Agree with a lot of the observations above. I have done quite a bit of work in the NHS and have seen the issues at close quarters and from the different perspectives of service provider Exec Teams, managers, clinicians, allied healthcare professionals and ancillary staff such as porters. In my work we directly engaged patients in different needs segments (followed their journeys over months) as well as looked at the associated costs and care outcomes. Here are my conclusions from the work we did.
1. As the clinical and social needs of patients have changed over time, the NHS has not been able to adapt because ALL their discretionary capacity for change/adaptation has been swallowed up by unnecessary, ideology-driven NHS transformations or as now, they simply have no capacity to meet minimal standards of care. When each transformation goes wrong, they spend the time between transformations trying to recover from them.
2. There is a vicious and measurable cyclical pattern of Trusts falling into deficit, making extremely short sighted savings that make patients worse and increase the burden of care (demand) for a health region. Chasing short term savings with badly thought through cuts is encouraged by NHS England and DOH (who are aided and abetted by big 4 management consultancies). Once the inevitable clinical standards start to fall the Care Quality Commission (CQC) will step in and put pressure on the service provider to improve standards. The service provider will do this but often this will require equally knee-jerk measures that further increase the financial deficit (e.g. hiring locum staff). Rinse and repeat - this cycle continues. The biggest problem with this cycle is that this ‘catch 22’ regulation set-up leads to the institutions overall growing their own burden of care with each cycle.
3. In the worst examples of short term changes driven out of (1) and (2) above, patients become infantilsed and their rates of deterioration (mentally and physically) accelerate. Some of specific patients we followed in the study went from older people who were living active lives, staying on top of their multiple long term illnesses to becoming shells of their former selves with significantly higher care needs within the space of weeks - especially during long term stays.
4. As we all know, governments have failed to plan for and grow the NHS workforce. Stupid things like removing the nurse’s training bursaries have led to a dramatic workforce gap. That was even before we lost a further 22,000 EU based NHS staff (as known at 2019) following the EU referendum. This massive gap exacerbates the issue described in (1) above
To slowly reverse these massively unhelpful dynamics within our healthcare system will require the following:
a) Integrate the regulation of the NHS so that each service provider can reasonably manage a gradual improvement in both costs and clinical care quality in an integrated way. Allow providers to state what capacity they need to continuously adapt and improve and avoid short term interventions. Support the providers with innovation techniques and methodologies used by successful tech and service companies. These techniques look at life through the patients (customer’s) lens and we often see that quality of life is found to also to equate to lower costs of care - happy to share examples of anyone wants). Quality of life over quantity of life is also the most economical for the NHS.
b) Stop with the wholesale transformations of the NHS!!! No more!
c) To be able to do (a) we need a massive influx of NHS clinical and social care (also clinical) staff (let’s not get into a debate about how we attract them to this country for obvious reasons - we just need to have that outcome). As part of this, the government needs to negotiate with the pay demands. Not meet the number but negotiate.
In conclusion, no the problem isn’t that old trope that there are too many managers, it’s the combination of what I’ve described above which I believe is what
@safrane alludes to in his comment above. And we are bloody lucky that NHS staff continue to follow their vocation despite all the system hurdles put in front of their chief desire to simply make people better.