Photo: 20110827 from Andy Holt Flickr Photostream

Imagine a paramedic who is a dedicated clinician. Imagine her to be conscientious, caring and skilful. And now imagine that she is so disturbed by the conditions of today’s NHS that she is seriously considering leaving her secure employment as a senior clinician to move 300 miles to a less prestigious and poorer paid job. What could upset a dedicated professional so badly that she might abandon her patients and uproot her domestic life? What could be so devastating?

Picture Ms Conscientious as the ideal NHS employee – highly skilled and dedicated to her chosen profession as well as interested in that profession’s development in the NHS. Say, for instance, that having gained a Masters in evidence based health care, she studies for a doctorate to inform her clinical practice. Her exploration of research methods builds on her decades of accumulated clinical experience so as to develop her clinical practice and to make sense of the governance and policy that contextualise it.

Imagine that this ideal clinician was originally trained at a time when referral patterns were largely driven by clinicians’ convictions, personal experience and whim. And now appreciate how she has lived through, and actively participated in, the rise of evidence-based practice, seeing it as a means of promoting better treatment for patients on an equitable basis, avoiding the power-play of medical fiefdoms. Furthermore, her research training has given her a wider picture, allowing her to cope with the day-to-day contradictions of deploying her skills equitably in the hospital trust’s structures and routines.

The serious uncertainty that Ms Conscientious is undergoing about her employment can be personified by a line manager – let us call her Ms Brown – and a colleague – let us call her Ms Blue.

Consider Ms Blue, who could recently have been suspended from work due to suspected fraudulent activity. The fraud, while perhaps despicable, was on such a small scale that Ms Blue has been allowed to return to clinical practice. But we may further imagine that old habits die hard: Ms Blue is known to have buddied up with the sales rep from a commercial supplier of the main product used in this imaginary clinical service. Despite a higher price and an inferior quality, Ms Blue is promoting the exclusive use of this product. Perhaps she’s hoping for a kick-back, providing a target number of the new product is used? Is this type of shoddy behaviour very hard to conjure up?

In this imaginary healthcare scenario, in a service subjected to market reforms, irrational behaviour that increased costs without concomitant improvement would be prevented by an upstanding healthcare manager scrutinising the numbers, wouldn’t it? Step forward Ms Brown!

Sadly, line manager Ms Brown does not fulfil such hopes. Her basic arithmetic lets her down and, in estimating the cost of the product from the new provider, she fails to multiply by 2 in comparing the cost of a unit, thereby under-estimating costs by a half.

Needless to say, Ms Conscientious’ grasp of the two times table allows her to demonstrate the excessive cost of the inferior product, compared both to Ms Brown’s faulty forecast and compared to the superior product that she favours. Imagine her frustrated fury if her presentation of these figures was to be ignored, re-buffed and avoided.

So in this imaginary dilemma, Ms Conscientious is under pressure to use a product that is inferior for her patients’ prospects of recovery, while incurring greater cost to her department and the distinct possibility of earning Ms Brown a nefarious bonus.

‘Why can’t clinical outcomes be measured to demonstrate the deficiency of the product?’ I hear you ask. The chronic and cumulative nature of the conditions, the lowly medical status of the clinical specialism, not to mention the marginalisation of the patients involved all contribute to the lack of routine long term clinical outcome measurement. (Ms Conscientious’ doctoral work is addressing this omission).

The next step for Ms Conscientious would surely be whistle blowing. But now envisage the sums at stake in this clinical service as very small. Ms Blue’s use of her dodgy contact’s product has cost the hospital trust an additional 1,500 pounds sterling per month compared to her previous practice.

So now consider the damage that this relatively small (imaginary) sum does! As a global giant of an employer, second only to the Indian Railways, 1,500 pounds is nothing. The Washington-based foundation, the Commonwealth Fund found the British NHS the cheapest and best from 11 Western Nations’ health services even with the losses incurred by petty fraud and even imagining these to be multiplied across the NHS as a whole. The loss of funds is not the point.

Despite the NHS having been acknowledged as cheap by international standards, the logic of market reform has repeatedly been presented as preventing wastage and reducing costs. But what if exposing clinicians to the logic of profit means that maximising financial margins trumps all other aspects of providing care? What if chasing profit came to over-ride all other dimensions of work, including trust? What a terrible paradox if clinicians like Ms Blue put minimal personal profit above the trust of colleagues and patients! And what a disappointment if the system did not check such unfortunate human impulses!

But Ms Blue is only emulating her political leaders. Alan Milburn, former Labour health secretary warned his shadow cabinet colleagues against the “huge strategic error of judgment” of opposing competition in the NHS back in 2011. Since then Milburn’s company has amassed significant profits from his work advising Bridgepoint Capital, owner of a private company delivering NHS healthcare and Lloyds Pharmacy among others.

Current initiatives to prevent the exodus of NHS employees focus on increasing salary levels. But in an evidence-based system, someone should have noticed that pay is only weakly related to job satisfaction.

Ms Conscientious is at the top of her salary scale. She would willingly earn less if only she could trust her colleagues to behave decently.

Imagine that!


Link to #1 in the series: Raed Arafat