I find it both reassuring, and intensely funny, that after all the effort to get rid of the Secretary of State for Health’s duty to provide an NHS, top NHS officials are now moaning that Jeremy Hunt is micromanaging them. Sir Bruce Keogh can probably handle being micromanaged by someone like Hunt, and in general, the system has won.
Perhaps I should apply for Chair of the Whittington NHS trust.
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 Change.org 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.
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.
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.
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.
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.
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.
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.
So, that Total Defence plan. Not long after blogging about the weird way becoming an NHS Foundation Trust member is mostly about the staff discounts, my Google Alert tail-warning receiver lit up. Specifically, it caught the fact that the Haringey Clinical Commissioning Group was going to have a public meeting, so off I went with a little notebook of talking points.
My first impression (as I was on time) was the usual depressing one – they’re all 117 years old, there’s four of them, and Christ, they’re odd, and one of them’s reading something called God’s Word Made Plain. Why did I volunteer again? But the room filled up, and then filled up some more, and eventually we counted up 53 MOPs who turned out.
The original agenda was all about “how the CCG can communicate with the public”, but when it got communicating, the message from the public was that the public wanted no part of that. It turned out that the local “Patients Panel” hadn’t met for years. An effort was made to explain the new NHS structure, and at this point, astonishment and disbelief set in as the CCG vice chair and the (existing) NHS finance director tried to draw the organisation on a flipchart. (It reminded me of the enchanted PowerPoint presentation in one of Charlie Stross’s novels.) So, GPs were meant to commission everything, and the PCT and SHA had been shut down, with 54% cuts imposed on their staff, but to keep the wheels turning, they were reorganising as a cluster in the meantime. Then, the GPs would take over, but the GPs themselves couldn’t be in a position to commission their own work, so they would be commissioned nationally, while some other services would be carved out of local commissioning.
One of the CCG doctors said of the re-org that “in terms of human pain it’s quite remarkable – managers are people too, you know”. Before the CCG took over, it would be allowed to have a “shadow budget” but no actual money, because it didn’t have an accountable finance function. And before it did, everyone would be sacked again. The national commissioning board would replace the SHAs, but would have four or possibly more regional branches that might be quite a lot like them.
The questions kept coming and eventually they abandoned the agenda in favour of just standing there fielding. It turned out that there was a 93 page national test that the CCG would have to apply, but nobody had seen a copy and nobody was clear about who set the test or how. There was a Joint Strategic Needs Assessment, carried out by the cluster and the local authority, but how that fed into this process was a mystery.
On the question of specialist services that would be carved-out of local commissioning and reserved to the national level, the chair had to be told that it wasn’t right and it wasn’t OK to say that “normal people” wouldn’t need to know about it because a lot of them are psychiatric in nature. It turned out that they represent 40% of the budget. The service-user activists got angry. As well as a Health and Wellbeing Board, whose makeup a Lib Dem councillor told me was still being debated, there is a Mental Health & Wellbeing Board, but the GPs have yet to deign to meet them because after all they’re only nutters (I paraphrase, but not much).
It turned out that the NHS organisations being butchered have a variety of huge databases of information vital to the commissioning process. Nobody seems to know what will happen to this.
The specialist/local interface seems to be enormously crucial, and a completely undemarcated frontier. The GPs are hugely keen on “continuous follow-up”, but it’s far from obvious why anyone would want follow-up by someone who has no specialist knowledge of their condition.
The FD confirmed the following figures in my talking points: the Government has budgeted £25 per head per year for the CCGs and the Commissioning Support Organisations. Of this, the NHS North Central London cluster says it can do the CSO job for £15/head/year, which leaves £10*225 kilocitizens in Haringey or £2.25m a year in funds flowing to the CCG as such. The CCG plans to have CSO staff co-located with it, and in fact to rely on the CSO for pretty much all its day-to-day functions.
Apparently the Government arrived at the figure of £25 by halving the existing Londonwide figure and dividing by the population.
Anyway, my take-home points: CSOs are crucial (although we knew that). Status of staff – are they civil servants? Who has responsibility for the public money flowing through them? What happens to this database? Further, the frontier problem between central and local is important. And I’ve got to get on to some of these assorted boards.
I was really pleased by the turnout, and the degree to which the crowd were intelligently angry. A surprising number of people had evidently taken the time to brief themselves in advance.