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May


Not what the doctors ordered

Sun, 8th May 2005

THE MOST surreal episode in the election campaign was the panicked prime ministerial time-out from matters of trust, immigration and war in Iraq to instruct doctors how to make patients' appointments.

In itself, the incident might seem laughable. But there could hardly be a more telling symbol of Labour's greatest domestic failure: its inability to fathom how its relationship with the public services should be managed.

Think about it: after decades of privatisation, and the erection of a tentacular regulatory regime (now costing the public sector at least pounds 13 billion a year) with the express aim of distancing government from the day-to-day management of services, ministers are more dedicated interferers than at any time in the past 50 years - perhaps ever.

This is micromanagement on a gigantic scale (if you see what I mean). But it is more than that. Like the almost daily promises to get rid of MRSA, deliver cleaner hospitals, cut the number of asylum seekers, improve exam results, and shorten hospital waiting lists, the ministerial dictation of doctors' appointment systems is straight out of the Gosplan handbook for central planners, circa 1950.

Command from the centre didn't work in the Soviet economy, and it doesn't work in the NHS either. The first reason is that the government doesn't know what patients ringing up for an appointment actually want. Since it doesn't know the nature of the demand (how many calls are real emergencies, how many can be handled by a nurse, how many are follow-ups) it follows that it can't know the real capacity of the system to meet it.

In turn, this means that the famous target of all appointments within 48 hours is entirely arbitrary. Some surgeries may be able to meet it, others not. If enough pressure is brought to bear, those that can't will feel obliged to manipulate the numbers, as the only things under their control, to get the desired result. That's what happened in the appointments case, just as it hap pens in all other services subject to blanket specifications too.

It follows also, because it's a government representation of what patients want rather than the thing itself, that the system is not likely to be a good one. It's not patient-friendly. A follow-up appointment a week later may be much more important than a first-time one which has to take place within 48 hours. But as a mass-production system it can't handle this legitimate variety.

Moreover, ministerial prescription subverts any possibility of improvement. As the scientist-philosopher Gregory Bateson put it: 'Learning proceeds from difference.' Difference has the political disadvantage of inequality, since some solutions will be better than others. But it has the advantage of movement: given a degree of choice, a better solution for patients or customers will attract more adherents, to the exclusion of poorer ones.

The other thing Whitehall still doesn't seem to get is the costs of its interference. These are hidden but enormous. And although where they emerge is unpredictable, their incidence isn't. Tinkering with one part of a system always has costly ramifications somewhere else.

In the surgeries case, the cost of meeting the 48-hour appointments deadline is that some patients find it harder to see their doctors for a follow-up. The cost of insisting that hospitals treat all accident and emergency patients within four hours is that some infected wards can't be taken out of commission to get rid of MRSA.

So interference begets more interference, as ministers decree changes and regulators diligently amend and tighten the rules. But if the capacity isn't there - if there simply aren't enough doctors and nurses to attend to all the first-time and follow-up patients that need to be seen - surgeries will either not meet the targets or, if enough jobs depend on it, find new ways round them.

And so the dance goes on, with more and more invention and effort going into satisfying ministers' demands for the right numbers and less and less into finding better ways of treating the patient.

There are other casualties, too. Perhaps the most insidious is the degradation of official numbers. Paradoxically, the more the government prods, measures and intervenes, the less the figures it produces to show that the desired ends are being met, are believed.

There are good reasons for the scepticism. We should know by now that you can't use the same figures for measurement and control: the control function corrupts the measurement.

Because of the interventions, the figures are constantly being revised, so it's hard to compare like with like. But they're dubious anyway, partly because of the representation problem noted earlier, but also because in every public ser vice they are subject to systematic manipulation. The figures may purport to show that no one has to wait more than two days to see their doctor, but any straw poll says the contrary - a next-day appointment is rare. The figures don't correspond to the reality as people experience it.

The diagnosis from the doctor's surgery is that, the election over, New Labour needs a new start. Foreign adventures apart, its only hope of a fourth term is to win unambiguous recognition that public services are getting better. But to clean up the figures, it needs to acknowledge an unpalatable truth. The famous efficiency review, now being worked on in every department across Whitehall, has the wrong focus: the major engine of bureaucratic cost inflation is ministers themselves.

Accordingly, to win back control over the numbers, No 10's Delivery Unit should decree a self-denying ordinance: reform starts with conquering the atavistic urge to command and control.

That's not as paradoxical as it sounds. Curiously, there's a precedent under its nose. Practically New Labour's first significant act when it took office was to grant the Bank of England independence. Although the move was controversial then, it has come to be ranked as an almost unqualified success. No party wants to turn the clock back. The medicine is the same for any other public service. Set people a clear purpose, give them the keys to the system, hold them accountable - and stand well back.

The Observer, 8 Observer 2005


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