Sir Gus O’Donnell said famously, “If you treasure it, measure it”. This is happening in the medical profession too, with a policy drive that the best people to rate the NHS are the users of the service. These are the patients (or “customers” if you’re that way inclined). The ‘Friends and Family Test’ has come under fierce criticism, not surprising given that it has never been subject to proper analytical rigour, and the criticisms of it have been well rehearsed elsewhere. There is a fundamental difference in assessing your hospital stay, compared to “Trip Advisor”, but it is all part of the information revolution. Information, according to people interested in innovation like me, is not the same as knowledge, and not all information is useful. Whilst the corporates, who introduced their love for Big Data to the rest of the world are fully aware there is a lot of redundant, useless data, and the importance of certain datasets need to be explained carefully, this has completely passed the NHS by. The introduction of the vascular surgery rates was held by some to be a shambles, due to the poor explanation of these data as well as data inaccuracy. Forgetting the fact that certain fields in vascular surgery (e.g. abdominal artery aneurysm repairs for aneurysms diameter > 6.5 cm are considered riskier than sclerosing varicose veins, for example), or that safety is a team activity (though the root cause of a problem can be identified to a single reason), the data explosion is envisaged as empowering patients and persons with ‘choice’.

Enter the market. Jeremy Hunt continues to dodge completely the question why private sector entities under freedom of information legislation introduced by a Labour government are not under obligation to disclose data because of their ‘commercial interest’. As they are not public bodies, they are not amenable to judicial review either. Moving swiftly on, choice is supposed to empower the patient with information. How is that possible, that a patient will be equally fluent as a Doctor of about 7 years’ standing who has achieved registration with the General Medical Council? Very good question. Is it the case that vascular surgeons have a need to improve their mortality data because they are now operating (quite literally) in a free (pseudo)market? No, categorically not. The Royal Colleges of Surgeons and the General Medical Council are responsible for general professional training and higher specialist training standards in surgery. Doctors are increasingly seen as employees in a business case, with Trusts salami-slicing how much they want to spend on staff to achieve their efficiency savings as mandated by Sir David Nicholson and the Department of Health. They are that respect no more essential than an import of horsemeat for lasagna to improve the profitability of a venture capital investment. Registered Doctors are professionals though, and legal.

It has been noted that trust in GPs has plummeted from 70% to 30% since the implementation of the Health and Social Care Act (2012)? I, for one, would quite like to rate how management consultants conducted this important strategic implementation. This £3bn reorganisation had a critical piece of legislation, the “section 75 regulations”, which produced competitive tendering as the default option. The first set of Regulations were so bad they had to be withdrawn. The Medical Royal Colleges, the BMA and RCN all say the Act won’t work. The first rule of strategic implementation is that you involve all the stakeholders and engage in a realistic conversation about what is intended to be achieved, how, why, or when. None of this happened. That is why I award the Department of Health, despite what can be best described as “shuttle diplomacy” by Earl Howe, a big fat result thus:

And why has trust in GPs plummeted? Is it anything to do with the fact the media and politicians have been force-feeding the public with stories that GPs opted out of out-of-hours some time ago, and they got a deal which was quite lucrative? Or is it because there are now anecdotal reports of GPs having to advise non-NHS care to their patients in the hope that they can jump a lengthy NHS queue? It is very hard to tell. But certainly it is true that GPs have become first in the firing line for the NHS reforms. They in fact opposed the reforms, with clear leadership by Prof Clare Gerada, Chair of the Royal College of General Practitioners. The Government PR went into overdrive that “GPs are at the heart of commissioning”, the ‘clinical commissioning groups’, but this was obviously never the intention. CCGs are merely a vehicle for holding funds and assessing risk in a pooled population, in a manner of ‘statutory insurance schemes’. This has always been the case, and always will be. For all the talk of ‘entrepreneurial GPs’, the public do not appear to warm to the idea of GPs as businessmen (and GPs do not particularly wish to represented as businessmen). Germane to this is the “dual agent” problem, very well known in insurance markets. That is the idea that no person can have “two masters”, without a significant conflict of interest: this might be for example a GP’s professional duty to his or her patient, and his or her duty to the people who ultimately provide the funding. This issue of trust is possibly bound to get worse, as ‘scandals’ are drip fed to the media of a system in distress. The reason this score is nothing to do with Prof Gerada is because Prof Gerada, as the new “NHS SOS” book explains (edited by Dr Jacky Davis and Prof Ray Tallis), was one of the few NHS leaders to have a clear vision and have the charisma to set this out in confidence, a textbook example of a “charismatic leader”, who deservedly was one of the hundred most influential individuals in health. And, very clearly, she appeared to be representing patients as well as GPs.

Anyone who wishes to defend the NHS is accused of protecting a ‘national religion’. And yet the NHS is accused of being ‘monolithic’, ‘inefficient’, ‘dangerous’, ‘expensive’, and every negative adjective under the sun. Politicians are responsible for this deprofessionalisation of key non-managerial workers in the NHS, with talk of ‘it doesn’t matter who provides my care as long as it is the…’ (a saying which in the legal and medical sectors has increasingly been completed with the word “cheapest”). Every conceivable thing is blamed for the pressures under which the NHS functions; such as the “burden of the ageing population” and the equally pathetic and untrue myth that high-quality healthcare is dependent on expensive equipment. Tell that to the cardiologist who can discern an early diastolic murmur with a pulmonary hypertensive ‘heave’ due to a crappy £20 stethoscope, not a £5000 portable digital echocardiogram machine. The number of lies in the drive to make the NHS attractive financially to outsourcers and privatisers has been breath-taking. In view of this, isn’t it time perhaps we either rate how Doctors are actually treated in the NHS, or time to turn the tables and rate our NHS management and politicians?