We were addressed at our Lunch on 12th June 2008 by Ken Steven, a consultant on healthcare provision. At the heart of his deeply-felt words was a personal anguish that there are tectonic strains within the whole of the healthcare area, but neither politicians nor practitioners seem able or willing to promote an open discussion about the principles under which the challenges should be met.
The causes of the strains are obvious: an aging population with increasing demands, and an ‘industry’ with a high capacity for producing remedies that either generate huge costs or bring radical new opportunities. As an example, many procedures that once required a 10 day hospital stay can now be dealt in a day or little more; he quoted an example of a heart by-pass being performed as day-surgery. These radical changes involve quite different forms of hospital management, and perhaps quite different approaches to hospital real estate. In Ken’s view, the NHS is simply too large and too bureaucratic to be able to keep pace. Despite the best efforts of many of its staff, it is hugely wasteful, and often inefficient. As a consequence, and largely by default private sector patches are and will continue to be added, but within an entirely unconsidered framework.
Underlying this grim picture, Ken sees a curious public attitude that is being betrayed by government ineptitude. The Man-in-the-Street is being told that he is being given choice, but is given no information on which he can make his choice. Perhaps as a consequence, people view the consultants they meet as miracle-workers, until something goes wrong when they sue them. Like all professionals, medical consultants vary in their skills, but there is no means of getting at knowledge of this.
The ability of the NHS to respond to the capacities of the private and charitable sectors is weak, partly by political conviction but also due to bureaucratic inertia. He was also concerned by a probable inability to meet changes in the legal environment of healthcare.
If the NHS faces challenges, so too does the private sector. The organisation of the medical profession does not make it easy to formulate the long-term relationships that high hardware costs necessitate. Consultants, quite naturally, wish to migrate to whatever place offers the latest and best for their clients. Solutions are possible, but they need to be openly thrashed out. The absence of the debate has left the private sector in limbo. As a consequence, much of its management expertise and its finance now comes from overseas.
In response to a question, Ken argued that, whilst a limited number of attempts are being made, it was unlikely that private finance could be found for solutions similar to those for student accommodation. Whilst mechanisms are quite feasible, they require agreement on the ground rules, an agreement that is not even being properly discussed. The PFI (Public Finance Initiative) solution has been, in his view, no more than a deferment of the problems it was supposed to meet. Who is thinking about what will happen when PFI projects mature – and some are now 25% through their life-span?
This sombre view of the management, political and administrative, Ken sharply contrasted with the high skills and unselfish devotion of many practitioners. He left the question in the air – why can’t we formulate the debate?
Michael H. Mallinson CBE FRICS (Scribe, London Chapter, LAI)