In the NHS, there two main activities. One is helping sick people. The other is measuring, improving, correcting, extending, and promoting how well sick people are helped. Much energy is expended on the first activity: technical advances, new pharmaceuticals, further training for doctors and nurses in new ways to help sick people. But the more you read about the NHS, the more you get the feeling that a lot more energy is expended on the second activity.
There’s nothing particularly wrong with this; even in a business, delivering the product or service to customers is straightforward, if not always easy, and the bulk of business energy is expended on how to improve the product or service, how to measure whether or not it’s good, strategy for getting it in front of the market, selling it, and so forth. Large numbers of people are employed to do these things, and a lot of money is spent in doing them—money that is generated by the delivery side, both by delivering the goods and by finding new ways to reduce inputs and increase outputs. Greater productivity means greater profits, which can be taken home as pay or ploughed back into the rest of the business.
The difference between a business and the NHS, however, is that issue of money. Money is the simplest metric for business success: how much are we making? Allocating money in a business is also fairly simple: wages, tools, marketing, infrastructure, tax, in varying proportions, and what’s left over goes to the shareholders. And if the metric drops—we are making less money—the allocations drop too. Therefore business responds to money.
The NHS, on the other hand, doesn’t respond to money, because it doesn’t make any. You can argue whether this is an intrinsic function of what it does—healthcare—and you can even argue the ethical toss about measuring something as important as health by looking at money, but you can’t get away from the fact that the NHS has something to do with money, because helping sick people has a cost.
The NHS is sort of halfway in the market. It doesn’t directly charge its customers for its services, so it can’t respond to the “how much are we making?” money question. But it still has to answer “how do we allocate it?” and “what do we do if we have less to allocate?” Doctors and nurses don’t work for free, so it still has to think about wages. Medical supply manufacturers don’t manufacture for free—they are businesses, so they have to worry about how much money they’re making—and infrastructure has to be paid for as well. The NHS has all of the business problems of spending money, and none of the tidy business solution of earning it.
So when, in the NHS, the costs grow and/or the pool of money to spend shrinks, the sector has to find pseudo-business solutions to deal with this problem. “Pseudo” because what businesses do is frequently not an option for the NHS. For instance, a business could produce more goods or services. The NHS can’t do this, because it’s really unethical to go round trying to make people sick so that you can cure them more, but also because the NHS’s primary service—helping sick people—is actually a cost, and doesn’t make them any money. For the same reason, they can’t look for new markets like a business would, but also because the market for the NHS is already every person in Britain. Other solutions are simply odious. The NHS can borrow money, but their collateral isn’t private, so they end up mortgaging the public good. The NHS can ask patients to pay—private patients, or foreigners—but this invalidates the ideology that health shouldn’t depend on wealth. They can ask the government to raise taxes, but that’s a PR nightmare, and the existence of the NHS depends on people’s loyalty and goodwill.
So the NHS has only one option, and that is to reallocate its spending. Reduce the number of doctors and nurses treating the sick people, and thus lower the wage bill. Find cheaper suppliers, and thus lower the tools bill. Hire cheaper builders to patch up the estate, and thus lower the infrastructure bill. Use what you’ve saved to increase marketing healthy lifestyles, and hopefully the number of sick people will drop, and through all of these increases in productivity (in the NHS, it’s called “efficiency”), maybe you can break even, or even turn a profit (in the NHS, it’s called a “surplus”).
In the NHS, you can also do rain dances, make offerings, and perform collective prayer rituals that the UK economy flourishes enough for tax receipts to go up, giving the government the power to increase your budget again.
Unfortunately, all of these things make for a cumbersome and difficult-to-run healthcare system. Sacking nurses looks evil, and makes life harder for the other nurses. This, and using cheaper supplies, can literally endanger people’s lives. Infrastructure creaks as it gets older, and the population rapidly outgrows the limited space. Paying staff, suppliers, and contractors less reduces tax receipts. And public-health marketing is notoriously ineffective.
So what the hell do you do, if you’re the NHS? Do you say, “Fuck it, this half-business life is no life at all—let’s act like a real business and charge people money. Then if they pay us, we know we’re doing a decent job”? This doesn’t even have to mean that poor people die in the streets, because the government could just give them the money to buy their healthcare.
No. Instead, you bitch and moan and look for Rube-Goldberg-esque solutions to act as proxies for normal market behaviour. And then you can see why helping sick people is the least of what goes on in the NHS.
Let us consider, for example, the Health Service Journal, the premier trade journal for non-medical NHS staff. Does it have anything to do with awesome new and better ways of helping sick people? Does it fuck. It is Rube Goldberg literature for the Rube Goldberg system.
This week’s stories include:
(1) The way to improve the NHS’s effectiveness and efficiency is to set up an independent standing commission to look into the matter.
(2) Outsourcing middle management can, in ideal circumstances, reduce “overspend” (in the business world, “losses”).
(3) Medical unions are concerned that competition will lead to health “inequality.”
(4) A government quango will judge who is allowed to help sick people.
(5) The same quango prioritise patients over creditors when it puts private providers out of business by disallowing them from helping sick people.
(6) The same quango shouldn’t give NHS bodies credit ratings for borrowing purposes, because credit ratings are not an appropriate proxy for how well sick people are helped.
(7) Another government quango will measure how well sick people are helped by a series of inspections centred on 100 performance metrics.
(8) Another government quango will judge which GPs are allowed to buy healthcare from the NHS for sick people, but it will need management consultant help to do this.
(9) The GPs will also need to be helped to create a QIPP strategy. (QIPP stands for “quality, innovation, prevention, productivity.”)
(10) Publication of how well these 100 metrics are met may lead to health “inequality.”
(11) However, not publishing these data, because they are impossible to collect and monitor, is also unacceptable.
(12) PCTs can close down their competition but only if they don’t ask doctors whether or not they should do it.
(13) A commission will investigate whether imposing fines for making people sick with C. difficile will hurt hospitals.
(14) Some middle managers are unhappy about spending money, time, and energy on healthy lifestyle programmes for staff.
(15) Patients need a better way to complain about the quality of help they received when they were sick.
(16) In order to do all of this stuff, there needs to be a strategy for staff engagement.
(17) There also needs to be a strategy for adopting helpful technology.
And my personal favourite:
(18) “Salford Royal Foundation Trust’s clinical leaders development programme is part of an emerging organisational development strategy to engage senior medical staff in the business of clinical leadership and develop their talent.”
So there you have it. Because the NHS cannot measure how well it provides its service—helping sick people—by the money it makes from its customers, it has to invent Byzantine proxies, implemented and assessed with great energy and at enormous cost, none of which have anything to do with helping the sick people.
And why? Because this tremendous waste of time, money, talent, and human capital is preferred as a more humane outcome than letting sick people hand over money directly in order to get better.