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The Role of Government in Health care Delivery

Tom Sackville

November 2005

Thank you very much Mark.  I have been asked to hold on for a second whilst we get an audience.  OK well a couple of health warnings first if I may.  I am going to speak on approximately the same subject as Charles Auld who spoke already and who is a very hard act to follow.  I think you would agree.

The other health warning I suppose is as you heard I am a politician, I was a politician which means in some specialties I am a recovering politician and therefore you must all take I think everything that I have to say with a pinch of salt.  I guess if Kate Moss was around she would probably prescribe a pinch of something else but let's not go there.  However, Senator Kirby who spoke earlier thought fit to offer some kind of apology for being a politician so I will as well and say that I was probably unusual in various respects as a politician probably inappropriate in as much as I was in an almost completely in an ambition free zone and that I never felt any great wish to be recognized in the local supermarket or anywhere else.  This had its disadvantages as I discovered when I was first asked to join the Thatcher administrator as a very junior bag carrier to a Minister in the Northern Ireland office.  I went along to the security section.  I had an appointment and I said here I was living in London, Bolton, Northwest of England, Northern Ireland I asked are there any special precautions I ought to take.  This large, stout, standard, sergeant looked me up and down and he said – Mr. Sackville we would recommend continued anonymity.  So I've tried to follow that advice pretty faithfully and I have succeeded.  It's a rare treat to get out in bright lights here Mark.  Thank you very much.

My message in a nutshell is this and I think you'll understand where I'm coming from.  We all used to believe in Martians, did we not?  I don't know at what age, I was born in 1950.  We believed they were out there somewhere, we believed they were on their way here and probably would come here.  Then, sadly, our American friends with their enthusiasm for space travel achieved a sort of interplanetary regime change and sadly there are no more Martians.  They don't exist apparently.  But I think it's worth saying if a Martian did come and see us he would be puzzled by one particular thing.  We all have these revered institutions where we struggle with primitive, earthly technology available to us to try and cure each other of very often incurable diseases and try and protect ourselves from the ravages of nature.  The rational, if our little green friend, I think was to expect that we would search for the most respected and capable members of our earthling population to manage and optimize these institutions he would be surprised to find out that those in charge of them are generally among those whose capabilities we most doubt and who's utterances we place least trust, namely our elected politicians.  I think it's a serious point that in all businesses, of any sort of trading business, require a particular set of skills to prosper, which would include, foresight, decisiveness, ability to lead and motivate.  In my view, hospitals are a particular case where in fact, all health care with its particularly complex challenges and they require a much higher order of all those skills.

I say this because clearly the outcome of any health care process is of such importance to those consuming it and to their families that any mistakes can be catastrophic and very publicly so because I think I am right in saying some of those working in hospitals don't always recognize the privacy of those normally in charge of the hospital and because no public hospital can ever really deploy the sort of management tools that a normal business can in terms of measuring outputs meaningfully and they lack the disposed competition.  I am afraid there is no reason to think that politicians who are elected to office fit the criteria for that job.  People go into politics for all sorts of reasons.  I would contend that present company excluded that most go in to get attention.  Whether this is because they lacked it when they were small, or at teenage discos, I don't know but this is a feature I noticed amongst my colleagues in the 14 years that I moved in the circles.  Either way I don't believe they have necessarily the training or accompaniment to be successful managers.

Now this is not seen as a problem by what we call Sir Humphrey, who is a generic Sr. Civil Servant for those who watch the programme, who's ideal idea of a minister would be a complete – an individual with no foreknowledge or opinions on the subject - that is in his brief at all and prepared to accept all the hints, suggestions and sometimes demands emanating from permanent officials.

So let me know say a word in defence of the embattled tribe of health civil servants.  A civil servant, in my experience, and I have quite a lot of experience is a person who is obeying, who is tolerant, probably listens to opera, in our case probably approves of the European project which is of course is unfashionable in England, altogether a fairly civilized person.  Somebody who probably left university thinking to go into a profession where he or she would be writing and thinking, exercising that particular skill of turning the ethereal ruminations of his political masters in rational policy and committing it to eloquent prose over time.  This is not a person who entered a profession in order to fight off competition, or would stay up all night dealing with a crisis, to close deals, to constantly search for efficiencies to boost output.  So you may ask – What are these people doing running our hospitals?  But this Sir Humphrey is a sly fox or possibly vixen.  The day I arrived in my office, the Department of Health, where the machinery clicks and moves into gear, despite having no apparent qualifications for the job I was suddenly, terribly involved with private office staff lined up for duty, red leather dispatch box - dispatch boxes with royal crests were employed, dress officers, diary, chauffeurs, estate visit happened to the public secretary and never happened again.  Yes Minister, No Minister but it gradually dawned on me that all this was pretty much a sham, all the various things that I was nominally in charge of such as in my case it was NHS reorganization, acute hospital services outside of London, blood service, transplant services and on and on.  I wasn't in charge of it at all.  I was merely responsible for when things went wrong.  But soon, I am afraid I have to admit it, I bought into the whole denial that with a bit  more tweaking, a little bit more funding and everything would somehow come out right.  But it brought home to me fairly soon that this great machine was not viable as is currently constituted.  It will never be focused on efficiency and what they call elsewhere customer service, rather than just the rationing of supply.  It was and remains quite an unhappy organization.

Let me try and illustrate by anecdote, a rather than the unusual bullet point.  It is the sort of organization which lets and important hospital just north of London which I won't bother to name, a hospital with a famous Burn Unit and Plastics Research Unit, goes steadily downhill with its morale sinking fast because it has been blighted by lack of a decision for 15 years over closure and reconfiguration of local acute services.  This is the sort of organization where one day seeing your officials wake up and tell 400 hospital groups across England to bring all their IT procurement plans that day, however advanced, in favour of a 10 billion dollar central solution which I have to say as of now shows very little sign of arriving.  This is the sort of organization that continues to preside over theatres being shut on weekends and evenings when there are millions of people waiting for surgery.  The sort of organization where someone whom I know came recently to present a picture of radiology services review in one region of the NHS, and found that in a room full of 40 people at the presentation, only one in the audience had ever set foot in a radiology department.  The NHS in short does not live in the real world.  Much of this is undoubtedly familiar to you.

What may be more interesting is to investigate briefly, given such manifest failure, what prompts governments to perpetuate such a situation.  First of all the British people are emotionally attached to their NHS.  In fact, you could say they conducted a 50 year love affair with it.  I suppose we British must have a talent for this sort of thing when you consider our Prince of Wales and his new bride.

Second I think many of those most closely involved have a vested interest in the perpetuation of this situation.  Civil servants, out sourcing, everything doesn't suit the interests of the bureaucracy. NHS staff themselves probably do not fancy the sort of zappy private sector managers coming in and taking charge and telling them what to do with it.  Dare I say many senior medical practitioners are actually benefiting from waiting list problems.

Thirdly it is certainly true that the British establishment and media, even those lucky enough to be part of the 10% with private health insurance, do like to defend the NHS, both in private and public for roughly politically correct reasons.  It is not nice to criticize a much loved public service.

Now this point you may be wondering why this big guy is standing up here bad mouthing his colleagues, and by implication himself, and one of the great national institutions of his country?  Does he perhaps have an axe to grind or is he one of the ex-politicals that can still get into the backseat of our own car in the morning and wonder why it's not moving.  The answer is that I can assure you – no. I am having a good time and there is life after politics - of which I thought Preston Manning was a wonderful, tangible proof.  But I have regrets, I have regrets that I and others have failed to do more to expose and do something about a great lie.  When the NHS was set up, the politicians effectively misled the British public.  It was conditional on a state monopoly of health care delivery.  It was a lie then and it's a lie now.

It is also a betrayal of patients. Patients who collectively score almost the worse cancer and heart outcomes in Western Europe, wait unacceptable periods for not just hips and knees, but for diagnosis and treatment of many life-threatening conditions.  In my view, the betrayal of a generation of medical staff who instead of throwing themselves head long into the work that they love and feel to be their vocation find themselves constantly looking over their shoulders in a very unhappy situation surrounded by resentment and backbiting.

Two points perhaps I would like to make about the NHS. You may say – why has more not been done over the years to try and put all this straight?  The famous provider purchaser split which tried to introduce competition into the system and try and get really actually started working.  It started working extraordinarily well after about 3 or 4 years.  I funny enough, arrived in the Department of Health about a week after the whole thing had been compromised.  Mrs. Thatcher had gone and weaker brethren had taken over within her own party and the mice came out to play.  What effectively happened was the Great Sir Humphrey persuaded the Secretary of State for Health that it was not possible to have 400 hospital groups reporting directly to one person, and she agreed and it ended up they are started reporting back up through some things called the Regional Health Authorities, which I think you're familiar with here. The old fox cleverly subsumed Regional Health Authorities back into the civil service within about a year after that.  So it was really 40 love or maybe match championship to Sir Humphrey within 4 years which was sad because what was really happening is the hospitals were being put on the mantel and being made to compete with each other for fear of closure which is something of a harassment and you can see why perhaps the civil service didn't like it.

The second thing I would say is these long overdue privatization moves by the present government, the foreign and high STC Treatment Centres which were really very promising and will introduce somewhat shorter and new efficiencies into the art of delivery.  They relate so far into elective surgery.  They are extremely welcomed but I believe they are driven more by fear of the short term political problems of the waiting lists numbers going back towards the magic million than they are by an understanding of the real long-term issue which is surely this.  Unless a public health system like the NHS, or any other public health system around the world, starts bringing in people who actually know how to manage health care delivery on a much wider front, and reduce their own activity to little more than commission, the consequences will be dire and I would suggest that they be as follows.

We all know that there is a mountain of new costs just over the horizon which stems from huge advances in drugs and medical devices as well as a rapidly aging population and pandemics and other eventualities that we can't even predict.  This has to be faced up to.  Unless public health care is delivered not in the sort of moribund way that we see in most pubic health systems, unless it is delivered radically more efficiently than it now is the moment will arise far sooner when some very, very unpleasant decisions are to be taken about who is to get the available treatment and who is not.

Tomorrow I will give you some very firm advice and some options from a few other countries around the world.  In particular, a description of how the Australians have in the health insurance industry organized themselves to achieve something similar to what you are hoping to do at this first conference here.  For the moment I would just like to congratulate everybody concerned on this conference for embarking on this very worthy endeavour which if successful will, I am quite certain, benefit Canadian Health Care in general and urge you to follow the call to action sent out eloquently this morning by Preston Manning.  Thank you very much.