Health Service Management

I have worked in various NHS Trusts over the past 25 years and have seen a slow improvement in the management of the hospitals I have worked in. By far the best in my personal experience is my present main Trust honorary employer University College London NHS Foundation Trust.

When reflecting on the National Health Service I am struck by two possibly diametric concepts both derived from Nobel Prize winners.

The first is from a 1963 academic paper by the Nobel Prize winning economist Kenneth Arrow explaining why markets don’t work well in health care. He argued that unlike goods and services, folks obviously don’t know when they might need health services. And when such needs arise the cost can be crippling. The corollary of this being that one needs some kind of insurance or government run system. It is perhaps on the latter the UK has the wrong model i.e. a government run rather than insurance based system. The reason for this is exemplified in part by the concepts of another Nobel Prize winner, the economist Milton Friedman. Professor Friedman simplified spending money into the following four categories:

“There are four ways in which you can spend money.You can spend your own money on yourself. When you do that, then you really watch out what you’re doing, and you try to get the most for your money.

Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I’m not so careful about the content of the present, but I am very careful about the cost.

Then, I can spend somebody else’s money on myself. And if I spend somebody else’s money on myself, then I’m sure going to have a good lunch!

Finally, I can spend somebody else’s money on somebody else. And if I spend somebody else’s money on somebody else, I’m not concerned about how much it is, and I’m not concerned about what I get.”

These erudite statements define four kinds of spending in a way most of us can relate to.These words show the fundamental problem with the NHS, in that it is the example of the fourth category. WELCOME to the NHS!

More neonatal intensive care cots? Yes! Free parking at NHS hospitals, Why Not? More expensive drugs for cancer treatment Yes please!

At least we now have NICE to produce a guide as to which treatments the UK can afford.

Everyone likes something ‘for free’ but it is impossible for our brains to understand the vastness of the billions which are poured into the health service. A popular institution but in international terms well off the top spot.

How can we improve?

An example of where the NHS has failed and continues to do so is a fundamental lack of investment in IT. Why are we still using papyrus for notes? In my NHS Trust vast swathes of expensive equipment stand idle for significant parts of the 7 day week. This is the norm in the NHS acute sector and yet a lot of ourĀ  (UCLH) practices are relatively cutting edge (eg airline style OPD auto booking in machines) In civil engineering this kit (eg MRI scanners) would be regarded as ‘plant’ and would expexted to be used.In the airline industry planes have to fly 23 hours out of 24 to turn a profit. Staff need to become more accustomed to the idea that at least Saturdays would be popular for patients and allow that ‘kit’ to be used at an overall lower cost per test.

Until recently there was very little real activity data to analyse. My trust is only just developing a real time bed management system. IF we were a hotel and didn’t know which beds were occupied we would fail. Again this is typical of the NHS.

A salient document stopped me in my tracks ‘the NHS an organisation with a memory‘ Why had it taken so long for such a large organisation to not attempt to systematically document its error experiences with a view to learning and moving on?

We have a long journey to go, but our child patients need us to go there. To work side by side with (effective) managers to constantly raise our game. The public expect nothing less…

Dr Alastair Sutcliffe – UCLH Website