Mr Heath Robinson and the Health Service

I am a ‘member’ of the UCLH NHS Foundation Trust. Yesterday afternoon I attended one of their ‘Members Meets’ events, which was quite amusing – more on the event itself below.

But the whole idea of Foundation Trusts and their members is a very odd one. I think institutions serving the public and funded by the public through taxation should be accountable to the people they serve. The public do elect certain people every four years to make decisions about local services on their behalf, and they run education, housing and social services, and it’s pretty obvious to me that local health services too ought to be run by people that local people could sack or support at the ballot box (and also, at the appropriate tier, the police). In this I’m boringly on-message with Liberal Democrat policy.

But this government disagrees, and so they have set up this rather odd arrangement whereby people can ‘opt-in’ to being members of the local public for the purposes of health, by becoming ‘members’ of foundation trusts. Since I think local health services should be accountable to all local people I think everyone ought to sign up as a member of any local NHS Foundation Trusts in their area, and I’ve been enthusiastically signing up as a member of all the appropriate local ones I can around me. If you live near me, you can sign up here:

UCLH
Moorfields Hospital
Camden & Islington Mental Health Trust (currently bidding for Foundation status)
Barts

(and if you don’t live near me then a couple of minutes on google ought to help you find your own local foundation trusts.

Many people in the health service, of course, are horrified by the idea of being accountable to anyone locally. I’ve seen senior NHS managers splutter furiously at the idea of actually having to explain and justify to the public why they have taken a particular decision about a public service affecting the lives of real people and spending public money. For those of used to seeing councillors and officers quite used to explaining themselves to the public, this is quite an entertaining spectacle, but there is also a serious point behind it.

Some in the NHS have turned somersaults trying to come to terms with the idea of how you run a service which depends on expert knowledge and professional medical knowledge (science is not democratic), but in a way in which decisions are made in a way that’s accountable to local people. They splutter that you can’t have non-experts making decisions about which drug to give a patient with a particular problem. Either they’re being disingenuous or (more likely) they just haven’t looked very hard at the rest of the world recently: local government has a well-established model for allowing professional judgements to be made about how best to help individual people, while ensuring decisions about which areas are priorities and so should be invested in, and the general way in which services should be run, are made by elected councillors. We don’t have elected councillors telling classroom teachers that their pedagogical methods are wrong, and to raise the spectre of inappropriate interference in medical treatment by local councillors is complete nonsense.

But if some in the NHS think that the model of Foundation Trust members isn’t very promising as a way forward, then on the strength of this afternoon’s session I have quite a lot of sympathy with them!

There was one speaker at the event – unfortunately I missed the first few minutes so didn’t hear her introduced but she was obviously the Major Accidents Manager or something similar.

The main points that she wanted to get across in her talk, as far as I could tell, were (in order):

1. Attacking the Department of Health and ‘the centre’. The deficiencies of the contamination suits were particularly their fault and she concluded that the DoH was “like the Greek Gods - they just throw things at you – but you have no idea what or when” except that whatever it was it wouldn’t be sufficient and there wouldn’t be any funding attached to it

2. Attacking any other agency she had to work with – eg the police, ambulance service, the ‘Gold command’ emergency planning system; Camden PCT came off quite lightly!

3. Attacking and generally belittling anyone who asked a question in the questions session, or even coughed out of turn (someone who muttered a word of agreement to something she said was immediately stared out into silence!).

4. Saying something about the challenges of an emergency incident and how the hospital can respond to it (this was actually the title of the session)

5. Attacking other departments in the hospital, for example security, who it would be fair to say she did not give the impression she regarded as being on her side when dealing with security problems

All this made it quite an entertaining exposition, but I can’t help feeling if this had really been what the Government envisaged when it set up Foundation Trusts.

More particularly I wonder if this was really what the senior management of UCLH wanted her to say. All of us have gripes at work that we want to get off our chest – things like “none of our contingency plans ever work” (as was said this afternoon), but I wonder if that is really the right – or even an accurate – communication to convey as your key message to local people and service users. I know from experience how difficult it can be to get staff in the public sector to make good presentations to the public and in a way which presents the right image of the organisation, but I really do not think any body which is actually accountable to local people which ever allow anyone to be quite this blunt in generally slagging off itself and everyone else it has to have dealings with. (Actually it reminded me of the approach and problems of the European Commission, which also historically fails to understand completely how to behave and present itself to the public, in my view for the same reason that it is not elected by or accountable to the public – but that’s a subject for another blog post!).

If the presenter had an innovative approach then the audience were a pretty interesting lot too! Out of perhaps 40 or 50 people there, I would guess that perhaps around 4 of us had a full time job; the vast majority were retired and there were very few people of working age (hardly surprising if you hold ‘members events’ at 1 o’clock in the afternoon). Some of the questions asked were reasonably interesting but overall the tone was something like a meeting of the WI or the over-70s club under the impression that they had been asked to run a hospital.

If this is what ‘members’ events are then I must say I don’t really blame hospital administrators for wanting to run a mile from public engagement in decision-making. But of course that was the result of the way it had been set up. The public at that event weren’t very different from the public who turn up at local council or political events: the difference in this case was that whereas in a Council the public elect their representatives, the leading ones of whom (in all political parties) are really pretty talented leaders, in this case it was the raw unmediated public. And of course why would any local politician bother while the health service has no real accountability to local people (other than a couple of dozen pensioners on a Friday afternoon three times a year) and is accountable only really, if to anyone, to a national Secretary of State.

The event was quite interesting to be at, and I did learn something about the way that UCLH operates, which is why I went. I think at the end even our presenter wondered if she’d given an accurate picture, muttering something about the impression she wanted to leave us with, quickly reassuring us that they did know what they were doing really, they did do a lot of practices and – which I am quite is true – that they actually are really quite good when an emergency does arise.

I think she was talking about UCLH”s ability to cope in an emergency, but it might have been the whole system of Foundation Trusts, when she finished “I wouldn’t want you to think that Mr Heath Robinson is in charge here”.