Health Service Administrators – Careful FG/Lab

The London Times published an essay on administrators and their
prolikeration with markets in gthe NHS.

April 30, 2010

Scalpel! This NHS red tape needs removing The internal market has been a
costly disaster. Let the professionals manage medicine Jonathan Waxman

It’s election time, apparently, and our glorious political classes are
marching forward on the massed ranks of the electorate with banners that
claim that their party, only their party, will save the NHS. Politicians
clamour to praise its world-class status and laud the dedication of nurses
and the skill of its doctors. And all parties are united in the view that,
despite the need for austerity measures, frontline staff and services will
not be cut. So where are the savings planned? Watch the hand and not the

When I started in medicine, the hospital was run by about three people.
Things were so much more simple when doctors and nurses treated patients,
doing their best without the guidance of guidelines and targets, doing their
best … yes … to make the patients better. How did we manage without
forms to fill and waiting times compliance? Quite well actually.
The medical director ran the medical side of things while matron and the
accountant handled the rest. It wasn’t much of a business then: it didn’t
have to be, because there was no internal market to manage.

The internal market – Mrs Thatcher’s plan to introduce efficiency by having
hospital compete against hospital to provide patient treatment – has wreaked
havoc. It has spawned a nation of administrators, here today and gone to
another post tomorrow – while doing nothing to bring costs under control.

The internal market’s billing system is not only costly and bureaucratic,
the theory that underpins it is absurd. Why should a bill for the treatment
of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford
that pays the bill – there is only one person that picks up the tab: the
taxpayer, you and me.

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And there are big problems with the billing process. For example, if a
patient is seen in an outpatient clinic then there is a charge made by the
hospital for his or her first attendance – but follow-up appointments are
not charged. And if many treatments are given in a hospital to a patient,
only the most expensive of the treatment episodes is charged.

There are savings to be made. It is alleged that there are just 75,000
administrators at work in the NHS but this figure is laughably mythological.
Doctors and nurses know that there are many more than this.
They look around and see the numbers increasing. One report by the Centre
for Policy Studies published in 2003 indicated that there were 250,000
administrative staff employed in the NHS: at least one administrator for
every nurse. In recent times the rate of increase of admin staff within the
NHS has exceeded that of nursing staff.

There is a general feeling in the NHS of disempowerment of the
professionals. People can’t face up to the incredible struggle, the
disapproval that faces any of them if they have the temerity to suggest that
things should be run differently.

The principle of care for all from cradle to grave is worthy and wonderful.
But the current reality is a cradle rocked by accountants who are incapable
of even counting the number of times that they have rocked it. The reality
is gravediggers working with a cost improvement shovel made of rust.

Over the years politicians have made dramatic changes to the way that the
NHS has been run. Recent changes have caused fragmentation and not led to
any cost saving. Moving patients from one place to another does not save the
nation’s money, though it might save a local hospital some dosh. So the
internal market has failed because it does not consider the health of the
nation as a whole, merely the finances of a single hospital department, a
local hospital or GP practice.

So what should we do? Let us go back to the old discipline of the NHS. Let
the professionals manage medicine, empower the professionals, the doctors
and nurses and shove the internal market in the bin and screw down the lid.
At this election time please let us hear from all political parties that
they will ditch this absurd love-affair with the internal market. Instead
let them help the NHS do what it does best – treat patients, and do so
efficiently and economically without the crucifying expense and ridiculous
parody of competition.

Professor Jonathan Waxman is a consultant oncologist