Why can't Britain see the real problem with the NHS?
The management structure and the power of the doctors' union, the BMA, are fundamental to understanding why Britain's NHS doesn't work properly. You wouldn't know it if you listened to the blather from most politicians and journalists
The polls say that the future of the NHS is the number one concern for voters, so inevitably all the parties trumpet their solutions -- which are all the same. Chuck more money at it!
None go to the root of the real problems. There are two. The first is the management structure built into the NHS at its inception.
During WWII, the Government controlled everything, from what we ate to what we read. Belief in centralisation was paramount: ‘The gentleman from Whitehall really does know best!’
This continued to be the prevailing philosophy for the next 30 years. When the NHS was set up in 1946, it was given top-down control with a hierarchy of regional and local boards, all appointed by Whitehall.
This was virtually identical to the regime for nationalised industries and had the same defects -- remoteness of decision-making; lack of local accountability; a top-heavy bureaucracy. Mistakes could be expensive because they infected the entire service and took a long time to correct.
Aneurin Bevan famously said that ‘if a hospital bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall!’
‘Best practice’ in modern management prefers the ‘bottom-up’ approach in which every decision and action is taken at the lowest appropriate level.
Despite numberless and apparently fruitless attempts to reorganise the NHS, little appears to have changed fundamentally. Indeed, it is difficult for the layman to comprehend just what those changes have been.
The second big problem is the British Medical Association. As a trade union for doctors the BMA, with its ‘closed shop’, restrictive practices, and ruthless self-protection, makes UNITE look like the epitome of moderation.
In 1946 it voted to boycott the NHS altogether, forcing Bevan to compromise, and to abandon what now seems highly desirable; primary care centres with salaried staff. These local clinics would have provided initial patient contact in place of surgeries.
Instead, the new system was based on the large hospitals dominated by the consultants who to this day are independent private contractors.
Amidst all the political waffle about ‘the NHS is safe in our hands’, no party has grasped that the underlying fault in the NHS is structural. They are lacking something fundamental. It's that elusive ‘vision’ thing.
Robin Mitchinson is a Contributing Editor to The Commentator. A former barrister, living in the Isle of Man, he is an international public management specialist with almost two decades of experience in institutional development, decentralisation and democratisation processes. He has advised governments and major international institutions across the world
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