NHS: A suitable case for treatment! The simple solution is staring us in the face!

The NHS saved my life in 1998.  I saw the best of the NHS working but those dedicated professionals strived, on my behalf, despite the rules and procedures of the NHS.  Everything they did was wilfully and deliberately obstructed by a clumsy inappropriate top heavy bureaucracy.

In return I dedicated much of my time, since, to working as a patient advocate.  For more than a decade and a half I have sought to contribute to improvements by ensuring patient views were heard by those commissioning and providing services.  That has included sitting in on tendering processes to provide a patient voice.  It has included meeting with many very highly qualified professionals within the NHS.

Meanwhile I live with a charge nurse and so I see a staff perspective too.

The Problem

One thing everyone learns, when studying economics, is that economies are so complex they are impossible to plan.  Whatever plan you design the Law of Supply and Demand will act to negate what you planned.  The Soviet system stands, in history, as the definitive proof.  Every adjustment you make will result in a corresponding reaction to undo what you set out to do.

The NHS is, in itself, an economy.  It has all the complexities of any economy.  The attempts to plan, top down, is the root of all its problems.  That does not mean there can be no planning mechanism.  It does mean that such a process must be subservient to the demands of the market and no that does not mean you have to charge patients directly for services.

The Bureaucracy

Top Heavy Bureaucracy

In the course of my years as a patient advocate I have attended many meetings.  At each there could be any number of paid NHS officials and medical staff.  At some meetings this amounted to hundreds.  At others it was usually around fifty or so.  Smaller meetings slotted in between.

As a rule of thumb, in my day job, I would consider a meeting to be three days’ work.  A day to prepare, a day for the meeting and a day to follow up.  Clearly some meetings involve far more work but as an average this works.  That means that if 200 people turn up to a meeting then that involves 600 days’ work.

The average pay of those attending these meetings is probably around £100,000 per annum.  With overheads the cost would be around £260,000.  By simple arithmetic you can see that the cost of a meeting involving 200 highly paid professionals works out at around three quarters of a million pounds… plus the cost of the premises, travel expenses et al.  Nobody counts all this though!

If those meetings were really useful and delivered anything positive then this would be fair enough.  In my experience most of those meetings are a total waste of time.  Hordes of administrators, calling themselves commissioners, spend virtually their whole working lives moving from one meeting to another to another and so on ad infinitum.

A good manager is never in a meeting.  Regard a commissioner as a manager.  So what are these meeting supposed to achieve?

The purpose is to enable the collation of information to enable those commissioners to plan how and where to deliver treatments and who is entitled to deliver them, where at what cost.  Intricate “care pathways” are contrived in a futile attempt to pre-plan every intervention. I recall one very senior commissioner, faced with a very workable solution to a problem, declaring “…but how will we control it?”

Therein lay the problem.  Why should she, or anyone else, wish or be allowed to control whether or not a patient should be able to access the best treatment?

The NHS is burdened with hundreds or thousands of bureaucrats whose sole purpose is to obstruct access to services on the pretext of cost control.  They serve no useful purpose whatsoever.  A more libertarian approach would work far better.

The Market

“Market” is a dirty word in the NHS.  Partly this is because the components of the “market” that have been deployed have been misused.  There is also a deeply rooted and uninformed political philosophy behind much campaigning on behalf of the NHS.  It is disingenuous.

The real reason for objecting to any market instruments is that such an approach would lead to the redundancy of thousands of bureaucrats.  It would mean thousands of nurses who spend their days grappling with unworkable “care pathways” “risk assessments” and other such pointless activities would be able to devote their time to patient care.

An Alternative Model

Let us get one thing out of the way first.  There is no practical means of guaranteeing adequate medical, health and social care involving direct payment.  Insurance schemes fall down at the point where need is greatest.  As soon as an illness is diagnosed the patient is on a countdown to a point where support will be denied.  In my view ALL insurance is theft.

Central Funding

Funding from a central pot is the only viable and reliable mechanism for providing these services.  However once you have established this you create a need for price control.  If there is none then the other mechanisms of the Supply Demand equation will swiftly remove facilities from the reach of most people.


This means there have to be tariffs for various treatments.  However there must also be freedom to vary from those tariffs where need determines.  Clinical need must be the driving force.  At this critical point the NHS must and should depend on the skills of its paid professionals at the coal face.

The Doctor’s Role and Commissioning

When I see my doctor I do so for advice.  Decision making belongs to me.  The commissioning process interferes and overrides me.  That is the component of the NHS that is at the root of all its ills.

I would abolish the Commissioning process from the NHS apart from for certain rarefied conditions.  Hospitals should be free-standing not for profit trusts on the basis of Community Interest Companies.  They should be licensed by the Department of Health on the basis of an ability to deliver a defined set of services which must include, for example, an Emergency Department, a Maternity unit etc.

The Patient as Commissioner

The Patient should be the commissioner.  Patients should be free to decide to which hospital they go for services and which consultants treat them. Hospital trusts should be allowed to fail where they do not deliver the required quality.  The best people to decide on whether or not that quality is being delivered are patients. They will vote with their feet.  It is “The Law of Supply and Demand”.


The hospitals should be entitled to a retainer to cover basic costs and then tariffs, for each intervention, should make up the remainder of their income. If the hospital is licensed then it qualifies for the fixed retainer.

When a patient attends or receives treatment then the hospital or other service provider uses the patient number to automatically collect a fee from a central pot.  The central pot should be subject to an ongoing continuous audit process to identify any abuse that may arise.  This requires no additional administration burden.  Everything necessary is already collected.

Government Must Face Up To Its Responsibility

If the demand is greater than expectation then Government must stump up the money.

Those who oppose such a move will use the words of that senior commissioner “How will we control it”.

The market will control it.  There is a limit to how much healthcare society will or can demand.  If that is not being satisfied then the service provision is inadequate.  On an individual basis it must be the patient, advised by the doctor, who decides what treatment is obtained and where and by whom.  It must also be a patient right to decide which doctor they choose to be advised by.

This service has to be the top of Government’s priority along with defence.  No ifs, no buts.

National Should Mean National

There should be ONE National Health Service.  The devolution experiment has been a disaster and should be reversed.



© PJW Holland MMXVII

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1 Response

  1. Love Liberty says:

    Previous reforms were someone’s clever idea which were then implemented without first testing the idea in limited monitored trials.

    I suggest that your clever idea should be tested in limited monitored trials – a few hospitals, a few GP areas around the chosen hospitals. Then the results should be compared to before the trial and against a control group of hospitals and GPs not subject to the new system.

    An ongoing system of such controlled trials would help to decide what works better or worse.

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