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Be Careful What You Vote For

Posted on 03 July 2011

cmc.jpgNext time you meet a nurse, ask him or her what the NHS reforms are about. Almost certainly the answer will be ‘I’m not really sure…I don’t really understand them’.

Next time you see your doctor, ask him or her what the NHS reforms are about. A few might know, and give their version, seen through their political prism, but from the rest, the answer will be: ‘Waterworks OK?’ Sub-text: stop asking me stupid questions I don’t know the answer to.

Email your MP and ask them what is his or her position on the NHS reforms, and nine times out of ten you will get his or her party’s standard issue response. Probe further, and it will become clear that he or she hasn’t the foggiest.

And don’t even bother to ask your mates, because sure as eggs is eggs, they won’t have a clue.

Now, if we stand back for a moment, this is quite extraordinary. The individuals who work in Britain’s largest organisation, the punters who run the country, not to mention the rest of us, are largely in the dark about what Dr No can only describe as the nuclear option for the NHS that has been put in front of us in the guise of the Health and Social Care Bill. The NHS is facing its Cuban Missile Crisis; and not even Dr Strangelove knows what is going on. Instead, an apathetic fog of confused indifference has settled on the land, a perfect fog, as it happens, from which to fire the missiles of NHS Armageddon.

And yet there are voices warning of the ICBM’s hidden in the Bill. Puppets-in-waiting Stevie and Mildew may bat for the other side, but there can be no doubt that the British Medical Association, the ‘official’ voice of the medical profession, has rejected the Bill in its entirety. The Royal College of Nursing, the ‘official’ voice of the nursing profession, has passed an overwhelming (99 to 1%) vote of no confidence in Lansley’s reforms. Crimson Pollock, an outstanding academic, and it is the force of her argument not the colour of her politics that matters here, has totalled the Bill several times over. Dr Clare Gerada, the divine Chair of the Royal College of General Practitioners, has repeatedly warned that the reforms will ‘destabilise the NHS forever’. No one, who bothers to look, can be in the slightest doubt that the overwhelming tide of professional opposition runs hard against this Bill.

And yet Cammers and Broken Arrow, and their back-bench buddies, time and time again trot out that doctors – because GPs have signed up to commisioning consortia – are in favour of the Bill. Never mind that GP’s are only part of one profession, and never mind that most have only signed up under duress, or if not under duress, on a what-else-can-we-do basis…

And this is the paradox of our modern degenerated democracy, a democracy defined not so much by a positive intent to rule well (albeit only in the interests of ‘majority’), as the single limited and ultimately negative notion that all that democracy stands for , all democracy is, in fact, is rule by a government that you can throw out every few years. We may know that we can dump them from time to time – but they also know that in between those times, they are pseudo-mandated oligarchs – and can do pretty much what they like. And so they do.

And unsurprisingly, many of us, faced with years of oligarchy, end up crumpled on the heap of indifference. GPs sign up to commissioning consortia (which is not the same thing a signing up to commissioning) because they see little option but to do so. Faced with the nuclear option cloaked in a baffling four hundred plus page amending Bill, now subject to over two hundred further amendments, many give up the ghost, and say ‘whatever…’, resigned to the inevitability of government getting its way. The vocal opponents, the voices Dr No listed earlier, are just that: vocal opponents, yet blind to the force of inevitability. There’s no point in understanding the Bill, let alone wrestling with it, because it is all going to happen anyway.

Bad mistake. Once nuked, the NHS – an institution which in many ways lies at the heart of, even defines, modern Britain - will never recover. Some might even say Britain will never be the same again.

So what is to be done? Dr No, you will be relieved to know, isn’t going to urge you to read all the Bill, and all the amendments. If he is honest, he hasn’t read every line himself. Instead, he suggests you consider one core question: why is the Secretary of State so determined to remove his duty to provide, or secure the provision of, a free at the point of delivery comprehensive health service? Once you have the answer to that one, the rest falls readily into place, and the nuclear option at the heart of the Bill lies plain for all to see. You might even want to tell your MP about it.


You're absolutely right about the smelly state of our defuct 'democracy'.
Very little difference between the parties who represent the new aristocracy of old money mated with corporate power who need the money by giving a health regime as bad as the US, plundering ordinary peoples pensions while the payments into their mega pensions are tax free.
But us new peasants should be grateful for existing in the leftovers.

It could be argued that only one of the numerous amendments should have been discussed in the first instance.... The one relating to the Secretary of State's duty to provide. If the wording of the new bill is not changed to legally reflect this responsibility, then discussing all other amendments is a waste of time.

Those members of the medical profession on the Future Forum who have fudged this issue i.e. Professors Steve Field and David Kerr should be thoroughly grilled by their own profession for fudging this key responsibility of the SOS yet again in their report. Do they think we are all daft?

I think that the leaders are in the grip of fear - each to thier own.

What we need is to tell the public what is happening to the NHS

PFI is the main threat - not the aging popultion

Two weeks ago I was at a family gathering and my sister-in-law was there (consultant paediatric neurologist). She didn't know much about the Bill. Of course she didn't, she was much too busy with her job. The paediatric cardiac review (and the knock-on effect to her department) worried her more that the Bill. (Although, interestingly, she said that her job would most likely be affected - perhaps her department would close - and she was relaxed about this since she said that she wanted the best for her patients. Lansley should listen to her before making his claims about "vested interests" in the NHS.) I took the opportunity to explain some of the details, in particular, how McKinsey recommended the "£20bn efficiency savings" could be saved. ("No chance. That won't work at my hospital." Ah but, you simply work there, McKinsey know best, of course.)

Then last week a local GP (who I know since I'm an FT governor and he is a "stakeholder" governor) and the chair of the local Pathfinder wrote in our local freebee newspaper a piece about the reforms that was riddled with errors. Like many he was interpreting the reforms to be what he wanted (lots of phrases like "we would like to..." and all optimistic). It will be harder for me to explain to him what the Bill will really mean, since I am a mere patients' representative and he is at the centre of the reforms in the area...

Now, the SoS has a duty to 'provide', the original bill wanted to omit that and replace with 'monitor' only. After the forum report, this will become 'monitor and secure'. Some people say this is vague, I think not. Given PM's personal guarantees, I think, and I can be very wrong speculating, that this is a little gap in the door to allow for top ups. If a universal basic service is 'guaranteed' for all at the point of 'need', why shouldn't the worried well pay for their 'worry'? Why should our taxes subsidise them?

I remain deeply suspicious of the change in the SoS's statutory responsibilities. What, exactly, is the problem with 'provide'? It hasn't stopped the NHS contracting things out to 'other willing providers', fairly obviously, as contracting out has been going on for years under the present legislation.

'Monitor and secure' sounds to me FAR too much like a form of words to allow the Sec of State to acquiesce in some areas (for instance) having NO NHS provision at some level. Say Kaiser or United Health wanted to bid to take over all NHS hospital provision for Gruntshire, and buy up, one by one, debt-burdened Foundation Trusts there. Well, under 'provide', some awkward people MIGHT argue the SoS was not fulfilling his statutory duty if he let them do it and thus let all 2o care in the area go private provider. Under 'monitor & secure'... well, Bob's yer uncle.

Cameron guarantees us (if I have heard Sam correctly) that this is NOT what they mean. Oh goody - colour me(un)-reassured. But in that case, WHY CHANGE THE WORDS?

Sam - with all due respect - even at the most basic level, The PM's 'personal guarantee' is in the real world worthless, because it is only around as long as he is. It is personal, attached to him, and if he goes, so does the guarantee.

It speaks volumes to the contempt in which our politicians hold us that they think they can buy us off with tacky 'you have my word' stunts.

Things like our health service should be enshrined in law, not attached, like a bit of bum fluff, to a flaky here today, gone tomorrow politician.

On the wording: Dr No cannot find the phrase 'monitor and secure' either in the FF reports (don't these guys ever think about initials and acronyms?) or the government's response. Maybe it is another personal guarantee the PM gave someone, somewhere, sometime. What he can find, in the proposed amendments to the Bill, is this:

"1 Secretary of State’s duty to promote comprehensive health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of illness.

(2) For that purpose, the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act.

(3) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed."

The crucial paragraph here is paragraph (2): 'must act with a view' has been changed to 'must exercise the functions conferred by this act' - which could be said to be one step firmer than 'act with a view' (surely one of the vaguest phrases imaginable) but by no stretch of the imagination does it equate with 'duty to provide/secure the provision of'. It merely says he must 'do something' (act with a view/exercise his functions) but the vital component of duty (to provide...) is still absent.

As Dr Aust asked (as did Dr No in the original post): if they do mean to retain the original spirit (and meaning) of the earlier bills: why change the words?

Agree Dr Aust. Considering the creeping changes in diverting public NHS money over the years to private companies, why bother about a major bill reform at all unless privatisation is about to move into fast forward. Is it anticipated that some of the changes will cause such disquiet once people realise how they are affected that the clout of the law will be necessary to see them through?

Some form of rationing has always been going on in the NHS, often hidden for example in waiting lists. It is happening now in the form of patient referral committees and some "pathways." In my view these might turn out to be more dangerous forms of rationing than waiting lists ever were. As Sam says, a sensible thing might be to ration the worried well rather than those who are ill, but distinguishing between the well and the sick requires a diagnosis first - presumably funded by the NHS. The other problem is that the government seem to want to retain responsibility for public health and so the continual nagging, sorry nudging, we get about our "dangerous" lifestyles may result in many more worried well. Hey, My Black Cat has just pointed out that the government in their "public health" role could then create a nice little earner for private companies if the worried well were rationed further down the line!


I'm certain you are correct that fear is the force driving the NHS / social care reforms and educational reforms too. But politicians don't like to admit fear and they don't trust the people they govern to understand that fear. Instead they bombard our minds with words like "choice" "change" " pathways" "journeys" and "integrated care" But I think the fear that engufs politicians of all parties is much wider than demographic change or PFI - it is to do with the balance of power in a changing world. Perhaps those running our country should have confidence in the ability of the common man and woman to understand their fears and open up about them instead of patronising us with jargon.

"Perhaps those running our country should have confidence in the ability of the common man and woman to understand their fears and open up about them instead of patronising us with jargon" - ahh, what a lovely thought WD, but I fear our leaders are in thrall to the PR machine?

An excerpt from Charlie Brooker's Guardian column (commenting on ITV reporter Damon Green's reaction to interviewing Milibore, ostensibly the man representing the last bulwark in the fight against the coalition and marketisation).

"The first interesting thing is just how twatty the Miliband PR handlers appear to have been, demanding their man be positioned "in front of his bookcase, with his family photos over his left shoulder", and insisting on checking the shot themselves, like a trio of dull Stanley Kubricks.
Anyway, after posing several questions only to receive oblivious identikit responses from Miliband, Green says: "I began getting twinges of what I can only describe as existential doubt." By the end he wanted to ask him: "What is the world's fastest fish?", just to throw him off-stride. (Kudos to Green for a) being funny and b) describing how weird the Miliband encounter actually felt. Not usually a political correspondent, it was a new experience for him".

Here is the interview Brooker/Green was referring to - it does not convey the impression that the labour leader has a burning desire to be honest or candid?

I am not saying that we should not resist changes to the NHS just that we cannot rely on men like Milibore to do so on our behalf.

Hello Dr No, you said;

"The PM's 'personal guarantee' is in the real world worthless, because it is only around as long as he is. It is personal, attached to him, and if he goes, so does the guarantee."

Only what 'PM' gives as 'Guarantee' will be part of the legislation amendments. The bill is currently being revised and will still have to go through the two houses before it passes, if indeed it does. Surely, there are enough clever people there to ensure that PMs 'Guarantees' are included.

"Dr No cannot find the phrase 'monitor and secure' either in the FF report"

But this solicitor did;

"Today’s announcement by the Government does mention the possibility of a “duty to secure the provision of services” rather than a “duty to provide” but the wording around this is ambiguous. So although we know the “duty to provide” would be abolished if the Bill goes through, we don’t yet know if there will be a “duty to secure provision” proposed to replace it. And we won’t know this until the new wording of the Bill is published."

Again, this will be clarified by the ongoing scrutiny in both houses.


Because he wants to open the door for top ups, 'provide' doesn't allow him to do so.

I am beginning to sound like what many would consider 'a government stooge' aren't I? :-) Only this is not the case. I thought about this myself and it was time to decide; is the government out to get me? And the answer was 'No', because if it is 'Yes', that means lack of 'trust', and that's bad! Because it means we'll all get nowhere. And, since I am no anarchist, I am of the opinion that cooperate and work together is best. Indeed, debates like this one here is part of that cooperation, and hopefully will help our leaders make better decisions. A stand off helps nobody!

Sam - you should know better than to try and provoke a bunfight between a doctor and a lawyer! In fact, in this case it isn't going to happen because the lawyer and the doctor are on the same hymn sheet.

The post you link to (and quote from) (and which Dr No has previously read) is titled (caps as in the original):

'Government’s NHS rewrite does NOT save the “duty to provide”'

and continues in paragraph 2:

'’s [ie 14th June 2011] announcement by the Government still does not ensure that a duty to provide medical services will remain in the Act of Parliament that forms the legal basis for the NHS. This duty has been in force since 1946.'

The paragraph in the post that contains:

'Today’s announcement by the Government does mention the possibility of a “duty to secure the provision of services” rather than a “duty to provide” but the wording around this is ambiguous.' identifies 'Today's (ie 14th June) announcement' (by the government) but neither this hasty (14th June) announcement nor for that matter the fuller later (20th June) response include the phrase identified by our learned friend. Be that as it may (maybe his glasses got steamed up in all the excitement), yet again the thrust of what he is saying is the same: the wording is at best ambiguous, and there is no certainty the duty to provide will be retained.

In any event, we have moved on from the 14th (and 20th) June, and now have the proposed new wording, contained in the tabled amendments, and detailed above (8:21am) (source here, scroll down to 'New Clauses'. Once again, note there is no duty to provide/secure the provision of (services etc).

The government's chief wheeze appears to be to claim that the SoS's duty to promote is the same as the SoS's duty to provide. But even dunder-headed non-lawyer Dr No can see that the two are not the same thing at all...

There may or may not be a debate to be had about top up fees, the rich woried well, and all the other interesting questions that are floating around, but debating interesting questions is one thing, nuking the NHS by the back door is quite another.

"Sam - you should know better than to try and provoke a bunfight between a doctor and a lawyer! In fact, in this case it isn't going to happen because the lawyer and the doctor are on the same hymn sheet."

Me 'provoke' a bunfight?! Between an expert hands on docor in the NHS AND an expert lawyer?!!

Oh dear!

Well, thanks for the compliment Dr No! :-)

I think it's better then to wait for the two big houses to decide for me. I 'trust' they both have the ability, and the capacity to do so.

Meanwhile, I intend to 'trust' and cooperate with 'my' government, because IMO this would be the right thing to do. This however does not mean agreeing blindly with whatever they say, but object when there is reason, agree when it is time to agree and discuss when this too is due ... and motivate, praise and encourage them when they do well too.

Praise is due now for the stopping, the listening and the reaching out.

Well done Government, keep up the good work ... and we'll be out of 'it' in no time at all :-)

Sam - Dr No regrets that his default position with politicians is not to trust them. Mussolini may have made the trains run on time, but that didn't make him trustworthy (though there were of course fractions of British society that trusted him implicitly). It was perhaps unfortunate that some Egyptians trusted Mubarak for rather a long time. And closer to home, let us not forget Cammers said no top down reorganisation of the NHS, and less red tape - and what is he doing? The HSCB is a dirty neutron bomb and if it goes off that will be the end of the NHS - and he is breeding quangos like frogs (163 to 500 and something), with command and control structures so complex that no one, let alone Dr No, can understand them.

The problem with politicians is that they have ideologically driven ambitions. We cannot blindly assume that their ideology is sound; and ambition means power, and power corrupts. That is why, for better of for worse, we have elections, and so the power to boot them out, and a (now increasingly incompetent not to mention impotent) fourth estate, although there are some grounds to hope that the blogoshere in its own way can do its bit to take over that function.

Allowing 'pseudo-mandated oligarchs' a free rein for several years because we 'trust' them has all the potential to lead, as Dr No's biology teacher used to say, to diarrhoea, death and destruction.

Yes, praise is due for pausing (they could have crashed the bill through) - but they haven't listened, only heard what they wanted to hear. Stevie's 'forum' has pretty much been outed as the 'we'll tell you what you want to hear' forum (see Hansard here, col 134 et seq). The overwhelming voices (see links in original post) of the medical (BMA) and nursing (RCN) professions - both saying dump the Bill - haven't been listened too. Is it really a good idea to 'trust' a government blind as a bat and deaf as a door?

Comments I've had from MPs and their advisors include, "we are reforming the NHS along the lines of the French and German systems" "Are GPs private businesses?" and "The majority of GPs are in favour of our reforms"

I've been invited to speak to the health committee and have spoken at the commons to selected groups of MPs and Lords. I've had correspondence with my own MP and been forwarded correspondence from other MPs.

My conclusion is exactly as Dr_no states at the begining, 'they haven't the foggiest'. I do not expect Dr_no to know absolutely everything about medicine, but I do expect him to look it up or ask a colleague rather than patronise me with some made up drivel. This is precisely the political response to serious quesioning about the healthbill from concerned members of the public and the medical profession. You would not, and most definitely should not trust a doctor who behaves like that. As for politicians? Not on your aunt Nelly.

"Dr No regrets that his default position with politicians is not to trust them. Mussolini may have made the trains run on time, but that didn't make him trustworthy"

We're not comparing our current politicians to Mussolini, are we?! You haven't been to Al Alanain, have you?! There is Mussolini's legacy and the reality of it can't be appreciated till you see for yourself! Not only the row upon row upon row of bodies but the tens of millions of landmines still killing and maiming people to this day too! The 'man' was a heartless vulture! @@ If you like, you can read on Al Alamain in my 'Egypt' tag, not much, but the pictures are there.

And Mubarak was corrupt, yes, but not to that scale described in the media. Apart from that, he did do lots of good things, and I won't forget that ... god knows who will take over too! Now, that's worrying! ... and believe me, reolutions don't feel nice, they hurt!

"let us not forget Cammers said no top down reorganisation of the NHS"

It's just like a patient Dr No, when you can make a different diagnosis after you've done the tests. Cameron came to office full to the brim with trouble and that huge deficit too! It would then be unimaginable to expect him not to react ... and he did! Actually, I like David Cameron, he has stamina! And he is honest! Unlike many ...

"The HSCB is a dirty neutron bomb and if it goes off that will be the end of the NHS"

No! That won't happen so, fear not.

"he is breeding quangos like frogs"

That's what Dr Gerada said, but the final shape of the system will not be known until the fate of the bill is known too.

"The problem with politicians is that they have ideologically driven ambitions. We cannot blindly assume that their ideology is sound; and ambition means power, and power corrupts."

Nor can we say that your ideology, or mine, are sound. However, it is unfair to say that ambition and the resulting power in whichever way that might be is corrupt. If that was true, we'd still be living in the stone age.

"we have elections, and so the power to boot them out"

Mind you, I think if Cameron continues with his uniquely modern type of internal policies of reaching out and engaging the public, he may actually break the record! Age is on his side too! And he is well liked externally ... even I'm coverted and I never voted for him! This one is 'special', but don't take my word for it, lets just wait and see :-)

As for 'trust, it's in our interest to trust him since we so far have no reason to do otherwise, much as I would trust you just because you are a Dr even though I don't know how good you are, until I see for myself. Actually, loads to patients are let down by incomptent docs and the patients don't even know it! They never get to find out either! Politicians do not enjoy the luxury when they mess up, right?

And the bill's fate? We can only wait and see


"I do not expect Dr_no to know absolutely everything about medicine "

By the same logic, why do we always expect politicians to get it right first time? Are they not human too?

"This is precisely the political response to serious quesioning about the healthbill"

No. I was against the original too, but I believe that listening did make a difference ... to the point that I do not even want to speculate on what will become of this bill ... better wait and see

Let's hope :-)

Dr No used Mussolini (and Mubarak), both well known political figures, to make the general point that above all else politicians are political animals, and despite apparent, even evident, support from some quarters, they can be, and often are, found wanting. It just strikes Dr No as patently absurd to trust individuals whose primary drivers are ambition and power.

That is not to say that all politicians are always bad all the time - that would be equally absurd. Indeed, Dr No has made no secret of his admiration for Churchill. But he also knows Churchill has many black marks against his name.

Dr No's own view of Cammers is that the is a smug git - a pretty bog standard Tory, in fact. The smugness is unpleasant (even if not as repugnant as IDS) because of its I'm OK you're not OK tone and the git bit is worrying to say the least: either he really isn't very bright, or he can't be bothered to read his briefing papers. Whatever, he has been talking tosh on the NHS, and any 'listening' he has done has been to his own sycophants and aides, and to them alone. Today's news that his former Director of Communications (why do PMs need directors of communications anyway?) yet again might not be squeaky clean suggests fingers aren't always on buzzers at Number Ten.

If we are going to use a medical analogy, the government has failed dismally. It produced a diagnosis (woe is the NHS) and treatment plan (the Bill) without taking an adequate history or performing an examination. It is not a question of revising a diagnosis in the light of new information. It has sought to impose that treatment on an unwilling patient, without that patient's consent. It has then tried to sugar coat/disguise the toxic treatment plan by various deceits. And soon it intends if it can get its way to hold the patient's nose, and force the treatment down...

Perhaps all politicians would be better off if they turned their back on spin and we could see them as they really are (maybe we already see them as they really are). This would give them more time to get on with the jobs they were elected to do too. OK, a bit of pantomime in the House of Commons might be a good thing in attracting tourists, underlining some interesting cultural eccentricities, and keeping us amused, but maybe that's just about all the antics politicians should indulge themselves in. It could be the blogosphere needs to watch the PR machines and the Think Tanks more than the politicians, who are being spun around so much they might have difficulty thinking in a straight line at times!

However, we should never assume that any country, race or individual does not have the potential to "Creep" into unknown and even atrocious territory and it seems to me we should never let our vigilance slip in this regard and it could well be that the blogosphere turns out to have a major role in providing checks and balances.

" above all else politicians are political animals"

Same as, lawyers are law animals, docs as medicine animals ... etc; that's called 'professionalism'! And is a good thing that is to be supported, nurtured, preserved and encouraged! Preserve talent, let everyone do the job they were trained at great cost to do! No more 'soup'! Soup is incompetent and wasteful since it's an unidentifiable mix! Rings a bell? ...

As for the rest Dr No, keep watching, and I am sure you will change your mind soon :-)


Witch Doctor "Perhaps all politicians would be better off if they turned their back on spin and we could see them as they really are"

But that's exactly what Cameron is doing and why he is so successful as PM ... because no other PM has ever reached out to his people the way he does!

"This would give them more time to get on with the jobs they were elected to do too"

There you are, you're beginning to grasp the style Witch Doc, because if you look close enough, this is already happening, one example is how Ed Milliband, whom I happen to think is a transparent politician too, has recently supported the government over the strikes issue, which I happen to think was the right thing to do since negotiations are still ongoing, and now is offering cross party cooperation on 'elderly care'. Well done Ed!

"it could well be that the blogosphere turns out to have a major role in providing checks and balances."

There you go! This sums it up! It's engage with the people time -> to find the BEST solutions -> at best cost too!

Politics in Britain is changing ... for the much better ... and the world is watching, in Awe! Lead the way Big Boss! :-)


Note from Dr No: Sam - Have taken the liberty of adding your name (and link) to this comment (knew it was you anyway - content and style unmistakable!) and removed your Oops! it was me comment - hope that is OK.

My Black Cat is chuckling over this description.

She wishes she'd thought of it first!

"content and style unmistakable!"

What, another compliment! 2 in one post! Thank you :-)

Well then, since it's it's compliment pay back time, I must say that from reading you, I know that I would be in safe hands anytime, if I ever needed your services [god forbids]

And on the same theme, please have a think about the following;

You are an innovative doctor, you found a new way to improve your patients' access and pathway and want to implement that at your place of work. But, you have other colleagues, who are good and able people, although so used to their ways, they are not all as receptive of change or innovation as you are. You have already 'promised' your patients of your new ways and they like them. But when those patients visit they get treated by those colleagues in the old manner instead. And it's in your face!

What would you do?

Sam - The short answer is: Dr No would be very wary of promising anything he did not know he could deliver.

The longer and proper answer to the puzzle - which Dr No takes to be about how to stop the NHS stifling innovation - is that, wedded though he is to the principles of the NHS, he nonetheless too at times finds its monolithic stubbornness and resistance to change intensely frustrating. More times than he cares to remember, he has seen innovation suffocated to an early death. Even worse, he has seen up and running, flourishing and outstanding innovations crushed by the weight of NHS clay.

And the problem is getting worse, given the rise of the team fetish, because more often than not, NHS 'teams' are not teams, but reluctant assemblies of disparate professions all fighting for their particular corner.

The only real way in which innovation can develop is for management to let go. The frigate captains have to be let out from under the coat tails of their admirals. But in today's over-regulated, risk averse command and control culture, no one dare trust the frigate captains - and so they remain trapped.

Intra-professional obstacles - doctors stifling other doctors' innovations - is a 'special case', in that it is the doctor's peers who have been revealed to be made of clay. Although sometimes the clay is the natural (and not unreasonable - Dr No for example tends to avoid 'new' drugs until they have been out for a while such that more is known about them) conservatism of an ancient profession, more often than not, the motivations of the clay doctors are not honourable: lazy and complacent, they resent interruption to their cosy world. Here, the innovator faces a stark choice: carry on, and risk sabotage by malevolent colleagues (and we've all seen that happen); or accept that life is short, and wading through clay self-defeating (and we've all seen that happen too). Which path an individual innovative doctor will take will depend on his or her nature and inclination.

Oh, and by the way, Dr No is not going to be cajoled into saying the reforms are a blueprint for innovation! Yes there may be a few bizarre flashes in the pan as any willing cowboy rides into town, but the reality is that, if implemented, the extra layers of command and control (Dr No has lost count of how many separate bodies are going to have a say in what goes on) will act to inhibit innovation.

" Dr No would be very wary of promising anything he did not know he could deliver."

And why can't Dr No deliver? ... because, given the nature of the organisation, Dr No, and his good colleagues, are not 'free'. One is never free under monopoly rules. So do you therefore agree that unless this concept itself is addressed, a monopoly of any kind will waste? Not only money, but talent too, hence the frustration you describe! .. and someone like yourself just ends up doing 'his bit'! What waste!

" Dr No is not going to be cajoled into saying the reforms are a blueprint for innovation!"

Andrew Lansley's original proposals break the monopoly, hence do encourage innovation. But, because of the very nature of the organisation, ie, that it is to do with sickness and disease, you can't proceed as fast or include as many changes all at once because that would cause an upheaval [cowboys, etc] instead.

But was his ideas innovative and bold? Yes, and would most probably work whole as is in settings other than health. As they were intended for health, they lacked clinical involvement to tone them down to fit the sensitive settings. A classic example of why clinical leadership is a 'must' when it is a health setting, despite the brilliance of the 'manager' and 'their' equally brilliant ideas.

... and those 'teams' you mention, are just 'soup' as I said before, so I agree with you. Do they stifle innovation too? Of course, what else can anyone expect from a runny soup?!

I like this last comment Dr No, lots to reflect on.

I wonder where the idea of competition would improve the NHS came from. Look to the birthplace of competition and free markets in health, the USA. A larger proportion of the population die of treatable conditions than anywhere else in the western world. The largest number of personal bankruptcies are due to medical bills - even with those people who have health insurance. The average age of death is lower than the UK. Yet this health system actually costs a lot more than the NHS. If you can get insurance for £3000 a year, you will be doing well, but will still have to pay for loads of extras if you are actually ill. The NHS costs less than half this amount per person, its results for the population are better, and if we had not had a purchaser/provider system to pave the way for privatisation (foisted on the NHS by the big consultancy firms in their ideas for the NHS ) you could probably shave a few hundred off even this figure.

So we have a cheap, relatively efficient health service which has proved to be better than the free market model in cost and efficiency for delivering a comprehensive health care system for the population. Whatever criteria you use, the NHS scores over the free market model. So why are politicians of both major parties so keen on destroying it and bringing in an inferior model? Could it be that the politicians are tightly in the thrall of the consultancy firms, whose accountancy arms will make billions out of the privatisation? Could it be that ministers and the top civil servants in the department of health are awarded lucrative jobs with very little imput from them in the companies which are likely to gain most from privatisation? Just look at the records of past government ministers to see where they are earning their money now. They will say it is their expertise these companies are paying for, but can you gain that amount of expertise in the two or three years maximum when they hold their health posts?

We just see that a system, which has been grossly underfunded for almost all its life, has managed to provide healthcare at a price cheaper than almost any other system and the recent spending to bring it up to the cost of european systems has been largely spent in trying to change the system, not to provide extra facilities.

I cannot get too excited about this bill, so far as I can see all of the changes are occurring even before the bill has passed parliament. One wonders what the point of the bill and all the political capital is invested for?

Perhaps it is as meaningless as David Camerons promise. Even if the purpose was to set in stone the changes, it cannot do so. An incoming government could reverse it all in a new bill if it wanted. But I do not think a new govt would do this, after all it was a Labour government that brought in practice based commissioning, polyclinics and ISTCs. I don't Trust any politician, but all parties have concluded that private sector providers and competition would be good things. Perhaps they are right.

Dr Phil.

If you read the excellent comment above your own I think it will give you an answer as to why "all parties have concluded that private sector providers and competition would be good things."

I don't trust any politician either - whatever their colour, their persuasion, for after they are elected - it appears that the only colour they see is that of money.

Please see The Cockroach Catchers excellent post - for if the NHS does need remodelling - The Mayo Clinic and its excellent care, ethics and teamwork seem a fine example to follow.

Anna :o]

Hello Dr Phil,

Agree that no other government would attempt to reverse the bill if it became law.

"but all parties have concluded that private sector providers and competition would be good things"

It may be that a few in the higher echelons and some of their obedient followers in all parties have formed this conclusion, but I doubt whether the majority of MPs of any colour have reached this as an informed conclusion. Perhaps all the MP's should be made to sit a multiple choice exam on the contents of the bill to see which ones are informed and which ones are not.

Snap, Anna.

Synchronisation is rife in the blogosphere!

consider one core question: why is the Secretary of State so determined to remove his duty to provide, or secure the provision of, a free at the point of delivery comprehensive health service?


And that is something that all you NHS romantics just have to accept.

Change is necessary.

SaDali - Dr No has considered this question - here. He suspects all the major parties want to get the NHS (and education for that matter) off the government books because its 'just too expensive'. Or at least it appears to be. But it is not quite as simple as that:

(a) whether the NHS is affordable or not is at the end of the day a political question. We could certainly afford what we have now, and a lot more to boot, if we spent the same proportion of our GDP on health as the Americans currently do. Our politicians just choose to spend less than the Americans. Most of our European neighbours also spend a higher proportion of their GDP on health than we do.

(b) the second question is: what is the most efficient way to use whatever percentage of GDP we choose to spend on health to get the best health care - which for us 'NHS romantics', at least this one, usually means a comprehensive service provided on the basis of need, not ability to pay. And here all the evidence points to a public sector (with a public sector ethos) system funded out of taxation. The moment the third man (profit) joins the party, there is simply another mouth to be fed - at no benefit whatsoever to patients.

Tonymlv, above, makes similar, and other, equally valid points.

One of the problems, covered here and elsewhere, is that too many politicians follow the rhetoric of the demographic time bomb, seasoned by their own party's line, without really thinking about the questions involved.

That said - we NHS romantics really are not dinosaurs. The NHS has changed and evolved throughout its life, and there is no reason why it should not continue to do so.

PS Boots - good to hear from you! Dr No was beginning to worry you had stabbed yourself with your own endoscope!

Dear Dr No,

I can see myself drifting back in time to my blog, perhaps in revised form, after closing it down some months ago. These are difficult times in Borsetshire, and increasingly paranoid ones for even the most mild of dissidents.

I agree the NHS could be funded if there was the political will to do so. In the end tax cuts are of no benefit if one has to spend the extra on school fees, university fees, private health insurance, domestic security and private pensions. It is still money spent. The demographic time bomb is overrated. While it is true that the number of retired is increasing relative to the number of workers this is offset by other factors such as increased productivity of the workers, increased female participation in the workforce and fewer dependent children per worker. There will be demographic challenges ahead, but not terminal ones.

You've got to admire the NHS, we're under pressure all the time and now with the Nicholson Challenge/QIPP it's worse.
OK I admit that I wouldn't have done the white paper this way, but I am still optimistic that sooner or later a bunch of clinicans will decide to suggest a way forward, rather than point out how the Governmant is wrong and how wrong they really are.
The closest attempt so far was in pulse about "cooperative commissioning".
We need to define a better future not clarify our criticisms.

I have been away around the now collapsing Greece (thanks to advice from top bankers and the need to join EU monetary union)and as they charge an arm and two legs for slow internet, I have missed all the fun.

Dr No is absolutely spot on. Money can of course be found and if it cannot, then print some more (as with US) and in any case all our money can only buy half the gold now (so much devalued). Interesting to read in BIJ about GP premises ( which shows how the government failed to understand that the old ways of the NHS is very close to the Mayo model (thanks Ana!) or at least it could be improved on.

The Mayo model is significant as it operates successfully in the USA for 100 years. The old NHS system is great in allowing doctors to go into different disciplines as the NHS pay is nearly the same for all. Internal Market approach increase the cost and skewed clinical practice. Now CHOICE will be the push to lure gullible people to think that the reform is a good thing. Then allowing private providers is simply going to cream off the little money that the government say they do not have.

I do despair. This must be stopped!!!

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