Germany to reintroduce national service

Umm…couple of things

1) the NHS was appropriately prioritised..simply because we are getting older and require more healthcare…or we could let the old die. Also a healthy national health system is one of the fundamental requirements to fight a modern total war. I can go through the history of our health system if you like but I assure you it’s intrinsically linked to the last four major wars this nation had to fight. The creation of the NHS did not happen at the end of WW2 for no reason.

2) free schools is a right wing concept not a leftwing one. They were introduced by a conservative government.

3)As for people going to the U.S. to support elections all parties tend to do that as US parties also send people to support European parties…the Democratic Party has often supported the Lib Dem’s for instance..especially after they became a party of power in 2010.

4) right wing parties have been just as guilty of stripping defence as left wing parties….infact some of the most aggressive and militarised parties have been left wing…aka the communist of the Soviet Union and the Chinese communists party.

You think that the Conservatives are right wing?
Nonsense, they all came to the center where the votes are. That is why the Liberals are virtually extinct.

The Liberal Democrat’s are actually doing very very well indeed, infact they are at a high watermark. The reason the Lib Dem’s suffered was that they signed up with a conservative coalition. And if you think the party that voted in kemi is not right wing, you really have not had much contact with conservatives party members.

In times past but still relatively recent the Liberals were a major party.
Their demise started in the 50s and 60s for the reason I said.
We obviously have a different idea of right wing.

A protest vote.
Regardless of seats Reform actually got far more votes.

What are you talking about? Tories 121 MPs, Lib Dems 74 I think.
It’s the Tories that were nearly obliterated into 3rd place party. Hopefully next election the loons in the Tory party will be booted into 3rd place and Lib Dems will be the opposition party.

Chris.
Can I pick at some of these points? Devil is always in the detail and very few things are absolute.

1. There is a difference between the need for some more health services and “spaffing” ever more uncontrolled sums of money into the highly dysfunctional and inefficient public health service. That would be dumb enough but the over-politicisation of the NHS into an unofficial state religion by politicians risk criticism and calls for reform being labelled blasphemy.
2. Education is great. However the expansion of University education from covering 19% of 18 year olds in 1990 to 36% in 2023 is probably not the greatest attribution of resources. The only thing it seems to achieved is reduce the size of the available workforce and burdened kids with debt. Larger is not always better. Quality and outcomes are more important.
3. Yes they do…but it points at a Left\Liberal political class which isn’t modelling the world properly. The cost\benefit analysis of what happens if your side loses is not worth the warm feeling you get from your favourite side winning. The sane thing and ethical thing to do is if your the party in power is to stay out of it. Unfortunately the Labour Party machine has done the equivalent of picking a horse in a race which they chose because they liked its name in the newspaper but failed to check if the horse actually had 4 legs. A lot of us outside the London bubble could see which way the wind was blowing in the US. It’s a sign of cognitive dysfunction in the Labour machine that they couldn’t conceive of a Trump win.
4. Right wing parties are not what they used to be. Merkel, May, Cameron are allegedly Conservatives but aren’t really. They are Euro-Liberals. Social spending which they can sell at elections is what floats their boat. Their brains are not configured for Defence. It’s completely outside their cares or skillsets. The chances of them managing Defence properly is zero. The outcomes and failures we’re seeing today were inevitable. Cameron is a particularly disgusting creature. Hiding behind a gerrymandered target of 2% which held no relationship to the funding actually required to meet even the downgraded requirements of his finance led Defence review. The guy is a clueless sociopath.

Hi Cog the problem is there has never ever been buckets of money spaffed at the NHS, that’s a literal difunctional message that generations of politicians of all sides have fed the British pubic because no one is interested in the simple truth that a good western health system costs far far more that the British public have ver been willing to pay. Our big problem is that the treasury decide how much the NHS gets paid for the treatment it provides and that has little or nothing to do with the amount of healthcare required or the actual cost of that healthcare…I will give you one example knee replacements the NHS gets paid around £4500-£5000 per knee replacement..the private sector and other comparable systems will charge £15,000 to £20,000.

If we look at the German system which is a pretty good European system with similar staff and equipment costs pressures as the NHS has to work under. To provided for that health care the German healthcare system charges the German people £5000 per person per year..the French system gets almost £4500 per person…the US which has the most inefficient heath service in the world spaffs around £15000 per person..the NHS is provided £3000. In reality to provide adequate healthcare to that standard received in Germany or France we should have been paying 50% more for our healthcare than we do. And the important thing to remember is we have been paying that 50% less than we should for every person for the last 75 years…that mean the NHS over its life has been underpaid for what it provided by many many hundreds of billions of pounds..what that has created is a profound bankrupt health system in everyway that matters, because it has to provide basic emergency treatment and it’s gradually mortgaged everything to keep going.

1) staff training..it’s costs around £120,000 to train a nurse to a basic level, probably £150,000 to get a junior dr..same for pharms, physios ect…then to get advanced clinicians it’s even more hundreds of thousands ( to get someone like me probably cost close to £300,000 in training and a couple of decades of time)..so the NHS just stopped training the clinical staff it needed and ran by steeling staff from the third world..but international wage prices have gone up and the source of migrant professionals has dried up…and as a nation we are shy around a quarter of a million healthcare professionals..each costing hundreds of thousands to train up and a good 5-10 years.. and to even do the training you need free very experienced heathcare professionals to train and mentor..which we have not got because we mortgaged the workforce….let’s say that’s £150,000,000,000 of dept that needs to be paid in workforce rebuild costs.

2) maintenance of buildings and equipment…you can run with a leaking roof for a while before the roof falls in..that’s what the NHS has been doing and it now has a maintenance mortgage of 11,000,000,000

3) capital investment buildings ..simply put the NHS has not built and purchased the number of hospitals, health centres or scanners it needs to keep up with demand and replace buildings that are not fit for purpose. So we have around 120,000 hospital beds Germany build a load of hospitals and invested in secondary care facilities has 480,000. Many NHS beds are still in Victorian workhouses..I cannot tell you exactly how much building we would need to do to have the same level of acute hospital provisions as Germany but in reality it would swallow £100,000,000,000

4) capital investment scanners..we have the lowest numbers of advanced diagnostics of any advanced nation.. 10 CT scanners per million people, 8 MRI scanners per million and .5 PER scanners. Germany has 35 CT scanners per million, 35 MRI scanners per million and around 3.5 PER scanners per million…so we are basically down 55 advanced scanners per million population..or 3850 advanced diagnostic scanners a good advanced scanner cost around £350,000 or £1,347,500,000..but as we looked at staffing we would need another 10,000 radiographers and a 1000 radiologists on top of our quarter million misssing healthcare professionals..which is even more mortgaged money.

5) the final monster mortgage is preventative medicine…up stream care is so much cheaper than down steam care..but all the NHS has been able to do for a very long time is look after you at the very downstream point when you are just about to plunge off the waterfall and into the occean.. it’s costs around £50,000 a year to look after someone with many multiple morbidities ( long term health conditions) it costs less than a £1000 a year to look after somebody with no long term health conditions…because we have done no up stream care for a long time we now have a population with 27.5% having multiple co morbidities…

essential to have a good healthcare system..say to a German level we need to fund to the same level as Germany..which would mean we spend an extra 85 billion a year ongoing… every year. But we also need to deal with the mortgage…staffing, maintaining, capital building and scanner capitalisation..that’s about £260 billion pounds of recapitalisation…which is not bad considering for the last 75 year we have underpaid the NHS by the today equivalent of £85billion a year…

that’s the no bullish truth no political party or leader will ever tell you..or media outlet.

spaffing money on healthcare would have been to the US level of spending…that’s would equal around about an Extra £500 billion a year to get to their level or spend….they spend 4.5 trillion dollars a year on their health system.

Jonathan I’m happy with my use of the word “Spaff”. Whilst it’s true expensive thngs are expensive it’s also true that money misdirected to wasteful things is a waste.I’ve worked in both the private and public sector and trust me there is no comparison in terms of operational efficiency.

Primary healthcare is a dysfunctional mess which seems to be run for benefit of GPs not the public. Money devoted towards Primary healthcare should go towards servicing the public not golfing holidays.

Also do you think 212 Health Trusts is enough? Maybe there’s a few administrators looking for some work somewhere in North London and we could go up to 213? It’s not just about the administrator’s though it’s the infrastructure supporting them. I have colleagues working for one NHS Trust and that NHS Trust has 2 NHS datacenters dedicated to it.The HealhTrust next door does it’s own thing. Maybe the NHS could catch up with rest of the world. It could cooperate with neighbouring trusts and share facilities. It could virtualise its infratructure, host it in the cloud and every 10 years get cloud providers to compete in price to host it.

Let’s also not get started on the array of services put out by the NHS. Is gender affirming care for children really something we want our tax money to go on? Or 800 Diversity Officers employed by NHS England alone? Could we not introduce some sort of Lean methodology and just wrap this function into General HR? Do all nurses need to be graduates? They didn’t used to be.

The problem is this. The NHS could do many things to operate more efficiently. It doesn’t..it consistently doesn’t. This is a leadership and culture issue.This is the are of the public sector dominated by such intellectual titans as Matt Hancock and Mark Drakeford.You could give these sort of people infinite resources but each year they would deliver less and less.

A few things. Re health trusts…the number of these has very little to do with the NHS and a lot to do with central government politics..you have to understand why NHS foundation trusts were created. It was a way to break up the state owned element of the NHS into small chunks that could then bid for contracts and when the time was right moved to become private or third sector organisations.

“Andrew Lansley’s White Paper, Liberating the NHS, promised again to release NHS providers from central government micro-management and to increase foundation trusts’ freedoms to create the largest social enterprise sector in the world.”

in essence foundation trusts were created to allow the creation of a marketplace that could then replace the state owned part of the NHS.

The problem is that unfortunately it could never work because the Department of health does not pay NHS hospitals enough to be viable as private sector or third sector providers. Infact the one time a private sector healthcare provider ( one of the most effective in Europe) was persuaded to take an NHS district general hospital, it took it exactly 6 months to realise it was not possible to run the hospital within NHS tariffs and it resigned the contract gave the hospital back to.

So what we have now is a profoundly fragmented system..not because the NHS wanted it or planned it but because central government wanted it fragmented and forced it to fragment..as a senior leader in the NHS and someone who knows healthcare policy and design..it could only have been as a precursor to sell off.

infact the NHS since 2010 has been actively trying to reduce the amount of NHS foundation trusts..by merging them..so in the two counties cover around 3 million people I have worked in 2012 there were around 8 hospital trusts and 6 community trusts..now there are 2 complex vertically integrated trusts..each with its own community services and multi acute hospitals…the NHS never wanted to be split but it’s only recently that it’s been allowed to bring itself back into larger units..but to do that it has to consult every time it wants to..which costs millions.then it has to fight the local court cases ( people protecting their hospital) finally it takes an act of parliament to merge the trusts legally ( each trusts arecreated by an act of parliament)

And now we get to the IT issue and medical records…( this is a stone cold bitch and one job I had to do was modernise a whole NHS trusts records…75 years worth of paper records stored in 4 warehouses..totalling 2 million patients..many of whom had 4 or 5 separate sets of records…and my budget was nothing and my staff was 5 part time agency workers…because to modernise and make better you need money and the NHS does not have enough money to treat even the emergencies…so I was not getting the huge investment needed to put four warehouses or paper records on a cloud..and match them up with a million people). But the big kicker for the NHS is medical records have very very tight regulations around how and when they can be shared and who can have access..and each NHS trust is a separate legal entity..under a load of laws they are not allowed to have shared record systems..they must maintain their own separate patient records management system…also even if you can get past the law on records management..the NHS is a system made up of 50,000 separate organisations, each with their own IT systems and contracts with IT providers that end and begin at different times…the last time the NHS tried to create a single patient record system..it told the government it was not possible..but the best IT companies in the world told the government they could do it..13 billion pounds later every single one of those IT giants turned around and stated that the complexity of the number of systems, Sheer number of records that needed storing and cross referencing,linked in with the profoundly challenging legal requirements around sharing medicos records meant it was almost impossible to do and that was that…for information no health system in the world has a unified single records and IT system..the NHS was the first and last to try

As for GPS I was responsible for overseeing the contacts of 70 GP practices…they have been more and more screwed down, the reason Primary care is a mess is that no Doctor in their right mind will buy into a partnership and take the contract anymore. To become a GP partner costs around £250,000 as a buy in.. for that you are then completely liable for the financial liabilities of your partnership, I have know GPS loss their houses when their partnerships go bankrupt…they also have to both act as senior managers for the practice, work a full clinic, cover any absences and train new GPS..most of the partners I know and have reviewed tend to work from 7 in the morning to around 8 at night five days a week..and for all that financial risk and work they on average earn around £70,000 a year.. the lowest I know of was £48,000 a year for an individual that worked 70-80 hours a week..so no GPS are not taking the piss, they are being worked to death and leaving in catastrophic numbers, that is what the family GP practice is dying and no one can get an appointment…but just so you are fully aware primary care sees a huge number of appointments post pandemic compared to pre pandemic..and they are still not getting through the demand.

as for managers..the NHS has less % of managers in its workforce than any other industry, it also has way less than almost any other healthcare system…it’s literally a lie to say the NHS spends to much on management…healthcare is the single most complex system and endeveor in human history…it needs organisation and we do it on a shoe string..my organisation oversaw the delivery quality, purchasing, procurement’s and planned the healthcare for a million people, with a 2 billion pound annual budge paid to around 500 different contracts..to do that it has just less than 100 staff.

as for such things as equality managers..again only people who have no idea what they are taking about bring this up..why does the NHS have equality managers and what do they do:

1) when we design commission or decommission services..the very first change the public and solicitors make is have we done an equality impact assessment and engaged with all effected protected groups..if we have not we can piss away million pound contracts like water…reason one we have equality managers….the courts will murder us the moment we do something even one member of the pubic does not like of we do not cross every t and dot every I..
2) up stream care is cheaper and more effective than down stream care, because of this hard to reach groups who don’t seek help cost more in the long run if you don’t go find them and make sure they engage..equally managers go out and find out how we can engage ( I had one who would even drive out in his spare time to find the traveler camps so we knew where they were and how that would impact on provision and need.
3) staff..25% of our healthcare professionals are from ethnic groups other than British..we need to be able to keep attracting these groups or we run out of drs and nurses..

three basic reasons why equality managers pay for themselves many times over.

lean methodology is shite for healthcare and cannot and does not work because there is no defined product you are creating, each and every one of the 1.7 million new episodes of care per day in the NHS are completely unique and utterly random in their presentions..how do you lean sigma six someone deciding they are god,cutting off parts of their body and eating them, then stabbing themselves in the hands feet and chest with a combat knife) or and old lady with 15 different health conditions all acting in different ways each day…the NHS manages 600million unique episodes of each year..lean,sigma six only value is as toilet paper ( I have studied every improvement methodology under the sun).,infact the NHS works with the leading proponents of improvements in healthcare in the world the IHI ( a U.S. improvement think tank) and the NHS leads the world in developing healthcare improvement methodology and safety ( as the IHI..they don’t primarily work with US provider they work with the NHS). The NHS improvement methodology has to take into account that in each episode of care ( product) a unique human being,with a unique set of problems and reactions sits in the middle. We are not making and selling a defined product..we are dealing with individual catastrophic events every day…

do all nurses need to be graduates…yes and no. All registered nurses need to be graduates as they are professionals who have to have a vast array of knowledgeable in a huge number of subjects..from pharmacology, pathophysiology, psychology, sociology, management of crisis, grief management, technical skills in healthcare interventions, management of complex case loads and how to run and manage teams in life threatening situations…so yes all RNs need to be graduates..when you go into a hospital or ED it will be the judgement and knowledge of the RN that saves you or kills you because that’s the person that plans your care..decides who sees you and when, decides how I’ll you are and what priority you are..there is very solid research that tracks on the number of graduate RNs on a ward directly corresponds to reduced lengths of stay ( cheaper care) as well as reduced mortality and morbidity ( cheaper care and you don’t die as much)…but there are some tasks like making beds, giving out dinners, supporting basic care that can be done by people other than RNs..that is why in the NHS we have two other levels of Nurse roles.healthcare assistants ( qualified with a level 3 qualification in basic care processes) and assistant practitioners ( level 4-5 qualifications ) who can do some of the more technical tasks and manage some care under the professional guidance of a registered nurse…but we really only have these because we don’t have enough registered nurses..we have around 1 RN for every 8-10 patients on a ward,Australian hospitals have 1 RN for every 4 patients..they have more effective and better hospitals be we are to cheap and cash starved and have not trained the number of RNs needed to this ratio ( another 150,000 would do it).

finally the NHS cannot operate effectively and efficiently because it’s cash starved and overwhelmed..a hospital works most effectively and efficiently when it’s at about 85% capacity..this allows patients to be moved to the correct specialist wards..infections can be controlled by cohorts or isolation etc..in this hospital people will have significantly reduced bed days and the care is cheaper..NHS hospitals in the winter often can run at 110% capacity ( we make up beds in random places) patients have to go to ward that are not specialists in their care, they have to wait in ED for 24 hours..this care increase lengths of stay by weeks for some patients..it’s inefficient care caused by not paying enough.

as I stated before up stream care is profoundly cheaper than downstream care..but we have massively overloaded primary care and all the GPs are leaving for Australia or just quitting..this means peoples health is not monitored and a cheap intervention, changing a drug turns into and expensive intervention such as primary angioplasty, a minor mental health condition turns into a plummet from the fourth floor and 4 million pounds of lifetime care costs..these are the inefficiencies that are killing the NHS, causes by many hundreds of billions in underpayments…if we suddenly all decided we were only paying Tesco half the cost of our shopping trolleys would we call Tesco inefficient when it closed down its branches and stopped trading..that’s what we have done to the NHS for 75 years and to be blunt in the end it fucked me off so much I jacked in a £100,000 a year career, because I was unwilling to put up with it any more..and the NHS lost a senior clinician, leader and improver with 30 years experience as it’s losing a huge number of senior clinicians every day..we are just waking because we cannot put up with politicians and media lies about our so well funded health system..as an example farage went around telling everyone the French system gets the same as the NHS..it’s just better..the French system is better because every year for every person and for every year of their lives it’s gets £1500 more than the NHS….that’s around £120,000 more for each person over their lives…it’s so much BS it hurts.

Jonathan thanks for your comprehensive reply. I appreciate the time you’ve taken to reply and the detail.I don’t work in the health centre and I have only a tangential understanding of it based upon colleagues who do or my own experience of using it. Your reply helps explain a lot of the dysfunction.

I think my autistic layman’s view of this is that the NHS seems to be configured less than optimally and its run by clowns who want us to treat it as some sort of religion. Crticism is treated as blasphemy and holding leaders to account is met with “shut up and go outside and bang your pots and pans in homage to the holy NHS.” Meanwhile our personal experiences of using it are somewhat less than stellar.

The UK is surely more than a health service with a nation attached. It has other existential interests which need to be addressed and it has only limited resources to meet them. Certainly there is a limit to now much tax can be taken from the economy. Apparently we currently spend close to £300 billion a year on the public healyj or almost 11% of GDP.

If there are not enough resources to provide the current healthcare model and you are not able to provide more then you have 2 remedies.You learn how to do what your currently doing more efficently and/or you stop or reduce doing some of the things you do.

The health trust thing obviously isn’t working.I dont’t know the optimum operating model for the NHS but it would seem that there needs to be fewer trusts and more sharing of resources to reduce costs. I can only talk through the lens of IT since that’s my wheelhouse.

The current implementation seems somewhat archaic if not incompetent.Commercially most businesses are moving to cloud based solutions.They are much cheaper and they allow you to leverage capabilities of such companies as Amazon or Microsoft and their a lot better at maintinaing resileint IT than civil servants. For example just in the last year my one experence of trying to book an appointment at my local practice took 4 weeks. The principle issue being that a single hard drive failed on a local server and that took our their appointment system for 2 weeks. This is madness. This is comically bad.

In a perfect world you could probably aim at collapsing all NHS core IT into 3 geographically dispersed datacenters run by Amazon or Microsoft or IBM. I understand there are compliance and data security issues but other business areas get around this. Finance has an enormous amount of compliance and regulation to meet (probably more than health) and they come up with private\public cloud solutions. Even the MOD uses a commercial solution wrapped up in a private cloud.I would quite happily give the NHS more money today to their problems and to allow them to optimise and automate and build more and better efficient services but it is madness and wasteful to just to keep pouring money into the amateur hour (everyone gets a datacenter) dysfunctional mess that it curently is.

.

Indeed I don’t disagree, but the really important thing to remember is that the present insanity is not because NHS senior managers want it that way it’s that politicians forced it to be that way..if I had my way the structure would be completely reformed and it would be removed from political control. The fragmentation is entirely central government driven.

It would really suprise you how much central control and interference in the NHS there is. NHS senior managers will not ever admit it because it’s not their job to undermine those they report to ( the Secretary of State for health), but most NHS senior leaders spend their days enacting things they think are entirely shite, but have no control over.

As an example of central control.

The government promised it would deal with bed blocking and free up beds after covid and promised the NHS a extra 4 billion pounds to do this..my systems share of that was around 2 million per year.. now instead of just giving the money at the beginning of the financial year allowing us to plan what we were going to do with 6 months notice and having security of funding for next year..they refused to even let us know we would get any money..then in September we were told we had 2 million to spend between Nov and April..we had to have the plans in place for what services we would have in place for Oct and then implement for Nov..any money that did not have a full plan by Oct and was not inplace for Nov was lost..and anything then nots spent by April 1st was Lost and the funding ended 1st of April…as for next year we would have to again wait until sept for any information and do the whole same planing and implementing within a month..to make matters worse..each service I set up had to report to me every week on its impact, spend and activities, I had to compile all of these, get it signed off by the board, then sent to NHS England weekly, NHS England then had to compile all the responses from every system and send them to the department of health who would report to a minister..I would then get emails from ministerial policy advisers asking me questions like “ it’s not clear how many bed hours were saved by this service ( and it was a service that cost 10k and included one extra nurse for a a few months and I had a DOH policy adviser asking me minor questions on it..that’s the level of central control the NHS senior managers has lived with since 2010).

if I was running that little shit show, I would have given each system how much it’s allocation was at the start of the financial year given them 6 months to plan and development there processes and if the systems board signed off on the plan I would have allocated the money in sept. Just asking what their planned outcomes would be. Then in April I would ask them for their outcomes to confirm they had done what they said and if not take the money out of next year’s allocation and given them their new allocation really for next sept.

so how I would deal with the issue the NHS has

1) remove political control from decision making and dispand almost all of the department for health, it presently has 13,000 civil servants who’s only role is to bother the people actually managing and planing the health system. politicians should simply set the high level mandate for what the system looks like and let the system run itself, there should not need to be any day to day interference and a policy advisor should not be emailing a manager about a £10k service line.

2) remove funding control from the treasury. This is the big one. The German and French systems funding are not decided by the treasury. Funding should be decided on how much the service is asked to do and how much that realistically costs to provide. Basically the nation pays for what it actually uses and the actual cost of that, not what it feels like paying. We should adopt the German system. In this the providers and ensurers get around a table every year and agree how much needs to be provided and how much it will cost to provide the mandatory social security payments are then set to provide this funding..no politician is involved.

3) re intergration..as you pointed out it’s all to fragmented at present, we need to speed up the re integration of systems so we have fewer organisations..you cannot have a market place and competition in healthcare because healthcare is not a choice ( and if you pretend it can be a market you end up with a U.S. system that costs you 5 times more).

4) capital funding we need to admit we have left the system to die and it needs mass recapitalisation in the following:

A) staff ( we need to train around 250,000 Uk residents to be healthcare professionals and resist our training pipelines so we train the number of professionals we need for a sustainable service. In the end this will both reduce the number of people coming into the county and improve the economic outlook for large numbers of our population as well as keeping wage increases under control.

B)buildings, modern buildings are more effective and efficient to run in the end, they are also more staff efficient.

c) diagnostics..better diagnostics means faster treatment means reduced bed days means more efficiency.

D)better IT..I don’t need to tell you this. But we still have many records paper based,,we have a lot of investment needed and we can or really even start unless we have undertaken the re interpretation of services.

that’s how I would sort it..but fundament to all this is the need for the British public to understand that what they have been paying for healthcare is utterly unreasonable and if they want a system that keeps them alive into their 80s and delivers 21c care they are going to have to pay £4000-£5000 per person per year of life and not £3000…as you cannot have something for nothing…the other route it’s to go the way a lot of right wing politicians want to go and that’s a market let private system…and if we did that..well each household had better budget £20,000 a year, and that’s with the government still paying for the poor..the US government still pays 50% of the US total health costs..so more than the total cost of the NHS in tax costs before you get to the family insurance costs..if we go private market lead we will as a nation end up needing to look to find £700-800 billion a year after the market had finished with us.

I would also have a conversation with the British public about data..the preset obsession with privacy makes the system ineffective as it’s a barrier to sharing between organisations and requires massive resources to share ( setting up a sharing agreement takes a lot od time and money) And the data set the NHS has could be marketed for around 10 billion a year in revenue..all the while it would still be anonymous.

few things. Re health trusts…the number of these has very little to do with the NHS and a lot to do with central government politics..you have to understand why NHS foundation trusts were created. It was a way to break up the state owned element of the NHS into small chunks that could then bid for contracts and when the time was right moved to become private or third sector organisations.

in essence foundation trusts were created to allow the creation of a marketplace that could then replace the state owned part of the NHS.

The problem is that unfortunately it could never work because the Department of health does not pay NHS hospitals enough to be viable as private sector or third sector providers. Infact the one time a private sector healthcare provider ( one of the most effective in Europe) was persuaded to take an NHS district general hospital, it took it exactly 6 months to realise it was not possible to run the hospital within NHS tariffs and it resigned the contract gave the hospital back to.

So what we have now is a profoundly fragmented system..not because the NHS wanted it or planned it but because central government wanted it fragmented and forced it to fragment..as a senior leader in the NHS and someone who knows healthcare policy and design..it could only have been as a precursor to sell off.

infact the NHS since 2015 has been actively trying to reduce the amount of NHS foundation trusts..by merging them..so in the two counties cover around 3 million people I have worked in 2012 there were around 8 hospital trusts and 6 community trusts..now there are 2 complex vertically integrated trusts..each with its own community services and multi acute hospitals…the NHS never wanted to be split but it’s only recently that it’s been allowed to bring itself back into larger units..but to do that it has to consult every time it wants to..which costs millions.then it has to fight the local court cases ( people protecting their hospital) finally it takes an act of parliament to merge the trusts legally ( each trust is created by an act of parliament)

And now we get to the IT issue and medical records…( this is a stone cold bitch and one job I had to do was modernise a whole NHS trusts records…75 years worth of paper records stored in 4 warehouses..totalling 2 million patients..many of whom had 4 or 5 separate sets of records…and my budget was nothing and my staff was 5 part time agency workers…because to modernise and make better you need money and the NHS does not have enough money to treat even the emergencies…so I was not getting the huge investment needed to put four warehouses of paper records on a cloud..and match them up with a million people). But the big kicker for the NHS is medical records have very very tight regulations around how and when they can be shared and who can have access..and each NHS trust is a separate legal entity..under a load of laws they are not allowed to have shared record systems..they must maintain their own separate patient records management system…also even if you can get past the law on records management..the NHS is a system made up of 50,000 separate organisations, each with their own IT systems and contracts with IT providers that end and begin at different times…the last time the NHS tried to create a single patient record system..it told the government it was not possible..but the best IT companies in the world told the government they could do it..13 billion pounds later every single one of those IT giants turned around and stated that the complexity and interactions between the number of systems, Sheer number of records that needed storing and cross referencing,linked in with the profoundly challenging legal requirements around sharing medicos records meant it was almost impossible to do and that was that…for information no health system in the world has a unified single records and IT system..the NHS was the first and last to try

As for GPS I was responsible for overseeing the contacts of 70 GP practices…they have been more and more screwed down, the reason Primary care is a mess is that no Doctor in their right mind will buy into a partnership and take the contract anymore. To become a GP partner costs around £250,000 as a buy in.. for that you are then completely liable for the financial liabilities of your partnership, I have know GPS loss their houses when their partnerships go bankrupt…they also have to both act as senior managers for the practice, work a full clinic, cover any absences and train new GPS..most of the partners I know and have reviewed tend to work from 7 in the morning to around 8 at night five days a week..and for all that financial risk and work they on average earn around £70,000 a year.. the lowest I know of was £48,000 a year for an individual that worked 70-80 hours a week..so no GPS are not taking the piss, they are being worked to death and leaving in catastrophic numbers, that is why the family GP practice is dying and no one can get an appointment…but just so you are fully aware primary care has also been sees a huge number of appointments post pandemic compared to pre pandemic..and they are still not getting through the demand.

as for managers..the NHS has less % of managers in its workforce than any other industry, it also has way less than almost any other healthcare system…it’s literally a lie to say the NHS spends to much on management…healthcare is the single most complex system and endeveor in human history…it needs organisation and we do it on a shoe string..my organisation oversaw the delivery, quality monitoring, purchasing, procurement’s and planning the healthcare needs for a million people, with a 2 billion pound annual budge paid to around 500 different contracts..to do that it has just less than 100 staff.

equality managers..again only people who really dont understand the whole healthcare system bring this up..why does the NHS have equality managers and what do they do:

1) when we design, commission or decommission services..the very first change the public and solicitors challenge on is to make sure we have done a robust engagement, consultation and equality impact assessment and engaged well with all effected protected groups..if we have not we can piss away million pound contracts like water…reason one we have equality managers….the courts will murder us the moment we do something even one member of the pubic does not like if we do not cross every t and dot every I..even our providers most of which are private business will take us to court over a procurement they did not win or a contracted service we are decommissioning.
2) up stream care is cheaper and more effective than down stream care, because of this hard to reach groups who don’t seek help cost more in the long run if you don’t go find them and make sure they engage..equally managers go out and find out how we can engage…I had one who would even drive out in his spare time to find the traveler camps so we knew where they were and how that would impact on provision and need.
3) staff..25% of our healthcare professionals are from ethnic groups other than British..we need to be able to keep attracting these groups or we run out of drs and nurses..

three basic reasons why equality managers pay for themselves many times over.

lean methodology is not good for healthcare and cannot and does not work because there is no defined product you are creating, each and every one of the 1.7 million new episodes of care per day in the NHS are completely unique and utterly random in their presentations..how do you lean sigma six a process for someone deciding they are god,cutting off parts of their body and eating them, then stabbing themselves in the hands feet and chest with a combat knife) or and old lady with 15 different health conditions all acting in different ways each day…the NHS manages 600million unique episodes of each year..lean,sigma six only value is as toilet paper ( I have studied every improvement methodology under the sun).,infact the NHS works with the leading proponents of improvements in healthcare in the world the IHI ( a U.S. improvement think tank) and the NHS leads the world in developing healthcare improvement methodology and safety ( as the IHI..they don’t primarily work with US provider they work with the NHS). The NHS improvement methodology has to take into account that in each episode of care ( product) a unique human being,with a unique set of problems and reactions sits in the middle. We are not making and selling a defined product..we are dealing with individual catastrophic events every day…

do all nurses need to be graduates…yes and no. All registered nurses need to be graduates as they are professionals who have to have a vast array of knowledgeable in a huge number of subjects..from pharmacology, pathophysiology, psychology, sociology, management of crisis, grief management, technical skills in healthcare interventions, management of complex case loads and how to run and manage teams in life threatening situations…so yes all RNs need to be graduates..when you go into a hospital or ED it will be the judgement and knowledge of the RN that saves you or kills you because that’s the person that plans your care..decides who sees you and when, decides how I’ll you are and what priority you are..there is very solid research that tracks on the number of graduate RNs on a ward directly corresponds to reduced lengths of stay ( cheaper care) as well as reduced mortality and morbidity ( cheaper care and you don’t die as much)…but there are some tasks like making beds, giving out dinners, supporting basic care that can be done by people other than RNs..that is why in the NHS we have two other levels of Nurse roles.healthcare assistants ( qualified with a level 3 qualification in basic care processes) and assistant practitioners ( level 4-5 qualifications ) who can do some of the more technical tasks and manage some care under the professional guidance of a registered nurse…but we really only have these because we don’t have enough registered nurses..we have around 1 RN for every 8-10 patients on a ward,Australian hospitals have 1 RN for every 4 patients..they have more effective and better hospitals be we are to cheap and cash starved and have not trained the number of RNs needed to this ratio ( another 150,000 would do it).

finally the NHS cannot operate effectively and efficiently because it’s cash starved and overwhelmed..a hospital works most effectively and efficiently when it’s at about 85% capacity..this allows patients to be moved to the correct specialist wards..infections can be controlled by cohorts or isolation etc..in this hospital people will have significantly reduced bed days and the care is cheaper..NHS hospitals in the winter often can run at 110% capacity ( we make up beds in random places) patients have to go to ward that are not specialists in their care, they have to wait in ED for 24 hours..this care increase lengths of stay by weeks for some patients..it’s inefficient care caused by not paying enough.

as I stated before up stream care is profoundly cheaper than downstream care..but we have massively overloaded primary care and all the GPs are leaving for Australia or just quitting..this means peoples health is not monitored and a cheap intervention, changing a drug turns into and expensive intervention such as primary angioplasty, a minor mental health condition turns into a plummet from the fourth floor and 4 million pounds of lifetime care costs..these are the inefficiencies that are killing the NHS, causes by many hundreds of billions in underpayments…if we suddenly all decided we were only paying Tesco half the cost of our shopping trolleys would we call Tesco inefficient when it closed down its branches and stopped trading..that’s what we have done to the NHS for 75 years and to be blunt in the end it got to me so much I jacked in a career, because I was unwilling to put up with it any more..and the NHS lost a senior clinician, leader and improver with 30 years experience, as it’s losing a huge number of senior clinicians every day..we are just waking because we cannot put up with politicians and media lies about our “so well funded” health system..as an example farage went around telling everyone the French system gets the same as the NHS..it’s just better..the French system is better because every year for every person and for every year of their lives it’s gets £1500 more than the NHS….that’s around £120,000 more for each person over their lives…it’s so much BS it hurts.

Yep, that’s about the size of it…

I’ve had a good few discussions regarding inheritance tax of late, there are two intractable positions…

The wrong one:

“They have assets and should pay”

The right one:

“It’s government sanctioned grave robbing on property and goods that have already been paid for and taxed too”

My position on this grossly unfair socialist tax is abolish it, or do the people ‘socialist’ thing and apply it to everyone.

God knows we have had some wet blankets over the last 25 years John but for pure arroagance and smug faces this lot take the biscuit….actually along with a lot of our money!

That is why I see merit in the Swedish and Finish method of National Service.

Cheers SB. I seem to recall the RNVR was fairly substantial back in the day, around mine counter vessels? Agree that professional volunteering is the way to go.

still in the pipeline Bud -will let you know if it goes ahead in 2025.