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The NHS should not be like a conveyor belt
At first, I thought my criticism was simply because it was called “The Tony Blair Dictum”. For me, one of the most ‘successful’ Labour Prime Ministers in living history, and this is no time for hyperbole, was very good at knowing the price of everything and the value of nothing. This is what I thought was the heart of his failure to understand how modern business works, and the importance of people in the creation of value in the relatively new discipline of corporate social responsibility. But Blair was a lawyer and politician by trade.
The “Tony Blair Dictum” says “I don’t care who provides my NHS services ‘behind the curtain’, as long as it’s of the highest quality.’ Variants of it include the bit ‘as long as I don’t pay for it’, and indeed this bit is often tagged on to help to demonstrate that the reforms are not privatisation. However, if you include that the majority of contracts will be put out for competitive tendering, to avoid conflict, to the private sector – it is privatisation. It is taking away of resources to run a comprehensive, universal state-run service, and using the monies as consideration for entities running services for profit or surplus.
For ages, I thought my objection to this was purely in terms of my own business training. This training had taught me that increasing transactional costs was bound to magnify greatly the amount of wastage and inefficiency in running the system as a whole. Coupled with the loss of ‘economies of scale’, the likelihood of this process would be a fragmented service which costs money, and which is unlikely to be comprehensive. I don’t think my economic argument is incorrect. Nor do I think it’s somewhat disingenious for private contractors to run their services under the NHS logo, while it is well documented that programmed attacks on the NHS ideologically have taken place in parts of the media. Some parts of the media in an astonishing way have not reported on the ‘reforms’, estimated to cost about £2.5 bn so far, at all.
No, it’s not that. I think I find this Dictum potentially difficult, if it can be a different Doctor each time who sees you, and it doesn’t matter where they’ve come from. It suddenly dawned on me thanks to thinking about why Dr Jonathon Tomlinson (@mellojonny) loves general practice so much. My late father was a GP near Brighton for nearly 30 years, and he loved his job. He was a single-handed practitioner with a list of about 2500 with not a blemish on his professional record, and he did all his own on-calls. This means that he knew his patients (and often whole families) backwards – his families loved him as the community Doctor. He never breached medical confidentiality of course, but the continuity of care was of benefit to patients. This meant, like transactional costs, things would not get repeated to different people at different times, and things were not ‘lost in translation’ through Doctors reading the medical notes of other Doctors. My father knew his patients.
However, given that I have nothing to do with the medical profession, I am struck by how a ‘conveyor belt’ atmosphere had begun to emerge in the NHS, even in the brief time when I was a junior physician in busy Trusts in London and Cambridge. This means that the approach was that of a “production line”, what I would later know as ‘lean management’ (where it is very difficult to know the precise cause of clinical error because the system is literally firefighting all-of-the-time). In this production line, Doctors would never see the output of their combined efforts, the “product”, as the Doctor responsible for writing the discharge summary was invariably not the Doctor who had generated a ‘problem list’ when the patient was admitted to the Hospital in the first place.
This situation I feel is not unique to primary care, and certainly this is not meant to be any criticism of Group G.P. practices where Doctors are very keen to know the histories of all patients in their catchment. It is not meant to be a criticism of NHS Direct or the Out-of-Hours service, though the benefits of a patient seeing his or her own Doctor out-of-hours is not simply an issue of nostalgia. I think there is a clear parallel in the commodification of the legal profession. This commodification has seen law as not having a prominent place in one’s community (“There is no such thing as community” is possibly a more accurate phrase than “There is no such thing as society”), with the death of the high street law centre at odds with the flourishing multinational corporate law firms. Ironically, in the United States which has had a longer time to assimilate the effects of multinational corporates on modern life), there is now recognition from big-brand management consultancy firms that there is more value to be had inter-transactions rather than intra-transactions. This means that the approach of one ‘fee earner’ identifying and solving the legal problem, with that fee earner never to be seen again, is being replaced by a lawyer who is interested in the development of your issues over a long period of time.
This indeed had been the approach of the medical profession too. I remember being witness to some amazing physicians, who admittedly had remarkable memories but, who could remember events from the patients 20-30 years’ ago, which might have direct relevance to the symptom with which he or she was presenting today. Possibly, with the introduction of whole person care, this approach might take a comeback, and certainly continuity-of-care had previously been considered important for the conduct of medical professional life. Whether they intended to or not, my late Father and Dr Tomlinson have made me realise why I do actually find ‘The Tony Blair Dictum’, aside from macroeconomics, potentially very difficult.
Competitive tendering is no longer the solution; it is very much the problem
As part of the “Big Society”, medics and lawyers have now been offended over competitive tendering. Competitive tendering is no longer the solution; it is very much the problem.
Yesterday, it was the lawyers’ turn. The Bar Standards Board (“BSB”) yesterday extended (10 May 2013) the first registration deadline for the Quality Assurance Scheme for Advocates in the face of a threatened mass boycott by barristers. The Solicitors Regulation Authority is expected to follow. In a statement yesterday, the BSB said the deadline will be extended from 10 January to 9 March 2014 ‘to ensure the criminal bar will have more time to consider the consequences of government changes to legal aid before registering’. The end of the first registration period will now be after the Ministry of Justice publishes its final response to its consultation on price-competitive tendering. The SRA board is expected to approve a similar extension later shortly.
A group of leading academics, including Prof. Richard Moorhead from University College London, indeed wrote yesterday,
“As academics engaged for many years in criminal justice research, we write to express our grave concern about the potentially devastating and irreversible consequences if the government’s plans to cut criminal legal aid and introduce a system of tendering based on price are introduced. Despite the claim by Chris Grayling, the minister of justice, that ‘access to justice should not be determined by your ability to pay’, this is precisely what these planned changes will achieve. This is not about ‘fat cat lawyers’ or the tiny minority of cases that attract very high fees. As we know from the experiences of people like Christopher Jefferies, anyone can find themself arrested for the most serious of crimes. No one is immune from the prospect of arrest and prosecution.”
Previously, it had been the medics’ turn. That did not deter Earl Howe in collaboration with people who clearly did not understand the legislation like Shirley Williams in competition with the medical Royal Colleges, Labour Peers and BMA. The Royal College of Physicians set out their oppositions to competitive tendering articulated their position last month:
Competitive tendering is often considered to promote competition, provide transparency and give all suppliers the opportunity to win business. It may be that price tags are driven down, but most reasonable professionals would actually ask, “At what cost?” Competitive tendering, rather, has a number of well known criticisms.
When making significant purchases, frank and open communication between potential supplier and customer is crucial. Competitive tendering is not conducive to open communication; in fact, it often discourages deep dialogue because in many cases all discussions between a bidder and the purchaser must be made available to all other bidders. Hence, Bidder A may avoid asking certain questions because the questions or answers may help other bidders by revealing Bidder A’s approaches, features, and the like. At the moment, there is a policy drive away from competition towards collaboration, innovation and ‘creating shared value’. Dr. Deming also writing in Out of the Crisis, “There is a bear-trap in the purchase of goods and services on the basis of price tag that people don’t talk about. To run the game of cost plus in industry a supplier offers a bid so low that he is almost sure to get the business. He gets it. The customer discovers that an engineering change is vital. The supplier is extremely obliging, but discovers that this change will double the cost of the items……the vendor comes out ahead.” This is called the cost-plus phenomenon.
Competitive tendering furthermore encourages the use of cheaper resources for delivering products and services. A supplier forced to play the competitive tendering game may come under pressure to keep costs down to ensure he gets a satisfactory profit margin. One way a supplier can lower costs is by using cheaper labour and/or materials. If the cheaper labour and materials are poor quality, the procurer will often end up with inferior, poor quality product or service. However, warranty and other claims may result –raising the price of the true, overall cost. Another area where suppliers may be tempted to lower costs is safety standards. This current administration is particularly keen on outsourcing, and sub-contractors may cut corners and creating safety risks. This is obviously on great concern where patient safety in the NHS has recently been criticised, after the Francis Inquiry over Mid Staffs NHS Foundation Trust. Furthermore, then government agencies, and indeed, private companies use competitive tendering it can take several years to choose a successful bidder, creating a very slow system. The result is the customer can wait incredibly long periods for product or service that may be required quickly. Finally, insufficient profit margin to allow for investment in research and development, new technology or equipment. Already, in the U.S., private “health maintenance organisations” spend as little as possible on national education and training of their workforce.
So the evidence is there. But, as the Queen’s Speech this week demonstrated on minimum alcohol pricing and cigarette packaging, this Government does not believe in evidence-based policy anyway. In the drive for efficiency, with a focus on price and cost in supply chains, the legal and medical professions have had policies imposed on them which totally ignores value. This is not only value in the product, but value in the people making the product. One only needs to refer to the (albeit extreme) example of a worker being retrieved from the rubble of that factory in Bangladesh to realise that working conditions are extremely important. This is all the more hideous since the policies behind the Legal Aid, Sentencing and Punishment of Offenders Act (2012) and the Health and Social Care Act (2012) were not in any of the party manifestos (sic) of the U.K. in 2010.
Competitive tendering is no longer the solution; it is very much the problem.
Competitive tendering is no longer the solution; it is very much the problem.
As part of the “Big Society”, medics and lawyers have now been offended over competitive tendering. Competitive tendering is no longer the solution; it is very much the problem.
Yesterday, it was the lawyers’ turn. The Bar Standards Board (“BSB”) yesterday extended (10 May 2013) the first registration deadline for the Quality Assurance Scheme for Advocates in the face of a threatened mass boycott by barristers. The Solicitors Regulation Authority is expected to follow. In a statement yesterday, the BSB said the deadline will be extended from 10 January to 9 March 2014 ‘to ensure the criminal bar will have more time to consider the consequences of government changes to legal aid before registering’. The end of the first registration period will now be after the Ministry of Justice publishes its final response to its consultation on price-competitive tendering. The SRA board is expected to approve a similar extension shortly.
A group of leading academics, including Prof. Richard Moorhead from University College London, indeed wrote yesterday,
“As academics engaged for many years in criminal justice research, we write to express our grave concern about the potentially devastating and irreversible consequences if the government’s plans to cut criminal legal aid and introduce a system of tendering based on price are introduced. Despite the claim by Chris Grayling, the minister of justice, that ‘access to justice should not be determined by your ability to pay’, this is precisely what these planned changes will achieve. This is not about ‘fat cat lawyers’ or the tiny minority of cases that attract very high fees. As we know from the experiences of people like Christopher Jefferies, anyone can find themself arrested for the most serious of crimes. No one is immune from the prospect of arrest and prosecution.”
Previously, it had been the medics’ turn. That did not deter Earl Howe in collaboration with people who clearly did not understand the legislation like Shirley Williams in competition with the medical Royal Colleges, Labour Peers and BMA. The Royal College of Physicians set out their oppositions to competitive tendering articulated their position last month:
Competitive tendering is often considered to promote competition, provide transparency and give all suppliers the opportunity to win business. It may be that price tags are driven down, but most reasonable professionals would actually ask, “At what cost?” Competitive tendering, rather, has a number of well known criticisms.
When making significant purchases, frank and open communication between potential supplier and customer is crucial. Competitive tendering is not conducive to open communication; in fact, it often discourages deep dialogue because in many cases all discussions between a bidder and the purchaser must be made available to all other bidders. Hence, Bidder A may avoid asking certain questions because the questions or answers may help other bidders by revealing Bidder A’s approaches, features, and the like. At the moment, there is a policy drive away from competition towards collaboration, innovation and ‘creating shared value’. Dr. Deming also writing in Out of the Crisis, “There is a bear-trap in the purchase of goods and services on the basis of price tag that people don’t talk about. To run the game of cost plus in industry a supplier offers a bid so low that he is almost sure to get the business. He gets it. The customer discovers that an engineering change is vital. The supplier is extremely obliging, but discovers that this change will double the cost of the items……the vendor comes out ahead.” This is called the cost-plus phenomenon.
Competitive tendering furthermore encourages the use of cheaper resources for delivering products and services. A supplier forced to play the competitive tendering game may come under pressure to keep costs down to ensure he gets a satisfactory profit margin. One way a supplier can lower costs is by using cheaper labour and/or materials. If the cheaper labour and materials are poor quality, the procurer will often end up with inferior, poor quality product or service. However, warranty and other claims may result –raising the price of the true, overall cost. Another area where suppliers may be tempted to lower costs is safety standards. This current administration is particularly keen on outsourcing, and sub-contractors may cut corners and creating safety risks. This is obviously on great concern where patient safety in the NHS has recently been criticised, after the Francis Inquiry over Mid Staffs NHS Foundation Trust. Furthermore, then government agencies, and indeed, private companies use competitive tendering it can take several years to choose a successful bidder, creating a very slow system. The result is the customer can wait incredibly long periods for product or service that may be required quickly. Finally, insufficient profit margin to allow for investment in research and development, new technology or equipment. Already, in the U.S., private “health maintenance organisations” spend as little as possible on national education and training of their workforce.
So the evidence is there. But, as the Queen’s Speech this week demonstrated on minimum alcohol pricing and cigarette packaging, this Government does not believe in evidence-based policy anyway. In the drive for efficiency, with a focus on price and cost in supply chains, the legal and medical professions have had policies imposed on them which totally ignores value. This is not only value in the product, but value in the people making the product. One only needs to refer to the (albeit extreme) example of a worker being retrieved from the rubble of that factory in Bangladesh to realise that working conditions are extremely important. This is all the more hideous since the policies behind the Legal Aid, Sentencing and Punishment of Offenders Act (2012) and the Health and Social Care Act (2012) were not in any of the party manifestos (sic) of the U.K. in 2010.
Competitive tendering is no longer the solution; it is very much the problem.
"Britain's hidden alcoholics" by @campbellclaret. It made me cry.
This was an incredibly powerful programme presented by Alastair Campbell (@campbellclaret). Anne Robinson says she nearly died. I nearly did too – on June 1st 2007 I was admitted to the Accident and Emergency Unit of the Royal Free Hospital NHS Hampstead, having sustained an aystolic cardiac arrest and epileptic seizure. I then stayed in a coma for six weeks in ITU due to proven acute bacterial meningitis.
Nick Lessar, paramedic, remarked that he thought that people who’d fallen victim to alcohol excess on the streets of London were mainly professional people, and this observation apparently is confirmed by the Office for National Statistics. Alastair describes how he started off as a problem drinker, before he started drinking to excess. He described how felt he was good at hiding it, and indeed I have found from my own experience that alcoholics tend to become expert liars.
Like Alastair, I have never bought the argument that 24/7 style drinking works. My late father was the first to agree. Like Alastair, I also believe that this licensing is to be lame. I used to drink at home on my own, after a full day’s work; I don’t think as a professional I am the first or last to have done this. Furthermore, alcohol is cheap from supermarkets, so like as explained by Prof Ian Gilmore, former President of the Royal College of Physicians, proponent of the ‘Alcohol Health Alliance‘ I feel a safer environment was provided by traditional pubs.
Alcohol problems cost the country £2.7 billion last year. 41% of professional people apparently drink more than the recommended limit. My concern is that the legal and medicine professions are full of them. Many City firms are within a stone’s throw of pubs. Lawyers with problems need to know where to get help, and fast. 9,000 people a year die of alcohol-related disease.
One person describes that her life was “spiritually and morally bankrupt”. I recognise this aspect of many alcoholics.
I paid a very high price. Not only in terms of my working life so far, I ended up in a wheelchair. I learnt how to walk again, thanks to the wonderful help of the physiotherapists and occupational health therapists at the National Hospital for Neurology and Neurosurgery. I learnt how to speak again thanks to the wonderful Speech and Language Therapists there. My late Father witnessed the worst of it, but thankfully he lived long enough to witness the beginning of my recovery. And, for the record, I now walk and talk absolutely normally.
I have, originally from a wheelchair, completed my Bachelor of Laws. I then did a LLM by distance learning in international commercial law. Last year, I completed a MBA, and I am now doing the Legal Practice Course. I had a two hour interview with the Solicitors Regulation Authority in December 2010, having disclosed I had a previous problem with it. By that stage, I had been only 3 years in recovery. Now I am four years in recovery. I know that if I have another drink I’ll keep going, and I’ll be dead.
Drink does endanger work, health, relationships and their lives, as explained by Alastair. Like Alastair, I went to Cambridge, and my gut feeling is that alcoholism is far from simply only a working class problem. In fact, one might say that universities like Oxbridge have a formidable drinking culture, with numerous drinking culture and the notorious ‘Suicide Sunday’ at Cambridge in May Week. The professions need to have a strong attitude to getting professional away from harm’s way in being near the public. Someone though has to pick up the pieces to ensure that these ill people get help. I picked myself up.
Well, never mind, you live and learn. I’ve met, though, some wonderful people on the way, and they know who they are. Like Alastair, you spend ages pretending you’re not an alcohol, until you finally have to give up the pretence. I agree with Alastair’s Psychiatrist, though – I don’t think it’s safe for people like me to drink at all.
The author is the Shibley, President of the BPP Legal Awareness Society, a student society for all BPP students to promote the understanding of law and regulation to corporate strategy. He tweets at @legalaware.
