Ministerial Advisory Group on the NHS: a start but more to do…

Rajan Madhok

The work of the Ministerial Advisory Group (MAG) set up by the Cabinet Secretary could lead to some improvements, but not in the way that some people may be expecting.

To expect a dramatic change in services through increased efficiency and productivity over the next few months is very optimistic.

However, what the MAG report could do is shine a light on the deep-seated problems, bring them out into the open, and force the necessary debate on what should replace the current model, and how to organise and deliver it.

After all, if it was that ‘simple’ then why not most of the improvements recommended by MAG already have happened?

If they have not happened, then why not, and why will things be different this time? In any case, the MAG was very limited in its terms of reference and has looked at four areas: planned care, diagnostics, cancer and urgent and emergency care; but how can you fix any of these in isolation?

Emergency care

Take the last one: urgent and emergency care for example, and which without a fundamental reform of GP and Out of Hours services at the front end or Social Care at the back end cannot be solved- it is not a hospital problem only, though they could and should improve what is in their control.

There is a danger of over-estimating the system’s capacity – physical and intellectual – to deliver the recommendations, especially with the tight timetables.

As an example, take the first recommendation: “Recommendation 1 : All health boards should develop a plan to reduce referrals to outpatients in high volume specialities with a particular focus on unwarranted variation and ensure the adoption of new models and best practice in outpatient management. Timescale – within 3 months.”

Can anyone say what this means in practice and what a good plan would look like; as a health services researcher and scientist I would struggle.

I realise that the key phrase is ‘develop a plan’ (sic), not necessarily deliver the improvements (yet) and also this recommendation is referring to out-patients only and which are different things altogether.

Sadly, the system thinkers and designers to develop such plans are in short supply in the NHS- there is little knowledge and expertise to look at big systems, understand the processes, design new models and ensure adoption of best practice.

‘8am Morning GP appointment scramble’

If we had them then why have not we sorted out some of the basics, like the ‘8am Morning GP appointment scramble’ whereby everybody has to ring, listen to the muzak, and if lucky get an appointment; the unnecessary and upsetting wait for medications on discharge from hospital whereby patients, and relatives, sit around after being taken out of the bed, waiting; or the provision of comfortable chairs and refreshments for patients who have to wait more than four hours in an A & E department.

And there are many other such examples, which seem so basic, and yet insoluble at present.

If we cannot solve these basic problems, how will we deliver MAG recommendations or transform the NHS?

I do not say the above to criticise, unlike a very respectable clinician who wrote to me: “We ‘post MAG’ are in so many ways exactly where we started last year; maybe (probably) worse”.

I am aware and appreciative of some of the good and innovative work going on in the NHS, but good practice does not spread and overall patient experience is unsatisfactory.

The recent Llais report on Maternity Services perhaps sums up the situation: “While some families described compassionate and professional care, many others told us they felt unheard, unsupported or unsafe at 2 different stages of their journey: especially during labour, after birth, or when trying to raise concerns”, and “Although no one described an entirely positive experience from beginning to end, many families praised individual staff members whose kindness and personal care made a lasting difference.”

So, we need to be realistic; the NHS is not in a good place, as the current Ysbyty programme on S4C also shows.

There are many reasons for this situation, and it will take time to turn things around. It will be a shame, and set us back, if wielded as a stick only; rather MAG report can be a catalyst for the much needed change.

Used wisely, it can be the start of something useful: it can start systematically identifying the problems/bottlenecks, it can start people thinking imaginatively and using creativity to design solutions, and it can start changing the culture of management and accountability.

New Social Contract

Most importantly, it can help start the conversation about a new Social Contract – a contract between the State and the Public, between the State and the health and social care bodies, between the State and the Professionals, and between the Professionals and the Public. The problem with the NHS has been that it over-promised from the beginning, and then did not keep up with the times.

The way the NHS was sold to me, when I came to the UK soon after qualifying as a doctor in India, went like this: Everyone is registered with a general practitioner (GP) who is the custodian of the health of the person and takes care of most of their medical needs , and if the GP needs specialist advice, then they ‘refer’ the patient to the relevant ‘Consultant’ at the local hospital, who after seeing the patient (thus, being consulted) would write back to the GP with their assessment and a proposed management plan.

The correct format for writing a letter back to the GP then was: Thank you for asking me to see ‘your’ patient etc…..If the patient was admitted to the hospital, the nurses were in charge, and when the Consultant did the ward round, he (sic) would seek the permission of the nurse in charge to come and see the GP’s patient on her ward.

So patients belonged to the GPs and the hospitals to the nurses, with specialist advice/treatment from consultants as and when needed, with the three parties working together seamlessly as a team, supported by administrators, to look after people from cradle to grave giving them comprehensive and free at the point of use services.

Of course I was hooked and have spent the last 45 years since coming here looking for this utopian vision, and although there have been occasional glimpses, on the whole this NHS has been missing.

There never was an ideal NHS, and with all the medical, technological, social etc changes since the inception of the NHS, there never will be.

Health inequalities

Rather than promote this utopia, we need to start recognising the reality: the reality where the NHS itself is the cause of health inequalities as it sucks money out of all other essential sectors like education, social care, housing, policing, and whichever area of services you look at it is ‘Broken’: GPs, dentistry, hospitals, ambulances, social care not to mention children, mental health, or elderly care; the education and training systems; organisation, governance, and regulation; and the list goes on.

It is a challenge to get into the NHS as a patient with waiting times for every aspect, and bit of a lottery whether one will get safe care, and staff are voting with their feet or becoming disillusioned with being ignored and disrespected.

But it does not have to be like that, things can be better than they are. And therein lies the challenge – because it will mean a rather different NHS and social care system.

But no one seems prepared to take this challenge up currently; sweating the existing assets, even if we can, to improve productivity and efficiency, as MAG suggests, will not deliver what is ultimately needed, and which is a new health and social care system fit for our times.

I appreciate the pace demanded by the MAG, and we must maintain momentum, but going by past experiences, things do not change fast in the NHS, and hence my final plea. Can we please start planning for the winter now; let us not be seduced by the current fine weather, winter is only a few months away, and the last thing we need is a repeat of some of the horrendous scenes of last year.

Rajan Madhok is a retired Public Health Doctor.