Social Scare

The unseemly collapse of Cambridgeshire and Peterborough’s older people’s services contract is another smoke alarm for the NHS and social care – and highlights the folly of putting highly complex care out to tender. The £800 million contract over five years sounds a lot until you realise it’s supposed to transform care for frail, vulnerable older people often with multiple diagnoses across England’s largest clinical commissioning group. The plan was to join up services and keep the neediest patients well and out of hospital (particularly emergency departments) – and to discharge those patients who neither need nor want to be in hospital more quickly.

Cambridgeshire and Peterborough CCG spent over a year and £1 million on ‘the tendering process’ with the help of assorted management consultants and NHS England’s Strategic Projects Team (SPT). Part of the payment for the contract was to be dependent on successful outcomes (such as keeping patients out of hospital). Several private companies looked at the deal and pulled out, and the tender was awarded to the NHS, or rather ‘UnitingCare’, a limited liability partnership established by Cambridgeshire and Peterborough Foundation Trust, and Cambridge University Hospitals FT. It began running services in April 2015 and 1,200 staff were transferred to the new employers. After 8 months UnitingCare and the CCG have terminated the deal as it is “no longer financially sustainable”.

Cambridgeshire and the SPT have form in calamitous tendering. When Circle pulled out of Hinchingbrooke Health Care Trust, at least it tried to explained its reasoning in public before passing the buck onto the CQC, but no detail has been given on the latest failure. NHS England is planning to roll out similar schemes with capitated budgets for entire populations and payment by outcome, but if the budgets remain absurdly tight and neither the commissioners nor providers have the financial nous or knowledge of complex systems to make it work, there could be a few more ‘de-tenders.’

One difficulty with outcomes based payments is that the ultimate outcome for all of us is death. It can be a gentle and welcome release or a very long, expensive and unpleasant process. Keeping death at bay is more to do with individual behaviour and life circumstance than health services. All providers of social care are struggling to give high quality care for the elderly on such a tight budget. The demands of paying for the living wage, pensions, travelling time, regulatory and training burdens, and the longer visits these patients needs makes it almost impossible to break even.

Debt and bankruptcy amongst social care providers could spell disaster for the NHS. There are currently more than 12,000 organisations, from big corporate chains to small family-run businesses, charities and social enterprises, fighting for custom. Less than 10 per cent of social care is now provided by councils or the NHS (long term care fell off the NHS with little debate under the Thatcher government). There are three times more care home places than hospital beds, and half a million people have home care services to be able to live at home. Many of these providers are in dire financial straits particularly the larger chains that rely on local authority funding.

The amount local authorities pay for this care has fallen 5% in real terms over 5 years. Many care homes now charge up to 40% higher for self-funding people to compensate for the shortfall in local authority funding. Others are simply refusing to accept state funded placements. Rumours abound that another ‘Southern Cross’ style failure of a big social care provider is imminent.

As with the NHS, there is a shortage of nurses and high spends on agency staff. In 2014, the Care Quality Commission found 20% of nursing homes did not have enough staff to provide good, safe care. The CQC also lacks the resources to pick up and close down rogue operators who keep re-registering under different names. The social care system has been underfunded for decades, and failed to keep pace with increasing life expectancy, frailty and dementia. In shifting social care to a private business model, both good and bad care homes go bankrupt in times of austerity. And now state providers in the new NHS market are pulling out of care for the most vulnerable and needy patients because the figures don’t add up. Those most in need of care are least likely to get the care they need. Without investing in social care, the NHS will be forever in debt. Happy New Year.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

What is a ‘truly 7 day NHS?’

Jeremy Hunt’s belated U turn on ACAS mediation with the BMA over the junior doctors’ contract postponed strike action but came too late to prevent the cancellation of 600 operations and 3,500 outpatient appointments. This could have been avoided had Hunt taken up the offer of ACAS talks on November 19, rather than a week later. Hunt may have been teasing George Osborne, using the threat of a strike to force a better than expected deal for the NHS from the spending review. Or he may simply have blinked first when he realised junior doctors were serious about strike action.

Osborne was also pressured by NHS chief executive Simon Stevens who publically asked for £4 billion of the £8 billion promised by 2020 to be ‘front-loaded’ next year, and then secured himself a slot on ‘Any Questions’ on Friday in case it wasn’t. Osborne had the last laugh by claiming to give £3.8 billion next year and making lots of absurd claims about how many more doctors, nurses and operations it would buy. In fact, £1.5 billion has been stolen from existing Department of Health budgets, cutting the budget for public health (such as smoking cessation and sexual health) and clinical training (including the cost of junior doctor placements and nurse bursaries).

Stevens wanted additional funding for ‘a seven day NHS’ but this has now to be found from existing budgets. Overall, 2010-2020 will be the tightest 10 years of in the history of the NHS, with an average annual increase of under 1%, and lagging further behind GDP health spend of France and Germany. £3.8 billion will just about pay off this year’s debt and keep the lights on for another year. Hunt may have to choose between being remembered as the Health Secretary who prioritised patient safety but failed to stick to an impossibly tight budget or trying to please Osborne and risk harming patients.

Hunt’s further difficulty is that the government has made a manifesto pledge about a ‘truly 7 day NHS’ that no one understands. The NHS already provides round the clock emergency services that doubtless could be better staffed, but not for free. If the government demands 7 day non-emergency services with identical outpatient appointment times, operation slots across all specialties every day, and GP surgeries open 7 days a week, that clearly has significant resource and staffing implications that Osborne won’t pay for. Hunt and David Cameron have repeatedly sighted Salford Royal NHS FT as a hospital that already provides ‘truly 7 day working’ but the staff on the ground are less convinced. These quotes from SRNFT doctors were collected by GP and journalist Dr Faye Kirkland:

“I work at Salford. They do not have 7 day working yet. The weekends are ‘on call’ cover only.”
“There is excellent daytime anaesthetic cover at the weekend but the only lists are emergency lists.”

“Neurosurgery is 7 day full emergency cover and elective ops only take place Monday to Friday.”
“We do not do what Hunt claims. We have also not told him that we do. I doubt the trust will rebut & risk both sides turning on them. Don’t get me wrong – I am immensely proud to work at Salford and think we do a load of things brilliantly. But there’s loads we don’t and we have to save money now so definitely can’t expand into weekends in the way the press reports.”

Dr Pete Turkington, Salford Royal Medical Director, said: “Our vision of a seven day service has been primarily focussed on providing reliable and standardised emergency care (non-elective) every day of the week. It has never been our intention to have a full seven day elective service. We’ve made enormous strides in delivering a safe and effective emergency service to our patients across the entire week.”

If Hunt and Cameron are to regain the trust of doctors and other NHS staff, and avoid the huge risk of strikes in the middle of January, they must stop spinning and start telling the truth. Staff and patients need to know exactly how much is available and what services can safely be provided at a time of such austerity without spreading them so thin that they collapse entirely. A ‘truly 7 day NHS’ is a pipe dream, the focus must be on providing the best emergency care, 24/7, including Christmas.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

Junior doctors employed by a community interest company (CIC) in Plymouth have been told they do not have the right to be balloted or participate in Industrial Action – even if they are BMA members. Follow the e mails and meeting minutes below.

Dear all

Further to the LNC meeting that was held this week to discuss the Industrial Action (IA) for junior doctors it was agreed that I would write out to you on behalf of Steve Waite and the Board to give an overview of the BMA advice and agreement that was reached with LNC members.

Due to PCH being a non NHS employer (albeit the medical staff are employed on national terms and conditions) the trainees were not entitled to either ballot nor take part in the IA during December. I have attached a copy of the notes taken at the LNC meeting along with the e-mail that has been sent to PCH trainees on Wednesday.

Those trainees employed by Devon Docs and Plymouth Hospitals are entitled to strike and in view of this I have asked medical staffing to provide an overview of the key areas that will be affected. Teresa has detailed what action is likely to be required and I would ask those particular consultants to verify the details and add any further information to ensure that appropriate action can be taken on the 1st, 8th and 16th December. Can you please provide any updates to Teresa Duggan by the 1st December – thank you.

It was acknowledged at the LNC that the Consultant body along with the specialty doctors are likely to want to offer support to the trainees, both those who choose to strike along with the PCH trainees who find themselves unable to take this course of action. Senior management wished me to pass on their appreciation to you in helping to ensure that clinical services are maintained and patient safety and care remain the priority at this time.

David Furze

Head of HR & Interim Chair of LNC

Dear Trainee

I am writing to those of you who are directly employed by PCH. An LNC meeting was held yesterday, which both Jenny Price and Rbbiya Noor (previous core-trainee, now specialty doctor for West CMHT) were present.

Richard Griffiths gave an overview of the Industrial Action which is scheduled to take place on the 1st/8th and 16th December. I have attached a copy of the e-mail that Richard has sent outlining that you are legally not entitled to take strike action on any of these dates.

Trainees employed directly by Devon Doctors or Plymouth Hospitals are entitled to strike and their employing organisations have contacted them about this. I have copied those doctors into this e-mail so they are aware of the situation within PCH.

I will be e-mailing out again to medical staff and senior managers to clarify what cover arrangements are going to be in place for those areas particularly affected by the Action.

It is recognised that you, along with Senior medical staff are likely to wish to show support to those trainees during this period. Richard mentioned that the BMA are producing free badges etc. that are available off the website and advised that you contact the BMA direct about this.

Please do not hesitate to contact me if you have any queries or there is anything else that I can help with.

Kind regards

Teresa

Teresa Duggan

HR Medical Staffing Manager

Plymouth Community Healthcare CIC

HR Department

Hi Teresa

Following are meeting this morning,

I can confirm the following:

The BMA had confirmation that legally the CIC is not regarded as an NHS employer for the purposes of balloting, although we do know that the junior doctors are employed by the CIC on national terms and conditions.

In the circumstances, we believe it prudent to advise the CIC employed Juniors that they do not participate in the Industrial Action but instead support their colleagues in the wider NHS in the same way as the consultants and SAS doctors who are not taking industrial action will be doing. That would mean that they would work normally on the IA dates and we have advised the employer accordingly.

This does not apply to junior doctors who are directly employed by PHT or Devon Doctors who were balloted and may participate fully in the planned industrial action

Richard Griffiths

Industrial Relations Officer

Regional Services: South West Centre

British Medical Association

The BMA is the voice of doctors and medical students in the UK.

We are an apolitical professional association and independent trade union, representing doctors and medical students from all branches of medicine across the UK and supporting them to deliver the highest standards of patient care.
_______________________________________________________________________

This email and any attachments are confidential and intended solely for the addressee. If you have received this email in error please notify postmaster@bma.org.uk. Email sent or received by the BMA is monitored.

The British Medical Association.
Registered as a company limited by guarantee in England and Wales under registered number 00008848.
Registered office: BMA House, Tavistock Square, London WC1H 9JP
http://bma.org.uk

NOTES OF EXTRAORDINARY LNC MEETING

HELD ON TUESDAY 24 NOVEMBER 2015

Present:

David Furze (DF) (Chair)

Ben Jameson (BJ)

Naresh Buttan (NB)

Alin Mascas (AM)

Alison Battersby (AB)

Rbbiya Noor (RN)

Fernanda Garcia Costas (FGC)

Jenny Price (JP)

Richard Griffiths (RG)

Teresa Duggan (TD)

In Attendance:

Steve Waite (SW)

Michelle Thomas (MT)

Tracy Davis (Minutes)

Apologies:

Soni Bhate (SB)

Mohammed Ismail (MI)

Thorsten Brandt (TB)

Lara Strang (LS)

Ashley Dingle (AD)

Leanne Tozer (LT

1. WELCOME AND APOLOGIES

DF welcomed everyone to this extraordinary meeting and noted apologies as above. He stated that the purpose of this meeting was to discuss the proposed industrial action to be undertaken by Junior Doctors nationally on three dates within December 2015 and the actions that could be taken to ameliorate the effect on our services.

2. TD confirmed that the BMA had stated that Junior Doctors employed by either Plymouth Hospitals NHS Trust or Devon Doctors (or other NHS employer) were entitled to join the industrial action as they had participated in the ballot. However, Junior Doctors who were directly employed by social enterprises such as Plymouth Community Healthcare (PCH) were not entitled to participate in the ballot and so not allowed to join the industrial action.

This meant for PCH that the following posts would be affected:

· GPVTS trainees (3 x Psychiatry and 4 x HCE)

· Foundation Year 1 (2 x Psychiatry)

· Foundation Year 2 (4 x Psychiatry)

Discussions took place on the reasoning behind the decision by BMA to not allow Junior Doctors employed by social enterprises to participate in the ballot and resulting industrial action. It was confirmed that all Core and Higher Trainees directly employed by PCH were not entitled to join the industrial action.

3. RG provided an overview of the situation that had arisen and the BMA’s rationale that social enterprises were viewed as non-NHS Employers as they had ‘no strict obligation’ to adhere to the national terms and conditions. He further commented that though PCH did employ medical staff under the national terms and conditions they could not be imposed and any changes would have to be agreed through the LNC. He reiterated that the advice from the BMA was that if Junior Doctors had not been balloted they were not entitled to join the industrial action.

4. NB requested confirmation that it was legal advice that had clarified who was a NHS employer. RG agreed that this was the case. NB further queried how this would affect other grades of medical staff, i.e. Specialty Doctor and Consultant. RG was not sure this could be challenged – he saw PCH as an NHS employer with national terms and conditions.

5. DF queried whether these other grades of medical staff would be balloted. RG stated that he would seek to work with PCH and ensure that everyone fully entitled to national terms and conditions. SW commented that PCH had a Trade Union Recognition Agreement that included the BMA. He confirmed that PCH were happy to work with Trade Unions but within a legal framework.

6. DF remarked that industrial action occurred across a range of healthcare organisations. Members were balloted and action occurred, which showed that it can be done but trade unions did not always recognise social enterprises.

7. MT stated that she was keen to clarify the impact on any industrial action. TD confirmed the following areas that may be potentially impacted:

· F2’s – Inpatient Units: Plym Bridge, Glenbourne, Cotehele

· F1’s – Psychiatric Liaison

· GPVTS – Community Mental Health Teams

· GPVTS – General Medicine: Local Care Centre and Liskeard

RG commented that PCH should assume 100% support for the industrial action and plan accordingly.

8. MT enquired if PCH needed to communicate with all staff on who would be participating in the industrial action and the reasons why other staff would not and the plans that would be in place to support those areas affected. RG stated that this would be useful in providing clear information to clarify the position of who was and was not participating in the industrial action and the reasons.

TD confirmed that the proposed dates for the industrial action were:

· Tuesday 1st December – 24 hours (equivalent to Public Holiday emergency cover)

· Tuesday 8th December – 8am to 5pm

· Wednesday 16th December – 8am to 5pm

AM stated that it would be good to explain what constituted an emergency, i.e. medication management for an acutely unwell mental health patient. RG confirmed that medical staff would do exactly what they would do if this was Christmas Day. TD commented that Glenbourne had a ‘full shift’ rota at Christmas.

MT requested a written plan of what cover will be in place. Action: T Duggan

9. MT enquired what would happen if there was a major incident on any of the dates, as PCH was a second responder. TD replied that we would call staff. The LNC supported this occurring if a major incident was called during any of the industrial action dates.

10. NB questioned what would happen if staff requested leave for any of the proposed dates. TD stated that only leave that had already been approved would be accepted.

11. MT queried what if nothing happens as a result of the industrial action, would the BMA ballot again? RG stated he was not sure, the BMA were encouraging employers to write to the Secretary of State in support of the Junior Doctors. There were no plans for further action at present, but this was now in the hands of the Department of Health.

12. Discussions took place on the current situation and the perceived lack of trust between the BMA and the Department of Health. It appeared that the Department of Health had been surprised by the level of support for industrial action. The new contract was not due to start until August 2016.

13. NB asked what other local Trusts were doing. RG stated that there would be a picket line at PHNT.

14. NB requested advice if the media contacted any doctors. RG suggested that if doctors were not confident they could contact the BMA for support/information. JP stated that the Plymouth Herald had contacted her, she had requested support/advice from PCH Communications but had still not received a response. RG commented that if the interview was off-site then there was no need to contact an employer. SW agreed there was no issue if the doctor was not representing PCH.

15. AB commented that RG mentioned other ways trainees show support, what were they. RG replied that they could wear badges and if at Derriford they could give verbal support to the trainees. SW stated that he was conscious that those trainees who were not entitled to join the industrial action could face criticism, as it may not be understood that they were not against the action they just could not legally participate. We needed to ensure that it is know that they had no choice.

16. NB queried how to raise public awareness of the reasons why some staff were participating and others not. MT stated that she would discuss this with the Communications Team to provide a pro-active statement for the public. TD commented that Devon Doctors had written to their trainees about the situation and she was proposing to do the same for PCH staff.

17. SW thanked everyone for attending and participating in this meeting.

7. DATE OF NEXT MEETING

The next LNC regular meeting will take place on Tuesday 12th January 2016 at 10.00am in the HR Meeting Room, Admin Building, Mount Gould. The Staff Side pre-meet will start at 9.00am.

_______________________________________________________________________

Jeremy Hunt Can Avoid a Strike – But Will He?

The British Medical Association’s offer of ACAS mediated negotiations with Jeremy Hunt and NHS Employers to try to solve the junior doctor dispute was met with predictable reluctance by Hunt. The health secretary was doubtless smarting from the overwhelming vote of junior doctors to strike (98% of a 76% turnout said yes), but also because so many consultants and GPs have publically expressed their support. Hunt’s charge that doctors must resist the lure of the radicals seems all the more absurd given the medical profession has never been more united around its 53,000 junior staff (many of whom are far from ‘junior’).

Hunt has not ruled out using ACAS at some later stage, but by refusing the offer immediately he knows he is allowing the strike action to go ahead, perhaps hopeful of the damage it might do to the reputation of junior doctors and the BMA. Theoretically, patients requiring urgent care would not be harmed as that care should safely be provided by consultants and non-consultant grade specialists, but some patients may suffer from delayed diagnosis due to the cancellation of out-patient clinics and delayed surgery as non-emergency services are suspended.

This short term harm would be far less than the damage caused to the NHS by the mass exodus of junior doctors, but it’s hard to envisage how a solution can be found with the government’s insistence that more services can be extended over 7 days in the NHS whilst keeping the overall budget for junior doctor pay the same and making £22 billion efficiency savings elsewhere in the NHS by 2020. Even Simon Stevens, the normally unflappable chief executive of NHS England, has warned that ‘considerable more progress is needed to get a workable funding settlement for the NHS’ in the next 2 years. George Osborne has offered £3.8 billion this year, but how much of this is new money, and how much has been clawed back from cuts elsewhere? At a little under 1% a year in a service starved of funding for 5 years, it will just about soak up the debt and keep the lights on. When will UK citizens be offered the choice to fund their health service at the same level as, say, France or Germany?

Juniors just don’t believe the same number of doctors can be stretched further over the working week without making their working conditions unsafe, and it’s up to Hunt and NHS Employers to convince them otherwise. Hunt’s belief that stretching the same number of doctors over seven days would reduce the higher mortality rates observed in hospitals between Fridays and Mondays is entirely hypothetical (Eye last), and it’s his bad science that infuriates doctors most. He was at it again this week, claiming that in only 10% of hospitals are patients seen by a senior doctor within 14 hours at weekends. GP Faye Kirkland asked three statisticians to review the same NHS data. They concluded ‘the average percentage of patients assessed by a senior doctor within 14 hours – across all hospitals, specialties and the whole week – is around 79%. The available data are only for emergency admissions and they cover the whole week and not just the weekend. It is not possible to cut the data by weekday/weekend.”

Hunt keeps spinning but it simply doesn’t wash with doctors. Drawing unsubstantiated conclusions form complex data is how newspapers are sold and political arguments are won bit it won’t win over the hearts and minds of NHS staff, many of whom simply distrust him. That’s why ACAS is needed – a sensible suggestion put forward by a number of Royal Colleges in the hope of avoiding strike action.

Will Hunt accept the offer? And if he does, will he remove the threat of imposition? The threatened strike is at least providing useful cover for the looming winter crisis and has allowed the government to push ahead with its mandate for the NHS in England for 2016/2017. Citizens could in theory contribute to this but the process received no publicity and closed on November 23. As MD predicted, Virgin Care has won a £64m contract to run the entire community child health services in Wiltshire. Virgin already holds nearly 330 NHS contracts. Across England, community hospitals and services for pathology, sexual health, end-of-life and cancer care are being put out to tender. A draft NHS England Whistleblowing Policy is horribly inadequate and the Cities and Local Government Devolution Bill could land the NHS with another huge untested bureaucratic mess. So maybe Hunt is wise to keep the focus on junior doctors.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

Junior doctors speak up

As health secretary Jeremy Hunt and the BMA prepare to do battle over the junior doctors’ contract, spare a thought for the doctors themselves, many of whom aren’t even members of the BMA. Many have shown great courage to speak up in person, not anonymously. They are also numerate and understand the scientific method, two qualities that appear to have eluded the health secretary of late. Jeremy Hunt is relying on his manifesto mandate (i.e. the votes of 24% of the eligible electorate) to enforce whatever he means by a seven day NHS, supported by a paper in the British Medical Journal in September entitled ‘Increased mortality associated with weekend hospital admission: a case for expanded seven day services?’ Note the question mark.

The article reported an analysis of 30 day mortality after admission to hospitals in England and found an excess number of deaths among patients admitted at weekends. It found that 11?000 more people die each year within 30 days of admission to hospital on Friday, Saturday, Sunday, or Monday than on other days of the week. So not just weekends, but Fridays and Mondays too. It was not able to determine why this occurred or whether any of the excess deaths could have been avoided.

The paper ‘arose from a request by Bruce Keogh’, the medical director from NHS England, and he also appears as one of the authors. So the most senior doctor in NHS England has ordered and co-authored a paper that is politically very convenient for Jeremy Hunt, who promptly spun it to support his threat of imposition of new contracts for junior doctors and consultants. This prompted BMJ editor Fiona Godlee to write to Hunt ‘to register my concern about the way in which you have publicly misrepresented an academic article’ In essence, Hunt’s proposition that the excess deaths would be reduced if, say, more doctors worked at weekends is entirely unsupported by evidence. It may be that patients admitted between Friday and Monday are simply sicker and therefore more likely to die.

Even if more doctors would help reduce mortality, they need to be supported by other hospital services and more social care, and noone numerate believes this can be done in the context of £22 billion efficiency savings. Hunt’s offer to junior doctors is cost neutral, which can only mean that more staff at weekends would leave less staffing on weekdays. And having boldly promised that no junior doctor would lose out, Hunt had to backtrack and admit the 500 junior doctors currently working the longest hours in the critical care specialties will lose out substantially. The ‘salary guarantee’ for others is only until 2019 and as just about all NHS contracts at present have built in savings year on year, it’s unlikely that doctors salaries will be immune in the longer term.

Bruce Keogh, who had angry letters from a thousand doctors, has now distanced himself from Hunt. “We were very clear that it is not possible to ascertain the extent to which these excess deaths may be preventable.’” Hunt has not lifted the threat of enforcement of a new contract on junior doctors and the BMA’s ballot for strike action has gone ahead. It’s a high risk strategy on both sides but Hunt may secretly hope the BMA backs itself into a corner to distract from the wider ills of the NHS. The service is on its knees not because of the way doctors work but because, as the OECD pointed out last week, it has had zero growth in health spending since 2009. The UK is in the bottom third of OECD countries in five-year relative survival for colorectal cancer, breast cancer and cervical cancer, and survival after hospital admission for a heart attack or stroke is also worse than in many OECD countries. Stretching the same number of doctors over 7 days probably won’t solve this.

Junior doctors are the smoke alarms of the NHS. They know the service is seriously under-resourced, their stress and debt levels are high and they are anxious, angry and unhappy at a health secretary who has lost their trust and is now trying to threaten them into submission. Above all, they need a work life balance to allow them to rest, relax and recover. Many will end up seeking this abroad. Others will carry on working unpaid illegal hours to cover vacancies, sick colleagues and even sicker patients until they burn out. No-one avoids death in the end. But as the Mid Staffs scandal proved, the deaths in a service cut to the bone can be deeply unpleasant and scar those who witness them for life.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here