Health services in the 21st century

Our lectures on Thursday were all about management within the NHS, including the description of a real tendering exercise that took place in Doncaster last year. The Strategic Health Authority (SHA), acting on government priorities, had decided that an obesity management service was required in the area. This imperative was passed to the Primary Care Trusts (PCTs), which are the bodies that currently commission health services (although this is due to change any day now).

The PCTs consulted practitioners and others to determine what obesity management services should look like. Then they invited tenders for three contracts: adult, adolescent and child obesity management services in 'Tier 2', which is for people already overweight but not automatically eligible for bariatric surgery.

The dietetic department in the area had been part of the group that defined the services, and also decided to bid for the three contracts. You may be able to imagine the paperwork and bureaucracy that is involved in bidding for a public sector contract, but the process also included the requirement to produce a short film summarising the bid, as well as the paper documentation. All this for each of the three contracts.

Two of the contracts, for child and adolescent services, were won by the 'Carnegie' weight management program, based in Leeds Metropolitan University - not a health service provider at all. The dietitians won just one of the contracts, for adult services. They had put in a bid for new services not currently being provided, so dietitians and others were recruited and equipment bought so that they could start delivering and measuring outcomes.

The issue of outcomes is also very interesting. The SHA and PCT are not health practitioners, but they make the ultimate decision about how success or performance will be measured or indicated, through Key Performance Indicators (KPIs). Of course they are guided by clinicians, including dietitians, but they also have strategic targets to meet, set nationally in the UK and by the World Health Organisation. The amount of weight loss within the period of the intervention, and the longer term targets for weight maintenance are both outcome measures within the contracts, and notoriously unachievable.

I suspect that the younger students would have found the whole talk tedious in the extreme - I would have in their place. The only reason I was engaged was the amount of soul-destroying bidding/tendering that I've had to endure through my past career. A few things stood out:

• The cost of putting in the three bids (and winning just one) was £40,000;
• The contract has been awarded for just 3 years, at which point the whole tendering/bidding thing happens again;
• The 'success' of the service depends on outcomes, some of which are probably not achievable.

The NHS has improved a great deal over the past few years from the point of view of transparency, accountability and best practice. I don't know the full intimate details of either case, but if we compare the seemingly measured decision to stop paediatric heart surgery in Oxford with the scandal in Bristol over a similar issue, I think the progress in monitoring the quality of care is clear.

A ton of money has been poured in, and some of it has been wasted, but I don't agree with Sir Philip Green that a public service can be run like a retail store. I am glad that some attention is being paid to the bottom line, and some level of greater fiscal responsibility may ensue, but the burden on health practitioners is high - it is clinicians, not managers who have to lead on these bids, because they are the ones who understand the service being tendered, and ultimately whose jobs are at risk if the bid fails.

If in three years the contract for adult obesity services moves to another provider, then equipment bought for the service and staff employed to run it will be surplus to requirements. Maybe they will transfer to the new provider, but probably not. While I welcome the principle and clarity of a well-written contract to deliver a specific service with defined indicators of performance, the devil, as ever, is in the detail.

Other than lectures, the only two activities allowed to me are university work and housework, neither of which is provoking much interest. I took the car for a service, interviewed three more of my research subjects, bought some vegetables and came home yesterday. Then I thought a lot about the different bits of coursework I have to start, but didn't actually start anything. I have spent most of today in my pyjamas. It's a tough life.