I am possibly being a little kind in describing those that continue to tinker with the structure of the NHS as 'lunatics', there are other words that better fit their misguided actions. It is tricky to get across the sheer stupidity of the way the system is run to people who peer into the goldfish bowl from the outside. Although I reside within the bowl I shall try to describe it for someone who is looking in.
Lord Darzi's recent NHS review talked a lot about improving quality, and we know when the government talk a lot about something they invariably are about to do the exact opposite, just like the NHS constitution in fact. This NHS Review also talked a lot about reform being locally driven and patient centred, this was just as central government ordered Lord Darzi'sportacabins to be erected in every PCT so that the old and vulnerable would have to walk that bit further to see their varying not so local doctor; in fact they may no longer be able to see a doctor, this government seems intent on empowering anyone to do jobs that used to be done by people with lots more training and medical degrees, quality, err, anyway that's another story.
In surgery the government pays hospitals for the operations that they perform, this initially sounds sensible, however when one probes beneath the surface it is far from sensible. This is because the tariff system was not thought through, they forgot about numerous surgical procedures, meaning that the most complicated and specialist surgical procedures frequently result in the same remuneration as the most simple and straightforward procedures. This is results in the big specialist surgical centres routinely losing money as they are taking on the most complicated, expensive and unrewarded work. These big centres of excellence dared to point out to the hair brained managers that the payment system was stupid, the managers just said that the specialist centres were inefficient.
Meanwhile ISTCs are paid for work they don't even carry out, and a lot of their work appears to be slightly shoddy to say the least. The tariff based system doesn't even work for the NHS alone, as centres that carry out lots of bad, quick and cheap operations will make lots of money, while centres that carry out lots of tricky specialist work well but expensively are being driven out of business. Take fractures of the neck of femur for one example, if one treats this with a bad and arguably negligent operation which is also cheap then one can make a lot of money, however if one carries out a good total hip replacement in some patients one will start to make a lot less money. The same goes for many other fractures, where fixing fractures badly with cheap materials is much more profitable than fixing fractures well with expensive devices.
I'm sure you get the point, the system is barmy, it has been created by morons who were obsessed with the gimmick of the market who understood nothing of the clinical practice of medicine. It results in market forces pushing standards of care lower against the best interests of patients. As I have been rather frantic at work recently I haven't had much time to read, but I always try to find time to read Dr Grumble, he has a wonderful knack of being able to succinctly sum up the daftness of the NHS we live and work in.
PCTs sum up the daftness, they used to be small organisations, they are now huge bureaucratic monsters which are run by people who have no understanding for what they throw money at. It is simply amazing that people with no medical training are allowed to spend thousands of our money on evidence-light health initiatives without a public health doctor in sight, it is as barmy as a country being run by ministers who are shuffled around so frequently that they barely have time to learn the name of their new department. The more they talk of quality, the more you should feel very very afraid.