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.

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.

Search curation delivers better results

Everything is on the Internet, and that’s the problem. Because everything is there, it makes the one thing you’re looking for hard to find.    It’s somewhat easier if you’re looking for a particular item that’s a paid for business service. Flights and hotels bookings are pretty straightforward and we could all find a flight from London to Paris. However, despite the simplicity of this search, there are numerous aggregators of services. Some show all of the flights, others all of the hotels. Some put both together.

But the sites that attract most views are those that curate the search experience. These sites ask for or understand our requirements. They answer questions like Winter Sun or Short City Breaks.

This is not a common approach in local government, perhaps this is the next area where curation might help the someone find the things they need. A citizen might need to view all the local government services for a family living in a house, or services for a single person living on their own in a flat. This curation should aim to make sure that citizens understand what is available to them.

For older people, this is even more important. Services should be simple to find and in one place, curated for need and provide access to health, social care, voluntary and commercial provision.   They need to be appropriately segmented to keep things simple.  There are plenty of designs for that.  “people that booked A also booked B.”

Should local government only choose to provide answers to citizens needs from their own resources they will fail to access the less costly and sometimes more effective voluntary and commercial services. At BriteLives that’s our mission, put all the services in one place and make them easy to find and book.

Just realised you’re a carer? Three things it’s good to know now.

Lesson 1  – Don’t be passive in any situation, I don’t care how senior they are or what specialist knowledge they have.

Right off the bat I realised I needed to be the decision maker; I felt that there were some occasions when I thought someone else was the decision maker?  This was never the case, at the bedside in a hospital ward, during some social care meeting or just choosing a hairdresser to come to the house; I realised I had to make all of the decisions. That does not mean I did not include my Mother in these decisions, but it became pretty clear all decisions would have to be made by me.

This is particularly the case in healthcare situations. During my Mother’s last stay in Hospital, which should have been a short one, I quickly realised that the ward staff were unable to make any decisions about my Mother. She was not well enough to go home without a care package and no one could decide how big that would be or who should provide it.  So we kept going round and round in circles with me asking their advice.  I found I had to guard against being passive and learnt how to challenge decisions that were or were not being taken.

Lesson 2-  When someone tells you something check both you and they understand what they are saying.

People called me out to the blue and started chatting about my Mother and her needs. This initially seemed like good news.  On at least two occasions I realised that they were not talking about my Mother, some transposition of phone numbers on a list perhaps.  So when I  got one of these calls I did the following:

  • Asked them to identify themselves
  • Got their contact details –  I always did this first. Get their general contact details to and their specific job title.
  • I recorded all of these interactions into an Evernote Notebook; you can, of course, use a paper notebook
  • I confirmed who they thought they were talking about –  I did this through active questions like; “ You wish to discuss Mavis Coulthard with me who’s on Ward XX at the Royal Surrey Hospital?  Is that correct?
  • I would then confirm who they thought they are talking to.
  • Then and only then would I have the conversation
  • Finally, I would confirm the agreed actions back to the caller.

Lesson 3 – Write it all down and keep your eyes and ears open

Don’t rely on your memory, write everything down how ever trivial it might be.  A mobile phone camera is really good at capturing complex meds and forms.   I found that I was often the only person that had all of the information.  The last hospital discharge letter, a list of the latest meds, the name of the intravenous antibiotic Mum was on.  I found that no one seemed to have the right information at the right time.  More of this in another Post.

Once my Mother was discharged from the Royal Surrey Hospital without any medication.  At the time, she was on about 13 different pills.  Fortunately, I had a photo of her medications and the schedule associated with them.  I was able to send this to a local pharmacy and they were able to sort out the mess with some help from my Mother’s GP. Without that intervention, I guess Mum would have been back in Hospital that night.  The healthcare ombudsman has recently published a report into the discharge of older people from hospital.  It does not make good reading.

I found I needed to be aware of the conversations around me and my Mother, I read all of her medical notes, I asked open-ended questions and listened hard to the answers.  I found it easier and easier to challenge the jargon. The NHS loves jargon, three and four letter acronyms abound and I just asked what they meant.  Sometimes not even the user knew what they stood for.