News and Comment from Roy Lilley.
So the story goes; Frank Dobson, when secretary of state for health, remarked...
'Whitehall has all the levers of power, but it is not until you get into government you discover they are not connected to anything!'
Whatever we think of whoever is in power, we do have an enviable system of government. It looks like a government, it does its business in a place that looks like a parliament and has traditions and customs that make it sound, well... like a government.
In fact it's made up of people, just like you and me, who are seldom brighter than us, often less experienced in life and the departments they occupy are just bits and pieces of organisational ideas, trying to sort stuff out and are about as joined up as a four year old's handwriting.
Beset by internal arguments between themselves, confusion, lack of information, no idea where they are headed... all the same things that curse every day life. Ministers are just as tired, just as confused, just as hassled as the rest of us!
All governments, like all businesses, need to ask themselves three questions...
- Who is the customer
- What are we trying to do for them
- How will we know if it worked
That looks simple but it isn't.
Take benefits. Who is the customer?
The recipient of the benefit or the people paying for the benefit. Government cannot serve two masters. They should say who they are serving.
What are we trying to do? Brexit is a good example.
Government is trying to extricate the country from a 40 year tangle of law, custom, practice and regulation and at the same time, keep business as usual. It can't be done and they should say so.
How will we know if it worked?
We can see. When it doesn't we become the victims. Austerity funding; the evidence is all around you. They'll never admit it. Get over it!
Health policy is just as messy.
The simple facts are in the last 30 years, the number of NHS beds have halved and the number of patients doubled. On top of that, in the last ten years, bed-stays have halved and funding dropped behind Germany, France and Iceland.
The same three questions apply; who is the customer, what are we trying to do for them and how will we know if it worked.
Primary care isn't working because the DH+ can't decide who's their customer. If it's you and me, the GP contract would have gone years ago and the choice overload between services with no obvious salience; extended hours, walk-in clinics, minor injury clinics, NHS11, 999, OOH would be fixed and the money better employed.
What are we trying to do?
We are trying to pretend we can get twice the health care for people with double the complexity, juggled between two organisations with half the money. The queues of ambulances outside A&E are telling you something about the third question; 'is it working'.
The latest wheeze, advice; take your sick kids to the pharmacist.
Joyce Robins, from Patient Concern, sums it up:
"Most of the time when a child [has] the snuffles it's not likely to turn serious - but identifying the subtle differences is really difficult for parents, and things can turn nasty really quickly.
Parents aren't doctors and pharmacists aren't doctors either. We know the NHS is overloaded but this is a very high risk strategy."
Who is the customer for this policy?
The parents facing the sort of uncertainty that even hospital doctors get wrong? Or, the overloaded, swamped, knackered A&E system. Ministers need to be clear.
What are we trying to do for them?
Provide safe care for children or cut attendances, improve target outcomes in A&E to make the DH+ policy seem like things are looking up.
How will we know if it worked?
I'm guessing; we will know, soon enough, if a child with meningitis dies, delayed, getting to A&E by a well-meaning trip to a pharmacy...
Ministers with kids, MPs who have families should use the 3 question test, just like you and me.
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Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.