Disinvestment in health care
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1413 (Published 17 March 2010) Cite this as: BMJ 2010;340:c1413
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Dear Editor,
Apparently, the difference between a chicken and a pig at breakfast
is that the chicken is a participant, but the pig is involved. In terms of
the NHS, we are all not just the holders of the stake, but usually its
object, and always paying for the meal.
We should all be sharing a common agenda - the need to focus on those
practices that are not necessarily driven by current whim or policy but by
the evidence-base for what ministers to humankind and the need not to
borrow from the future in ways that are completely wasteful and
unsustainable. If we continue at the present rate then we are simply going
to run out of the oxygen required to sustain competitive, egosystem-driven
conversations anyway.
The English way is that of perspiration, but as the Rapid Response
highlights, we frequently neglect the power of aspiration in human
endeavour. Most people do not enter the NHS, health and social care or
teaching to be mediocre: just like 'change', instead of enabling people to
"be the change they want to see", they have it thrust upon them from on
high by the latest freshers from University, business, or the Toyota
factory?
A very simply way for the NHS to save money, reduce journeyings,
mitigate the trauma of overmedicalisation and reduce its carbon footprint
would be for people with lived experience to be far more involved in peer-
peer support of others going through the shared mangles of diagnosis,
treatment and distress that they have been wrung through. Indeed, this is
highlighted by Rich and Leonard on pp 628-9 of this very same issue.
Yours Sincerely
Dr Chris Manning
www.upstreamhealthcare.org
Competing interests:
None declared
Competing interests: No competing interests
Cooper and Starkey base their editorial on the premise that change
invariably provokes one emotional response; a natural resistance to
change and it would be unexpected if major change was enthusiastically
embraced. This would come as a devastating blow to Mr. Cameron who has
planned his entire campaign on the need for change.
Not only should disinvestment, as suggested by the authors later in
the editorial, be set in a positive context but the positive attitude
should create an atmosphere that facilitates changes wherever necessary in
the NHS. Psychology of change is not as negative as the sweeping claim
attributed to the psychologists t in the editorial. It is demoralising to
read that there is sociological and psychological research to back this
resistance to change. Aspiration to improve is inbuilt in individuals and
society and is the bedrock underlying change. The authors have chosen to
ignore the vast amount of research exploring how psychology aids
organisations and society to embrace change.
Ability to adapt and change with the times is a prerequisite for
progress within any organisation. Parliamentary system of democracy will
collapse without the willingness and ability to change. We cannot afford
the luxury of debating the sociological and psychological aspects of the
attitudes to change within the NHS. The NHS can and must change.
Graham Rich and Phil Leonard have identified cuts that will not harm
health care. Zalmanovitch and Vashdi practising their art in Israel claim
that balancing the need for funding coverage and quality will necessarily
lead to a trade off of one component against the other two. In fact the
illustration based on Lami’s theorem of three forces acting at a point
goes against their own arguments claiming instability between these
forces and would on the other hand be a perfect illustration that it is
feasible to attain a state of equilibrium between the three competing
forces. Their claim that “a government resolved to implement major budget
cuts must accept reduced standards for the other two objectives ignores
what the politicians and public have known in this country for a very long
time, that the three factors are not operating under optimal conditions.
Rather than starting with biased assumptions what is required is to
approach the problem as set out by Rich, Leonard and the experts at
individual specialty levels.
May I however point out a glaring omission from the list of
specialties, namely the department of diagnostic imaging. Jane Dacre,
consultant rheumatologist has alluded to the cuts that can be made by
planned and rational investigation. This is not entirely the fault of
clinicians. Radiologists are not blameless, performing the investigation
requested because it is easier to do it than to argue against it but at
times through refusing to bite the hand that feeds them. Radiologists
should be far more pro active in determining the appropriate investigation
for a given clinical situation.
Competing interests:
No related interest
Competing interests: No competing interests
Some at least of your readers work in the NHS. They may even be
reading you in NHS time. Please cut out artcles like Room 101, the
Editorial on Disinvestment, Feature (p 622) Analysis, (p 628) and Teach
doctors economics...(p 657).
Cut out the posts of doctors, nurses and their "support staff"
engaged in non-clinical work. By non-clinical I mean not directly
supporting care of INDIVIDUAL patients.
I hear screams of protest from these ladies and gentlemen.
Look back at the health service man-power before the 1974
reorganisation (better described as DISORGANISATION). Compare it with the
man-power today. Compare the proportion of hangers-on, pre-and post 1974.
Further,compare the salaries paid to these people and those paid to
staff examining and treating people and tell the public how the
comparisons stand.
And in all this, do not forget the staff costs of the Whitehall
departments managing or servicing or monitoring the NHS. Tell the public
what these costs are.
Forget about teaching doctors economics, management. Abolish the
various health service management institutes.
JK ANAND
Competing interests:
Elderly, fully retired doctor
Competing interests: No competing interests
Disinvestment in health care
The editorial and linked articles in the BMJ were an excellent
example of the kind of involvement and debate health care professionals
should have regarding the inevitable painful cuts ahead, but I feel it did
not go far enough with the solutions.
The editorial talks about "..a positive agenda of disinvestment.."
from a "..co-ordinated dialogue between health care managers and health
care professionals..." - but why was there only a brief mention given to
"users of services"?
Why are the public so far-removed from the debate on cutting costs?
Surely it is about time someone asked the "users" what they want?
The Department of health will claim that the Government has a public
mandate that it possesses by virtue of election to public office and
therefore it has the right to decide the nature of cuts. But like any
"expert" body of doctors, nurses, health economists, psychologists or
managers it merely shares the common delusion that it is the one with the
most important expertise to decide what is best for the NHS.
If we are to create a viable alternative, it is vital for patients,
managers, civil servants and health professionals to engage with each
other as the editorial suggests. The "shared vocabulary, language and
narrative of change" must describe the constructive process of discussion
between those disparate groups, and not the talk of dysfunctional
committee meetings where everyone voices an expert opinion, no-one listens
and there is no holistic understanding of the problems being faced and no
common solutions.
In an ideal world, the next health secretary will bring those groups
together and will be a nurse, consultant or GP with experience of primary
and secondary care, an MBA, degrees in economics and psychology, who has
passed the civil service exams and has a chronic medical condition (stress
from getting 5 degrees would not count) and we will have a sensible
coordinated long-term plan for disinvestment which does not include
repeated cycles of restructuring.
Or we could get someone with none of the above who will be available for
hire in 2 years time to lobby for any private contractor looking to get a
slice of what's left of the NHS.
Like most change in the NHS, the following years of disinvestment are
going to be shambolic. It is inevitable because political convenience and
good management do not mix. The Government had the courage to make the
Bank of England independent and let the Monetary Policy Committee make the
tough decisions it had the expertise to make, while being fully
accountable to parliament and explaining its decisions to the public.
Doesn't the NHS deserve the same?
Competing interests:
None declared
Competing interests: No competing interests