Friday, 25 April 2014

Taking The Pulse

In the olden days before parents could be gaoled for asking teenagers to do something useful I was packed off to help an uncle sort his surgery papers out.  In 1951 he had just qualified as a doctor at a rather later age than most. 

Other matters had delayed him between 1939 and 1946, one of the few men to see service at both Dunkirk and the North West Frontier with a trip to North Africa in between.  He had this notion that his job was to deal with patients and he needed a body to put paper in the right places.

So I can truthfully claim to have been active in the National Health Service in its earliest years.  My uncle had a basic problem as a fresh junior doctor in an established practice.  He was anxious to fit in and work within the new NHS scheme of things. 

His senior partners did not like it at all and went their own way as far as possible.  After a short time he moved on to establish his own practice and work within the system rather than against it.  It was a common story in the NHS not just at the beginning but for some time after.

Over the next few years there were medical connections in both the Army and studying as well as doing the odd stint for uncle and some fellow doctors dealing with their papers.  The reality was often different from the image and the doctors were about as easy to organise as herding cats.

The culmination of all this and the impact of increasingly rapid change and development in many areas led to many areas of dispute and uncertainty and problems in provision and management.

One that did occupy a lot of time and trouble was that between the NHS and the Medical Officers of Health service in local authorities.  Being in the middle of a situation where the MOH did not talk to other chief officers and the GP's and hospital doctors did not talk to the MOH required diplomatic skills of a high order.

This was resolved, up to a point in the 1974 creation of Area Health Authorities.  The professionals, the doctors and consultants still called the shots and in theory there was unity.  But in the medical profession old habits died hard so a lot of conflict and uncertainty still arose.

This was all very well, but now there was big money, new hospitals to build, new services needed and new forms of treatment and techniques.  The professionals had learned to manage on the job, if at all, with a handful of financial and law people to man the crow's nest.

It was not anarchy although those wanting ordered structures and accounts to be in balance sometimes may have thought so.
Politicians had to "do" things for the NHS and make promises.  These had to be popular both with the public and the staffs.

Those old generations of medical staff have gone.  Also gone in the recent decades of change is the idea that the professionals are in charge.  Now we have management essentially working to idea's and rules culled from business or organisation theory.

For the people most of their ideas come from media coverage or fiction or all the claims made at general elections, none of which nowadays approach what is happening in real life.  One effect is that case management deals with the cases, the care element has been thrown out.

This is especially in what is called "efficiency" in which rapidity of turnover allied to reduction in the number of beds had yielded figures that suggest more is being done with less.  The trouble is the effects this has in a variety of cases where care is in fact critical to real recovery.

What many of the figures grinders and managers did not realise was that increased demands from new population and the ageing of the former one were going to challenge the basic assumptions. Also case but not care had the effect that too many were not so much cured but only temporarily fixed.

There have been other matters which were less easy to foresee in medical terms but have created their own challenges, the booze culture and weekend problems, the obesity problem and related dietary issues.

The upshot of all this is an NHS now vulnerable to any shock that might arise.  Be it an epidemic of some kind, a really prolonged bad spell of weather or air conditions or some combination of circumstances which creates a major spike in case load.

The signs in some maternity wards are that there are times when the case load exceeds any real capacity.  There are risks building up in other areas of medicine.

So what will be the bad one and when and where will it happen?


  1. My verruca may add to the local caseload. Unless I just get a file from the shed as usual.

  2. In health systems people dont matter. There is never a shortage of people.
    The next crisis with be a shortage of paper clips. Computer people and such like do not know how to handle paper clips.