Can the NHS work 7/7 without working 7/7?

The last week’s headlines have been very NHS focused.

Yesterday, Welsh hospitals reported being at “tipping point” in terms of stretched resources. At the weekend the media was full of the latest the government initiatives. A & E and supporting services would be open 7 days a week with admissions being seen by a consultant within 14 hours (Sunday Times 15.12.13). This in response to research that was showing mortality rates higher at the weekend than midweek. According to Sir Bruce Keogh “these are pretty radical changes with some pretty hard levers behind them”.

As an aside, these changes will cost around 2% of the NHS operating budget but he was confident they could be found elsewhere in the service.

The Sunday Times called it “victory for Sunday Times on weekend NHS care”.

Only a day later the Guardian reported that £1b was being diverted from some of England’s poorest NHS areas to support the ever ageing population in others. Deprivation indicators were being replaced by age.

Finally, just to keep the media barrage going another news item reported that apparently a third of English GP surgeries failed on initial assessment examinations.

The NHS is unlike any other institution. Not only do patients expect free, high quality care and service, but they expect their politicians to come up with the cash, making it the UK’s biggest political minefield. Not surprisingly, ministers change with alarming regularity and initiatives such A&E seem focused equally on patient and ballot box.

All this tends to divert attention from the key issue – ensuring the NHS is fit for purpose in an era of ever growing life expectancy, increased expectations, medium term austerity.

If you believe the headlines, you’d believe that the NHS was pretty much broken. The reality is different. There are thousands of dedicated, hard-working people endeavouring to deliver good care. But the service does need to improve.

Courtesy of the Guardian
Courtesy of the Guardian

My work with the NHS has shown that there is a need for some fairly basic management practices. Which ones? Apologies if these appear obvious but obvious works:

1. A plea to the legislators!

Most businesses know certainty of funding focuses activity. Problem is that NHS funding would be a great title for a new Christmas board game! Extra funding here means reduced funding there. So when will government ministers take the responsibility to bring some certainty into NHS funding – across the board? Then the service at least knows what it has to work with.

2. Think horizontal, not vertical

The NHS operates vertically. Patients move from one part of the service to another and the services do not always communicate.  My daughter recently experienced one process – minor exploratory procedure followed by consultation – organised by two services. Result, when she had to move the date of the procedure, the date of the consultation remained the same. Inefficient both hospital and patient. Vertical problems are not restricted to the NHS. How many times have you tried to do business with your bank, insurance company or council or bits of them? The difference is that they’re not concerned with your health – you can “try again”.

Courtesy of srft.nhs
Courtesy of srft.nhs

3 Patient or customer?  

Always a thorny issue. My belief is that patients should follow clinician instructions (within reason). If this means eating and drinking less or giving up smoking, so be it. You can’t fix a problem without fixing the causes. But patients should still be treated like customers. There is no reason why a GP surgery or hospital cannot adopt sound service delivery principles. In the long term they save resource.

4. Rationalise initiatives

My experience of the NHS has shown me there are just too many initiatives. Quite often projects (or initiatives) are greeted with, this will never work or it’s just another project, stick it on the pile! The number on the go at any one time can be overwhelming. So Trusts need to rationalise, develop those which can deliver both cost efficiency and improved patient experience. Of course, this needs some clarity on behalf of government. The revolving door of initiatives cannot continue.

5. Get rid of the cynicism

I’ve noticed that some (by no means all) consultants favour the status quo. But life today is different from 20 years ago. Consultants need to be part of the 7 day culture and be available when needed. After all when you’re not well, it’s the consultant you need to see.

6. But 7 days doesn’t mean 7 days!

A 7 day service can’t be delivered by 7 day individual work plans. Consultants and nurses can’t work 7 days a week. Resources need to be used effectively and efficiently – back to fewer projects and much better asset utilisation through enhanced capacity management, understanding peaks and troughs, improving efficiencies through improving services.

Is this all too simple? Is the NHS too complicated to adopt sound and simple service business principles? Will the legislators ever put health first, vote second?

What do you think?


  1. Roslyn Beattie - 12/19/2013 , 01:10 PM

    Thought-provking Julien.

    I agree about having too many iniatitives or new projects: staff become bewildered and adopt the attitude of “let’s sit this one out; another will be along soon.”

    To move from the vertical approach would be challenging but a hospital could try the customer care approach with all levels of staff involved in how patients can be treated better and more quickly.

    One organisation I was with had a customer care course where the senior partner was sitting next to the office junior and coming up with good ideas. It resulted in a big change in the perception of clients and a greater understanding and willingness to help from staff who were not customer-facing.

    Sadly I think that the vote will come first but it could be first in front of a better organisation of individual units of the nhs.

    • Julian Rawel - 12/19/2013 , 01:10 PM

      Hi Ros
      Thanks for your very interesting input.

  2. Russ PIper - 12/19/2013 , 01:10 PM

    Hi Julian Insightful as always, I think you highlight a number of key issues and whilst the NHS is a special British Institution, basically the same rules of business apply.

    To have an effective strategy you need some degree of certainty, both funding and political direction. An economist from British Chambers made an interesting point regarding Germany and Britain recently. In Germany the politicians all understand there are certain areas of their economy they all agree on. Populist policies account for 10% of the manifesto, whereas in the UK populist policies account for 70% of he manifesto, and the politicians bumble on from crisis to crisis.

    Without doubt the NHS needs to change, but it needs a degree of certainty about direction and priorities based on the changing demographics. It needs buy in and co-operation from all its constituent parts especially GP’s. They are asked to provide more local services (fair enough) but also to run their practice as a business. A very diverse and challenging business. You would not ask a local company CEO for a medical diagnosis so is it reasonable for a GP to have to run his practice as a business. Some will fail, but in healthcare, we regard that as not acceptable.

    Remove some of the strain by reintroducing tax relief from medical cover. People who choose to fund some of their treatment privately actually release resource within the NHS.

    You are correct 7 days is not an individual working 7 days. In the 1960’s everything closed on Sundays, and the thought of somewhere being open on Boxing Day was a million miles away. Times have changed, we all need to adapt.

    One thing is for certain, the Politicians cannot expect the NHS to change unless that change from populist and ideological outcomes for NHS services.

    • Julian Rawel - 12/19/2013 , 01:10 PM

      Hi Russ
      Thanks for your comments.
      If the politicians adopted the 10% rule we would be much further on.

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