Guest Editorial > God Bless the NHS by Roger Taylor
God Bless the NHS by Roger Taylor | Jenny Diski
Can the NHS be saved by statistics? A new system based on cost-cutting and 'patient power' raises more questions than it answers.
This review was first published in the Guardian on 15 March 2013
At the beginning of March, Roger Taylor wrote in the Daily Telegraph: “The NHS needs to move away from its blame culture in which performance is assessed on the basis of report cards and targets. It needs to develop a culture in which quality is assessed with skill and judgment.” The old targets, he says, should be replaced with “measures of the outcomes of care and the experience of patients”. God Bless the NHS is full of slick statements like this, delivered in a breezy, for-every-problem-there’s-a-statistical-solution, mildly patronising style of someone used to giving lectures to people who believe they need his expertise.
Taylor, an ex-journalist from the Financial Times, collaborated with a doctor-statistician at Imperial College to form a private company, Dr Foster, which is now half-owned by the NHS. Since 2001 it has produced an annual Hospital Guide which compares hospital performance in terms of outcomes and safety. The website claims Dr Foster was founded on the belief that only through better information and measurement could hospital performance be improved and variations in performance reduced.
The company produced statistics that showed Stafford Hospital was failing. The response was that the local strategic health authority spent a good deal of money and energy setting up committees to discredit the data. Answering questions at the recent Commons health committee hearing, Sir David Nicholson, NHS chief executive and, at the time of the report, chief executive of the West Midlands strategic health authority, replied to a question about the 2001 Dr Foster report by saying the mortality figures “do not tell you how many deaths are avoidable. Going from excess deaths to being able to say they are avoidable is a big step.” Numbers, he said, were “indicators to go and look”. But nobody did, said his questioner. To which Nicholson replied that this was the point he was trying to make. Nobody did, but they should have. This is, as well as being a dizzyingly evasive answer, a standard “we’ve learned lessons” response that is the equivalent of a naughty child’s “I didn’t mean to do it”. In the case of Mid-Staffs Hospital, hundreds were treated abysmally and some died.
Taylor’s confidence in the statistical and IT solutions he offers in his book must have been bolstered by the contrition of those who tried to suggest that statistics were not the way to solve the problem of the NHS. He is a data man, and has no doubt, as I have, that the use of data in various ways has the power to clear up the mess. Along with a profound focus on mortality and safety statistics, he suggests that, however resistant they are, doctors’ taking responsibility for budgets will have great benefits in providing incentives and insights into the way the system needs to run. Doctors, historically, have thought about the patient in front of them: now, says Taylor, they must learn to include the “patient in the waiting room”, by which he means money. This dual focus seems quite a good description of precisely what has gone wrong with the NHS since the early days of the Thatcherite “internal market”.
He suggests, too, that the NHS is an organisation that could learn a lot from global commercial and financial organisations, although you might think this isn’t the best time to be extolling the efficacy of large businesses and banks. An Indian doctor, Dr Venkataswarmy “looked at eye surgery as if it was flipping hamburgers. He broke it down into simple tasks and trains lower paid employees to do as much as possible.” Standardising and streamlining provides more and cheaper cateract operations and is, therefore, Taylor says, “of enormous social benefit”.
In the UK, thanks to contracts with private for-profit companies such as Care UK, 10% of cataract operations are now performed in independent sector treatment centres. Learning from business, the NHS is closing small, local services multiplied throughout the country and opening a few large specialist centres which are far more efficient in terms of cost-per-treatment and have better statistically medical outcomes, even if people do have to travel further and at greater expense and inconvenience.
And “the fact that the ISTCs compete directly with the NHS hospitals has put pressure on NHS organisations to up their game,” he says. The profit motive is supposedly teaching the NHS’s public service how to function. Last week we learned Serco, the private contractor in charge of out-of-hours GPs in Cornwall, falsified data on patient calls, it is suggested, to improve the poor staffing levels. Nevertheless, according to Taylor, healthcare is a business and needs to think like a business with “chains” of services and NHS franchises for centres of specialism. Toyota makes cars, Costa Coffee makes coffee, and their focus on doing one thing well should be the guide to NHS planning.
Bradford General has a similar income as Costa Coffee, but it behaves like “a souk”. The hospital chief executive has to oversee each stallholder with their own different expertises, whereas it would be much better apparently if, like Costa, each expertise was catered for by separate specialist treatment centres. Even if you accept the profit motive as legitimate, Selfridges operates effectively much like a souk, and souks behave like souks, providing what is needed to the community in one local geographical area without having more management than salespersons and stallholders.
Moreover, for Taylor’s complete solution to the NHS’s failings to fall into place, all patient medical and social data should be collected and centralised for the use not just of the NHS, but of all patients and social services and those interested. People may worry about privacy, says Taylor, but the usefulness far outweighs such concerns. Then doctors will be able to see everything about a patient, but more importantly, patients will be able to take control of their own medical and social welfare. They should have access to all electronic records and then be able to use them to hook up with similar groups of patients on the internet to find out more about their illnesses and treatments.
Doctors should regard patients as partners (that’s even a step up from “clients”), both parties setting up an agreed programme of care. Patients would then have “responsibility” for themselves. “The role of the doctor will become increasingly that of expert advisor to help you in the management of your own health.”
To be treated with respect is a basic requirement of any person consulting an expert, but if you are currently feeling unwell, or have been told that you have an elevated rheumatoid factor, and lack a medical education, you might find managing your own health a daunting prospect. The benefits to the system, Taylor thinks, would be great, with patients being able to order “additional supplies of wound dressings or colostomy bags”. The rather understated purpose of patient power, as Taylor tells it, seems to be about cost cutting, both in equipment, treatment and medical litigation bills. In addition, patients would probably make more sensible decisions about end-of-life treatment, and that would cut costs too.
All of Taylor’s ideas are based on improving systems in an incredibly unwieldy NHS. The question is, what is wrong with the NHS? Apparently, it costs too much – not, Taylor says, because of an ageing population, but because modern medicine requires such massive investment in technology and is capable of keeping sick people alive for so much longer than before.
Actually, the question is, is anything really wrong with the NHS? It has never had a higher public approval rate, Taylor acknowledges that. And what if the NHS doesn’t cost too much and isn’t spiralling towards impossible budgets, because, as the French believe, the point of a nationalised health system is that you spend whatever is needed to keep it going because it is the basis of the welfare of society? Nicholson had said that NHS reforms were “fraught with risk”. At the parliamentary hearing he amended this to “With less money, the NHS needs to change.” The government taking money from the NHS – creating the need for reform – is justified on the basis of the national debt. But that means NHS funding is being cut – social welfare funding is being cut – in order to repay international speculators.
Taylor says that only people emotionally committed to the public service ethos of the NHS could complain about his suggested reforms, and emotional responses have nothing to do with statistical outcomes, medical or financial. The British public are irrational and deluded about their NHS, attached sentimentally to it as if it were our darling child. I am certainly one of that mind. I suspect that streamlining almost anything risks losing a messy core that human beings need in order to function humanely.
Jenny Diski’s What I Don’t Know about Animals is published by Virago.