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Rapid Responses: Rapid Responses published:
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world-wide organisation with no discernible leader
- J Lindley Owen (19 December 2003)
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Why the patients of the NHS have no leader
- Jeremy G Jones (21 December 2003)
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Is it possible for a leader to lead the NHS?
- David Zitner (22 December 2003)
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Don is ill - he needs a ROTS and RETDAM
- Nigel Dudley (22 December 2003)
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An identifiable leader for the NHS.
- Morris P Doublet-Stewart (22 December 2003)
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A single voice
- Chris Smith (23 December 2003)
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A Pro-Active Health Expert Patient Body
- Robert J Cremona (26 December 2003)
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Will NHS benefit from a single leader?
- Sandip Raha (1 January 2004)
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J Lindley Owen, Director, Cornwall & Scilly HAZ St Austell PL25 4NQ
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To Richard's Smith's repeated, but so far unanswered question (what other organisation, of comparable size to the NHS, has no clear single leader?) I would suggest the World Wide Web. It works, because it is in the interests of every user that it does so. Problems arise, all the time, but are resolved collectively. Not only does it have no leader, it also lacks any formal hierarchy. The stronger and more obvious the vision underpinning an organisation, the less need for formal leadership structures. "Health care free for all when we need it, paid for when we don't" has served the NHS reasonably well since 1948. The problem is, it omits the personal responsibility of each beneficiary to reduce our need to use a 'free' good by modifying our personal behaviour. This, in a society which has moved markedly from post-war, rationed, collectivism, to self-centred capitalism, is at the heart of the dilemma of a service using increasing resources, while apparently making little headway. Competing interests: None declared |
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Jeremy G Jones, Consultant in Rheumatology and Rehabilitation Medicine Queen Elizabeth Hospital, Rotorua, New Zealand
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You ask why the NHS does not have a single easily identifiable leader. The answer is because the agendas of the stakeholders in the NHS are so different and so often conflict. This means that a single leader will find himself leading in opposite directions at the same time. Something even Napoleon could not do. For example were the leader a local politician he would be fighting to keep his local hospital open, whereas a policymaking moderniser would wish it closed. A socialist leader would be manipulating the system to try to close the gap between rich and poor (and so creating mediocrity) which is in direct opposition to those seeking excellence through change and competition (eg Foundation hospitals). Trade unionists strive to manufacture as many jobs as possible and stick strictly to outdated work practices, while those trying to develop an efficent service want fewer and more flexible workers. Doctors are trained to treat disease and disability, while social engineers medicalise social ills like wife beating, drinking and gambling, call them addictions and expect doctors to act as their agents for social change. The doctors themselves build hospital inpatient empires with high tech specialist services and yet don't provide for the needs of the people who actually come to the hospital (witness Dr Kerr's Struldbruggians -page 1451-3 of this issue- and all those patients with fibromyalgia, irritable bowel syndrome, tension headache, atypical chest pain etc who clatter around pointlessly from one specialist department and their inevitably normal tests to the next one). There is no service to meet their need so they block up scarce inpatient beds and outpatient appointment slots. One could go on and on. The thing to note about all this is that nowhere does the person for whom the service is intended, the patient, have a say. And whose life and wellbeing is in the balance? and who actually is forced to pay huge amounts of taxes to sponsor all these groups to behave in such selfinterested ways? This explains why there is no single leader of the NHS. While he give his money to the system for others to use for their own self determined ends, the patient has no power and cannot therefore expect to have a leader with any power. Give him control of his money and you will shift the power. With the shift of power will come leaders for a service which is designed for patients rather then the present one which is designed by the stakeholders of the NHS for the stakeholders of the NHS. Competing interests: None declared |
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David Zitner, Director, Medical Informatics Dalhousie University Faculty of Medicine, Canada B3H 4H7
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Carolyn Bennett, a Member of Parliament for St. Pauls riding in Toronto, Canada, and now a Canadian Minister of State for Public Health leads a group titled "Good Health Through Good Governance". The Good Health Through Good Governance group uses the working assumption that health care is a complex adaptive System. In order to adapt and continuously improve an adapting system requires feedback. Feeback in this case is regular, reliable and pertinent information linking health care activities with the results which follow these activities (changes in comfort, function and life expectancy). Without pertinent and timely feedback leaders are operating in the dark and it matters little if there is a single leader or a consortium. Information sign posts are necessary in order for leaders to know where to lead us. The NHS and other health systems will be enabled to continuously improve, when and only when, they provide patients, payers, administrators and the public with reliable information about access to and the results of care. Such information is rarely available today. David Zitner, M.D. Competing interests: None declared |
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Nigel Dudley, Consultant in Elderly Medicine St James's University Hospital, LEEDS LS9 7TF
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Dear Richard, Having read the very enjoyable HARLOT (How to Achieve positive Results without actually Lying to Overcome the Truth) piece in the Christmas edition of your journal I was then concerned to read about your American friend Don who appears to be seriously ill. The diagnosis of GRIGELS (GRass Is Greener ELsewhere Syndrome) became clear with his final statement that, "I would trade the UK's NHS, warts and all, current leaders in the bargain, for my nation's healthcare chaos any day." Yes, there are and were a few good leaders within the Department of Health who have recently achieved more funding and some service improvements. However, there are many equally as good managers, if not better, elsewhere including here in Leeds. There are also potential leaders out there such as Jan "get those Department of Health and SHA tanks off my front lawn and let me get on with the job in Bath" Filochowski. He would get my vote if the NHS chief executive post became vacant; a superb performance in front of the Public Administration Committee last year coupled with the ability to be clear and call a spade a spade, including in relation to management failure and lax external scrutiny and the corrosive effects that has on quality and governance, would make him a breath of fresh air in the Department. Read his comments on page 8 of the 11 December 2003 Health Service Journal. He seems to be someone with the vision to help others learn from mistakes. Unfortunately, I suspect that Dr Reid and some of the other ministers may not appreciate or warm to such a blunt and direct approach to problems and learning from mistakes. At times the Department's leaders seem to prefer to choose to shut their eyes, cover their ears, and hope that all will work out for the best rather than address corporate governance failures and hold individual executives to account using the codes of conduct and the other regulatory tools at their disposal. The good news for Don is that he can be easily cured of GRIGELS. First he needs a ROTS (ROse Tinted Spectaclectomy) followed by RETDAM (REality Therapy for Deluded American Managers). RETDAM is currently free on the NHS, even for Americans. He simply needs to log into his nearest computer and check out the exchanges that took place between the Committee of Public Accounts MPs and the leaders of the Department of Health in January 2002 and then look at the regulation and accountability reality in the Tinston report about the corporate governance failures in Bath, the Deloitte & Touche report about events surrounding the recent £44 million financial meltdown in North Bristol, and the little known events around the waiting list fiddles in Scarborough that were documented so nicely in Nik Patten's report. I hope Don enjoys and benefits from the suggested reading and gets well vey soon. If that reading does not work then perhaps the next step of reality shock therapy from the recent October and November pages of the Yorkshire Post will be required. Merry Christmas and Happy New Year Nigel (The views and opinions expressed are my own and do not represent those of my employing organisation) Competing interests: I would have liked to have assisted Don more in achieving a speedier recovery but that risked getting a repeat threat of a SHARKS (Striking Horror and Retreat through Killer Solicitors) attack from an exiting trust chief executive; the Attorney General's office has replied to a question about what may be libellous comments about chief executive performance, that could be generalised,that, "he cannot give legal advice to members of the public of the sort you have asked." Merry Christmas and I look forward to 2004 and the long overdue introduction of a register and regulatory body for health services' senior managers in the public interest. |
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Morris P Doublet-Stewart, GP Principal Grasmere Street Health Centre, Leigh, Lancs. WN7 1XB
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What I believe we need is not another man in a grey suit but an icon to represent what the NHS stands for. Somebody like Nelson Mandela. Mother Theresa or the Dali Lama for example. Of course, there is always St. Jude, patron saint of lost causes for those of us having a bad day at the office. Morris Doublet-Stewart Competing interests: None declared |
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Chris Smith, Psychiatry l;ocum Buckinghamshire
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The NHS would benefit from a single leader, not purely by the efforts or qualities of having such a person who can direct policy and action, but by the process of getting there: Would it be a nurse - a manager, or, unfashionably, a doctor? Can one person (who must always have one predominant or identifiable professional background) speak for all the disparate professional groups who make up the NHS? Well, they could, if everyone was clear about the aims and values of the service - as I think I am right in saying they once were. We have become divided over what and why we are doing or trying to do due to the rise of competing value systems, ever more elaborate, that have evolved to allow one group to club the others with their ethical and political views, as politicians stand by and exploit the chaos that reigns in states of conflict, and rule the divided. If a single leader could rise above the games, then they would be a force to be respected, and to be reckoned with by those who will fight their corner to the last so as to be standing on the highest point of the ship as it sinks under the waves of initiatives and ever-proliferating perceived needs. They might even suggest we work as one against sickness and its causes and enable us to do so once again, but that might be too radical a platform...... Competing interests: None declared |
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Robert J Cremona, Volunteer Tutor, Counselling and Researcher Surrey, GU21 4UA
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Having been involved with the NHS as both patient and medical professional for the last 30 years, this is the only way forward. Amalgamation of knowledge is an identifiable pro-active method that empowers the good in a system that can only get better. Finances have corrupted many a promising venture, so there is no further need for basing a national health system on Government hand-outs alone. The current archaic abilities and inabilities of the NHS in general are genuinely heartbreaking. So much needs to be brought into the 21st century that only genuinely caring professionals and long term patients can now honestly assist the many recommendations that will be revealed in the much -awaited Wanless Report. Administration and Hygiene are just about the worst in Europe and in a private sector, half of the pointless gangs of beaurocratic employees would have been sacked long ago. It is important to commence a plan that accepts that long term illness is on the increase, we are living longer and we rely on foreigners to handle everything from medical treatment to administration. The number of medical staff who cannot hold the most basic conversation in English is causing numerous cases of negligence and misunderstanding throughout the country. Acute admissions are not adequately catered for and the public has long lost their confidence in an NHS system that purposely appears to be complicated and ineffective. In a recent survey on a large London Hospital, all the patients and staff on a over-subscribed Renal Dialysis Ward were conversing in a multitude of languages, some even had interpreters(paid for by Public Funds). Only two of the patients(from 20+) and only one of the Staff were actually British! We are a charitable and generous country and this is to be highly commended, however when it becomes to the detriment of people who have lived, worked and paid their taxes all their lives, this is totally nonsensical, frighteningly alarming and an insult to everything that stood for the nobility of this country. With regard self- monitoring and plans for the future of protecting the nation, the word 'nil', springs to mind. In my experiences and dealings with a number of NHS bodies, total chaos runs rampant, too much responsibility is put on the shoulders of the irresponsible. Patients are vulnerable like never before. Unless many of the recommendations made in the Wanless Report are immediately instigated, the continual decline of previously high standards will reach further depths that so many fear. The amount of errors in the system are visibly terrifying and, statistically speaking, we are already losing the battle to reform many departments. One only has to compare British Health hospital admissions, waiting lists, professional mismanagement and the continaual recruitment of 'supposedly' English speaking medical staff with other countries on a financial and cultural par to us to be alerted to the total mess our current system is in. In a nutshell, an honest cause for desperate measures is upon us and only the lazy, inadequate, irresponsible and uncaring will disagree for the sake of salvaging their own salaries. A health system for the future has to start with a health system for the present. Competing interests: None declared |
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Sandip Raha, Hospital Physician Princess of Wales Hospital, Bridgend, Wales
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I have worked in NHS for 23 years and being an overseas graduate find some of the comments in this section strange! NHS today and in 1980 and 90's is different in many ways other than number of staff and money. Organisational issues of NHS can be better solved in GOVT. stops meddling with new initiatives every year. Health system cann't be judged on basis of Waiting lists. A single leader for the system is unlikely to change anything till we have far less political interference and targets (as was in 1980's). What NHs needs is vision and planning for decades not from election to election. We have many overseas staff in NHS and they contribute valuable service without which present NHS system would be a third world service. Britain cann't produce and train enough people to run it's services in Health, Education and many other areas. Information technology in NHS is still primitive and in dark ages, transformation of this will save many waisted hours and manpower in NHS to improve patient service and delivery. People who feel that scantly English speaking staff in NHS are a burden should put forward ideas how they think we can have thousands of extra doctors and nurses without paying for their training and and investment. Competing interests: None declared |
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