As is stated at the beginning of the report McKinsey "were instructed by the Department of Health to provide advice on how commissioners might achieve world class NHS productivity to inform the second year of the world class commissioning assurance system and future commissioner development." They then produced this report, I have only just got around to reading it. In summary the report just comes up with the obvious such as reducing funding to save money (what genius), efficiency savings and moving care out of hospitals. However when one looks into the details of the report the logic behind these 'savings' is sadly lacking.
The report is full of stupid and naive statements like "Acute providers – Potential savings of £1.9–3.0b if all providers below the median productivity achieve 50–80% of the potential improvement of stepping up to the median." and "Acute providers – £1.5–2.4bn savings if all providers below the median of clinical staff productivity achieve 50–80% of the potential improvement of stepping up to the median". Well obviously if we could improve everything below the median then you will get efficiency savings, however saying it is much easier than doing, often trying to improve efficiency can result in the very opposite.
"Acute providers – In addition, £0.4–0.6bn savings if all providers below the median of non clinical staff productivity achieve 50–80% of reaching the median", "Community services – Potential to deliver same level of activity with 11–15% less staff, if district nurses achieved median productivity or 10% above", "Mental health – Potential to reduce beddays by 8–12% if providers achieve 50-80% of the potential improvement of stepping down to median ALOS", "Potential GP productivity improvement could be worth of £0.2–0.4bn, if weak performers achieve standard performance": These are just a few more of the examples of McKinsey suggesting that everyone below the median just magically gets better and then money will be saved. There is very very little on how this is actually going to be done in practice, it is like saying if we magically get much better then we will do better, it is pure baseless and meaningless speculation.
"Mental health – Crisis resolution teams can reduce the need for admissions by 40–50% based on controlled trials": Here is an example where McKinsey do quote the evidence, in this case a BMJ paper, however the BMJ paper itself quotes the results as being 'equivocal', hardly solid backing for more McKinsey savings.
"Acute providers – nurses spend only 41% of their time on patient care", "Study across FTs found only 55% of community midwives time is spent on patient facing activities", "A low-performing GP can spend less than 30% of their contracted hours actually seeing patients": there seems to be a bit of a recurring theme here, a lot of clinical staff are spending a lot of time not seeing patients. A large reason for this is the bureaucracy that has been assembled around the target and tariff driven market based system we have now, strangely McKinsey just want clinical staff to find more time for patients, as if by magic again. This doesn't address the root cause of the problem, only scrapping the market, tariffs and targets would.
The McKinsey talk of 'non-effective interventions' as if numerous things we do are completely ineffective and could be scrapped at no cost at all to patients. Apparently 'spinal injections and fusions for back pain', 'trigger finger surgery' and 'knee washouts' are all relatively ineffective. Apparently "Inguinal, Umbilical and Femoral Hernias, Incisional and Ventral Hernias" are all potentially cosmetic procedures. Hernias don't give significant pain to patients and have a serious risk of strangulation do they? And now a huge list of procedures that are not that beneficial in mild cases "Knee joint surgery, Primary hip replacement, Hip and knee joint revisions, Cataract surgery, Female genital prolapse/stress incontinence (surgical), Dupuytren’s contracture, Cochlear implants (inner ear surgery), Other joint prosthetics/ replacements": McKinsey may be surprised to know that clinicans do not throw around major operations without considering the risk benefit of that procedure, no doubt it would be a manager with no clinical training who would decided what consituted a mild case of hip arthritis or a mild prolapse? Apparently these conditions should not be treated surgically in the first instance "Carpal tunnel surgery, Elective cardiac ablation, Anal procedures, Bilateral hip surgery"; McKinsey obviously don't know much about a severe rapidly progressive carpal tunnel syndrome being left too long.
"Reducing variance of GP referrals for new outpatient appointments could lead to savings of £0.2-0.4bn.", "Potential savings of £0.2-0.3b, if PCTs achieve the median follow-ups to new OP ratio or 80% of the potential of stepping down to bottom quartile", "Variability in performance between SHA indicates opportunity of £60-100m1 if median or 80% of top quartile achieved", "Assuming similar potential savings for all other PCTS, potential savings from shifting acute care to primary care of £0.2-0.5bn": it goes on and on like this, McKinsey wants everyone out of the bottom quartile, everything up to the median, but the details of doing this in practice are extremely thin on the ground.
It is obvious that the report has been written by people with intelligence as it is well written and glossy, however it is also abundantly clear that it has been written by people who understand very very little about medicine. Most of the 'savings' suggested by McKinsey are as a result of the magical transformation of under performers into good performers, somehow McKinsey will get rid of anything below a median, it is truly cloud cuckoo stuff of the highest order.
A massive problem with everything in this report is that the 'savings' suggested are invariably only 'pseudosavings', by this I mean that the work will still be being done it is just that no one will pay for it, this is a great trick of the useless market based system we have now. The inefficiencies in the system today are largely as a result of the ridiculous market based system with all the tariffs and targets that comes with it, McKinsey's approach does nothing to address these problems, in fact a lot of their suggestions would worsen the situation.
Overall I am dismayed that so much taxpayer's cash has gone towards funding McKinsey to produce this evidence-lite report. Fundamentally the market based approach is failing the public and resulting in an extremely inefficient and overly bureaucratic system. We would be a lot better off if secondary care were to be centrally funded directly from the state purse, then hospitals could spend their money as efficiently as possible and a lot of the waste from the excessive bureaucracy would disappear.
The proposed White Paper is a disaster in the making, it will result more and more money being frittered away on the process and less and less going on the patients. The one person who has been forgotten in all this mess is the patient, as power is transferred from the clinically astute to the clinically unaware, the one to suffer will be the patient and that is what the market does, it results in the clinical being forgotten, protocols and guidelines become enforced by the clinically unaware managers, money is saved and the patient is left to rot as the medicine is forgotten.
The White Paper for health will see the NHS destroyed. The market is to be left in control of matters. Sensible long term central planning for the nation's health will be a forgotten thing of the past, the market will do all this, as if by magic.
As bottled water, useless products that are a complete waste of money will proliferate, this will lead to more inefficiency and patients struggling to get proper treatments that do have solid evidence behind them. The market for health care is no Utopia, it is just a way in which a lot of private firms will get very rich by providing easy treatments for the worried well while proper treatments for the sick are not appropriately prioritised.
A perfect example of the market leading to completely useless rubbish being sold is the APOS treatment from BUPA, it is complete and utter nonsense. Read all about it and be very afraid. You had also better get used to these kind of junk evidence-lite treatments, these bottled waters of the medical industry will proliferate in the next few years, this is what the market promises for your cash. What a sad and terrible waste, but the marketing is very shiny, one can't forget that.
Another extensive political document outlining yet more restructuring of the health system, yes it is time for another white paper and this one has been delivered by Andrew Lansley. It's a shame that with all the talk of reducing costs and minimising the bureaucratic inefficiency, these new reforms will see almost 2 billion pounds ring fenced for yet more deckchair rearrangement.
The market remains, and until the market is destroyed then any hope of an efficient public system is dead. Commissioning is doomed to failure, whoever does it, it is a definite poisoned chalice that GPs would do well to avoid it at all possible.
The logic behind this reform is sadly lacking. GPs are the providers of primary care and are not trained/suited to hold the purse strings for secondary care. Handing the vast majority of NHS funds to GPs is barking mad, it is something that could only have come from a stupid politician with no grasp of how healthcare is delivered.
Billions and billions are being wasted yet again in moving around a set of failing market based deckchairs. All that will be proven by this latest white paper is the fact that our politicians have no clue as to how to run a health system. Lansley is clueless, but so is Burnham, the NHS has been tampered with by successive groups of morons and it will not get better until be have a sensible moderate centrally funded system run by the clinically and medically aware.
There is absolutely no method to this madness. The idea of fining hospitals for re admissions is just plain stupid and short sighted, just as the idea of paying hospitals again for re admissions was. Lansley is an idiot, dishonest or both, and frankly I don't care which combination he is.
Lansley's chatter is nonsensical, just as Burnham's was, just as Hewitt's was, just as Johnson's was, the list goes on and on. The fundamental problem with these cretins is that the internal market is a moronic idea. The fact that primary and secondary care are not set up to cooperate in the best interests of the patient is plain foolish and until that problem is addressed, the politicians talk is just hollow garbage.
Primary and secondary care need to work together, currently they do not and the stupid payment systems serve to decrease the amount of cooperation between the two, thus worsening patient care. There is a massive needless bureaucracy in place in which both primary and secondary care are fighting over a few scraps, while the interests of patients are forgotten. If Lansley thinks these new ideas will reduce the bureaucracy and squabbling then he is quite wrong, the opposite is true.
The internal market is the enemy and our politicians continue to side with the enemy because their corrupt ideologies are deeply flawed. The Tories are no different to New Labour, both are groups of muppets who refuse to address the systematic problems with the internal market. Top down control of the market won't work, we need a system in which patients are prioritised and the movement of money does not trump clinical need. We need cooperation, not competition, until that is done money will continue to be frittered away on these stupid top down market based initiatives.
Remedy are taking the General Medical Council to court this week on behalfof 1600 doctors. The GMC have been accused of blocking a Fitness to Practice enquiry into Sir Liam Donaldson, days before he is due to step down as Chief Medical Officer. The case has been branded as ‘The Double Standards Challenge”.
The litigation arises over Donaldson’s management of MTAS – thecomputerised recruitment system for junior doctors. The Health Select Committee concluded that “Candidates and assessors alike were justifiably outraged by the sheer inadequacy of MTAS. The period between February and August 2007 was characterised by unrelenting chaos and severe anxiety for thousands of junior doctors. …
The reputation of both the Department of Health and the leaders of the profession were severely diminished”. The GMC was asked to consider whether those responsible should face a disciplinary hearing. But they declined to refer the matter to their Case Examiners. In a letter to Remedy they stated that Donaldson’s involvement could not render him unfit to practice “whatever the conduct’. This conflicts with the GMC’s own published guidance for Doctors in Management,which states ” You remain accountable to the GMC for your decisions”.
It is unheard of for thousands of doctors to take their own ruling body to court. But Remedy believes that we have been completely let down. There should be one rule for all medics, without exceptions. We are drawing aline in the sand over cronyism and lack of accountability in the upper echelons of the medical profession. This is the first time a case of deficient professional performance has been made against a doctor in management.
If you want to support Remedy then you can donate money here, or join their Facebook group here. Come on Remedy and come on Justice!
The health service has been dumbed down magnificently since Labour came to power in 1997. In order to try to save money a lot of work previously done by highly trained doctors has been handed to people with much less education and training. Some people think this makes sense, but the fallacy of their arguments is obvious, you simply cannot expect those with less education and training to do as good and as efficient a job as those with the higher skill levels. This tale demonstrates just what is going very nicely indeed:
According to the Telegraph Labour have been crafting secret plans to cull large number of junior doctor training jobs if they magically win the election with Gordon Brown at the helm. This sums up the rank dishonesty and incompetence that this government have shown regarding doctors' training in the last thirteen years.
Labour have presided over a massive over expansion of medical student places at Universities. I call this an 'over' expansion because they have not maintained standards, they have stuffed medical schools too full, they have dumbed down the quality of the undergraduate medical training system in the process, much the same has been done to all University degrees under Labour.
The expansion in numbers has led to the typical boring propaganda from Labour such as 'more doctors', 'more nurses' and 'more degrees'. This may be true, but it has come at some cost and that is the standards of education, and also the fact that many of these people will have no long term career prospects in their area of training.
Modernising Medical Careers (MMC) and MTAS are two of the government's biggest cock ups, the former being the flawed dumbed down reform of medical training and the latter being a hopeless application process that wrecked many a junior doctor's career. The threat of culling training posts now could be devastating to the service with many rotas being massively short staffed as things stand.
This government simply cannot be trusted. They promised us so much and have delivered so little. The referendum on Europe never happened despite being promised in the Labour manifesto, many other promises have been broken in recent years since Labour came to power.
Medical training is in crisis despite all the money that Labour has wasted on the NHS. This government promises to protect front line services, this is a very dubious promise given these secret plans to scrap training jobs for doctors. The bottom line is that Gordon and chums cannot be trusted, they have lied time and time again. Do not give them your vote next week, they simply do not deserve it. Labour need to be removed at all costs.
Having watched bits of the Election debates and various interviews on TV in recent weeks, I can conclusively say that health and the NHS has been generally ignored and when talked about, the real issues have been completely skated over. All three major parties seem unable to talk about making any cuts, this is ridiculous given the amount of money being wasted on various crackpots schemes in the NHS.
We have billions being thrown away on the pursuit of the internal market when it clearly doesn't work. We have numerous layers of administrators who are not needed such as the PCTs and the SHAs, these bureaucratic layers actually spend a lot of money trying to avoid doing work rather than actually funding the front line services. We have numerous QUANGOs doing sod all of use and we have billions being wasted paying for ridiculous PFI schemes that are often run by the banks owned by the tax payer, this is beyond farcical.
There has been no open honest debate about this waste and this inefficiency, the politicians are too afraid to talk of the NHS, it is a political hot potato. The market needs to be dismantled, the way health care is funded needs to be radically simplified and transformed from the current overcomplicated shambles it is.
Gordon Brown's comments have been beneath contempt. Not only have Labour been sending out misleading leaflets to cancer patients in the most abhorrent of circumstances, but they pretend that scrapping their stupid top down targets would be the end of the world for patients, this is clearly not the case. Gordon Brown has been pretending that targets are the key for patients, actually a lot of the scientific research shows that targets are probably doing a lot more harm than good.
Targets are a waste of time. It is the capacity of front line services that is key, not the centralised targets imposed by the ignorant and uneducated bureaucrats. The 2-week cancer target is a great example of this, without extra capacity the 2-week target will arguably worsen outcomes as it will allow cunning patients a way of jumping the queue in a way that overrides clinical priority.
The old system in which referrals were overseen by the expert clinicians was far better, clinical priority was far better served. The same is true for the ridiculous 18 week surgery targets, a blanket rule such as this helps no one, it leads to ridiculous tactics in fiddling the paperwork to make money, while if capacity is not increased then no one is better off. Some people need their operations urgently, others are happy to wait for a year, lumping everyone in the same box is just plain stupid.
Targets are just one of the ways in which this corrupt abhorrent regime have tried to control the NHS from the top in a way that has not helped the majority of patients. The government's paranoid desire for complete control helps no one, it results in a system in which cooperation is dead, fear and intimidation rule. Clinical priority is now decided by medically ignorant managers and not the highly trained doctors, taking the expertise out of the prioritisation of treatment has been a massive backwards step. This government has empowered idiots because they are easier to control and rule. Gordon Brown is a liar or he does not understand the NHS, the targets need to be scrapped, we need power to be handed back to the clinicians and we need a massive cull in the layers of managers who do nothing more than obstructing patient care. And after all if those in charge think everything is so much better, why are they trying to hide the public from reality?
With the election looming I thought it worth emphasising just what 'new' Labour have done to the NHS and doctors since they came to power in 1997. Instead of working with professionals, they have demoralised and undermined them with their megalomania and top down control freakery. This short tale is from one of many who have had their career destroyed by Labour in such a heartless fashion, it gets across just what this current regime represents:
As the election fast approaches, one could be forgiven for getting carried away with all the excitement about polls, TV debates and campaign trails. If one takes a bit of step back then one can see our democracy for what it really is, a steaming pile of dishonest horse manure.
The vote should mean something, many people have fought and died for the right to vote, politicians even claim to this day that not voting is an insult to those who fought for the right, I disagree with these politicians. The vote has come to mean very little and this is one great shame.
There is no genuine choice, despite the endless shiny waffle and propaganda in the mainstream media, if one quickly scratches beneath the surface then one soon sees that all the major political parties have pretty much identical policies on the key issues. The vote is practically meaningless, it is a token gesture, party politics is corrupt and has run out of democratic steam.
Take the health service for example, there is simply no choice for voters on policy, all the major parties are not questioning the market ideology, the PFI schemes that are wasting billions, the privatisation agenda, the dumbing down and dis empowerment of the educated professionals. The mainstream media are silent on this scandal, bloggers are the only genuine voice against this disgrace and the election propaganda goes on and on.
Politics is broke, meaningless superficial Television debates will not fix this problem, unless someone in a position of power does something about this disillusionment of the general population, then the time bomb will keep on ticking and eventually it will go off.
Calling a spade a spade should not leave one liable to be sued, yet this is precisely what happened to Simon Singh when he took on the quackery of the British Chiropractic Association. The claims made by the BCA that spinal manipulation could be used to treat children with colic, ear infections, asthma, sleeping and feeding conditions and prolonged crying were nothing but utter hogwash. Singh's decision to call their claims bogus has been shown to be 100% correct by the Court of Appeal.
The Court's judgement can be read in full here, and this really is a victory for common sense and for scientific progress. Quacks should not be allowed to make unfounded claims about their dodgy treatments, whether this be companies peddling nutritional supplements, practitioners of alternative therapies such as acupuncture, herbal medicine, chinese medicine, homeopathy and on and on, there are just so many quacks out there.
The way in which the British libel law was used to intimidate by the BCA is rather scary and it makes the case strongly for a proper overhaul of our antiquated and repressive libel laws:
"The ruling, by England's two senior judges, Lord Judge and Lord Neuberger, together with Lord Justice Smedley, was scathing of the way the BCA began libel proceedings rather than taking up the Guardian's offer of a right to reply. It acknowledged that the action had a "chilling effect on public debate". The BCA's actions had created the "unhappy impression" that it was "an endeavour by the BCA to silence one of its critics" "
I would urge anyone reading to sign the petition here are the libel reform site and have a look at the senseaboutscience site here. The likes of the BCA need to be shown up for the dishonest rip off merchants that they are.
This eloquent letter sums up so much that is wrong with the way that the government creates policy. Obviously this letter refers only to the ACMD (Advisory Council on the Misuse of Drugs) but the same problems are present across the board. The government's policy should be crafted in the best interests of the general public, when one sees what has happened as regards drug policy one can see that policy is created to satisfy political expediency and not the long term best interests of the public.
The same is true on health, policy is not based on the evidence or on the best expert advice, it is created by politicians and government cronies who have no proper education or knowledge of that particular area, and it is created to satisfy the short term needs of politicians and the Daily Mail, not the best long term interests of our country. Anyway the letter is an excellent insight into the disastrous way in which our stupid politicians create useless policy:
The ferreting award for the most stupid, dangerous and idiotic NHS target ever has to go to the Trust which is bribing the Ambulance service not to take patients to hospital. This is unfortunately no joke. Money should not come into clinical decisions like this and it will only result in more needless deaths as a result of the under trained being pressurised into making reckless clinical decisions for which they have not been adequately prepared. This is rather similar to the equally dangerous scheme that was bribing GPs to not refer patients on to hospital specialists.
David Fisher had a history of heart trouble, he collapsed at home, but thanks to the bizarre system of targets and payments he was not greeted with an immediate ambulance, his call was downgraded in urgency and he was fobbed off with a telephone helpline. Untrained idiots on a phone line won't cure cardiogenic shock, so Mr Fisher was left to die at home. The dangerous way in which non medically trained people are now being empowered by protocol is beyond belief, it really is.
The market that we have is a disgrace, we now have an epidemic of managers to oversee this barbaric rationing of care, we are spending more and more money to avoid actually treating patients, this money would be better spent actually dealing with medical problems, not hiding from them via payment systems and tonnes of meaningless paperwork. The number of managers in the NHS is now 84% greater than in 1999, that is one hell of a statistic. Even Kafka would have trouble writing a book on the bureaucratic nightmare that is today's NHS and its dysfunctional network of SHAs, PCTs and Whitehall monkeys. No wonder private firms are using think tanks as a dishonest way of bribing politicians so that they can get greasy hands on this easy money as the NHS is sold off bit by bit. Cooperation is being replaced by dysfunctional competition, doctors like myself are fuming and patients like David Fisher are needlessly being left to die thanks to the substandard services on offer. The managers and politicians presiding over this shambles should be shot.
This investigation for the Sunday Times reveals the tip of the iceberg in terms of business bribing politicians for direct reward. It is simply scandalous and it has been going on left, right and centre in every area of policy from health to defence for years and years. The politicians caught indulging in this should be locked up and the keys jettisoned. This is blatant corruption at the very root of our so called 'democratic' system of government, it is nothing but a complete and utter disgrace.
After several recent rather high profile deaths a lot of light has been cast on the topic of the way in which medical practitioners are regulated in the European Union. It is not something I thought I would ever say, but the GMC are talking some sense for once on this issue:
A survey of nurses has revealed what a lot of NHS workers and patients already knew, that patients are routinely being treated and housed in storage areas, offices, TV rooms and outpatient clinics.
This comes on the back of news that massive cuts in the London NHS could well result in the loss of 5,600 beds, this is almost a third of the total number of beds available in the capital.
Bed numbers go down and down thanks to PFI schemes and the internal market's forced cuts, targets forced patients to be shunted out of AE quicker and quicker, it's really no wonder that patients are spilling over into TV rooms and storage areas.
It's all so predictable and it was all so very preventable. The internal market and the government's program of enforced privatisation has left us with this disastrous legacy of patients dying in corridors, at least the private providers are making their healthy profits come what may.
The shambles that is the coverage of health and health policy in the media is exposed by this excellent lecture that Dr Grumble pointed me towards. It is a topic I have spoken about many times in the past, the fact that that so many of the journalists that cover health and health policy have no education or training in this area is an utter shambles. The lack of decent educated journalists for health has combined with the problems with the mainstream media (that has been dumbed down as a result of reducing revenues that have led to much cheaper, lazier and more poorly researched stories) to quite devastating effect.
This has led to the current shambles. All one reads in the mainstream media on health is the cheap and easy reproduction of press releases by short cut taking hacks, these press releases from lobby groups and government direct the direction and news follows. There is no sensible analysis of the drivel that is fed to them in the form of press releases, the journalists just churn out manufactured partisan dross. The point made in the above lecture is a good one, this key point is that the public are now so unaware and uneducated on these serious issues in health that the government is able to get away with wasting billions of taxpayer's money on the current corrupt and grossly inefficient privatisation agenda. The government has done this quite deliberately, if the public were aware of what was going on thanks to an open and well informed media then they would not stand for it, as things are when people wake up to it, it will all be too late to do anything about it and turn back the clock.
