Hunt’s Choice

In the 31 years since MD first set foot on an NHS ward, there have been a dozen major political disruptions to the NHS. Margaret Thatcher sewed the seeds for an NHS market by splitting it into purchases and providers. Tony Blair’s Labour trebled the budget but also insisted on the ‘constructive discomfort’ of competition. Alas, billions were squandered in paying private providers over the odds ‘to encourage new entrants into the market’ and on PFI deals that are still crippling hospitals today.

The current government’s big idea is to use the global financial crisis as an excuse to starve the NHS and social care system of funding, in the hope that some miraculous better value innovations will rise from the ashes, with the wind of private sector partners beneath their wings. Wary of resistance to privatization in the NHS, the government is using the Trojan horses of ‘integration and collaboration’ to create accountable care organisations (ACOs), which will have budgets for (almost) the entire health and social care of a fixed population, and the entire staffing and administration costs. All the providers within an ACO have to grow up and collaborate fast to ensure patients are treated in the most clinically and cost-effective way. A penny wasted is a penny less to spend on wages.

For patients, treating health and social care as one joined up system makes sense, and it might provide a better service. The experience in America is that ACOs can modestly improve quality but don’t have a huge effect on cost, so they won’t immediately help the NHS make the £22 billion savings George Osborne is demanding. However it does give the opportunity for multinational corporations with experience of running ACOs to win bids in the NHS market. In one fell swoop, a huge chunk of NHS power and money could be transferred to overseas companies driven by shareholder profit.

More urgently, none of the 850 delegates at the recent National Institute for Health and Care Excellence (NICE) conference believed that the NHS can make £22 billion worth of savings without dramatically worsening access to or quality of care. Ged Fitzgerald, the chief executive of Liverpool city council, detailed the staggering levels of poverty and inequality in his city, and said that his entire budget for adult social care will run out in two years’ time. Given this is a statutory service, the government will have to come up with the funding eventually. But why is it putting the NHS and social care system (and patients and carers) through the stress and pain of funding delay?

One answer comes from comparatively affluent Wiltshire, where the chair and accountable officer of the Clinical Commissioning Group (CCG) have written to all GPs to say ‘the financial situation is dire.’ Their predicted funding gap for 2016/17 is £23 million, as the demand for services far increases the funding for them. The only solution will be to ration services and delay referrals. The NICE conference was full of examples of CCGs either illegally rationing NICE approved treatments, or raking up huge debts to provide patients with care they are legally entitled to.
Under huge pressure, Wiltshire CCG has handed over its entire community child health service to Virgin Care. Children’s specialist community nursing, vital and complex child protection, disability and special needs work, health visiting and speech and language therapy will all come under Mr Branson’s umbrella, and staff who wish to stay on will all be reemployed by Virgin care as of April 2016. Will it provide a better service, will it be able to make a 5% profit or will it try and fail?

Overall, the NHS in England has a £960 million overspend for the first quarter of the year, many trusts have ongoing safety issues according to the CQC, most are in debt and 33 don’t have a permanent Chief Executive. The publication of safe staffing evidence has been delayed by the government because Trusts don’t have the money to comply, the retention of student nurses is poor and the retention of junior doctors may will get catastrophically worse if Jeremy Hunt doesn’t see sense over their new contract. With so many Trusts in debt, there is a certain gallows spirit and safety in numbers. Chief Executives barely last a couple of years in the NHS anyway, and most would prefer to go down pissing off the accountants and the Treasury rather than killing patients and being demonised by the Daily Mail. Jeremy Hunt may soon have to make the same choice.

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

Very honest letter from Chair and Accountable Officer of Wiltshire CCG. This situation is being replicated throughout the NHS. Liverpool council will run out of money for adult social care in 2 years if the situation doesn’t change

Wiltshire CCG Dire Financial Situation

Feeling the Squeeze

The Tory conference continued to peddle the delusion that routine NHS services can be safely extended to seven days a week whilst making eye watering efficiency savings. The government has a convenient blame figure lined up in Simon Stevens, the chief executive of NHS England, who calculated that the NHS shortfall by 2020 would be £30 billion, based on an ageing population that demanded more care. He also pronounced that £22 billion of this could be recouped by ‘working smarter’ and encouraging people to take more responsibility for staying healthy. This left the government with just 8 billion to provide at some unspecified time before the next election.

In the first year of Stevens’ ‘five-year forward view’, no efficiency savings have been made at all. Indeed, the NHS deficit will soar to over £2 billion, leaving the NHS to somehow make £24 billion worth of savings over four years. Even worse, the performance of the NHS has nosedived. Waiting times are up across the board, some Clinical Commissioning Groups are rationing NICE approved services illegally and every day 100,000 people aren’t able to see a GP when they want to.

It’s not just Stevens feeling the heat. Having dangled his balls over the balcony of the British Medical Association (Eye 1398), Health secretary Jeremy Hunt has been surprised at how vigorously junior doctors have squeezed them. Hunt initially threatened to impose a new contract on consultants but then decided to turn his fire on junior doctors. He described the BMA as “utterly irresponsible” for trying “to scare people into believing” he wants to cut pay. And yet the only way to extend services and make huge savings is to force doctors to work more hours for the same money. Many politicians have a deep animosity to the BMA, but many doctors find their union self-serving and ineffectual. However, in now threatening to impose a contract on junior doctors who have walked away from negotiations, Hunt has simply acted as a recruiting sergeant for the BMA.

The BMA is making bold claims of balloting for industrial action, but a compassionate and ethical workforce is very limited in the protests it can make. Hunt knows that if he toughs it out, he will win but at what cost? Every junior doctor who moves abroad, or even to Wales or Scotland, is a huge loss to NHS England. And anyone who leads an organisation but does not have the majority of the workforce on his or her side is doomed to fail. Hunt has already upset many NHS staff by suggesting they don’t already work at weekends, and by claiming that higher mortality rates at weekends would be reduced if more doctors were on duty. The evidence does not support this, and doctors are busy collecting evidence of ‘the Hunt effect’ – citing examples of patients who have come to harm by not seeking help at weekends because they were worried it was too dangerous to do so.

If Hunt is not careful, he will become the new Lansley, losing the confidence of the staff but still forcing through unproven policy based on ego and ideology. He has at least written a conciliatory letter to the BMA junior doctors’ committee, but whether he can recapture their trust remains to be seen. Hunt’s former health minister Dr Dan Poulter, who was involved in the junior doctor negotiations, has warned that some specialty doctors may indeed be facing large pay reductions.

The key point about junior doctors are that they are doctors in training. As well as providing a vital NHS service, they need to be properly trained and supervised. Great Ormond Street hospital (GOSH) has lost all of its haematology and oncology Registrars and SHOs because they were reduced to being ‘clerking monkeys’ and getting no training. Hunt wants to widen the normal hours of doctors in all hospitals, which means he will also widen the training mandate of each Trust, and this has to be properly costed.

GOSH is also closing its highly regarded paediatric chronic fatigue syndrome/ ME service, because it is no longer financially viable. In MD’s home city of Bristol, the NHS is giving up on providing community paediatric services for the same reason, leaving ‘private sector partners’ to bid for the contract. The suspicion that the NHS is being starved of funding to create opportunities for the private sector is hard to ignore, but it’s extremely unlikely that, say, Virgin, can do extremely delicate and vital child protection work any cheaper or more competently than the NHS.

For the NHS to balance the books under the current funding restrictions, the service must somehow make 3-4% efficiency savings a year, something it has never done, or simply provide less care. David Cameron’s announcement of a new contract for General Practice is a recognition that CCGs aren’t delivering savings, but select groups of GPs may yet be offered ‘a total budget’ to buy health and social care for large groups of patients. It’s a last roll of the dice for Cameron, Hunt and Stevens.

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

Addenbrooke’s on Fire

The ‘special measures’ meted out to Cambridge’s prestigious Addenbrooke’s hospital by the CQC is a symptom of an NHS struggling to cope nationally and locally. Fifteen NHS trusts are now is such measures, whilst two thirds are in debt and 33 are without a permanent chief executive. Many services are deemed inadequate and unsafe because they don’t have sufficient clinical staff, particularly nurses and midwives, which makes NHS England’s decision to halt and refuse to publish NICE’s work on safe staffing levels all the more inexcusable.

Even if more money was available, failings in workforce planning mean many hospitals and GP practices struggle to recruit staff, and the working conditions and static pay make them hard to retain. A new contract is to be imposed on junior doctors which could mean some specialties – particularly GP trainees – face large salary cuts which is hardly likely to help recruit the additional 5000 GPs needed to keep the NHS afloat. Large cuts in benefits, social care and local authority budgets are pushing up demand in the NHS, as is an ageing population. Clinical Commissioning Groups are also in debt and struggling to cope with their responsibilities. And despite the myriad inspections, there are still huge variations in the quality and standards of NHS care.

The recent publication of the third NHS Atlas of Variation got much less coverage than the hospital failures in Cambridge and East Sussex because it doesn’t name institutions or individuals, so it’s far harder to blame anyone. But the statistics were still alarming. There is a 2.1 fold variation in the number people under the age of 75 losing their lives to cancer, and patients who received an early-stage diagnosis – a critical factor in treatment outcome – ranged from 22.7% to 60.8%. Some is down to patient education and behaviour, some is down to bad luck and some is down to a failing NHS.

With strokes, 40% of patients are still not admitted quickly to a specialist unit, despite longstanding NICE guidance (Eyes passim). Some diabetic patients are receiving less than half their recommended check-ups and are more at risk of complications. Elderly patients in some parts of the country are nine times more likely than in others to be admitted to hospital as emergency cases. Lack of resources is only one cause of poor quality care, but it’s the most important. And yet the NHS is sinking deeper into debt with a likely £2billion deficit this year.

Alas, the CQC does not have a ‘requires investment’ category. Along with the government and NHS England, it is in denial about the scale of NHS debt and believes the problems or poor quality care, and lack of access to care, can be solved by further efficiency savings, collaborations, mergers, hospital chains and federated GP practices. With most struggling hospitals, the earliest signs are a poor staff survey and unhappy whistle blowers. The NHS Staff Survey 2014 for Addenbrooke’s saw the trust performing worse than average for 62% (18/29) of the key findings. 52% of key findings fared worse in the 2014 survey than it did in 2013. Measures of ‘staff engagement’ were worse than in 2013 and staff reported worse rates of harassment, bullying, or abuse from other staff.

The CQC heard staff voice concerns about unsafe staffing levels and the chaotic introduction of a new IT system but did not comment on its treatment of whistleblowers. Dr Narinder Kapur was sacked as head of neuropsychology at Addenbrooke’s in 2010 after raising concerns about staff shortages and unqualified staff working without proper supervision. An employment tribunal ruled in 2012 that Kapur had been unfairly dismissed, ruled that accusations of fraud against Kapur were unfounded and that he was a man “of the highest integrity”. Dr Kapur has since campaigned for an inquiry into the sacking of three Indian consultants who raised concerns by Addenbrooke’s. One was a highly regarded Obsetrics and Gynaecology consultant. The department was rated ‘inadequate’ by the CQC.

Some of the trust’s failings were doubtless due to problems with the introduction of an ‘eHospital programme’ and an ‘Epic’ electronic patient record system which “affected the trust’s ability to report, highlight and take action on data collected on the system.” But the surest sign of a trust in trouble is poor staff morale caused by overwork, understaffing, bullying and not having concerns listened to. If there is no money to invest in better services across the NHS, then the CQC will find far more of them inadequate and unsafe in the next five years. Already, the CQC is failing its own inspection targets because it can’t recruit inspectors. How long Jeremy Hunt can tough this out remains to be seen. Meanwhile Addenbrooke’s needs a new chief executive. Any takers?

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

Do you believe in the Care Quality Commission?

Do you believe in the Care Quality Commission? Health Secretary Jeremy Hunt clearly does, pronouncing that a “good” or “outstanding” rating is now the “single definition of success” in the NHS. This implies that something as complex and fast moving as health care can have a single definition of success, and the over-stretched CQC – which often only produces its reports many months after it has inspected a hospital – is up to the task of measuring and monitoring it. The previous badge of excellence for NHS hospitals in England was the prestigious ‘Foundation Trust’ status, but this lost credibility after Mid Staffordshire hospital became an FT despite appalling failings in the care it provided, and it has lost further credibility after the CQC rated 33 FTs as “inadequate” or “requires improvement”. FT’s are rewarded for balancing the books, whereas the CQC rewards the quality and safety of the services provided. So a highly rated CQC trust could be a basket case financially, and a financially prudent trust could be hiding appalling care.

The CQC inspects hospitals, GP practices, ambulance services, care homes, clinics, dentists, community services, mental health services and home services in both the NHS and private sector. It’s a massive and very expensive undertaking. – of its most recent inspection ratings, 20 services were judged outstanding, 646 good, 334 require improvement and 74 were inadequate. Hunt is doubtless keen for patients to shop around and take their custom to the outstanding trusts but choice is hard in healthcare, particularly when care is needed urgently. A further complication for patients is that a single large hospital may contain a mixture of outstanding, good, inadequate and unsafe services. For example, on 17 August, Homerton University Hospital in Hackney recently received an overall rating of ‘Good’ from the CQC. It’s urgent care centre was deemed outstanding, and all of its other services were judged as good apart from Maternity and Gynaecology, which ‘Requires Improvement.’

‘The maternity unit reported a high number of serious incidents including two maternal deaths in 2013, two in 2014 and a further one in January 2015. The service was not consistently learning from all these adverse incidents and implementing all the necessary improvements. Woman and their babies were not always being adequately monitored. The environment and equipment were not appropriately cleaned. Equipment was not consistently maintained or checked…. We found the majority of issues identified at our first unannounced inspection, such as the environment, documentation and patient safety, which the trust stated they had taken action to address, had not been resolved when we returned one week later for an announced inspection.’

Read further and the CQC report gets even more unsettling. ‘Not all incidents in maternity service were reported. There were unacceptable levels of serious incidents and never events. Reported incidents were investigated but the response was slow resulting in continued potential risks to mothers and their babies. Staff were not proactive in maintaining a safe environment and both the environment and equipment were not appropriately cleaned. Resuscitation and emergency equipment had not been consistently checked to ensure it was ready for use. Drugs were not administered or stored safely in the maternity service. Midwifery staffing levels were less than the recommendations of Birthrate Plus. Some shifts on the labour suite were staffed predominately with bank and agency staff.’

None of this is news to readers of the Hackney Gazette, where an anonymous whistleblowing group called ‘the unhappy midwives’ have been raising concerns about the quality of maternity care for some time. A separate petition was set up to investigate neonatal deaths. The Eye received an allegation of a delivery where a baby’s head became separated from its torso. In response the trust stated that ‘Legally we cannot discuss details of individual cases. We can confirm that on that day there was a delivery of a non-viable foetus and this was reported to the Coroner’s Office who felt that this did not require further investigation.’ The CQC appear not to have been told about this.

Homerton provides maternity services for 252,000 people in Hackney, and its maternity unit delivered over 5,500 babies in 2014. It’s caseload is huge and extremely complex, and yet for the maternal death rate to be so high and the service to be judged unsafe on so many measures suggests it is not a unit you would choose to have a baby in. And yet the vast majority of people who use its services have no choice, whatever Jeremy Hunt or the CQC says. So how will Homerton improve? Or Addenbrooke’s?

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