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Quality standards to die for


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Friday, 2 December 2011

Quality standards to die for

Medecins Sans Frontieres treats 7.5m outpatients every year. Compared to the 69m outpatients seen in the NHS in the past year, that’s a differential of around ten.

MSF’s budget last year was €634m, compared to an NHS budget approaching £120bn, a differential of about 190. 

There are a few other important differences between the medical aid organisation and the English NHS. 

The main one is that MSF provides care in unimaginably difficult conditions to people who would otherwise have only the most basic care or no care at all.

Premises and estates are not contentious. A new build is a hastily erected canvas in a muddy field. 

We worry about the cost of pathology. It isn’t a problem here. Without serology, haematology and microbiology, it’s a QIPP workstream to die for. There is no radiology either. Younger doctors are perplexed by the lack of lab support, but it puts a twinkle in the eye of some of the older ones who rediscover clinical skills they thought were lost.   

The prevalence of HIV/Aids, which can be as high in 40% in some of the populations served by MSF, means that chronic conditions are rare. There is no time for them.

Nor is there a shortage of innovation, not just the make do and mend kind that teaches nurses to fashion inhalers out of plastic bottles, but the kind of innovation that gets to the heart of things. Treating malnourished people won’t work if half of them have HIV/Aids. Giving them medicine will help, but they have to be supported to keep taking it. Just because you’re in a warzone, it doesn’t mean you stop worrying about the care pathway, co-morbidity, integrated care. These terms are even more meaningless to the recipients of MSF’s services than they are to NHS patients, but the logic is just as persuasive.

MSF delivers 100,000 babies each year, barely enough to make a small dent in the planet’s child mortality figures. Unicef has been reporting that 4000 children die each day from contaminated water for at least six years. Either no-one has bothered to update the stats, or the problem hasn’t gone away.

But a dent is a dent. MSF doctors don’t always have the oxygen our hospitals take for granted. They need to rely instead on the kiss of life, which sometimes works and often doesn’t.

Failure on the frontline does not set in train an endless round of enquiries or a witchhunt in the tabloids, it serves a purpose. 

As Marc Dubois, executive director of MSF, puts it: “What we hope is that that lingering imprint of a dead child’s mouth on our doctor sparks an outrage in that doctor who then stands up and says ‘This is not good enough’.”

It’s depressing but not surprising to learn that just like the NHS, MSF faces significant budget cuts. It relies on private funding and that’s in short supply. The impact of reduced funding does not take years to show up in the public health statistics. It’s more obvious. The consequence, says Dubois without melodrama is that there will be “blood on the floor”. 

Dubois makes his point without sentiment, special pleading or dwelling on the difficulty of the job. There are no complaints about the system, the role of clinicians, bureaucracy, regulation or running costs.

He might be angry about the trillions spent propping up the world’s failing banks or the fact that his budget in Angola was less than the value of luxury car imports that year, but he doesn’t dwell on these things because outrage delivers no practical benefit, dodges no bullets and saves no lives.

MSF runs its global operations on a PCT size budget. Of course you can’t equate a humanitarian aid organisation with a western health system, except to make shock-horror comparisons and instil a sense of get over yourself gratitude that things aren’t worse in the NHS. But perhaps we’re right to feel a twang of shame about our introverted obsessions and the growing disconnection of the NHS from its purpose. 

MSF’s mission is to preserve life, alleviate suffering and maintain dignity. It is striking that it never uses the difficulty of the job, or the extreme circumstances in which it operates as an excuse for lowering standards. 

There are no rhetorical italics when Dubois says “It’s not good enough just to deliver the care.” It’s just a statement of fact.


mark.buckle@journey-group.com says:
Dec 02, 2011 01:22 PM
I sometimes find myself regularly laughing at these blogs because they operate in manner of 'the HSJ meets Private Eye' and although they tend to drift between satire and cynicism, they normally raise a smile at least.

This piece is a step above all of that. A powerful comparison articulated with calm and objectivity, but powerful none the less.

Congratulations. I hope the NHS leadership gets to read this and , for once, take 10 steps back from the interminable deck-chair changing and start to focus once and for on healthcare outcomes (on a budget) - and choose to choose to make themselves accountable for their own performance. 'It's not good enough just to deliver the care' should become the new motto of the NHS and the rallying call for all those in the NHS who give a shit about the people they are delivering a service for...
peggyb says:
Dec 02, 2011 03:23 PM
I agree, Mark.

Additionally, though I don't think it was the author's intent, I'm going to increase my donation to MSF as a result of this blog. Some of the stark realities outlined also serve to put into perspective pension changes and(the lack of) pay increases which are consuming energies in the NHS at the moment.
mike.kemble@proconsortia.co.uk says:
Dec 02, 2011 03:25 PM
Great piece - always a pleasure to read and as Mark mentions 'A powerful comparison articulated with calm and objectivity...'

Good stuff!

Corinne says:
Dec 02, 2011 04:46 PM
An illuminating and humbling read. It should be read by everybody. Thanks you.
wende003@yahoo.co.uk says:
Dec 03, 2011 02:18 AM
Indeed a humbling read. Not all the work undertaken by members of the NHS abroad is in conflict areas and not all of us could cope with that intensity. Some of us work for other NGOs (like VSO) on longer term placements in post conflict areas but are still trying desperately to make a dint. It can be the most frustrating annoying and infuriating thing that you will ever do. The enduring hardship for the patients, lack of resources and in some cases less developed training for staff can at times sap anyone’s strength but it is also the most rewarding, challenging and life changing thing you can do, in my view. Maybe some of you might like to just consider what skills you might have to share.
iancross@nhs.net says:
Dec 03, 2011 10:16 AM
Super article. I worked overseas for five years (in Africa mainly) for Save the Children, at the start my career in 1979. Coming close to retirement, I wonder about finishing my career working overseas. Does anyone have any advice to give?
peterashton says:
Dec 05, 2011 11:24 AM
Excellent item. I recall reading Dr. Pauline Cutting's book 'Children of the Seige' (about her experiences treating patients in Beirut's Bourj a-Barajneh refugee camp at the height of civil war) which had a profound impact on me. This article is in that area. A dose of humility is not a bad thing.