What a Waste

It’s a shame that the Academy of Medical Royal Colleges report on protecting NHS resources is subtitled: ‘a doctor’s guide to cutting waste in clinical care.’ NHS waste is everyone’s responsibility, from patients to politicians. The report claims 20% of mainstream clinical practice brings no benefit to patients and there is widespread overuse of tests and interventions. The cost of prescribed medicines wasted is around £300 million each year. The average NHS cost of admission to general hospital is £1713, a consultant outpatient £135, an outpatient psychiatric assessment £145, one bed day for adult mental health inpatient £430, 11.7 minutes with a GP £45, prescription cost per GP consultation £41, cost of an MRI scan £187, cost of ambulance call out £235, cost of a hip replacement £5485. The carbon footprint of most of these interventions is listed, and a scenario where one patient ends up having many of these when they could have been avoided.

Interventions towards the end of life are often futile, costly and unkind and yet staff may feel pressured into doing something by patients and relatives. No mention is made of the waste of political reform. The current ideological absurdity – to believe a market system will reduce waste and inefficiency – is a huge delusion that fragments services and diverts precious resources to the pockets of lawyers, management consultants and shareholders. The NHS desperately needs good managers with the stability of secure jobs, not a merry go round of firing, compensating and then rehiring the same staff in new organizations that have lost the organizational memory of their predecessors.

The report repeatedly emphasizes that climate change is the largest threat to human health in the 21st century, and yet mental illness is a far bigger immediate threat. A culture of fear and bullying still persists in parts of the NHS. Threatening GPs with public outing for failing to spot cancer won’t improve their stress levels or reduce the number of investigations ordered. The human and financial waste of NHS staff trained but unable to find a job is not mentioned. After the MMC medical training fiasco (Eyes passim), a nurse contacted the Eye about her husband – a surgical trainee whose NHS job prospects were destroyed. ‘I ended up with a husband at the end of his tether. Indeed I took a day off work as I thought I would come home to see him hanging.’ He went off to train and work abroad, as many newly qualified doctors are doing at huge cost to the NHS.

The wasted lives of NHS whislteblowers who try to do as the report suggests, and speak up about unsafe and unnecessary care also gets no mention. On October 27, BBC1 broadcast ‘Baby P-the untold story’ which repeated the allegations made in the Eye in 2011 (Shoot the Messenger) about how Dr Kim Holt was not listened to by Great Ormond Street Hospital management when she repeatedly raised concerns about patient safety in Haringey clinic where Baby Peter was seen. She also made a disclosure to the lead inspector of the Healthcare Commission in November 2008 and was not even interviewed. The Joint Area Review of Haringey, ordered by children’s secretary Ed Balls in November 2008, made no mention of Dr Holt’s detailed evidence of clinically risky system failures but she was suddenly invited, by GOSH’s lawyers, to retract her concerns and offered a £120,000 gagging payment signed off by both the Treasury and the DoH. It took four years for her to be reinstated to her job in Haringey, a huge waste given that last week her team won a clinical excellence award as team of the month for Whittington Health, and she has been listed as one of the top 100 NHS clinical leaders by the Health Service Journal and one of top 50 women in the NHS.

Hopefully, the same happy ending may yet become Professor Ed Jesudason and Mr Shiban Ahmed, two extremely gifted surgeons who blew the whistle on what they believe are unnecessary, harmful and wasteful operations on some children with acid reflux at Alder Hey hospital in Liverpool. NICE agrees there is no evidence for cutting the vagus nerves and the stomach sphincter, and the Chief Inspector of Hospitals, Mike Richards, has been asked by NHS England Clinical Director Sir Bruce Keogh to investigate. However, the punishment for Jesudason and Ahmed for raising concerns is that they are unable to get another job in the NHS which, given their undoubted talent and the millions it has cost to train them, is a phenomenal waste. What are the Royal Colleges doing about that?

Here’s the latest survey from the British HIV Association. Further evidence that Local Authority commissioning changes were poorly thought through and executed.  <5% of services have improved since April 2013, over a third have deteriorated, some markedly.

From: “O’Mahony Colm (COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST)

Subject: Chester situation email sent to local GP’s and CE of Chester Council by Dr O’Mahony

Date: 10 November 2014 12:54:15 GMT

Dear General Practice Colleagues

I have just seen this latest Public Health Update which has been issued to all practitioners and partners and feel I need to make some comment.

All of us in Sexual Health and HIV, running integrated services in the city of Chester and my colleagues in Leighton Hospital, Crewe, were totally shocked when the council initially awarded the contract to East Cheshire Trust in July 2014.

The joint bid between The Countess of Chester, Mid-Cheshire Trust (Leighton Hospital) and Body Positive had been put together by a very experienced team of 5 consultants in Sexual Health and HIV, along with procurement teams from both Trusts. This extensive clinical experience on the ground in Cheshire was used to create a comprehensive bid which would have given equity across Cheshire and improved the services in Mid-Cheshire to the current high standards of both Chester and Leighton.

In Chester, extensive consultation with local GPs had established that it would be best to move a significant portion, ie; all level 1, level 2 and a lot of level 3, into the specially designed Fountains complex which would have seen seamless working between General Practice and Sexual Health. This would have provided a perfect hub right in the city centre for Chester, leaving HIV at The Countess with some STD there and keeping the HIV and Sexual Health team intact.  The current innovations already at The Countess, ie; Telephonetics (web based results system which patient access 24 hours a day) and web based booking (already purchased) would have been introduced into the Mid-Cheshire clinics where they do not currently have such facilities. The council had indicated that £2.4M was the amount of money available.  It was therefore extraordinary that the council awarded the tender to East Cheshire Trust whose bid had been £2.8M, ie; £400,000 above the allocated sum.   It was also a surprise that there was no medical person whatsoever on the initial assessment panel.  Unlike every other tender submission we were involved in, there was no interview process.  This interview process is critical in differentiating bids prepared by a slick professional tender company from those prepared by real doctors working in the specialty.  A properly constructed panel at interview can easily establish from the shortlisted bidders whether the bid is fantasy or reality.  Not doing this is the equivalent of appointing a candidate to a post based totally on an uncorroborated CV with no interview and no references.  Indeed, the only full-time consultant they have in sexual health in East Cheshire Trust had no input into the bid.

Naturally, The Countess of Cheshire and Mid-Cheshire objected and the council were forced to re-run the tender process but the writing was on the wall.  If they were prepared to award the tender to East Cheshire at well above the amount of money available, it was inevitable that they would simply re-award it when East Cheshire re-submitted a sum equivalent to The Countess.  None of our exhortations and advice to the council to have a properly constructed panel was taken on board. The ‘new panel’ now had a GP with a  ‘special interest in sexual health’ (whatever that means) from outside the borough.  Can you imagine the council assessing a vascular tender and not having a consultant vascular surgeon on the panel and simply using a GP ‘with a specialist interest’?   This tender included level 3 services which involves managing complex STDs, genital skin problems and complex contraception – all level 3.

This inexplicable and illogical decision became even more bizarre when it was realised that the core of the East Cheshire Trust bid was to establish flexible units in Chester and Winsford. The technical term being used is ‘pods’ but the word ‘portakabin’ does spring to mind.  We had pleaded to the council to include the Fountains in the specification but they refused to do that. So here we have a magnificent, carefully designed floor at the Fountains which was at the heart of the Countess bid being left idle and instead, at vast expense, a pod is going to be put in, an as yet undetermined, location somewhere in Chester with water, sewage, electric, IT and fully equipped by the end of January 2015.

If this goes ahead, it will see the disintegration of the integrated service which local GPs and patients treasure. See attached spontaneous comment cards.  (Note: any comment with a ‘y’ beside it is where the patient gave mobile number and happy to be contacted to discuss their comment).

The total separation of sexual health from HIV will split the team which has worked together for 20 years and inevitably lead to reduced ability for partner notification, particularly in HIV and indeed an increase in late diagnosis².

The Public Health Update also mentions that East Cheshire Trust “….has extensive experience of operating this type of service in the East Cheshire and in the Vale Royal area, and is excited to transfer some of this practice to West Cheshire….”  All of us working in sexual health in Cheshire and Merseyside are not aware of any novel, innovative or new practice in the Macclesfield area which we would wish to emulate.  Some more detail about what the current East Cheshire Trust service is doing which is so exciting would be of interest.

In summary, I am concerned at what has happened and fear a return to the portakabin culture which we struggled to shake off 20 years ago.  The main points which need addressing are:

East Cheshire bid prepared without any consultant input. CoCH and Mid-Cheshire had 5 experienced sexual health consultants with in-depth knowledge of the specialities and the localities

CoCH and Mid-Cheshire had at its core using the specially developed Fountains as the Chester hub. East Cheshire are proposing a pod (portakabin)

Initial assessment panel had no medical input whatsoever. Second panel had a GP with a special interest but remarkably no sexual health consultant

Initial East Cheshire bid was £400,000 above the stated price yet was still awarded the contractHaving been taken to task over the first bid, Chester council took the unusual step of refusing to have a standstill period after the second bid where legitimate complaint could have been madeI hope this clears up some of the background for this tender issue.

I had contacted Steve Robinson, Chief Executive of Chester City Council at steve.robinson@cheshirewestandchester.gov.uk  and if any of you have any views on this issue, I presume you can send them to him.

Regards

Dr Colm O’Mahony MD. FRCP. BSc. DIPVen. Consultant in Genitourinary & HIV

www.chestersexualhealth.co.uk  Appointments: 01244 363091

Integrated Contraception and Sexual Health Service Countess of Chester Foundation Trust Hospital, Liverpool Road, Chester.  CH2 1UL e-mail: colm.omahony@nhs.net Phone  01244 363097 Fax      01244 363095

References:      www.independent.co.uk/life-style/health-and-families/health-news/late-diagnosis-of-hiv-blamed-on-coalitions-health-reforms-9760086.html?utm_source=twitterfeed&utm_medium=twitter

Summary of comment cards from Sexual Health Dec 2013 to June 2014

Simon Says Sort Yourself Out

The five year plan for the NHS, as seen by NHS England CEO Simon Stevens, is mercifully free from the government’s five minute gimmicks (£55 and a pat on the back for GPs who diagnose dementia, a red flag and public humiliation for those who fail to diagnose cancer). But his big idea to reward workers for losing weight – an incentive that helped Stevens shed 3 stone in America – may not ‘gain traction’ over here. Steven’s predecessor David Nicholson became obese and developed type II diabetes whilst in the job, which he managed to disguise with Marks and Spencer elasticated waist trousers. Poor physical health usually starts with poor mental health, and the most urgent health need facing the NHS staff is to reduce the stress, overwork, bullying and fear.

Steven’s inherited chaotic structural reforms that unnamed senior Tories apparently told the Times are the government’s ‘worst mistake’. The idea of making clinical staff as responsible for spending taxpayers’ money wisely as they are for getting the diagnosis and treatment right has merit, but it could simply and cheaply have been done by putting clinical staff in control of the old PCTs. The hugely over-complicated structural reforms had no mandate and will be forever tainted with the suspicion that its part of some long term privatization plan. However, private companies such as Serco are dropping out of the NHS because there is no profit to be made, and large losses.

Stevens believes the £30 billion 5 year black hole can be filled with £22 billion of ‘doing stuff better’ and ‘people getting healthier’, with another £8 billion from the taxpayer. Steven’s is cleverly passing the buck for health onto citizens. Unless people take responsibility for staying as well as they can, the NHS cannot thrive. Steven’s other big idea is to offer patients a budget for buying their own health and social care. In theory, giving those with complex physical and learning disabilities, mental illnesses and multiple chronic diseases more power and control sound enticing, provided they’re willing, able and supported to do it, but it needs evidence from NICE that this is a sensible use of precious NHS resources (Eyes passim). The financial black hole in the NHS is eclipsed by the information black hole. For an organization that spends £110 billion a year, there is remarkably little evidence as to what treatments actually improved patients’ lives or helped them die with dignity. Until the NHS measures outcomes that matter to patients, it will continue to fly blind, driven by political gimmicks, medical fads and fear of failure.

The NHS can only improve by learning both from both its failures and its successes, without hanging people out to dry for challenging the system or standards of care. The fact that staff who raise safety concerns are still being punished and ostracised shows the enormity of the task facing Robert Francis and his Freedom to Speak Up Review. And the very public evisceration of consultant urologist Paul Miller (who MD trained with) shows how far the NHS has to go to investigate allegations fairly and humanely. The treatment of prostate cancer is complex and uncertain but whatever the result of the investigation, Miller’s reputation as an international prostate cancer expert has been brutally destroyed. His lawyers will now do battle with lawyers from Surrey and Sussex Healthcare Trust .

The worst bullying in the NHS is often doctor on doctor. The Alder Hey surgeons who raised concerns about techniques and standards in paediatric surgery (Eye last) have been so fiercely discarded by their former colleagues that they may struggle ever to work in the NHS again. The complaint MD and Andrew Bousfield made to Bar Standards Board about the conduct of Simon Gorton, Alder Hey’s barrister, has been dismissed but one of the whislteblowers has appealed against this. Now NHS England Clinical Director Bruce Keogh has asked to see evidence relating to the evidence. Whatever investigation follows, it needs to be done fairly and humanely, and focus on whether children are having the right operations backed up by evidence. Stevens is right – the money spent in the NHS on investigations and treatments of no or low benefit is staggering. The NHS needs value as well as values.

MD’s new book and ebook, What Doctors Really Think, is available here