Is an NHS monopoly a good thing?

Public sector monopolies are a good thing right. They can’t affect private provision or innovation, and they are what they are. And in the case of the National Health Service in the UK, it’s a miracle. Thank goodness laws protect us from private companies taking over the NHS.

That’s the public service dialectic. Well, I have some worrying news for you.

Baxter’s law (also known as the Bell doctrine) is a law of economics that describes how a monopoly in a regulated industry can extend into, and dominate a non-regulated industry, named after law professor William Francis Baxter who was an antitrust law professor at Stanford University.

Here’s an example:

A new nurse-led social enterprise sets up on the South Coast of England to provide a wound dressing service. The local CCG likes the new service and signs a three-year contract. Costs go down as the service dresses wounds more innovatively, patients spend less time as an inpatient and pharmacy bills reduce.

At the end of the Contract, the CCG advertises a new Contract. The local NHS provider offers a lower price for the next tranche of the agreement. They undercut the local social enterprise by using funding and revenue from other areas of the local health monopoly. They win the new contract. Of course, they do this to protect their income in others areas of their business. Classic monopolistic and anti-competitive behaviour.

So what happened?

Did the cost of care on the South Coast go down? Did the quality go up? Or perhaps the NHS used it’s monopoly to reach into a Third Sector and kill innovation and alternative provision and protect its income. I would content that Baxter’s law applied and the NHS used its power to stifle innovation.

My concern is that many are unaware of the anti-competitive nature of this monopoly position.    Next time you attend a meeting looking at NHS Contracts or as a member of the public at a Health and Wellbeing Board you might think to ask;

  • What steps are we/you talking to limit the monopoly of NHS provision?
  • Are we/you aware of any examples of the NHS limiting innovation or new service provision through the use of economic muscle?

The NHS and the public it serves will be better for it.

When work tells you, “we’re family here”.

Decoding the world of work is becoming more tricky by the day. Our colleagues at work get mixed up with our Facebook friends and become frolleagues. Our employer tells us that “we are like family here”. Perhaps in the back of your mind, there is a worrying thought that this is all about trying to make sure work is the most important thing that we do in our lives.

I like the way Reed Hastings of Netflix puts it.

Netflix

Have this slide in the back of your mind when you hear the paternalistic siren call to family values. It isn’t at all what it seems or what it should be.

 

 

 

 

Are single-handed GP practices safe?

You may have felt a tremble in the force over earlier this month.   NHS England got its revenge or  perhaps better described as a “premptive cringe”, in early ahead of a BMA strike on the Director of Primary Care at NHS England Dr Arvind Madan.   I am no expert but the BMA (the Doctors Trade Union) is not keen on the closure of small GP practices,  I am sure they will comment below if they’re concerned about my lack of understanding here.

But here is some evidence, there’s not much of it, but it’s pretty clear; if you’re a patient stay away from small GP practices. 

Elaine Kelly and George Stoye published Does GP Practice Size Matter?
GP Practice Size and the Quality of Primary Care in Nov 2014. You can read it for yourself.

Here are a few bullets from the executive summary:

  • Single-handed practices have the lowest average (mean) QOF scores
  • For ACS admissions, there is some evidence that smaller practices perform
    worse, on average, than larger practices and are more likely to be among the worst performing.
  • Practices with three or fewer FTE GPs are less likely to refer their patients for secondary care than larger practices. Single-handed practices are also less likely than larger practices to refer patients for treatment by independent sector providers (ISPs)

So what should you do as a patient, well you can make your own mind up?  I look for the largest practice with the lots of doctors and nurses.

It’s a shame that NHS England felt it could not stand up for patients and those GPs that provide better care.  I’m sure their action is counter to the NHS Constitution Principles 3 and 6, but we don’t hear much of that these days.

 

What’s the point of Health and Wellbeing Boards?

You may have been following the changes to the NHS over the last few years. Or perhaps you are just a user of services, going to your General Practitioner and then to a local hospital. Either way, you should know that your local Council has been given some wide-ranging powers to provide local health and social care services. Who cares? It’s a reasonable response to all of the changes. But there are some things should concern you.

Look at these three data points about health services in England.

  • One in two hundred babies are stillborn in England
  • Young people can wait months to receive mental health services
  • In the UK young men die younger than in just about any other European Country.

in the light of these issues I want to look at what Local Health and Wellbeing Boards are discussing in their meetings.

Using a search engine of your choice, you will quickly find the papers of you local HWB on the internet. And that’s where it pretty much turns to rat shit. The jargon and impenetrable language are there in the first paragraph. Here is the explanation of what the HWB does in Brighton.

The purpose of the Board is to provide system leadership to the health and local authority functions relating to health & wellbeing in Brighton & Hove. It promotes the health and wellbeing of the people in its area through the development of improved and integrated health and social care services.

The HWB is responsible for the co-ordinated delivery of services across adult social care, public health, and health and wellbeing of children and young peoples’ services. This includes decision making in relation to those services within Adult Services, Children’s Services, Public Health and decisions relating to the joint commissioning of children’s and adult social care and health services (s75 agreements).

Are you any the wiser? Perhaps the focus on young people caught your eye. Although you may now be worrying about the three data points I highlighted.

Reading the Agenda and the Minutes of the meetings won’t help you. They’re even more Delphic.

The most concerning element for any Public body are the meetings they held in camera. They regularly exclude the public from their discussions.

Members are often keen to show they have no conflict of interests, and it’s usually the first agenda item. But no one seems concerned that as mainly elected officials they are in conflict with their electorate for excluding them. You might also reasonably ask why there are so many doctors and so few nurses as members of your HWB. Perhaps too much interest all round.

So, if you have the time to attend an HWB meeting, go and listen to their arcane discussions, see if you understand what they are doing in your name.

The next meeting here in Brighton is in September. I will be there.

Sepsis – NHS England’s Plan A failed!

Did you notice the rise in cases in Sepsis reported by the NHS? You may know that NHS England has an action plan

Bottom line;  the NHS England plan has not worked.   So I guess we need Plan B.

Here are three things that NHS England could do now:

  • Create a Sepsis Registry – we would then know the extent of the problem. NHS England currently doesn’t have a succinct policy for Registries (perhaps they could get round to that).
  • Adopt the international standards of Sepsis treatment. Making sure the poor primary care practices are called out and addressed. (although you need a Registry to do that).
  • Refer every Sepsis death to a Coroner to investigate.

That should cut the number of entirely avoidable deaths.

 

Who pays for local journalism – we do?

You may have felt a little schadenfreude when you read the $Billion reduction in the value of Facebook. Not unlike the 2008 crash, this money has gone to money heaven, and will probably never reappear.

However, something else is also dying as the Facebook and Google scorched earth policy rips the heart out of the paid-for newspaper advertising revenue. It’s journalism, as the business model of newspapers comes under threat, the newsroom can no longer afford a full roster of journalists.

The effect is both National and Local, but the local impact is much more significant as there is no one else to scrutinise local political and public services.

In New Jersey, the state’s lawmakers will begin to  fund community journalism, and this will include for-profit as well as non-profit groups.

I sadly can’t see this coming to our communities anytime soon; who would be prepared to pay for such a subsidy? It’s a real dilemma, failure to scrutinise local political decision making will lead to poorer decisions. In turn, this will lead to a more significant waste of public money. Undoubtedly more than the cost of the subsidy in the first place.

I think there may be three practical steps we can all take:

  • Find our local news site; it may be a newspaper or a community group, sign up and join the discussion.
  • Attend local Council and Public service meetings and remember to ask a question, how they handle the response may tell you a great about how they feel about scrutiny.
  • Support national and regional newspapers through their subscription services, pay a little to benefit a great deal.

Full-time work – it’s over rated

Full-time work is overrated!  It’s also a recent thing.   It arrived with the industrial revolution, and it will leave hand in hand with one of the many trends weathering the way we work today.

Dan Rasmus looks at these trends in his book Listening to the Future published in 2007, he identified the trends as:

  • One World of business
  • Always on always connected
  • Transparent Organisations
  • Workforce Evolution

By looking back at a book written ten years ago, we can get a sense of its insight.   If you’re in the UK, it predicts and explains, the rise of Amazon, Brexit, the advertising domination of social media, WikiLeaks and millennials in the workforce.

But most of all it predicts the way work has changed from full-time jobs for life into a spectrum of work from the precarious to the fully employed.  The balance of that spectrum for many is heading towards low paid, zero time contracts that define poor job quality.   For a few, it’s the sunlit uplands of work anywhere when they want, and for significant reward.

The leadership challenge of the next ten years to manage the quality of that spectrum of work and make sure that work has an innate quality and provides a respectful and decent living for all.   And the one way to begin redressing the balance is to pay the National Living Wage.