Two front page articles in the Guardian this week emphasise the government's committment to social enterprise in the NHS. The first emphasised the principle of common ownership, as in John Lewis-style cooperatives. The second made clear that GP consortia will go ahead despite all the opposition.
The concern expressed in the second article by the new President of the Royal College of GPs about GPs having to bear the brunt of rationing in the NHS may be misplaced as a new system of drug pricing is to be introduced. It seems to me likely that the new NHS Commissioning Board will determine what happens about the prescribing of expensive cancer drugs, rather than individual GP consortia.
Nonetheless, she's right that "this is the end of the NHS as we currently know it". I'm not convinced the NHS needs to be as bureaucratic and risk-averse as it currently is. However, that said, there is a sense in which the impetus to increase social enterprise is welcome. But it brings all sorts of problems with it and it's still very unclear how the government measures will work out.
Despite that, I'm preparing for the new system and have set up Anglia Mental Health Community Interest Company. In a letter to all GPs, the Secretary of State has encouraged them to "begin now to establish the knowledge of, and approach to services, which will inform their approach to later decision-making". Health professionals are not being given any alternative.
A Department of Health press release says that a "review of the National Programme for IT (NPfIT) has concluded that a centralised, national approach is no longer required". But where is this review? There's no link in the press release, as one might expect. There's no explanation on the Connecting for Health website, beyond a reference to this press release.
We need to know why the programme has failed. At face value the concept of the Summary Care Records system made sense. It seemed as though money had been wasted by allowing the individual parts of the NHS to develop their own patient information systems. But then the NHS just seemed to get locked into contracts that were never delivering.
The Computer Weekly Editor's blog suggests lack of clinical involvement and changes in technology were amongst the reasons, but these do not seem a sufficient explanation to me. You can understand the government abandoning the project when so much money has been wasted. But the NPfIT has hindered Trusts developing their own hypertext linked systems, which are not that brilliant anyway, because it was always said we had to wait to see what NPfIT could produce.
Have we just all been naive and trusted people who did not really know what they were doing? The people working in the project and the developers have done alright out of it. Why was it so difficult to produce a national system that worked?
Chris Ham in a BMJ article Why the plans to reform the NHS may never be implemented points out the uncertainty about whether the Coalition government's NHS White Paper will be implemented. It's not clear how negotiations with the BMA will go. GP consortia may not be that much different from PCTs. I also suspect that Payment by Results will introduce too much instability and distortion of priorities for it to be implemented without more controls. Consultation on the proposals closes next month.
Mike Brierley in the Observer points out that Kevin Pietersen needs his confidence boosting. England have just beaten Pakistan (see Guardian report, who beat Australia in England (again, see Guardian report). England are likely to need Pietersen in good form to beat Australia in Australia.
As Chris Ham says in his BMJ editorial, Andrew Lansley came into government with a plan for the NHS. This has moved on rapidly from the Tory manifesto. The encouragement of the enterprise culture is welcome, but the implications are unclear.
I hope the The Independent Police Complaints Commission judgement about the individual police officers in the Kirk Reid case does not have the same pompous disdain as Kathy Lette writes about. Isn't the problem us, society and the police, rather than three individuals?
Liam Fox's interview in The Times quotes him as saying "We are not in Afghanistan for the sake of the education policy in a broken 13th-century country". I think he must be meaning that the war isn't about the Taliban banning education for women and making the madrassa the main source of education. I presume he doesn't mean that Islam is not a 21st century religion.
Richard Gregory explains the Charlie Chaplin mask in this video. Read his Times obituary. His book Eye and Brain is known to just about every psychology undergraduate. The use of illusions is important for understanding the dynamic nature of perception. Mind Hacks sums up Gregory's significance well.
In a previous post, I said we needed independent academic opinion to publish comment on the use of hospital mortality data to justify the investigation into Mid Staffordshire NHS Foundation Trust (also see another previous post). The recent BMJ editorial by Nick Black is pertinent.
The hospital standardised mortality ratio (HSMR) depends on the proportion of deaths that take place in hospital. Availability of alternative forms of end of life care, such as hospices and community palliative services, as well as characteristics of the local population, therefore, influence the different figures between hospitals. To score well, it's better for a hospital not to admit a dying patient. In fact Mid Staffs has improved its mortality ratio by 34% over the past three years. There are also shortcomings with the HSMR measure itself.
Cavalier use of such data by government and NHS management does not give clinicians confidence that their work is really understood. Unjustifiably singling out a management team that may be no worse than many others is no help. Robert Francis, who conducted an independent inquiry into Mid Staffs, is supposed to be doing a scoping exercise for a further inquiry of the commissioning, supervisory and regulatory bodies, which has draft terms of reference.
PACA press release. Why is it that the GMC gets these sort of matters wrong? Doctors need to have trust in the GMC that it will not make defensive risk averse decisions. I have always supported David Southall (see previous post and letter to THES).
It's important the history of the therapeutic movement in psychiatry is not forgotten. A major advance in psychiatric care was the opening of the doors of the traditional asylum. Unfortunately, to some extent, there has been a reinstitutionalisation of psychiatric care and sometimes the worst excesses of the asylum are now repeated in the community. Risk averse policies and interventions can actually cause problems for patients in terms of their rehabilitation and recovery.
Chris Ham's BMJ editorial describes the situation in the NHS that the next government needs to improve:-
"... the destabilising effects of constant organisational restructuring, the negative consequences of a command and control style of leadership, and the lack of engagement of clinicians—especially doctors—in quality improvement."
There has been a "pervasive culture of fear" in the NHS, and clinicians are not always able to speak honestly and may be subject to disciplinary procedures if they do. For example, Mr Ramon Niekrash gives his story in the Independent on Sunday.
I'm not sure why three government reports prepared for the Department of Health only came to light through Freedom of Information requests from Policy Exchange (see its press release). It is clear that the government had indications that there was something wrong with healthcare regulation. Lady Young, who was chair of the Care Quality Commission (see previous post) was someone who may have been able to put it right. Her post-office interview in The Times reinforces that the problem is political sensitivity to criticism.
Remarkable successes of John Hendy, QC, to obtain an injunction twice in the case of Gillian Mezey: firstly in September 2006 to bar her employing NHS Trust from suspending her from non-clinical duties; and secondly in December 2008 to restrain the Trust from taking disciplinary action. The court of appeal has recently upheld the second injunction (see BMJ story and court judgment).
Mezey gave one hour's ground leave to an informal, previously conditionally discharged, patient readmitted to a medium secure unit. This was at the end of a phone on a day when she was away giving a speech at a Home Office conference. Unfortunately, the patient absconded over the fence, attacked a stranger in the park with a knife and killed him. In retrospect, it is difficult to see what the purpose of the ground leave was, although the patient was informal anyway, and an investigatory panel set up under disciplinary procedures criticised her decision.
Mezey may have been fortunate in that new Maintaining Higher Professional Standards had not been implemented by the Trust, so this panel report was produced by a QC and two reasonably disposed psychiatrists. The court decided that it would be a breach of contract to proceed on this basis. It is possible though that intervention by the National Clinical Assessment Service could have had the same effect under the new procedures.
Nonetheless, Mezey has been humilated by Trust processes and the temptation to find a scapegoat in cases of homicide by psychiatric patients needs to be countered. As far as I know, her case for compensation is still outstanding (see story in The Sun).
I think the Kosovo situation was different. Blair seems to be less clear now that he did get as far as advocating a "new interventionism" (see my webdomain page from March 2004). It was NATO that intervened in Kosovo. Article 2 of the UN Charter says: "All Members shall refrain in their international relations from the threat or use of force against the territorial integrity or political independence of any state." Blair decided he would act without UN support, and for that the Chilcot committee, even with Lawrence Freedman on it, should damn Blair's legacy, which meant so much to him.
Mental health teams can recognise the limitations of what can be achieved and will respond to challenges to improve care in this context. Mental health is not a technologically driven service, although CNS drugs are now the highest net ingredient cost to the NHS of all drug groups. Still, drug costs are a fraction of the main expenditure on staff. There is evidence that mental health services create a vulnerability to relapse but they understand the need to encourage independence. Creating a more patient-centred service can actually reduce costs.