If you let the fox into the chicken coop: profit & ‘efficiency’ in the NHS

A couple of news stories have caught my eye over the past few days, because they’ve confirmed developments in the NHS that I’ve predicted in this blog as well as because they signify bad news both for the people who work in the NHS and for the patients who rely on it.

But the most tragic and most damning aspect is not simply that these damaging developments were always completely predictable, but were actually intended by the government – no matter how much they might protest otherwise.

We’ll look at those stories in a moment, but first let me tell you a quick, true story:

I have a friend who has a house with a huge garden, in a row of large houses with large gardens. My friend kept chickens at the end of his garden – until one day a fox got into the chicken run during the night. Of course, this was great for the fox – and very bad news for the chickens, not one of whom survived the experience.

My friend felt no surprise that the fox had killed the chickens. That’s what foxes do. If you keep chickens and care about keeping them alive, you make every effort to keep foxes out of the coop. But if you open the door and usher the fox inside, you don’t get to protest when it does what foxes do.

Which leads me on to the first of our news items.

‘Efficiencies’ or destruction?

Yesterday, the Guardian published a report claiming that NHS trusts are ‘putting patients’ lives at risk’ by rationing drugs and operations because of cost-cutting imposed by the government. The claims, by new chair of the BMA council Mark Porter, allege that the ‘drive to meet demanding efficiency targets is so serious that the NHS is offering some GPs surgeries extra money if they send fewer patients for tests and treatment in hospital‘, a move which he condemns as morally wrong. And I doubt that many of us would disagree.

Porter also claims that rationing and reduction of NHS services are ‘being hastened by the coalition’s health reforms, creeping privatisation of services and the system’s need to save £20bn by 2015‘. This saving – which represents about 1/6 of the NHS’ total annual budget – is only the tip of the iceberg, as the service is expected to cut £50bn from its spending by 2020, which has been described by experts as unachievable.

Eager as ever to dodge any responsibility for what happens under its massive re-structuring of the NHS – which can’t of course be a top-down re-organisation because David Cameron promised there’d be no more of those! – the Dept of Health said “If patients need treatment, they should get it when they want it and where they want it. If local health bodies stop patients from having treatments on the basis of cost alone then we will take action against them“.

Sounds good – except that it’s like strangling someone and then saying it’s unacceptable for them to stop breathing! Or like releasing a fox among chickens and then complaining that it kills them. It’s insane to criticise the fox – that’s what foxes do. Similarly, the government has unleashed a rabid, ravenous monster into the NHS in the form of unachievable spending cuts – and it had to know, when it did so, that ‘efficiencies’ of 17% and more couldn’t be achieved while maintaining unchanged, unrationed levels of service – which means lives lost that needn’t be. Of course it knew – and it’s all part of the plan. Which makes the government’s protests about the measures taken by some parts of the NHS, to try to achieve the impossible, just so much PR-oriented hot air.

Porter also states that the government’s ‘reforms’ are fragmenting the NHS and having a ‘severe impact‘ on care. Which leads us onto story #2.

In a separate article on the same day, the Guardian also reports that Royal Cornwall Hospitals Trust has failed to hit its target of treating Accident & Emergency patients within 4 hours – because of an increase in the number of patients sent unnecessarily to A&E by private health provider Serco’s out-of-hours GP service.

This story actually represents at least two foxes released into the NHS chicken coop:

The first is:

The profit-motive

I’ve written variously about how the only way that a profit-making provider can compete with the non-profit NHS on cost is by cutting staff, cutting wages and cutting corners.

The Guardian’s article states that the increase in unnecessary A&E attendances are caused by Serco’s service relying on a new system of computerised scripts that operators follow instead of relying on medical training. In fact, this misses the mark slightly.

Out of hours services have included computerised scripts for some time. In 2003, the University of Sheffield’s Medical Care Research Unit carried out a study on the use of computerised scripts by nurses in the NHS Direct out-of-hours service. The study found that the scripts were useful guides and safety-nets for the trained nurses operating the helpline. The nurses ‘described both the software and themselves as essential to the clinical decision-making process‘.

Talking of the process of making good decisions and ensuring the accountability for those decisions and the resulting outcomes, nurses stressed the the importance of medical experience and training, ‘because otherwise you’d just sit trained monkeys in front of the computer terminal wouldn’t you?‘

The key problem with Serco’s service is not the scripts per se, but rather the fact that Serco is relying completely on them so that it doesn’t have to pay medically-trained staff to use the scripts and take decisions on whether to follow or over-ride them. By using operators without medical training, who have no choice but to follow the computerised decision-process slavishly, Serco was saving cost and improving its profits – by pushing cost and responsibility onto the NHS trauma facility.

But in one sense, it’s hard to blame Serco for acting like what it is: a profit-making operation. The real blame lies with the government, who knew and knows perfectly well that by introducing a vastly-extended profit-motive into the NHS, it is creating not just the risk of cost-driven decisions that are bad for patients and more expensive over all – but the inevitability of them.

Government knowledge also features heavily in fox #2 of this situation, as well as in the situation described by Mark Porter of the BMA above:

Fragmentation

It’s well-known that Andrew Lansley vetoed the release of the Dept of Health’s risk-analysis of its planned ‘reforms’ – even after a court ruled that it must release the analysis following a ‘Freedom of Information Act’ request for it. But eventually a heavily-edited extract from the risk report was released – and even after editing, it was damning of the effects of Lansley’s insane restructuring.

Even the DH’s own risk-analysis said that the ‘reforms’ would result in fragmentation of the NHS, leading to adverse consequences for both patients and budgets – exactly what is being seen in both of the news stories referred to in this post.

The government knew that this kind of thing was bound to result from Lansley’s Act – despite its protests that such things are unacceptable. But this is not just a case of the government pressing ahead recklessly with its measures in spite of adverse consequences.

As I’ve shown before, the government wants the kind of consequences described in the two news items, because – on various fronts and various ways – it is setting the NHS up to fail. By starving the NHS of resources, forcing it to ration treatment and by fragmenting the service into unmonitorable, unmanageable, variously-owned parts, the government:

– makes the NHS cheaper for the sell-off to private interests that it is unquestionably the government’s long-term (and already underway) aim

– damages the prestige of the NHS in the eyes of the public, reducing the likelihood of concerted public resistance to the sell-off and to attacks on the pay, security and pensions of NHS workers

– makes it far harder to gain a cohesive picture of what is being done to the NHS, by whom, and to what ends

The government has set these forces in motion in the NHS with deliberate intent – and its protests that it didn’t approve of or expect the results are as hollow and meaningless as those of a farmer who shooed a fox into his chicken-coop and then laments the ensuing destruction. But they hope you – or at least enough people – will believe them.

Everyone knows what foxes do – and the government is far fonder of its foxes than it is of the people its supposed to protect. Don’t believe Cameron, Lansley and co when they claim otherwise. If they really cared about the NHS or about the people it treats, they wouldn’t have ushered the foxes into the coop in the first place – criticising the foxes for doing what foxes do is pure posturing.