Category: NHS

#iwaswrong – public sector co-op edition

Here’s a brutal sickburn on the journos, wanktankers, and pols who were taken in by the privatisers of Hinchingbrooke Hospital, who have now done a bunk ahead of the inspectors after the place turned out to be a sinister deathtrap run by Nurse Ratchet:

We heard the staff member say to the patient ‘don’t misbehave, you know what happens when you misbehave

With a little help from the Dnepropretovsk No.1 Nail Factory:

Circle loudly proclaimed its rapid improvement in the key ‘4 hour A&E waiting time’ target as evidence that privatisation had quickly turned Hinchingbrooke around’.

But the CQC discovered the hospital kept patients waiting too long in ambulances before they were allowed into A&E. And after they were seen in A&E, they then waited far too long – up to 12 hours – to be admitted to hospital

Obviously this is all terrible, and I strongly recommend you read the whole of both links and then, uh, occupy everything. But the point I want to make is a different one. Here goes:

Circle likes to present itself as the John Lewis of healthcare, run by its staff. The Sun; the Times; the Mail; even the Financial Times have indulged it, the latter calling Circle “a John Lewis-style partnership.”

It isn’t true. Power rests with the majority shareholder, Jersey-based Circle Holdings, owned by six venture capital and hedge funds (whose founders have, entirely coincidentally, donated fortunes to the Tories).

Yet nearly all of Circle’s victims reported that the key to its success was the empowerment of its staff. “Hinchingbrooke has become a model hospital in which clinical staff make decisions,” wrote columnist Alex Massie. But a survey showed that staff actually “felt bullied and harassed by managers.”

Circle wanted everyone to know about ‘stop the line.’ Moore duly reported that staff were “encouraged” to use it. “Someone stops the line in Hinchingbrooke most days” – although not, apparently, on the days when the Care Quality Commission was there. According to the Commission’s report:

“Staff told us that they had been actively discouraged by managers from calling a ‘stop the line.’ When we found a significant failing the matron was unwilling to call ‘stop the line.’ Even during the discussion of this issue with the CEO, it was the Care Quality Commission who called a ‘stop the line,’ not the Trust.”

TOYOTA PRODUKSHUN, YR DOIN IT RONG. But the person who is wrong here is me. Back in 2007-ish, I thought the idea of public services as co-ops was a great one. So did a lot of other people in the blogosphere, notably Chris Dillow. I was wrong and so are they.

Someone who was right, by the way, was international bankster and Camden glitterato Daniel Davies. We were talking about this outside the Crown & Goose pub in Camden Town one evening that summer, a lovely evening, the sort that would pass for one of those summer evenings before the lights went out across Europe. In a sense, of course, it was, even with the crow eating chips by my beer-stained desert boots and the diesel fumes. It was 2007.

Anyway, he put forward a scenario for its failure of such gruesome horror and dreadful plausibility – call it Project Cthulhu Cupcake – that when we left the pub, we agreed never to disclose any of its contents in case we gave someone the wrong idea. As the deal is still in force and the Tories are still in office, I am not going to say anything more about it except that D^2 was right.

In which IDS eats out of his fridge for a week and straight to the Lords

A couple of things. For a start, I’m not all impressed with this “let’s see if Iain Duncan Smith can live for a week on JSA”.

Of course he fucking can; he owns his home, he pays his bills on monthly direct debits, his fridge is probably full, and if he’s any less daft than he looks he’ll fill up the car ahead of time. Of course he also has the use of a government car and driver, can take his calls at the office, and he’s married, so failing all else he can bum off his wife. The £53 would just be beer money.

The only possible outcome of this is that he comes up in a week’s time smelling of roses, and you know, you know the media will lap it up. Consider the vast unearned political capital gain he got from just walking around an estate in Glasgow in two-thousand-oatcake, smiling and nodding. He’s still dining out on that now.

Further, it’s been done, repeatedly, in the 1980s and the 1990s, and on every occasion the results were the same for the same reasons. If I were a Sinister Tory Spin-Doctor, I would confidently advise IDS to go for it, and I’d accompany him in person to make damn sure he didn’t fuck it up. I might even use Gove’s missus’ e-mail to sign up for and start a petition. I’m not sure that hasn’t already happened.

That said, I can think of one thing that might work here; if he does it, wait a quarter and then FOI his expenses.

Secondly, if today you stop a red bus the hard way, you will be scooped off the black top by a big white taxi, resuscitated, conveyed to the hosp, and treated, and you won’t pay a fucking penny. Like yesterday. Also, the entirety of your treatment will be carried out by the public sector as well as being paid for by it. Given that, I am really not convinced that the wider public will believe anyone who tries to tell them that the “NHS is dead” or has been “abolished” today, and I suspect that anyone who tells them that might come across as a little bit strange and overexcited. Especially if, having failed to convince once before, they hit on the obvious solution of SHOUTING.

Going from “OMG THEY KILLED KENNY!!!” to “Well, actually, it will still be a single-payer free-at-the-point-of-use system with universal coverage funded by general taxation, and probably about 90+% of it will be provided by the public sector because when did you last see a giant new private general hospital going up in your area, but they’ll do more contracting out, a bit like ISTCs in the mid 2000s or fundholding in the 90s” is the sort of argument that doesn’t carry conviction.

I’m also sceptical that quite so many people outside the trade really care intensely about NHS internals, much as I doubt many readers even of the Guardian read its hyper-detailed coverage of BBC management ego wars. NHS people tend to be emotionally attached to its being a civil service line managed organisation. As the experts, their view ought to be respected, but that doesn’t necessarily mean they are right. And from a point of view of tactical politics, how many people who don’t work there actually care?

This is of course an important point about the Act. It’s all about internals. And, of course, < save-our-thing campaigns are specifically beside the point. The H&SA is a hellishly awful policy, and it must die. But save-our-thing won’t work and neither will trying to pretend that the NHS doesn’t exist any more, because it looks silly. The problem is that either option is easier than trying to understand and master the comitology – a handy word from the European Union – of CCGs, CSOs, NCBs, H&WBs and gum it up good and proper.

Fixed in place

It’s time to review this post on the implementation of the Tories’ Health & Social Care Act in my local area. The news is, I think, good. The local rag:

The Haringey branch of national pressure group 38 Degrees is only the third in the country to get all its suggested amendments on buying health services written into the constitution of the Clinical Commissioning Group (CCG)…

Last month, 38 Degrees presented the CCG with a petition signed by more than 2,000 people backing its proposed amendments, which includes only using contractors or providers which are “good employers” and prohibit using companies which use improper tax avoidance and off-shore schemes.

Nice and all, but a bit fairtrade biscuits. The really good news flipped up on a Google alert a while back – it looks like the key Commissioning Support role, which provides the legal, administrative, IT, contract management, and other functional guts underpinning the CCGs, has stayed with NHS North-East London, aka the existing organisation.

In fact, looking at the list here, it seems to have kept all the CCGs on its patch on side. As a major concern is that the CSOs get outsourced to American companies who then arrange to give everything to their mates, this is an achievement.

Also, they have binned dreadful failco “Harmoni” from the out of hours GP service.

So, I’m classifying that as “under control, for now” and leaving the Google Alerts drone to watch it.

Sensible ideas.

Well, I’m on record as saying that since June, 2010, I’m all in with Team Desiccated Calculating Machine. And wouldn’t that be a good name for a blog.

So, here’s a bland and technocratic thing. The Health Service Journal reports Andy Burnham’s NHS speech, and seems to think it’s pretty good.

The key points are that the health, mental health, and social care elements would be rolled together, the CCGs and CSOs zapped, and most of the funding handed to local authorities (aka “people you vote for”). The central specialised services – basically the stuff carved out of CCG commissioning in the Lansley setup – would stay with the Department of Health, with the super-CCG also taking its hat and coat. NHS in-house provision would be the default option.

Well, I think I can work with that. Most of the HSJ commenters do, too, although they worry that the local authority social workers are suspicious of medics and the culture boundary would be a problem.

Now here’s something else. The Chamberlain Files from Birmingham reports on something that sounds a lot like a local version of the Future Jobs Fund/job guarantee, which apparently:

owes much to the previous Labour Government’s Total Place project, which encouraged public bodies to pool budgets and work more closely together

To put it another way, Total Place was the Brown government’s belated recognition that chopping up public services into a mess was counterproductive and a bit of clarity was helpful. But if you screw your eyes up, perhaps there’s a strategy emerging here: treat the Tories as damage and route around them. Not just trying out ideas at the local level, but actually following through and starting to deliver. Obviously, the Simple Plan is a prime example.

M-Health apps that don’t suck.

Pretty much everyone in the mobile business loves “m-health” these days. There are a couple of reasons for this – they imagine there’s money in it, it’s great CSR/public relations/lobby fodder, and it’s the sort of thing futurists chinstroke about. But I think we’re all barking up the wrong tree.

Here’s the problem. The typical use-case is as follows – it’s something integrated in a special-purpose medical device, that is sold, and whose function is monitoring. What it monitors, in particular, is the patient or as we know her, the user, or indeed you. It is of course telling that you’re not considered the user. Partly, what’s going on here is that we’ve just repackaged 1980s SCADA technology. Here’s a SIM, here’s a cellular radio, and let’s have the flood level gauge text headquarters every five minutes. You’ll also note that there is no user interface.

The stereotype application could be defined as “bugging granny”. We’re going to check some metrics at intervals, stick them into a control chart, and then badger you about it.

Who does this really benefit? Obviously, device vendors, and telcos. It also benefits doctors, both in an absolute sense, and in a relative sense – a lot of this stuff would otherwise have been carried out by nurses, who are icky, girls, and in the union. It also attracts pseudomedical systems like insurance companies.

The underlying mental model here can be characterised as the surveillance-compliance model. The basic idea is that patients’ problems are their own stupid fault, and if they remain ill, it is because they didn’t comply with instructions. Monitoring generates metrics. They can be judged on the metrics and badgered. You get some lip service to patient autonomy, but to some extent all this does is to demand that the user internalises the surveillance. It is very depressing the extent to which doctors talk about “managing” their patients these days.

Now, there is obviously some truth to this. Giving up smoking is a really good idea, as is taking your damn pills. But it is also highly problematic. For one thing, it assumes that the problem is non-compliance. In that sense, it transfers your problem from the domain of reality – a physical problem to be solved – into the domain of morality – a statement about good and bad. Rather than being poor, stressed, addicted, etc, the problem is that you are wrong and a bad person. As a rule, this is normatively evil, and of course it only works if the problem is not actually a real problem.

Another problem is that it assumes that the medics are always right. They aren’t. And replacing the front-line carers with SCADA technology can be see as a way of hiding from criticism. You can shout at the box but it doesn’t record your voice and report that back.

Also, there is the surveillant temptation. If the surveillance itself doesn’t work – and it won’t, for reasons we have seen – the answer is usually to enforce it. Perhaps your sick pay might be cut, or your premiums hiked. I’m sure we can all name politicians who would fucking jump at this.

So, Cap’n Swing he say LUDD SMASH. Or…Stafford Beer, he say redesign system. What would a user-driven m-health app look like? One that was pro-you? One whose design brief began “Don’t be evil”?

Well, I would start by thinking about how to manage your environment in hospital. This is notoriously vital and difficult, and the current staff-solution is to get a really tough, intelligent, and assertive woman to visit every day and whip the piss out of the medics. But having someone like my partner around is a rare privilege and one which is unavoidably class-skewed, because it really helps to be of similar or higher social status than the doctors and also to know their code-words.

At this point you might think we’d stumbled into a TV show called Operationalise This!

But let’s consider this from a systems perspective. Most of the time, what is it that you’re actually doing by monstering the doc? It’s usually either trying to extract information, or else to intervene in the ward’s operational routine on things like hydration, food, sanitation, and nursing care.

Someone close to me was recently in hospital and needed various post-surgical care, which they were only insufficiently getting because they were in the wrong ward and being taken care of by people outside their specialisation. As a result they were in serious pain, and their recovery was making no noticeable progress. The problem was to find out what instructions had been actually written down and compiled into the ward routine, make the specialist aware of this, and get them to insert correct ones into the system. These are not, in fact, tasks that can’t be operationalised.

This is rather like Doc Searles’ notion of Vendor Relations Management or VRM as the opposite of CRM. The problem is getting a look at the invisible infrastructure of instructions, records, and organisation that defines the hospital environment.

When another relative of mine was seriously ill not so long ago, I got into the habit of photographing all the paper that crossed his bedside, so as to have copies for reference and also so as to distribute them to other members of the family. (At one point, I half-inched the case file and perched on a bed to photograph it page by page, like Olga the beautiful spy with her microfilm camera.)

Medical systems are very papery, and they do have their reasons – if you have to evacuate the flooded building into ambulances with the power out at 3am, you can just take the file along with each patient and you’ll be able to read it at the far end, and a lot of information technology still can’t really say that. However, there’s a lot of interesting stuff you can do with paper and mobile devices.

The really depressing thing here is that had we gone a different way in 2002 we could have had an Open311 or FixMyStreet for hospitals. But we don’t have sensible data exchange formats, privacy/authorisation models, or URIs for any of this stuff because Tony Blair said so, and by the time Gordon Brown was listening to people like Tim Berners-Lee and Tom Watson, the NHS NPfIT (like the National Identity Register) had become a bureaucratic-industrial monster so big it took a government-killing nuclear bomb to stop it. And the Tories…well, you’ve never seen people who are more suspectible to Atos Origin lobbying them to make sick pay conditional on adequate five-a-day performance, have you? Really? No.

Now, the other problem from my point of view is that my customers, over on the other side of the fence, still believe that this time, it’s going to be like they thought it would with ISDN and IMS and so on and so forth. Everything is a network service. Delivered by us. But I don’t think it will happen. As an industry, we have a terrible record of pushing things that make sense from our point of view but just suck, so badly that they never happen.

Beware of the leopard

So, if this new localism stuff is meant to be so fucking local, why is the NHS foundation trust I joined, which covers this area, holding its AGM in Rainham, Essex*, and its board meeting the next day in Ilford (at 10am, so nobody who has a job can possibly attend)? Come to think of it, that Douglas Adams quote should probably have tipped me the wink about this from the word go.

Perhaps this is why Lord Wolfson wants to build a series of flyovers across London. I’m actually almost regretting not driving.

Update: I couldn’t go – I was working. hey, hold a public meeting at the opposite end of London at the same time, why don’t you, they’re only nutters.

Barnet, Camden, Enfield, Haringey, Islington CCGs: Applications Open Now

OK. So you want to be part of Total Defence of the NHS. You want to join the 10,000. To be the first of the few. If you’re in any of the London boroughs in the title, here’s your chance. You have until the 15th July, Saturday, to apply on this web page.

There’s a gaggle of documentation to read, which I’m getting through now. Here’s a first and amazingly important point. Each one of those CCGs needs a lay member to act as Chair of the Audit Committee. This is probably the most important public appointment accessible to you, and it is especially accessible to anybody with accounting or financial experience. If you want leverage against privatisation, this is the place to stick your crowbar.

It’s a job in itself; all of them are. But they’ll even pay you. Time to take hilltops and create facts on the ground.

Notes from Netroots UK, and NHS total defence

So I went to the TUC’s Netroots UK shindig yesterday. I missed the first session, and chose to not go to the one with Paul Mason in order to go to one with practical content, specifically Richard Blogger and Ellie Mae O’Hagan’s on defending the NHS from within. Having joined an NHS foundation trust, it seemed useful.

Things that are worth knowing follow. First of all, Richard Blogger has the only sensible org chart for this I’ve ever seen. (You may remember our local NHS finance director’s effort to explain it.) A key fact is that there are some 10,000 elective or otherwise representative posts that want filling in the new structure. This is the biggest opportunity for shameless entryism in decades. If there are going to be representatives on boards for GP practices, there may be at least another 5,000 and perhaps more.

At the same time, the Health & Wellbeing Boards are standing up. These will incorporate between 500 and 1,000 local councillors. Town hall politics just got very important, and isn’t the big Labour win in the local elections sounding useful right now? A lot of these appointments will happen in the next 3 months, so you better get weaving.

This raises an important strategic question. Is it better to concentrate on entryism or lobbying (and electoral politics)?

Resources for people joining foundation trusts, CCGs, scrutiny committees, H&WBs, MH&WBs, etc. are poor and this is our fault. I met a couple of other people who had signed up, like me, and were now wondering what the next step was. Further, everyone else involved has staff except for the public. An argument can be made that it’s a better use of our valuable time to target the councillors. Councillors are expected to put in the hours, they get the support of officials, they get expenses. And they are subject to re-election, so they’ve got to listen.

The scrutiny committees are powerful, and are probably good targets. Also, the H&WBs (and of course the MH&WBs) have to prepare a strategy, which then informs the CCGs’ decisions. This is perhaps the Joint Strategic Needs Assessment I heard about, and sounds both important and also something councillors bear on.

I don’t think there is a clear answer here, at least not while the Labour Party itself hasn’t damn well ordered Labour councillors to join the committees. At least we didn’t arrive at one.

One thing that is a clear answer is that HealthWatch is apparently subject to compulsory tender, so we can probably write that one off. By contrast, it turns out, there is no statutory duty to tender for actual NHS services, and the campaign in Stroud set a legal precedent in this line. Unfortunately, the “Fighting the Cuts through the Courts” session clashed with this one, as lawyers rapidly turned out to be a big issue.

Another item on the schedule is the revision of the NHS constitution, which is a document with legal force. A working party is currently in being, including both Virgin and UNISON, with a consultation later this year.

An important operational issue seems to be access to information. Local authorities have to publish their forward plans and agendas ahead of time, and it’s not clear if this is so of CCGs.

As an interesting side question, someone wants to know what’s happening with “Dr Foster”, the semi-private thingy which acts as a combined management information system and media shop for the NHS.

Anyway, the take-aways for action were to get FOIA requests in for any and all consulting reports about CCGs and CSOs at the local level, and to identify the people writing H&WB strategy documents and lobby them.

This reminded me that MySociety built a Web application for recruiting local volunteers in constituencies and pushing out calls-to-action, Democracy Club, and indeed managed to get 100% coverage in the run-up to the 2010 election for things like collecting election literature and details of candidates.

It also reminded me, and I buttonholed Sunny Hundal about this, that somebody should be paying Richard Blogger.