When he encouraged Leeds General Hospital to stop heart operations on children a week ago, the NHS medical director said there were three aspects of their work that worried him. One of these was their failure - which the hospital disputes - to refer complex cases elsewhere.At the heart of this is one of the great conundrums of the new NHS. In my choice review, I put it like this:
"There are certainly ways in which a narrow interpretation of choice can make choice meaningless in practice."
The problem is that, for very good reasons, responsibility for meeting budgets has been devolved to NHS units. That is as it should be. But what happens when the managers start interpreting that responsibility so literally that they begin to maximise income at the expense of their patients - when competition starts to corrode the good of the people the NHS is supposed to benefit?
Hospitals make more money when patients are referred direct from GPs than they do when they are referred from inside. So it is hardly surprising that, sometimes, patients are sent back to their GP for the next referral - when it could have all be sorted there and then.
There are even managers who discourage their hospital doctors from talking to GPs. Sometimes they have been known to forbid them, in case it means that a patient is not referred because of the conversation. Leeds is one of the places where doctors across the city have created their own informal communications mechanisms to make sure this doesn't happen.
Sarah's aunt had been referred to a heart recovery nurse who never followed up as promised. To get back onto the programme, she has to go back to the GP and be referred again to the cardiologist, and thence to the nurse specialist. The hospital will earn money from all these unnecessary appointments - what John Seddon calls 'failure demand' - but the resources of the NHS as a whole are stretched further.
Sarah's aunt had been referred to a heart recovery nurse who never followed up as promised. To get back onto the programme, she has to go back to the GP and be referred again to the cardiologist, and thence to the nurse specialist. The hospital will earn money from all these unnecessary appointments - what John Seddon calls 'failure demand' - but the resources of the NHS as a whole are stretched further.
This kind of gaming is happening around the NHS, even if it doesn't happen most of the time. There are already rules that are designed to prevent hospitals from wasting patients’ time in order to earn extra revenue, especially as this also clutters up the system unnecessarily. There are target ratios for follow-up appointments that are intended to prevent abuse, but in the end targets are probably too blunt an instrument to be effective.
Patients need to have basic rights which they can appeal to. Some kinds of behaviour may also need to be ruled out by NHS regulators or under the NHS constitution. Free communication between doctors and patients, and between professionals, needs to be absolutely guaranteed.
Personally, I think Monitor should define as 'anti-competitive' any behaviour which unnecessarily takes up capacity or wastes valuable time for patients, or wastes resources in the system as a whole.
We await the verdict about Leeds and their heart operations. But clearly one of the charges against them - which, as I said, they deny - is that they clung to complex cases because of the earnings, when they should have been referred elsewhere.
That is the question at the heart of all this - it is about a narrow and intense kind of competition paradoxically compromises the real needs of patients. In the end, it probably needs to come from the patients themselves. Give them more power, I say...
The NHS is never going to allow the terrors of total competition. Nor is it ever, it seems to me, going to relax the budgetary pressures on individual trusts. That means some kind of accommodation between these contradictory forces is needed in practice.
The problem is - where is the pressure to make sure these contradictions are resolved in favour of individual patients?