BIG changes are taking place in the National Health Service in Scotland, albeit less obviously and more slowly than south of the Border.
Although the great majority of people have a perfectly satisfactory experience of the NHS, this conceals the facts that the risks to some patients and the burden of waste on all taxpayers have greatly increased over recent years.
Donald Berwick, Health Care adviser to President Barack Obama, and now to Prime Minister David Cameron identifies quality, feedback from patients and carers, training staff to be “expert improvers”, and absolute transparency as key to improving the NHS. He said that motivational leadership and greater accountability were needed rather than reports, inspections and targets. He also said that responsibility in the NHS is too diffuse: “When responsibility is not clearly owned, with too many in charge, no-one is.”
Out-of-hours calls to the NHS used to be taken by nurses who immediately reassured, advised or summoned further help. Calls to the Scottish NHS 24 service are now taken by a “call handler” with little over a week’s training. Questions are generated from a computer “algorithm” that prescribes the action to be taken. This time-consuming process recently failed to recognise severe post-operative bleeding as an emergency, but attempts to have this investigated have failed because the “clinical content of the algorithm is the intellectual property of Capita Clinical Solutions”.
Health Boards encourage patients to complain, and the Scottish Government has introduced Patients’ Rights Officers to help them to do so. But complaints are now processed bureaucratically rather than being dealt with by those directly responsible – with the aim of rebuttal rather than using them for learning and improvement. The Scottish Public Services Ombudsman reports that over half the complaints he receives had been unfairly rejected by the NHS.
“Consultations” with the public are a similar sham. The Scottish Health Council is responsible for ensuring that “consultations” are held, but it has no responsibility for ensuring that action is taken in response.
For this reason, those who are unhappy about the Scottish Government’s 100 per cent single room policy have been unable to make any impact. They fear isolation, missing a meal, lacking water or even abuse; or that a fall, dislodged drip or even cardiac arrest may go unnoticed. Rather than listening to their arguments the government has made a series of statements defending its policy – such as: “Patients consistently express a preference for single rooms; single rooms promote dignity and privacy and minimise the risk of infection; and 26 Scottish hospitals already have 100 per cent single rooms.” Each of these statements is either misleading or untrue.
NHS quangos and other bureaucracies have mushroomed over recent years and there has been no attempt to rationalise or prune them. NHS boards are a particular concern. Board membership has increased greatly, and chairs and members are often repeatedly re-appointed or rotate between similar posts in other public bodies. Often the relationship with the executive is too cosy with boards merely rubber-stamping what the executives have already decided.
As in England, our most profitable public services are being replaced by private, often multinational, organisations to the virtual exclusion of small, efficient innovative providers (as in the case of NHS 24). These are not accountable to NHS management, their board meetings are private, and they are not subject to the Freedom of Information Act. Contracts are often set up to make comparison of outcomes with traditional providers difficult or impossible; and the ability of the government to monitor them is very doubtful.
The resignation of Derek Feeley, Chief Executive of NHS Scotland, should be an opportunity to establish the dynamic leadership necessary to transform the culture of the NHS in Scotland. But the appointment of his successor is entirely in the hands of the Scottish Government, so is anything likely to change? «
• John Womersley was Consultant in Public Health Medicine 1979-2006 for Greater Glasgow Health Board and NHS Greater Glasgow & Clyde. He is health spokesperson for the campaigning group Accountability Scotland