to be rough and bumpy until grants are available for their upkeep’. These were the days before the Barnett Formula – and northern roads were obviously not considered a priority.
     Published less than a decade before my first motoring tour of Scotland, this book was a stark reminder of how dramatically our society, and in particular travel, changed in the latter half of the 20th century.

The NHS empire builders

John Womersley

For many years there has been criticism of NHS management from national and international commentators. Criticism now comes from very much closer to home – the Scottish Parliament’s own health and sport committee: report No 8 (2010), NHS board revenue allocation.

     For example:
     ‘The state of affairs that senior NHS board managers describe (employing more staff without achieving greater productivity) raises issues about the way the NHS system has been overseen and the way NHS boards are made accountable.’
     ‘There is a sense that things have been allowed to drift during the years of financial growth with inefficiencies allowed to continue.’
     The mechanisms for holding NHS boards to account – namely annual reviews and their performance against targets – do not adequately address efficiency. Witnesses from several NHS boards described changes as being a slow process, but the committee does not believe the NHS has this luxury any more. Staff have seemingly been employed in jobs that have no productive value.
     What criteria are being used to approve new spending, what standard of evidence is expected to support a spending plan, and how are changes monitored to ensure they have the desired effect? There are fundamental weaknesses in NHS management.
     ‘The committee is concerned about the lack of a mechanism to ensure that "good practice" in one area is spread to other areas within weeks or, at worst, within months.’
     Among other examples of waste in health boards are surveys and ‘consultations’ that address issues that have already been fully explored; intensive planning and report-writing but with no resulting action; profile-raising ‘events’; structural reorganisations; and of course management consultancies. Direct elections to health boards are unlikely to resolve the problems of mismanagement and waste in the NHS, the chairman of the BMA in Scotland commenting that they ‘will not improve the transparency of decisions and accountability of the actions of health boards’, and that ‘the health budget is better spent on services rather than on a costly election process’.

People have no faith in complaints procedures or in their independence, but politicians appear to prefer the appearance of ‘people power’ to genuine public representation and effective scrutiny.

     A culture appears to have developed in the NHS and in public life generally in which the most important thing is for organisations and individuals to be seen to be doing something (high profile, glossy literature etc) rather than achieving real benefit. At the same time very considerable resources are spent by NHS Quality Improvement Scotland (NHSQIS) and other governmental, academic and voluntary bodies in producing well-evidenced reports, but health boards are free to ignore them – often preferring to spend resources according to their own poorly-evidenced priorities.
     Rather than being used as important evidence for the improvement of services, complaints now initiate formal internal procedures with the aim of rebuttal, thus avoiding probing by the abandoned local health councils. People therefore have no faith in complaints procedures or in their independence, but politicians appear to prefer the appearance of ‘people power’ to genuine public representation and effective scrutiny.
     The Scottish Government itself spends about 25% of the health service budget before distributing the remainder to health boards. Government enterprises of dubious value include (among many others) ‘programmes’ such as Better Together, Independent Living in Scotland, the Long-Term Conditions Alliance, Managed Knowledge Networks, NHS Shared Learning, Care Information Scotland, the Scottish Public Health Network and ‘Observatory’, and media campaigns (£600,000 spent on ‘healthy living’, anti-racism and alcohol abuse ‘campaigns’ in April alone). NHS24 and the Scottish Health Council might also be included.
     At both government and health board level the culture has changed from bettering health to establishing costly ‘initiatives’ to persuade politicians and the public of great works – but with little evidence of effectiveness. A radical change is needed – from continuous organisational change to one of continuous service improvement. The many planning and ‘peripheral’ activities that have mushroomed over recent years in health boards and central government should be dissembled, freeing resources for front-line patient care.
     It was perhaps understandable to ignore empire building and burgeoning bureaucracy during the times of plenty, but can this be allowed to continue? Writing in the Times Jonathan Waxman, professor of clinical oncology at Imperial College, urges ‘serious evaluation of the unaccountable, self-serving structures that impede patient care’. Truly independent audit of the multitude of organisations and ‘initiatives’ that have sprung up over recent years under the banner of improving health and ‘user involvement’ is urgently required.