A productivity challenge too far?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2416 (Published 19 June 2012) Cite this as: BMJ 2012;344:e2416
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I have no means of deciding whose figures are right,indeed they may all be false, particularly as we were being told that 'productivity' was poor even when waiting times had fallen to an all-time low. The thing that really worries me is that we have swallowed the classic illusionist's trick of accepting square 1 and then believing that everything else we are shown must be real. Most con tricks depend on fooling the victim right at the start. Having spent a working life-time exclusively in the NHS I worry that the term 'productivity' is not the appropriate one to describe the beneficial effects of NHS work. It is the language of commerce and therefore suits those who want the NHS to be run by private enterprise. Perhaps we should admit that we need better ways to define the value of the NHS before we decide about value-for money.
Competing interests: No competing interests
We need to understand that the distinction between health and social care is spurious.
Patients are stuck in hospital because there is insufficient social care. Patients are attending my GP surgery to talk about cuts to incapacity and other benefits. When people are distressed, they stop taking care of themselves. Self-management of chronic diseases is half-way up most poor people's hierarchy of needs; undermine their welfare and their healthcare suffers. I cannot discuss glycaemic control with patients whose benefits have just been unjustly taken away. The recent Marmot report about health inequalities in London, the BMA report on welfare reform and the Glasgow Deep End reports make this abundantly clear. Furthermore, the NHS will be doing social work as those without welfare have nowhere else to go and medical productivity will not stand a chance of improving.
To avoid this catastrophe we need to end the spurious distinction between health and social care and properly understand social determinants of health as co-morbidities. We do not stand a chance without political commitment, and urgent economic analysis is needed to help make the case for this.
Competing interests: No competing interests
John Appleby makes a fair point about 'stretch targets'. However, those asked to deliver those targets must be able to believe success is still within their reach.
Setting targets that are unrealistically high, on the other hand, can be a powerful demotivator.
Best to build on people's pride in their achievements.
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Re: A productivity challenge too far?
It is ironic that this short but hard hitting paper comes in the same week that the priority setting debate between politicians hits an all-time low. The Labour Party’s offering for the week was the NHS Check Report while the Conservative Party’s offering was its response: that no care should be rationed on cost.
Trying to understand the reasons for such derisory contributions to the financial challenge facing the both NHS and Society is hard but the following are offered:
• Wilful or neglectful ignorance of the facts.
• Delusion because politicians appear to genuinely believes that 2 and 2 equals 5. The political tactic of creating ‘facts’ and ‘self-evident truths’ by repeating statements over and over again may have resulted in self–delusion.
• Deception because politicians want votes and keeping the public believing that they can have everything they want seems to be the best way of getting them.
The ‘shock’ and outcries of ‘unacceptable’ from the mouths of politicians last week at the suggestion that any treatment should be rationed are likely to be viewed as being little short of disingenuous by anyone holding a budget anywhere in the NHS.
The postcode variations which have the most impact on inequity of access arise from: inequitable distribution of resources (with Chelsea and Kensington PCT, for example, getting 20% more funding than has been allocated to it while other PCTs serving poorer populations get less than they have been allocated), inequitable distribution within the locality with GPs serving wealthier populations being more likely to overspend their budget allocation while those serving poorer areas under spending and, finally, clinical variation. To illustrate the last point - if clinicians in one area do 100 more caesarean sections in response to patient demand (as the politicians would have the NHS do) than another area – about £100,000 additional funding will be required. Such practice will have a ‘post code’ knock on effect on other services as it reduces the overall funding available. These important issues are barely discussed in the context of rationing within the NHS le alone in the public domain.
And the politicians are not prepared to acknowledge the current scale of rationing. One year a PCT had to decide how to distribute the £5 million across £46 million of worthy service developments that were needed. In the end there was little decision to be made as NICE’s mandatory technology appraisals came with a bill of £5 million.
At no time over the last 20 years has the NHS been able to look to politicians for leadership and guidance on the issue on priority setting and none can be expected to help deliver the ‘Nicholson’ challenge (let alone the ‘Douglas’ challenge which is staggering if true). Politicians' behaviour will not change. The public will remain in the dark, in part because of Society’s own ambivalence about facing up to the implication of scarcity. Civil servants will continue to praise the Emperor’s new clothes and keep their private thoughts to themselves. The NHS will continue to be asked to turn straw into gold (through ever increased productivity). The only rationing allowed will be covert (which means only affecting those without a voice). Industry will be kept happy at all costs regardless of the relative value of their products. Everyone will kick the commissioner. What is the chance that we will face up to the relative reduction in funding available for health care with honesty and courage? And if we do not how can Society and the NHS make the best and fairest of decisions?
Competing interests: No competing interests