Friday, 24 February 2017

NHS Reform as Botched Quality Management

I’ve been following reports about the latest top down reorganisation of the NHS with interest, or I should say following those that made it over the wall  as the plans have been well suppressed. The secrecy is not surprising, top down reorganisations of the NHS usually fail to deliver the promised results and its status  as a deeply cherished national treasure constantly being circled by wolves makes it a highly sensitive subject. I don’t believe it does everything right, but it punches well above its weight and is struggling heroically with demographic changes and funding shortages.

Seems to me these proposed changes have some merit, at least in theory. There is evidence that focusing treatment into specialist centres can deliver better results than having more widely dispersed services. There is also evidence that moving certain types of medical care out of hospitals and into community care is beneficial. Let’s face it; as long as the required support is in place, most people would rather be in the peace and privacy their own home than hospital which is usually a busy places full of sick or dying people. Medical advances mean we often don’t need to stay in hospital as long as we once did, in the past minor procedures involved multiple days stay, now many  procedures can be handled as outpatient cases like my recent snip (which I must get around to writing something about).

The big problem is the availability of the necessary support. Most sensible people know that the resources to shift more patients out of hospital and into community healthcare simply don’t exist. As far as these plans go it's the ‘Elephant in the Room’. Both Government and NHS bosses  know full well that the NHS, England and Wales especially, barely has enough GP’s and other community healthcare professionals to cover existing demand. At the same time the related provision of social care services which is delivered by local authorities is on the verge of collapse due to years of Government austerity. Some improvements may be possible with tinkering around the edges, but it's wishful thinking to believe this can work without massive incremental investment in community healthcare and social care.

There is a fundamental lack of trust in the Government to do the right thing, it’s not helped by the fact that the leadership of the Conservative Party sends out ambivalent signals on the NHS. Whether it is ideological dogmatism over privatisation to the whiff of individual venality, trust is low. It’s not something to dwell upon here, but my own anecdotal experience as a former Conservative activist tells me  there is a clear divergence between the grassroots and upper echelons on this one. It is all reinforced by constant disingenuous responses from the Government that it's spending additional billions on the NHS, when a more truthful assessment is that any such money is simply plugging deficits, inflationary pressures and is probably just shuffled from elsewhere in the health budget. Similar claims around allowing local authorities to increase council tax to support social care are also mendacious. The Government's deliberate political decision to weight the pain of austerity away from the central portfolios, combined with raises to the minimum wage and the demands of an ageing population mean local government led social care system is already collapsing. 

This whole mess bears the hallmarks of the classic quality management clusterfuck. Way back in the day when I studied Management I was taught W. Edwards Deming’s mantra that you focus on quality and the rest follows, organisations that invest in quality and get lower failure rates, less rework, higher throughput as consequently long-term cost reduction. Conversely where the focus is primarily on costs any short-term saving tends to be followed lower quality and higher long-term costs. Over the last twenty years I’ve seen this play out in real businesses, I’ve seen incremental investments in quality deliver long-term benefits, and I’ve seen short term focus on cost cutting simply restack the pain for later (I was once partial to a confidential call where a “corporate superstar” exec suggested cutting a quality programme that had successfully demonstrated £8m per year of cost savings in order to save the £2m a year operational costs). 

Now the NHS is a special case, certain things don’t apply, for example fixing someone up now might only lead to more healthcare needs long-term, but that doesn’t mean some principles don’t apply. It’s still better to fix someone up properly today so you don’t have to do same thing again tomorrow, better for both patient and budget. The top down approaches to NHS reorganisation, and the Government’s reluctance to properly fund social care, repeat the same classic costs over quality stupidity. To make long-term beneficial changes there has to be genuine up front incremental investment in quality, not simply using accounting tricks to restack the deck chairs. There will of course be legitimate challenges to this, such as whether incremental investment is just throwing money at a problem, and there will be illegitimate opposition to it such as the brainless political fetishes around deficit reduction.

Perhaps it’s time to start resolving some of the fundamental problems? Such as admitting that healthcare and social care cannot really be separated, that attempting to shunt patient care into places where there simply isn't resources to treat them (or even worse where the Government's own policies has removed those resources) is just stupid? But most of all maybe we just need to be realistic about the fact that we don't really spend enough in this area and we should maybe reprioritise certain expenditure (I'd start with these sacred cows)?  

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