A leadership crisis

On paper, running the NHS seems relatively straightforward. You have to provide universal healthcare (or at least the treatments NICE deems are both effective and value for money), you have to do it a standard that is both safe and effective, and you have to stick to your budget. Yet in the battle to achieve access, safety and affordability, very few NHS leaders succeed, or are given the time to succeed.
The average job span of an NHS chief executive is two and a half years and only one in 10 trusts has had the same chief executive for a decade or more. One-fifth of trusts have no substantive director of finance and one-sixth have no substantive chief executive. It is the same picture for directors of nursing and medicine. The jobs are so tough, and the culture of fear and blame so prevalent, that very few clinical staff want to do them. And yet the NHS will collapse if they don’t.

Between 1948 and 2011, NHS annual funding growth averaged 4%. From 2011-2015 it was 0.9%, and the target growth 2015-2020 is 1.5%. The current budget requires another £22 billion of ‘efficiency savings’ in the course of this Parliament, and yet demand for care is rising. I in 3 people can now expect live to a hundred and half of those diagnosed with cancer live well over 10 years. For dementia alone, there are currently 850,000 people in the UK who have been diagnosed, costing the UK £26 billion a year. According to the Chief Medical Officer’s latest annual report, almost two in three adults in England weigh more than they should: 37 percent are overweight, and a further 25 percent obese. Over the next 20 years, the number of obese adults is set to rise to 26 million with a huge impact on the NHS. Many illnesses (cancer, diabetes, kidney, liver, heart and vascular disease, stroke, dementia, depression) are more likely if you are obese, and many treatments are higher risk and more expensive.

There clearly is no easy answer, but encouraging the brightest clinicians to take up senior leadership roles in the NHS is vital. This makes the government’s threat to impose rushed new contracts on consultants and junior doctors all the more nonsensical. A decade of austerity it tough enough without alienating the staff who are best placed to keep the NHS afloat. In a brilliant letter that has been shared 175,000 times on Facebook, intensive care junior doctor Janis Burns vents her frustration on David Cameron. She is part of a team, including consultants, that provides a 24 hour, 7 days a week, 365 days a year service.

Having worked 11 hour overnight shifts on Friday, Saturday and Sunday ‘on Monday night I did something Jeremy Hunt has openly chastised. I worked another night shift as a locum in another hospital. Why did I do this? Because I, 34 years old, did not want to have to borrow money, yet again, from my elderly parents. As a student, my student loans did not even cover my rent. I accumulated £20,000 professional studies loan and £7000 of credit card debt. Over £1000/month of my salary is used for debt repayment and I still have 26 more months to pay before I am only left with my student loan repayment. Living in London, my rent is £926/month. Will ever be able to afford to buy a one bedroom flat in London?’

The staffing time bomb in the NHS is as much of a threat as diabetes and dementia. Young doctors are leaving the NHS to work abroad, and many doctors and nurses are choosing to work for locum agencies because they need the money. The BMA’s junior doctor committee has now voted not to re-enter contract negotiations with NHS Employers following the government’s insistence it accepts all of the recommendations on a new contract without question by mid-September. The new contract would extend routine working hours from 60 hours per week to 90, and deem that working at 9pm on a Saturday is the same as working at 9am on a Tuesday. Junior doctors may be bounced back into working dangerously long hours and their pay would not match the experience junior doctors’ gain through their training. Doctors on 1A banding face a 15-20% pay cut, those who spend 4 years on a research PhD get no pay increase, and a hospital doctor who retrains as a GP may get a big pay cut. None of which will inspire recruitment and retention in the short term or the loyalty needed to develop the leaders of the future. It’s time for the government to listen to and collaborate with NHS staff.

The petition for a vote of no confidence in Jeremy Hunt has garnered enough signatures to be debated in Parliament on September 14 – but it probably wont be

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

Medicine Balls

Cradle to Grave

An FOI request from the Observer to the Care Quality Commission has revealed it was notified of 30,000 allegations of abuse involving people using social care services in the first six months of this year. Allegations ranged from physical, emotional and sexual abuse to financial fraud. The rate at which allegations of abuse have been made in 2015 is double that of 2011. In 2013-14, a professional carer was the alleged abuser in care homes in 57% of allegations. In people’s own homes, professional carers were identified as the abuser in a third of cases.

The CQC seems powerless to stop the flow of allegations it receives – 150 a day – and its chief inspector of adult social care, Andrea Sutcliffe, has publically blamed a lack of political leadership and huge cuts in funding. £4.6bn has been cut from social care budgets in the last five years. How to train, motivate, pay and retain a million care workers with less funding is unclear.

Poor care of the elderly gets most media attention because elderly patients are the main users of the NHS and social care. However, the greatest long term health benefits come from investing in the social care of the youngest. £377 billion a year is spent in the UK on social spending, including benefits and pensions, but only £12 bn on childhood interventions. The UK’s record on disease and deaths among under 5s is poor, and those that survive child poverty can have long-term health issues.

Children living in poverty in the UK are more likely to die in the first year of life, be born small, be bottle fed, breathe second-hand smoke, become overweight, perform poorly at school, die in an accident, develop chronic diseases, have a poorer quality of life and to die prematurely as adults. Investing in better health, education and social care for mothers of unborn babies and children up to the age of five has huge long term benefits in reducing physical and mental illness, family breakdown, drug use and obesity And yet this area is facing the biggest cuts.

Children’s health services are likely to be most affected by £200m cuts to local authority budgets in England by 2016, as NHS budgets for 0-5 year olds are transferred to LAs in October 2015. The Government has already ditched its child poverty targets, and cuts to tax credits and welfare spending are likely to make child poverty worse. Child poverty was assessed as the proportion of family households with an income below 60% of median income, which meant that 2.3 million children (almost one in six) are below the poverty line. Tony Blair’s commitment to eradicating child poverty by 2020 looks unlikely.

At the other end of life, Healthwatch England has published Safely Home, a report of the problems facing older people and their families when they leave hospital. 15% of patients aged over 65 are readmitted within 28 days. This is both expensive and distressing but the reasons again are complex. Some elderly patients are simply discharged too early because the NHS has so few beds and they are needed for acute medical care. Others develop a relapse of a long term condition or a new illness or injury when they get home. Some of these could be treated at home with the right health and social care support, but this requires significant investment. The struggle to access out of hours care means that many elderly patients are either advised to go, or are taken, directly to emergency departments.

Some patients are kept in hospital longer than needed as commissioners wrangle over whether the NHS or social care service should pay to support their discharge, or try to find a care home bed. And the longer a hospital stay, the more likely an elderly patient will lose function and independence, making it more likely they will be readmitted after discharge.

In England the NHS is stuck with the view of its CEO Simon Stevens, who has asked for only £8 billion extra over the next 5 years in the hope of making £22 billion savings. This has allowed the government to crow that it will give the NHS all the money it needs. But the extra demands on the NHS caused by child poverty, chronic disease, elderly care and cuts to social care and benefits will be huge. Stevens needs to do his sums again, and quick. The NHS is already unsafe and unsustainable.

My book – Staying Alive – How to Get the Best from the NHS – is available here

Bad Science, More Blame and a nasty U turn

Why has health secretary Jeremy Hunt been dangling his balls over the balcony of the British Medical Association? In his speech setting out a 25 year vision for the NHS, he claimed the BMA ‘was not remotely in touch with what its members actually believe’, that ‘your chance of dying on a Sunday in an NHS hospital is 16% higher than dying on a Wednesday’ and that ‘6,000 people lose their lives every year because we do not have a proper 7-day service in hospitals.’ The evidence for the 6000 lives lost is complex and imperfect. One study, from hospital admissions in England in 2009-10, was retrospective and observational, so only designed to spot an association not to prove cause and effect. The numbers were large – there were 14,217,640 admissions and 187,337 deaths in the 30 days after admission. Your overall chance of death was just 1.32%, so a 16% increase in risk sounds a lot but in absolute terms is still small.

Another study allegedly supporting the 6000 figure has yet to be published and scrutinised properly, so to make such bold political claims on the back of an unpublished source is very bad science. Hunt has cleverly manipulated the debate to look as if the barrier to ‘a proper 7 day service’ is consultants who have opted out of weekend working. This prompted a barrage of social media posts of NHS staff of all grades working at weekends, including many consultants (#IminworkJeremy) and a petition for a vote of no confidence in Hunt that has gained well over 200,000 signatures.

Hunt may have been warming up for a pop at the Tory leadership but he’s also saddled with some election pledges that simply aren’t deliverable in the context of a further £22 billion of efficiency savings. Promising everyone over 75 a same day appointment with a GP when 30% of GP training schemes have vacancies and older GPs with full pension pots are lining up for early retirement is hard enough. An NHS where every day offers the full range of elective and emergency care is impossible without considerable investment and safe staffing levels.

A sensible approach would have been to focus the 7 day service on urgent and emergency care, which all NHS staff would support. Attempts to extend routine general practice to 7 days were tried by Labour and found to be expensive and unpopular (few people choose to spend their Sundays at a GP surgery). And you can’t have a 7 day NHS with a 5 day social care service, itself facing even more draconian cuts than the NHS. Hospital patients are largely elderly, and many very frail, and they can’t be discharged without proper social care support.

Most worrying is the government’s – and NHS England’s – lack of transparency on safe staffing levels. NICE – the National Institute of Health and Care Excellence – is an internationally trusted source of evidence that has finished vital work on safe nurse staffing levels in accident and emergency departments, along with four reviews of safe staffing in other settings such as mental health and community nursing. The NHS needs to see and act on this evidence now to prevent similar understaffing tragedies to Mid Staffs.
Having been told by NHS England CEO Simon Stevens to halt the work so it could be taken over by a new organisation, NICE promised to go ahead and publish it for the good of the NHS (and other health services that rely on NICE evidence) before doing a dramatic U turn. How much it was pressured to shut up by the Department of Health and NHS England remains to be seen. But it was ironic that NICE should announce its capitulation in the week that the Department of Health published its response to the ‘Freedom to Speak Up’ review, claiming that the NHS would no longer tolerate cover ups. To then cover up the safe staffing evidence when it is the vital to prevent future scandals and patient harm is an act of breath-taking hypocrisy.

Even more worrying for NHS staff is that if an organisation as powerful and supposedly independent as NICE feels unable to speak up and publish vital safety information that is clearly in patients’ interests, what hope is there for individual whistle-blowers? Research by the Health Service Journal found that 84 per cent of acute trusts failed to meet the existing nurse staffing targets for both day and night in April 2015. If the NHS cannot afford the safe staffing levels that the best available evidence says it needs, the public should be asked if it wants to pay more for the NHS, not have the evidence hidden from view because it is politically damaging. Never mind the truth. Just blame the BMA.

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

The Right Care

The eighth patient safety congress in Birmingham (July 6&7) turned out to be feistier than MD had predicted. In a show of hands, the vast majority of the audience – largely patient safety experts – declared it wrong that NICE had been told by Simon Stevens, CEO of NHS England, to halt its work on safe staffing levels in different NHS settings, including emergency departments. The work was a recommendation of the Francis report into failures at Stafford Hospital. Professor Mark Baker, director of the centre for clinical practice at NICE, told the conference “I think the reason they don’t want it is they don’t like the answer to the question. … The underlying problem is that the NHS has survived for most of its history by taking risks and not getting found out.”

NICE appeared to show commendable balls in announcing it will press ahead and publish its recommended nurse staffing levels for accident and emergency departments which are likely to propose minimum nurse to patient ratios. It would not be official NHS England policy but trusts may feel obliged to comply. NICE later announced a U turn – probably under pressure from the DH and NHS England – which is absurd and unsafe given the research was publically funded and is the best available evidence on safe staffing not just for the NHS but for other health systems that rely on NICE’s evidence.

Safe staffing levels for nurses per se don’t make the NHS safe – it also depends on the skill mix of other staff (doctors, paramedics), their competence, teamwork and leadership. But it’s very hard to deliver a safe NHS without enough frontline staff and with the pressure on to save another £22 billion, and a national shortage of doctors and nurses, NHS England is clearly worried that hospitals will either fail to hit financial targets or simply not be able to fulfill the required staffing levels in many parts of the country. Would units then be forced to close or struggle on under-staffed? Either way it would be a field day for lawyers if patients came to harm.

In 2013-14, the NHS set aside £15.6 billion to deal with clinical negligence claims and paid out £1.1 billion in settling claims. As it becomes more transparent about staffing levels and the duty to tell patients and relatives when they have been harmed by NHS care, the fear is that the legal bill will rise further. The safety congress made a business case for patient safety, arguing that giving patients the right care, right first time, is a lot cheaper than getting it wrong but the right care is not always easily apparent.

The right diagnosis is clearly critical but around half of all symptoms are ‘medically unexplained’ and don’t fit easily into a diagnostic box. Some hospitals spend so much on expensive investigations for chest pain, abdominal pain and headaches with ‘normal’ results, that they’ve set up ‘Medically Unexplained Symptoms’ clinics. If you do get an initial diagnosis, it’s likely to be wrong 15% of the time. That’s not usually negligence, just the way informed guesswork goes. Always ask ‘What else could it be?’ And ‘How would I know?’

The right care also needs the right treatment but for most diagnoses, there are now a lot of options to choose. Doctors try to go through all of them – what’s right for one patient may be completely wrong for another – but sharing complex decisions in ten minutes is near impossible. Fortunately, most decisions don’t need to be made immediately, many symptoms improve in time and many treatments and screening programmes are surprisingly ineffective. If you ask ‘What’s most likely to happen if I just watch and wait’, the answer is often that you’d live just as long as if you have your life expensively and inconveniently medicalised.

If you opt for treatment, the chances are NICE will have published what standards of care you should expect. Patients generally take even less notice of NICE than NHS England. Hence 135 amputations a week are performed on diabetic patients, the vast majority of which could be prevented if they were treated to the standard that NICE dictates. But patients and a surprising number of NHS staff either aren’t aware of the standards, or don’t have the resources and staff to follow them. High quality care costs money, and the biggest cost is staffing. And yet 70% of what can be done to prevent chronic diseases – and to prevent them getting worse – is down to lifestyle and life circumstances. The NHS is powerless to deliver the right health care unless patients do the right self-care. Education may help, and so may taxing sugary drinks. 26,000 children were hospitalised for rotten tooth extraction last year. A third of 5-year-olds and half of 8-year-olds were found to have decay in their milk teeth. Healthcare begins with the education and support to self-care.

MD’s book on how to self-care and get the best from the NHS is available here

Safe Staffing

Will patients be harmed by the government’s relentless demand for more efficiency savings in the NHS? Former health minister Norman Lamb believes that the proposed £22 billion savings by 2020 are ‘almost impossible’. And Morecombe Bay investigator Dr Bill Kirkup has warned of disastrous consequences if the NHS focuses on financial savings at the expense of patient safety. Meanwhile Mid Staffs investigator Sir Robert Francis is outraged that NHS England has halted the work on safe staffing levels by the National Institute of Health and Care Excellence. NHS England has instead decided to ‘take over the work’ despite lacking the independent authority and expertise of NICE, and not being able to cope with its current workload. As one senior NHS England manager told MD; ‘I get hundreds of e mails in my in box each day, many of which concern serious governance issues that have arisen out of the confusion of the Health and Social Care Act. I cannot possibly deal with them all – it’s a high risk strategy trying to pick out the urgent concerns.’

The topic was at least debated at the annual Patient Safety Congress (July 6/7) but pressure is being piled onto Directors of Nursing and others to shut up about safe staffing. It shows how little the NHS has changed despite all the rhetoric about encouraging free speech. The government and NHS England knows it cannot safely staff hospitals or indeed GP and community services, so the ‘safest’ political option is to dampen down the evidence to show how importance safe staffing is. A high quality study by NHS England leaked to the Health Service Journal found a significant correlation between the number of nurses on duty in hospitals and 40 indicators of patient safety outcomes such as slips, trips, falls and picking up vital signs such as high temperature, respiratory distress and signs of sepsis. Many hospital inpatients have multiple illnesses and highly complex needs, and can deteriorate rapidly. They require highly skilled staff in sufficient numbers to give them the right care.

The Safe Staffing Alliance is at least prepared to keep shouting and has five important, evidence based messages:

1) Numbers matter when delivering safe and effective care. It is unsafe to care for patients in need of hospital treatment with a ratio of more than eight patients per registered nurse (excluding the nurse in charge) during the day on acute wards. There is evidence that risk of harm to patients is substantially increased when staffing levels fall below this ratio so it must be considered as a ‘red flag’ event and immediate action taken.

2) National standards need to be agreed and enforced. 45% of wards have insufficient staff to meet care needs safely – a situation reflected outside hospitals in the community. Statutory mechanisms should be put in place and guidance issued based on patient dependency, acuity and complexity in different settings.

3) Studies demonstrate that poor care costs more. Employing sufficient nurses and midwives to provide high quality compassionate care, so that patients are treated with dignity and respect, should be viewed as an investment not a cost. Nursing is a 24-hour seven-day-a-week activity and budgets for staffing must be protected to reflect that.

4) There must be genuine transparency over nurse numbers. There is inconsistency in the data recorded with some trusts including the nurse in charge in their nurse/patient ratios. In many areas staff nurses are caring for 10 patients each – more in some cases.

5) Staffing levels based on clear and recognised standards will need investment. Safe, high quality healthcare is expensive and sufficient nurses and midwives need to be trained now to reduce reliance on short term and expensive solutions such as recruiting staff from overseas and reliance on bank and agency staff. There must also be humane jobs available for them when they qualify. Many excellent agency staff started in the NHS but burnt out.

Unless the NHS provides humane and safe staffing levels, it won’t be able to recruit and retain sufficient staff to meet future needs. Junior doctors too are being pressured into dangerous overtime hours, and many are leaving the NHS. The NHS’s greatest asset is its frontline staff, and recruiting them in sufficient numbers to make the job a joy rather than a fast track to burn-out is a no brainer. But tell that to a government demanding immediate and impossible efficiency savings. NHS England needs to start speaking up for NHS staff and NHS funding. As for patients, the safety of NHS care is still hugely variable, propped up by professionalism and good will rather than properly evidenced, planned and resourced safe staffing levels.

MD’s book on how to get the best from the NHS is available here