The NHS is broken, what should happen?

[Dan U]

Basically what Manter said

I work in social care and interact with the NHS a fair bit - CCG/Acutes mainly - and have mixed views on it (despite being a massive supporter)

The internal market is a nonsense - for example you've got MH Commissioners in a CCG whose sole job is to manage the contract to provide MH services provided by the MH Foundation Trust (also NHS) who are a monopoly provider in each locality. It's nuts

Get rid of CSUs, merge CCGs back to PCT size (already happening really) as the duplication is so wasteful and then devolve money back to local integrated systems

Sort out the industry of CHC funding, its a wasteful process of councils and CCGs arguing about who pays and not looking at what people need. The NHS is always the decision maker so always wins.

Don't get me started on how much it fucks our budget everytime the acute goes on to black alert (all the time) and just chucks people out the door on 'discharge to assess' or in the nearest care home and then washes their hands and funding responsibilities of poorly thought out, expensive over provision with bad outcomes/creates dependency, many of who end up back in acute because they were chucked out the door.

but hey the stats look good.

A big chunk of the bed pressures could be sold by devolving a bit more power and money away from the NHS and into social care but local govt isn't
the sacred cow the NHS is so central govt doesn't get it (even if NHS folk do)

I love the thing, don't get me wrong, it is full of amazing people but systemically it's a fucking nightmare.

 

[IC3D]

The trust I work for have been pushing for staff to go onto bank to try to reduce the costs of agency staff. I do not believe those on bank get paid more than normal, substantive staff.

Bank staff are NHS not agency right. Bank shifts are how nearly all substantive staff top up their income, it's better paid esp weekends but not as well paid as agency.
Any shake up of the NHS would not be able or want to drop this.
However I'd like to know why managers can get away employing full time agency who don't have to turn up for work anytime they want and fuck up rosters.

 

[Dan U]

Taking away the nursing bursary was also the dumbest thing ever.

Now they are trying to recruit nurses back to the NHS it will cause a drain of nurses from nursing homes back to the NHS, there is only a finite number of nurses. In some parts of the country social care nursing vacancies are approaching 20% already. This means some smaller homes change registration to just be a care home which means there less nursing beds to discharge people to from hospital and round and round we go.

It's a complete lack of system leadership in central govt looking at the whole thing in the round.

 

[Dan U]

My final point as I am also being a bit ranty but just to pick up about what Manter said about NHS/social care and Public Health

It is about funding but it is also about where that money goes in the system, not necessarily always about more wards and more beds and hospital capacity (although it is needed) but about primary care, prevention and community care and how the whole system focuses on outcomes for people and keeping them away from hospital in the first place and keeping them well if they do end up there.

One of Osbornes decisions to take public health out of the NHS and put it in local govt and then effectively unringfence its funding was incredibly short slighted (no real surprise there)

 

[fishfinger]

honestly it’s because NHS angels. My trust have posters which say ‘Love the NHS, join the bank’.
But fuck that. Pay people, properly. Financially incentivise them. Value them. And give them free coffee.

Then blame the government, not the NHS. It's the government that has systematically underfunded the NHS and then forced the NHS to adapt to its way of working. It's the government that comes up with this "angels" propaganda to make people feel guilty for not enjoying worse conditions at work.

 

[kalidarkone]

Bank staff are NHS not agency right. Bank shifts are how nearly all substantive staff top up their income, it's better paid esp weekends but not as well paid as agency.
Any shake up of the NHS would not be able or want to drop this.
However I'd like to know why managers can get away employing full time agency who don't have to turn up for work anytime they want and fuck up rosters.

Because the NHS is on its knees and will take anything it gets.

The little extra that bank staff get is to cover the fact they do not get holiday pay. So it's not actually more then substantive wages in a lot of places .

 

[IC3D]

There are so many examples of negative feedback loops in the NHS, like relying on expensive agency staff meaning no money for more full time staff.
RNs wasting time having to countersign IVs and CDs because of mistakes caused by time pressure.
Staff not upskilling because they will just be made to work harder for nothing.
Where are the unions? They appear to be embedded deeply in the system and invisible to frontline workers.

 

[Riklet]

Get rid of all corportate senior and middle management and let it be run collectively and efficiently by healthcare workers and workplace elected figures. And end all future privatisation contracts.

Would save tens of millions being spunked up the wall and Im sure more could be done with the money there is.

edit: Also more controvertial - but is there a good argument for a move away from minimum wage in the public sector towards workplace bargaining agreements. For people working full time in shit conditions it's shocking that wages of 18-19k are normal. Making it a 10er an hour isnt going to change much.

 

[kalidarkone]

There are so many examples of negative feedback loops in the NHS, like relying on expensive agency staff meaning no money for more full time staff.
RNs wasting time having to countersign IVs and CDs because of mistakes caused by time pressure.
Staff not upskilling because they will just be made to work harder for nothing.
Where are the unions? They appear to be embedded deeply in the system and invisible to frontline workers.

There is money for full time staff. There is just not enough staff.

 

[IC3D]

There is money for full time staff. There is just not enough staff.

They're retiring in droves and it's going to get much worse than this unless they pull a finger out and make it an appealing career again

 

[kalidarkone]

They're retiring in droves and it's going to get much worse than this unless they pull a finger out and make it an appealing career again

Yes and less people are training as well. Plus more foreign nurses leaving as Brexit looms.

 

[Manter]

Get rid of all corportate senior and middle management and let it be run collectively and efficiently by healthcare workers and workplace elected figures. And end all future privatisation contracts.

Would save tens of millions being spunked up the wall and Im sure more could be done with the money there is.

edit: Also more controvertial - but is there a good argument for a move away from minimum wage in the public sector towards workplace bargaining agreements. For people working full time in shit conditions it's shocking that wages of 18-19k are normal. Making it a 10er an hour isnt going to change much.

I’m not convinced middle management per se is an issue. It’s too many layers of management (which just creates churn and noise and meetings) and the political fuckwittery at the top with wild swings of strategic direction.

You need a flatter structure definitely. There are layers of management who entirely exist to have conversations with other layers of management. And reducing the number of ‘organisations’ (with their own management structures) would help with cost, random busy-work etc. But at some point someone has to sign the purchase order for a gazillion swabs, and be held responsible when they don’t turn up/are wrong.....

....which triggers the thought that I’m not sure where that accountability sits at the moment. The complexity means it's difficult to find a person responsible if the ‘system’ fucked something up and there is no imperative for people to own decisions, take accountability for them, fall on their sword if they fucked up....(junior doctors left unsupported in busy wards are an exception, I guess. But that was probably scapegoating not accountability)

So I would suggest dramatically smaller, flatter management structure with very clear responsibility and accountability. But the key issue remains for me the wild swings at the very top- politicians scoring points and playing games

 

[Edie]

How and why?

I’ve been trying to think how to answer this.

I’m not convinced middle management per se is an issue. It’s too many layers of management (which just creates churn and noise and meetings) and the political fuckwittery at the top with wild swings of strategic direction.

You need a flatter structure definitely. There are layers of management who entirely exist to have conversations with other layers of management. And reducing the number of ‘organisations’ (with their own management structures) would help with cost, random busy-work etc. But at some point someone has to sign the purchase order for a gazillion swabs, and be held responsible when they don’t turn up/are wrong.....

....which triggers the thought that I’m not sure where that accountability sits at the moment. The complexity means it's difficult to find a person responsible if the ‘system’ fucked something up and there is no imperative for people to own decisions, take accountability for them, fall on their sword if they fucked up....(junior doctors left unsupported in busy wards are an exception, I guess. But that was probably scapegoating not accountability)

So I would suggest dramatically smaller, flatter management structure with very clear responsibility and accountability. But the key issue remains for me the wild swings at the very top- politicians scoring points and playing games

Athos this is the Too Big argument

 

[Edie]

They're retiring in droves and it's going to get much worse than this unless they pull a finger out and make it an appealing career again

They’re also going to Aus and NZ

 

[two sheds]

I’ve been trying to think how to answer this.

Athos this is the Too Big argument

No that's the top-heavy management argument. You can have small units with top-heavy management too.

 

[ice-is-forming]

They’re also going to Aus and NZ

Yeah, we're ridiculously short of nurses too, particularly in regional and rural areas.

 

[two sheds]

Only an single instance here but I've just had two cataract operations over the last year done at Truro. I never realized but they actually give you new lenses so you can see clearly again. I thought it was only for old people but I've been short sighted since I was six so not only can I see properly, but it's the first time in 60 years I've not had to wear glasses.

Can't believe how fast and easy and painless the operation was (after being somewhat nervous beforehand about someone cutting into my eyeball ). All the staff were really professional and friendly and put me at ease, from receptionist to (Asian) surgeon Mr. George who is a star and I now find has a real reputation throughout the region.

I've just been for my eye test afterwards and it seems they corrected my eyesight so from being really shortsighted all my life I now have pretty well 20/20 vision now. I can see well long distance and also at computer when I'm working/reading. I'm recommending it all to people whether they need them or not.

Like I had free education all the way through because of the Liberal who kicked the Post-War Social Contract all off and then Labour who implemented it (and it has to be said old school tories too because they signed into it all for 30 years), I fucking love the NHS.

I just wish the next generation would have the same.

 

[Manter]

No that's the top-heavy management argument. You can have small units with top-heavy management too.

Yes. And smaller units are (trend wise) more likely to end up top heavy as there are functions you need. Whereas bigger units (trend wise) can pool resources and make savings.
Meanwhile, humans fuck that up of course everything would be easy without pesky people

 

[two sheds]

Yes. And smaller units are (trend wise) more likely to end up top heavy as there are functions you need. Whereas bigger units (trend wise) can pool resources and make savings.
Meanwhile, humans fuck that up of course everything would be easy without pesky people

Well quite, for a single person doing the actual work you'll need a manager to keep them busy, plus a planner to make sure they'll work correctly in the future, an accountant to keep the finances straight, a human resources manager to ensure they're feeling fulfilled, a supplies manager to ensure all the inputs are up to specification, a quality manager to ensure the outcome is as required, a customer service manager to ensure all the customers are happy and a top manager above them to check that everyone is working to peak efficiency ...

 

[Athos]

I’ve been trying to think how to answer this.

Athos this is the Too Big argument

That's not actually an argument for breaking the NHS up into smaller units (as you propose), though; it's an argument for a flatter structure, with fewer middle managers. That's actually something that seems* sensible - would simplify communication, delegate more decision making to an operational level, and free up resources to be invested in the front line. (*Though I don't claim to have first- hand experience beyond the fact that my late mother worked in the NHS, and my sister does.)

 

[quimcunx]

What would attract better managers?

Why do you think it needs 'better managers'? Do you think its down to not attracting those amazing managers from the private sector?

Where is your evidence for good value? (not asked in an aggressive way, I’m interested).

In 2017, the UK spent £2,989 per person on healthcare

However, of the G7 group of large, developed economies, UK healthcare spending per person was the second-lowest, with the highest spenders being France (£3,737), Germany (£4,432) and the United States (£7,736).
From How does UK healthcare spending compare with other countries? - Office for National Statistics



From the link in here.

Is the NHS the world's best healthcare system?

On its 70th birthday, there are reasons to celebrate Britain’s favourite institution, though it has changed beyond all recognition from the service set up in 1948

www.theguardian.com

Of course their are loads of ways of measuring and different things to measure.

 

[Athos]

Why do you think it needs 'better managers'? Do you think its down to not attracting those amazing managers from the private sector?

I don't necessarily; I was responding to another poster saying the problem is (in part) the "muppets" in management.

 

[Edie]

No that's the top-heavy management argument. You can have small units with top-heavy management too.

Yes. And smaller units are (trend wise) more likely to end up top heavy as there are functions you need. Whereas bigger units (trend wise) can pool resources and make savings.
Meanwhile, humans fuck that up of course everything would be easy without pesky people

That's not actually an argument for breaking the NHS up into smaller units (as you propose), though; it's an argument for a flatter structure, with fewer middle managers. That's actually something that seems* sensible - would simplify communication, delegate more decision making to an operational level, and free up resources to be invested in the front line. (*Though I don't claim to have first- hand experience beyond the fact that my late mother worked in the NHS, and my sister does.)

Ah I see thanks.

I’ll think about what I’m trying to get at...

 

[weltweit]

..
However, of the G7 group of large, developed economies, UK healthcare spending per person was the second-lowest, with the highest spenders being France (£3,737), Germany (£4,432) and the United States (£7,736).
..

I wonder how much of the difference might be cost of drugs, because as I understand it the NHS buys drugs quite effectively?

 

[Manter]

I wonder how much of the difference might be cost of drugs, because as I understand it the NHS buys drugs quite effectively?

Not more effectively than Germany etc. More effectively than US. The debate in this country is skewed by the fact people see US and UK systems set against each other and think they are the only options

 

[Edie]

Not more effectively than Germany etc. More effectively than US. The debate in this country is skewed by the fact people see US and UK systems set against each other and think they are the only options

Yes that’s a big part of the problem

 

[weltweit]

I have heard good things about German and also Australian health systems but I don't know how they work.

 

[Miss-Shelf]

Isn't it relevant if someone's claiming insider knowledge? I've known sas almost 20 years and afaik he's not lived in germany in that time.

A recent German healthcare story

My friend recently moved to Germany to marry and work there (last few years) . She works for her wife's company so probably pays into state medical care via the company /individual levies.

She has had a number of complex health complaints since arriving and had excellent quick care each time compared with the NHS she reports.

She is a supporter of the NHS principles but just notes the current differences in treatment

 

[Manter]

I have heard good things about German and also Australian health systems but I don't know how they work.

Germany is a universal multi-payer insurance system. Money comes from individuals and employers, top up from state and federal funds, and unions often make contributions too. If you earn more than a certain amount (can’t remember what it is- 5k a month or so I think) you can choose to top up or opt out of the state system with private insurance. Hospitals can be state, private or charitable. Waiting times are so low they don’t collect the data as standard....the system is integrated so, for example, if you have a break, physio is part of the standard care plan and is likely to be in a pharmacy or local healthcare centre, really close to you so it’ll be daily initially.
I’ve used it. It’s outstanding. A friend of mine whose kid has cancer is in Germany at the moment (paid for by the nhs) getting treatment not available here, in a state of the art facility, with parental rooms, psych care and social support as standard. Totally different experience

 

[Manter]

In the course of 25ish years living and working all over the place, I’ve used the German, French, Spanish, Russian (well, international hospitals in Russia), Bosnian, Irish and American systems. German and Spanish systems best by a long way. American- and American hospital in Moscow- worst experience by miles. Irish experience came with nuns which was kind of fun. Bosnian hospitals are significantly funded by Japan, which I never knew
Oh, and I’ve dealt with french and Italian systems with other people- so I wasn’t patient or mum-of-patient, just a friend