The Invisible Hand


These huge hands have become very fashionable – seen most recently by me in Birmingham New Street station concealed for the most part behind the backs of rather embarrassed and giggling teenagers presumably there to give the newly arrived a clue in the chaos of the current works how to find their way out to the taxi rank. Directions do not work if they are not seen.

Don’t talk about the dosh

These thoughts are prompted by a KPMG report on health systems changing in response to ‘activist payers’ and how this represents another (yet another) chance to put patient engagement firmly on the NHS agenda. The report makes the point that the way things are paid for or rather what things are paid for influence the way patients get treated. An obvious enough point perhaps. Yet in the sort of fora and discussions we have with, for or about patients, for the most part we do have to go along with the great NHS taboo – never discuss the dosh. To mention money is to be a dupe of the forces of big money and capitalism. It is as if the survival of the NHS can only be assured by its status as a political and moral entity riding high above concerns about ££££ . The moral impulse is all and the economic imperative is vulgar and unmentionable.

The unseen driver

Yet if money remains invisible, a major (if not the major) influencer on the way the NHS treats us patients is hidden from those patients. This makes those choices being made on our behalf even more mysterious. Without understanding the real drivers of organisational behaviour because those financial incentives remain unseen as the invisible hand of the health market,  patient representatives are often left with the sole option of complaining after the event or trying to marshall arguments for or against change based on fragments of anecdotal evidence.

Learning for Leaders and the Role of Commissioners

We have written about the importance of patient leaders being well-trained and well-prepared. It is vital that they are able to ‘follow the money’. The new commissioning arrangements begin to make sense if they are up front about budgets and the provision of care.  Sir Ian Carruthers of the NHS was quoted recently as saying that while there have been some small scale achievements “We know that we now have to do it on a larger scale ..yet we do not yet know how”. He adds “although the Clinical Commissioning Groups will have a vital role to play”. I do not envy the commissioners – the list of ‘vital roles to play’ gets longer and longer but when they ask how they are going to do this, the list of answers seems a bit short.

Still ignorance admitted is as healthy a starting point as any even with a double dose of ‘yet’s. It would just have been nice to think that we have got a little bit further down the road than Sir Ian implies.

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