Down with 'frontline services'
Jul. 13th, 2020 01:55 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
livThe sentiment:
Better minds than mine have clearly outlined why we probably shouldn't be using war metaphors for healthcare in the first place. But even in a literal war, if you prioritize the frontline at the expense of logistics, training, intelligence etc you lose the war.
In the NHS, 'prioritizing frontline services' started out with not bothering to maintain the fabric of the buildings. Making sure the buildings can be maintained a comfortable temperature and are weatherproof and not full of hazardous, outdated electricals and are easy to clean and hard to burn down isn't directly curing patients with life-threatening acute illnesses, so obviously those sorts of things should be low priority. Hey, we could even make a quick buck by selling some of the publicly owned land and buildings to developers, or using them as collateral in PFI loans. Then we would have more money for frontline services, and if the population grows and ages and healthcare needs expand over the coming decade but hospitals no longer have physical space to expand, well, that's someone else's problem.
Prioritizing frontline services meant setting targets for waiting times. Not waiting more than 4 hours in A&E, definitely a high priority, definitely the most frontline of frontline services, this is people with every minute counts emergencies who are highly likely to die if they have to wait. But suddenly there's a whole layer of hospital bureaucracy tied up with measuring A&E waiting times, otherwise competent healthcare workers getting disciplined for not constantly improving the four hour waiting time target, funding just evaporating on improving headline numbers at any cost. Resources are being taken from other parts of the hospital to increase the proportion of patients seen within four hours of arriving at A&E. Worse, when the clock ticks over to 4 hours one minute, the patient might as well wait forever, because treating them won't help the target. And once this system has been embedded for a few years, you end up with far more referrals to A&E because anything that doesn't fall under the magic four-hour target, anything that isn't a frontline service, is so slow that A&E is the only way to get timely treatment at all. And then it becomes impossible to maintain the waiting time target.
Prioritizing frontline services meant outsourcing the cleaning to the lowest bidder. There's a pretty good correlation between rates of outsourced cleaning and rates of hospital acquired infections. Not to mention that the cleaners, who aren't directly employed by the hospital, often have terrible labour conditions, poor pay, poor incentives and training to actually keep the hospital clean enough for the frontline services to happen in a safe environment.
Prioritizing frontline services means completely separating hospital care from 'social care'. Providing support for frail and convalescent and disabled people to live as independently as possible for as long as possible, now that's in a completely separate budget. And it's a budget that can be cut almost endlessly, because social care isn't a frontline service. Not only does this cause untold suffering outside the hospital, but it leads to degradation of frontline services. People can't be safely discharged from hospital because there is nobody to provide the basic care they need to go home, so their needs have to be met by highly paid, overqualified medical professionals. They become 'bed blockers', hospitals are over-full because the only way to keep people safe is to define them as part of frontline services and frontline services only happen in hospitals.
Mental health is also not a frontline service unless people are actively suicidal right now. So there is no support for anyone not in crisis. Prioritizing frontline services means mental healthcare is pretty much in the same low priority bucket as social care. The number of life-threatening crises rises because waiting lists to get the kind of help many people need to avoid reaching the point of completely being unable to cope are infinitely long.
All this was already a problem under the previous government. Once the Tories take over, they start prioritizing frontline services by: removing the previous NHS Direct helpline staffed by people with medical training, and replacing it with NHS 111 which is basically just a call-centre where people read from a script. NHS 111 is completely terrible at keeping people out of hospital who don't need to be there, because an automatic script can't tell the difference between a pulled chest muscle and a heart attack, both tick the 'chest pain' box. And there are lots of far worse examples.
Defunding public health, sexual health, any kind of prevention. Those are not 'frontline services'. Of course, the net result is less resources compared to the level of need for frontline services, as more people will have health emergencies if there's no prevention.
Removing any sort of supportive facilities for medical staff, since those are not frontline services. No mess room, no break room, no dedicated staff toilets even. Healthcare professionals can get their food in the public cafe or from vending machines. They can't get any support from their colleagues because they have to take their breaks in public areas where talking about work would breach confidentiality. They might have to walk miles across the hospital to reach these public facilities, which are themselves further downgraded since a hospital cafeteria isn't a frontline service, and eventually there's a Costa and a Burger King and that's about it. Shift patterns stop taking breaks into account, because taking a break isn't providing a frontline service, or at best they assume that one can get food, drink and rest in 20 minutes because in the old system you had a breakroom available near every ward.
And maybe it's ok for these doctors providing frontline services to be tired and stressed and hungry and bursting for the loo. But patient food is also not a frontline service. The budget allocated to food gets less and less, to the point where even with advantages of scale it's impossible to make meals anyone would want to eat. There's certainly no slack for anyone with any kind of dietary needs, because who'd have thought that patients undergoing hospital treatment might have medical conditions which mean they can't eat certain foods? The time allocated to serving meals is cut to almost nothing because food isn't a frontline service, so anyone who needs any kind of extra help with eating, or even just eats a bit more slowly than the fastest possible, pretty much doesn't eat. People recover slower, or even don't recover at all, or get sicker, if they can't get adequate nutrition in hospital.
"Minor" operations are also pitted against frontline services. Conditions that cause pain and misery, like varicose veins, carpal tunnel syndrome, cataracts can be pushed off onto private providers, because they're not frontline services, they're not life-threatening. In theory the NHS isn't allowed to have a blanket ban on commissioning a particular treatment; in practice they're basically not. Trans healthcare, fertility treatment, I'm sure lots of you can name plenty of examples, have infinite waiting lists or cost money.
The way things really got worse in the last 10 years was because of the Tory war on "paperwork", again seen as opposed to frontline services. You can't run a large complex institution without admin (and that goes for lefties who hate bureaucracy too, looking at you Graeber). They dropped waiting time targets because they saw the proliferation of paperwork and managerialism resulting from focusing too much on particular numbers. But without someone keeping track you can't even tell whether people are being treated in a timely fashion for emergency conditions, let alone improve your speed at responding to emergencies.
Record-keeping is 'just paperwork'. A computer can do it. But then, giving staff access to up-to-date computers and user-friendly software isn't a frontline service, so they have to make do with antiquated Win95 machines and terrible databases. Healthcare professionals have to keep their own records on these terrible systems because there's no money to pay for 'admin'. Very little institutional knowledge of computer security - several large hospitals in England were offline for about three days a few years back because of some crappy ransomware which thankfully turned out to be able to be bypassed in a few hours by an amateur. But hey, security isn't frontline services. Likewise, people with real expertise in storing patient data securely and confidentially aren't paid enough to work in the NHS, because making sure medical information doesn't get into the wrong hands isn't a frontline service.
Almost anyone who's interacted with the NHS in the past few years has noticed that there's a huge hole in coordinative communication. You can't get an appointment, or your appointment gets rescheduled 6 times, or you get the letter informing you of a cancellation the day after you've already attended fruitlessly. Referrals get lost, or get sent to the wrong department. You have to personally chase up your own test results. All of these things, although they are mostly carried out by 'administrators' and are not frontline services, are causing real, measurable patient harm.
And of course, if you have no 'paperwork' you have no real governance. No oversight to stop the NHS being sold piecemeal, nobody who has enough information and influence to step in and prevent wholesale transfer of huge amounts of patient data to profit-making tech companies like Google.
Having some slack in the system to cope with increased demand isn't a frontline service, and it requires serious resource going into admin and management and measurement and coordination. That's why we've had a winter crisis every year for the past decade - having spare beds, additional staff etc available during summer is taking resource available from frontline services, so it isn't allowed. Having a stockpile of equipment not currently used on a just-in-time basis is inefficient, it takes up storage space and cashflow that could be used for frontline services. Pandemic preparedness was completely removed a couple of years ago because, guess what, planning for a once-a-century event isn't a frontline service.
This was partly sparked by a dispute on Twitter about parking charges, which have been contentious forever. I generally think that it's vital for society to move away from massive subsidies on driving and storing fossil-fuel driven private cars. But travel to hospital (for staff or patients) isn't the place to start. There should be 24-hour affordable safe convenient public transport to hospitals, but right now there isn't, and if you make nurses pay for their own parking you're essentially transferring the cost of running the service onto individuals. And the reason parking charges ever happened was because the NHS owning their own land was seen as not a frontline service, so all the land surrounding hospitals is rented or mortgaged and the money has to be clawed back by outsourcing carparking to largely predatory businesses.
In isolation, would I rather spend money on a ventilator or a carpark? Of course I'll pick a ventilator. But that's not actually the calculation that's happening. Calling an ongoing programme of cuts and privatization 'prioritizing frontline services' is a lie exactly designed to divert people, including passioniate believers in government funded public services, to looking at the wrong tradeoffs. The system is a system, there's no 'frontline versus back office'.
the NHS should prioritize spending on frontline servicessounds innocuous, but it's a big factor in all the harm done to the NHS since Blair became PM in the late 90s. Prioritizing frontline services means underfunding, outsourcing, selling assets and quasi-privatization. People opposed to these outcomes often claim, we should prioritize frontline services, as if that were the opposite, but it's not. It's at best a euphemism for destroying publicly funded healthcare, when it isn't an active deception.
Better minds than mine have clearly outlined why we probably shouldn't be using war metaphors for healthcare in the first place. But even in a literal war, if you prioritize the frontline at the expense of logistics, training, intelligence etc you lose the war.
In the NHS, 'prioritizing frontline services' started out with not bothering to maintain the fabric of the buildings. Making sure the buildings can be maintained a comfortable temperature and are weatherproof and not full of hazardous, outdated electricals and are easy to clean and hard to burn down isn't directly curing patients with life-threatening acute illnesses, so obviously those sorts of things should be low priority. Hey, we could even make a quick buck by selling some of the publicly owned land and buildings to developers, or using them as collateral in PFI loans. Then we would have more money for frontline services, and if the population grows and ages and healthcare needs expand over the coming decade but hospitals no longer have physical space to expand, well, that's someone else's problem.
Prioritizing frontline services meant setting targets for waiting times. Not waiting more than 4 hours in A&E, definitely a high priority, definitely the most frontline of frontline services, this is people with every minute counts emergencies who are highly likely to die if they have to wait. But suddenly there's a whole layer of hospital bureaucracy tied up with measuring A&E waiting times, otherwise competent healthcare workers getting disciplined for not constantly improving the four hour waiting time target, funding just evaporating on improving headline numbers at any cost. Resources are being taken from other parts of the hospital to increase the proportion of patients seen within four hours of arriving at A&E. Worse, when the clock ticks over to 4 hours one minute, the patient might as well wait forever, because treating them won't help the target. And once this system has been embedded for a few years, you end up with far more referrals to A&E because anything that doesn't fall under the magic four-hour target, anything that isn't a frontline service, is so slow that A&E is the only way to get timely treatment at all. And then it becomes impossible to maintain the waiting time target.
Prioritizing frontline services meant outsourcing the cleaning to the lowest bidder. There's a pretty good correlation between rates of outsourced cleaning and rates of hospital acquired infections. Not to mention that the cleaners, who aren't directly employed by the hospital, often have terrible labour conditions, poor pay, poor incentives and training to actually keep the hospital clean enough for the frontline services to happen in a safe environment.
Prioritizing frontline services means completely separating hospital care from 'social care'. Providing support for frail and convalescent and disabled people to live as independently as possible for as long as possible, now that's in a completely separate budget. And it's a budget that can be cut almost endlessly, because social care isn't a frontline service. Not only does this cause untold suffering outside the hospital, but it leads to degradation of frontline services. People can't be safely discharged from hospital because there is nobody to provide the basic care they need to go home, so their needs have to be met by highly paid, overqualified medical professionals. They become 'bed blockers', hospitals are over-full because the only way to keep people safe is to define them as part of frontline services and frontline services only happen in hospitals.
Mental health is also not a frontline service unless people are actively suicidal right now. So there is no support for anyone not in crisis. Prioritizing frontline services means mental healthcare is pretty much in the same low priority bucket as social care. The number of life-threatening crises rises because waiting lists to get the kind of help many people need to avoid reaching the point of completely being unable to cope are infinitely long.
All this was already a problem under the previous government. Once the Tories take over, they start prioritizing frontline services by: removing the previous NHS Direct helpline staffed by people with medical training, and replacing it with NHS 111 which is basically just a call-centre where people read from a script. NHS 111 is completely terrible at keeping people out of hospital who don't need to be there, because an automatic script can't tell the difference between a pulled chest muscle and a heart attack, both tick the 'chest pain' box. And there are lots of far worse examples.
Defunding public health, sexual health, any kind of prevention. Those are not 'frontline services'. Of course, the net result is less resources compared to the level of need for frontline services, as more people will have health emergencies if there's no prevention.
Removing any sort of supportive facilities for medical staff, since those are not frontline services. No mess room, no break room, no dedicated staff toilets even. Healthcare professionals can get their food in the public cafe or from vending machines. They can't get any support from their colleagues because they have to take their breaks in public areas where talking about work would breach confidentiality. They might have to walk miles across the hospital to reach these public facilities, which are themselves further downgraded since a hospital cafeteria isn't a frontline service, and eventually there's a Costa and a Burger King and that's about it. Shift patterns stop taking breaks into account, because taking a break isn't providing a frontline service, or at best they assume that one can get food, drink and rest in 20 minutes because in the old system you had a breakroom available near every ward.
And maybe it's ok for these doctors providing frontline services to be tired and stressed and hungry and bursting for the loo. But patient food is also not a frontline service. The budget allocated to food gets less and less, to the point where even with advantages of scale it's impossible to make meals anyone would want to eat. There's certainly no slack for anyone with any kind of dietary needs, because who'd have thought that patients undergoing hospital treatment might have medical conditions which mean they can't eat certain foods? The time allocated to serving meals is cut to almost nothing because food isn't a frontline service, so anyone who needs any kind of extra help with eating, or even just eats a bit more slowly than the fastest possible, pretty much doesn't eat. People recover slower, or even don't recover at all, or get sicker, if they can't get adequate nutrition in hospital.
"Minor" operations are also pitted against frontline services. Conditions that cause pain and misery, like varicose veins, carpal tunnel syndrome, cataracts can be pushed off onto private providers, because they're not frontline services, they're not life-threatening. In theory the NHS isn't allowed to have a blanket ban on commissioning a particular treatment; in practice they're basically not. Trans healthcare, fertility treatment, I'm sure lots of you can name plenty of examples, have infinite waiting lists or cost money.
The way things really got worse in the last 10 years was because of the Tory war on "paperwork", again seen as opposed to frontline services. You can't run a large complex institution without admin (and that goes for lefties who hate bureaucracy too, looking at you Graeber). They dropped waiting time targets because they saw the proliferation of paperwork and managerialism resulting from focusing too much on particular numbers. But without someone keeping track you can't even tell whether people are being treated in a timely fashion for emergency conditions, let alone improve your speed at responding to emergencies.
Record-keeping is 'just paperwork'. A computer can do it. But then, giving staff access to up-to-date computers and user-friendly software isn't a frontline service, so they have to make do with antiquated Win95 machines and terrible databases. Healthcare professionals have to keep their own records on these terrible systems because there's no money to pay for 'admin'. Very little institutional knowledge of computer security - several large hospitals in England were offline for about three days a few years back because of some crappy ransomware which thankfully turned out to be able to be bypassed in a few hours by an amateur. But hey, security isn't frontline services. Likewise, people with real expertise in storing patient data securely and confidentially aren't paid enough to work in the NHS, because making sure medical information doesn't get into the wrong hands isn't a frontline service.
Almost anyone who's interacted with the NHS in the past few years has noticed that there's a huge hole in coordinative communication. You can't get an appointment, or your appointment gets rescheduled 6 times, or you get the letter informing you of a cancellation the day after you've already attended fruitlessly. Referrals get lost, or get sent to the wrong department. You have to personally chase up your own test results. All of these things, although they are mostly carried out by 'administrators' and are not frontline services, are causing real, measurable patient harm.
And of course, if you have no 'paperwork' you have no real governance. No oversight to stop the NHS being sold piecemeal, nobody who has enough information and influence to step in and prevent wholesale transfer of huge amounts of patient data to profit-making tech companies like Google.
Having some slack in the system to cope with increased demand isn't a frontline service, and it requires serious resource going into admin and management and measurement and coordination. That's why we've had a winter crisis every year for the past decade - having spare beds, additional staff etc available during summer is taking resource available from frontline services, so it isn't allowed. Having a stockpile of equipment not currently used on a just-in-time basis is inefficient, it takes up storage space and cashflow that could be used for frontline services. Pandemic preparedness was completely removed a couple of years ago because, guess what, planning for a once-a-century event isn't a frontline service.
This was partly sparked by a dispute on Twitter about parking charges, which have been contentious forever. I generally think that it's vital for society to move away from massive subsidies on driving and storing fossil-fuel driven private cars. But travel to hospital (for staff or patients) isn't the place to start. There should be 24-hour affordable safe convenient public transport to hospitals, but right now there isn't, and if you make nurses pay for their own parking you're essentially transferring the cost of running the service onto individuals. And the reason parking charges ever happened was because the NHS owning their own land was seen as not a frontline service, so all the land surrounding hospitals is rented or mortgaged and the money has to be clawed back by outsourcing carparking to largely predatory businesses.
In isolation, would I rather spend money on a ventilator or a carpark? Of course I'll pick a ventilator. But that's not actually the calculation that's happening. Calling an ongoing programme of cuts and privatization 'prioritizing frontline services' is a lie exactly designed to divert people, including passioniate believers in government funded public services, to looking at the wrong tradeoffs. The system is a system, there's no 'frontline versus back office'.
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(no subject)
Date: 2020-07-13 01:03 pm (UTC)(no subject)
Date: 2020-07-13 02:05 pm (UTC)(no subject)
Date: 2020-07-13 02:34 pm (UTC)(no subject)
Date: 2020-07-13 04:18 pm (UTC)(no subject)
Date: 2020-07-13 01:08 pm (UTC)(no subject)
Date: 2020-07-13 01:59 pm (UTC)Lessons that they forgot? never learned?
Date: 2020-07-13 02:38 pm (UTC)I remember a while ago somebody griping on about nurses today 'doing paperwork' instead of, I don't know, holding patients' hands and soothing their brows at the bedside, and thinking that that paperwork was pretty material to them getting the right medicine at the right time in the right dosage etc. And what was actually needed was more nurses rather than whingeing about These Modern Nurses so unlike Florence Nightingale (a serious admin structures lady).
Re: Lessons that they forgot? never learned?
Date: 2020-07-14 10:32 am (UTC)I completely agree that redundancy is way more efficient than running everything at capacity. But you can't do that kind of medium-range planning if you think strategic decision making is just paper-pushing.
Re: Lessons that they forgot? never learned?
Date: 2020-07-14 08:55 pm (UTC)Re: Lessons that they forgot? never learned?
Date: 2020-07-23 01:43 pm (UTC)I wholeheartedly agree with everything you say about the importance of proper management and administration. However there is a caveat, if I may act as devil's advocate for a moment. In a large and complex system there is a strong tendency for Parkinson's Law to apply. Unfortunately, the NHS is a working example of the creation of multiple layers of management and of an environment of management for its own sake overriding clinical judgement. Your example of A&E is only one aspect.
Southernwood
(no subject)
Date: 2020-07-13 03:24 pm (UTC)(no subject)
Date: 2020-07-13 03:26 pm (UTC)$+\infty$
(no subject)
Date: 2020-07-14 10:38 am (UTC)(no subject)
Date: 2020-07-14 09:47 pm (UTC)(no subject)
Date: 2020-07-13 05:15 pm (UTC)(no subject)
Date: 2020-07-13 05:32 pm (UTC)this is exactly what I'm terrified of seeing happen in the US, if we moved to a single-payer system. obviously it would be hard to do any worse than what the US has right now, but, uh. goddamn. I'm sorry.
(no subject)
Date: 2020-07-13 07:33 pm (UTC)It's already happening without single payer, imagine how efficiently our healthcare services could be dismantled if we had single payer!
obviously it would be hard to do any worse than what the US has right now, but, uh. goddamn. I'm sorry.
I believe in us. I'm sure we could find a way. :/
I mean, I don't think – Liv or someone, correct me if I'm wrong – the NHS has to deal with a large demographic of voters who want to manipulate the NHS to deprive women or particular racial minorities of access to health care.
(ETA: Apologies for hijacking the thread and making about the US healthcare system!)
(no subject)
Date: 2020-07-14 06:11 am (UTC)I don't think they necessarily directly want to if asked that way, but the Brexit vote was largely based on a rhetoric of not wanting to share social services (or jobs or private housing or anything else) with nasty foreigners. There are some plausibly-good reasons to want to leave the EU (though I personally disagree with them pretty strongly and I don't even like the EU that much!), but the campaign was overwhelmingly based on lies and bad reasoning -- including a lie about there being more money for the NHS if we leave.
(no subject)
Date: 2020-07-14 10:48 am (UTC)There is a bit of a problem with wanting to ration healthcare to the right sort of people – part of the impetus for Brexit was a sense that "foreigners" were taking advantage of "our" free healthcare. It's very rarely on explicitly racial lines though, most of the political spectrum is proud, not always justly, but it's the myth, that the NHS is completely unbiased and treats all patients equally. And Northern Ireland, where abortion was illegal until March 2020 (I feel I have to make a conscious effort to remember March was a few months ago, not decades ago) is part of the UK and complicatedly part of the NHS. But I've not really encountered the idea that healthcare should be a luxury that you have to earn by being the sort of person who has a well-paid job.
(no subject)
Date: 2020-07-13 10:12 pm (UTC)Both of those make sense to me in isolation, like two opposing sides of a debate, but I don't understand how they're both simultaneously true.
(no subject)
Date: 2020-07-14 12:19 am (UTC)The A&E and other waiting times were always recorded, apart from anything else that's how you know if you need to declare a major incident and start shunting cases to sister sites, it's adding a target without adequately resourcing the capacity to meet it is the problem. Initially they did resource it and it worked well. But note, initially.
(no subject)
Date: 2020-07-14 10:55 am (UTC)(no subject)
Date: 2020-07-14 12:52 pm (UTC)So they were both bad because they were both elements of the focus on frontline services at the expense of non-frontline services?
That makes more sense now.
I initially misunderstood it as something like "prioritising frontline services means this bad thing Labour did, and it also means this diametrically opposite but also bad thing the Tories did", so I was confused. But (I now think I understand you're saying) they're only diametrically opposite *within* the whole umbrella of prioritising frontline services, and you're calling for a move away from that whole model, in an orthogonal direction.
Thanks for clarifying.
(no subject)
Date: 2020-07-14 01:22 pm (UTC)Social Care
Date: 2020-07-22 05:15 pm (UTC)(no subject)
Date: 2020-07-22 05:06 pm (UTC)Southernwood
(no subject)
Date: 2020-07-27 01:53 am (UTC)