The Cost of Chaos

MD takes a very simple view on NHS reform. The perfect structure doesn’t exist in any organisation, least of all something as complex as the NHS, and it can be profoundly damaging to keep reorganising in the hope of finding it. The side effects of the unnecessary and ill-judged Health and Social Care Act have been so severe that even lawyers are blowing the whistle to the Eye. As one put it: ‘I get so angry when the government says it’s reduced NHS bureaucracy. It might have cut the number of managers, but the bureaucracy has mushroomed after Lansley’s act. For example, to run community services out of a GP practice used to be simple – a single lease arrangement and contract between the GPs and the Primary Care Trust. Now the PCT commissioning powers have transferred to the Clinical Commissioning Group. The PCT’s interest as tenant transfers to NHS Property Services Limited. NHS PS are now the direct landlord of the provider of the services and the commissioning contract is with the CCG. So now there are four parties to the arrangement to provide simple community services from the GP premises – the GPs, the CCG, NHSPS and the provider.
To review the rent, NHS England needs to give approval if the GPs are to get their rent reimbursed and there is a knock on effect for all the leases in the chain so all parties need to be involved in some way. This simple process now requires the engagement and approval of the GPs, the Landlord, the CCG, NHSPS, the new provider and NHS England, and four leases and one community services contract. With each added party, there are more loops to jump through, more people on the email trails, more people at the meetings, more approval processes, more professional fees, more time wasted and greater delay. Frankly, I’d rather stay at home and nail my testicles to the table.’

The stated aim of government is to move some services out of acute hospitals closer to home, and yet the same government has created absurd bureaucratic hurdles and provided no new money for investment. Providers of essential community services that are just about breaking even are now being asked to pay higher property costs but do not have the money to do so and the government has made it clear they won’t be getting any more. Last month, North Bristol NHS Trust decided not to retender for its excellent community paediatric care services, which covers all community child health, and child and adolescent mental health services for Bristol and south Gloucestershire. The trust’s official reason for ditching such a vital service is that it wants to focus on its hospital based care. But the hidden message is clear. The government has made it near impossible for such services to break even in future and – along with the bureaucratic torture of running them – it’s easier for the NHS providers to give up and leave it to the private sector to tender for.

Meanwhile, an independent investigation into the collapse of the specialist adult dermatology service at Nottingham University Hospitals Trust has described the handling of changes by commissioners and providers as an ‘unmitigated disaster’. The trust had to close its internationally renowned acute adult dermatology service earlier this year after five of its 11 consultants quit rather than transfer to private provider Circle (Eyes passim) Circle is now relying on six long term locums costing £300,000 a year each because it cannot fill vacant consultant posts. Some of the locums are not sufficiently qualified to be included on the General Medical Council’s specialist register for dermatology. The current service faces the imminent loss of a further consultant rendering the acute rota unworkable and the possibility that, if any of the remaining consultants leave, the demise of the tertiary paediatric service. The consultants gave fair warning well in advance they would leave if the service transferred to Circle because of fears about the quality of the service and job security.

The decimation of the excellent Countess of Chester integrated sexual health service has also been an unmitigated tendering disaster by an incompetent local government (Eyes passim). Tendering is not mandatory, and the three sexual health services in Cheshire would have been far better off collaborating rather than competing and fragmenting. Sexual health relies on a complex network of joined up services (e.g. sexual assault, disease screening and treatment, sexual dysfunction, contraception, pregnancy advice). The new slimmed down services can’t cope with the demand. Waiting lists are rising, calls are not answered and the IT system is useless. HIV and syphilis are now treated in separate clinics, miles apart. Although the tendering could not be stopped, the adverse publicity from this appalling decision may explain why Chester bucked the national trend by returning a Labour MP at the slimmest of margins (93 votes) and gained control of the previously Conservative-led council. The scrutiny meeting discussing the tender is online, but probably not for long

http://www.cheshirewestandchester.public-i.tv/core/portal/webcast_interactive/158782

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

Consent Concerns

On May 19, the Health Service Journal reported that the Care Quality Commission and NHS England have written to the General Medical Council stating that the current system for securing patient consent for treatment is open to abuse. Allegations are being investigated that some doctors have retrospectively altered consent forms to cover up mistakes, and although patients should routinely be given copies of their completed consent forms, many of them aren’t. The GMC will doubtless look into this as a matter of urgency (i.e. within the next decade). The issue is not just whether forms are filled correctly, copied to patients or retrospectively altered, but whether doctors have time to properly gain the consent of patients in an over-burdened NHS. Improper consent was central to the Bristol cardiac disaster, which the Eye exposed in 1992. The results for complex child heart surgery were demonstrably worse in Bristol than at other units at that time, but there was no defined minimal standards forcing them to stop. The surgeons were only found guilty of serious professional misconduct because they had deceived parents in the process of consent, by quoting national average success rates for operations, rather than their own, far worse, figures.

MD has also exposed wide variation in consent procedures for prosthetic hips (Eyes passim). Patients should be told at consent for a newly produced hip or indeed any hip that has been modified (however slightly), that there is no outcome data to support their use in real life (rather than lab tests), and they should be offered a tested alternative approved by NICE. As one patient told MD: ‘One surgeon recommended a metal-on-metal hip. I asked him what the alternatives were but he said this one was the best and newest, and was much less likely to wear out, whatever I did. I didn’t fancy something new that hadn’t been used in humans before, so I asked for another opinion. The second surgeon recommended a very old fashioned Exeter hip. He said I shouldn’t go anywhere near a metal-on-metal hip. He said the potential risks were far too high and I didn’t need to take them at my age. He said I needed a tried and tested hip with great results that was just right for a man of sixty-eight. My new hip works a treat and I was so relieved when I read about all the metal hips that have failed. How can two surgeons a few miles apart give you such different opinions?’

The catastrophic failure of hip prostheses such as the ASR has led to mass litigation and misery, much of which might have been prevented if patients had been given proper informed consent and the choice of a proven alternative hip. For three years, MD has been trying to discover whether the parents of disabled children at Alder Hey hospital undergoing routine surgery for stomach acid reflux have been properly consented. One surgeon undertakes an outdated procedure that involves cutting the vagus nerve and performing a pyloroplasty. This is not recommended by NICE nor international experts in the field, exposes the children to significant risks and has been at the centre of whistleblowing concerns raised by two experienced paediatric surgeons who worked at the trust. The GMC, CQC and NHS England are all aware of these concerns, particularly the lack of hard data to support the operation and questions as to whether parents have been made aware of this. On 24.10.14, Sir Bruce Keogh, Medical Director of NHS England, wrote to MD to say that he had asked Professor Mike Richards, chief inspector of hospitals at the CQC to investigate. Professor Richards assures MD the CQC are taking the matter ‘very seriously’ and have gone back to the hospital to ask for more information. In the NHS, ‘consent’ is rushed through in minutes, but investigating serious problems with consent can take years. In the meantime, read your consent forms carefully, insist on a copy, and ask about the benefits and risks of operating, and the evidence behind them. Watchful waiting is sometimes better than surgery.

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Following MD’s advice that terminally ill patients should be seen at least every two weeks by a doctor to avoid any problems when registering the death, several GPs have written to point out that they are not obliged to visit a terminally ill patient every 2 weeks, and that if a patient dies having not been seen by a doctor in that time it can usually be sorted out by a phone conversation with the coroner, without needing a post mortem. This is indeed usually the case, although not always, as the experience of several Eye readers testifies. MD has just experienced superb NHS end of life care for a relative who died in Sherston, Wiltshire – compassionate, collaborative and competent. Thank you.

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

Dying Matters

Whatever the result of the election, and whatever promises were made, we are all still going to die. Three million UK citizens die during a five year Parliament, and millions more are bereaved. Better palliative care is one area where the NHS and social care system could make huge improvements in compassionate care and make considerable financial savings. 50 per cent of deaths are in hospital, yet fewer than 5 per cent of people say they want to die in hospital. Hospital costs at the end of life can be more than five times the cost of social care in the community, yet fewer than one in ten Clinical Commissioning Groups commission dedicated nurse-staffed palliative support, advice and co-ordination for dying people, their families and carers around the clock.

Unsurprisingly, there are significant variations in the quality of care that people experience depending on where they are, what services are available and what conversations they’ve had about dying. Kate Granger is an inspirational doctor with terminal cancer. She works with elderly patients and has this advice on death planning. ‘The most important first decision is “‘where?”’ Preferred place of death is rarely achieved in the UK and I think that’s because we don’t plan properly. It takes a lot of effort and preparation to die at home successfully. I personally think if it is someone’s wish to die at home and they have been diagnosed with an incurable condition, the planning for that event needs to start then. Patients and families need early conversations with health and social care professionals about what support and resources are available so that expectations are not dashed. Anticipatory medicines need to be in the house long before the final crisis.’

A death plan, like organ donation, is far more useful if you tell everyone. Anyone who might possibly find you on the floor one day needs to know your wishes. If you don’t want to be resuscitated, ask your GP to counter sign an official Do Not Resuscitate form and have on display so anyone coming to your aid can see it. The front of the fridge is a good place. If you don’t have it on display, you’re may be transferred to hospital for intensive treatment rather than cared for in your home.

Most palliative care is given by carers, community and hospice nurses but it’s also important that a doctor sees a patient who is terminally ill at least once a fortnight. As one Eye reader observed: ‘Our father died recently at the age of 90, after a being in bed for a month at home. The district nurse attended from the start and emphasised immediately that this was a case of “end of life care”. The care provided during this last month was excellent. My mother and my four attended regularly throughout this period, together with the various district nurses, day carers and night carers.

Eventually swallowing became difficult for my father and the district nurse fitted a morphine syringe pump. We were told that death was likely to follow within days, which duly occurred. Despite this being the most anticipated death possible, we were amazed to be advised by the GP certifying death, that because our GP had not attended in the previous two weeks, he was obliged to inform the police of a possible suspicious death.

The police turned up, we were questioned as suspects and the body inspected for evidence. The policewoman told me that this was a common occurrence for anticipated deaths, and it also happened to our neighbour. The body was then taken to the coroner’s mortuary, where eventually after a delay of several days, it was released to the undertakers. This episode caused unnecessary distress to my mother and I, and wasted the police and the coroner’s time.’

GPs are not obliged to visit a terminally ill patient every 2 weeks, and if a patient dies having not been seen by a doctor in that time it can usually be sorted out by a phone conversation with the coroner, without needing a post mortem. However, as this story shows, this is not always the case. MD has just experienced superb NHS end of life care for a relative who died in Sherston, Wiltshire – compassionate, collaborative and competent. Thank you. However, many terminally ill patients cannot get fast and free social care or 24/7 advice and support. And coordination between different services can be very disjointed. Dying, death and bereavement are part of everyone’s life. It’s time they got the attention and support they deserve.

FFI Dying Matters website

There is more advice on planning your death and improving your NHS care in Staying Alive

Funding the NHS fantasy promise auction – whose policies add up?

The pre-election NHS rhetoric has descended into a predictable fantasy promise auction. Politicians know they don’t have a hope in hell of providing a 7 day NHS (Tory), a same day GP appointment for anyone over 75 (Tory), or a midwife by your side every minute of labour (Labour). Even if the money was available, where would we suddenly grow 8,000 more GPs, 20,000 more nurses and 3,000 more midwives (Labour and UKIP)? And is being able to see a GP on a Sunday afternoon really the best use of the NHS’s precious resources? (Tory).

If the NHS is to improve, it needs to be funded at the level of other G7 countries (it’s currently bottom of the league) and it must stop wasting money on policies and treatments that are substandard or don’t have a good evidence-base. According to the best guess of NHS England, the NHS needs a funding increase of £30 billion over and above inflation by 2020-21, to cope with an ageing, frailer population. CEO Simon Stevens hopes that increased productivity and the efficiencies of ‘new care models’ will generate an extra £22 billion, leaving just £8 billion for the tax-payers and politician to fight over. The NHS has never in its history managed such productivity gains, and a far more likely scenario is that, with less money the NHS will just provide less service. The Tories and Lib Dems have pledged £8 billion, or an average real increase of just 1.1% a year. However, with no detail on where the money is coming from it could arrive too late to save the NHS, which is desperately short of cash now. Labour promises a one-off increase of £2.5bn a year over and above inflation now, but it may not be repeated if the tax on houses valued at over £2m doesn’t come good.

The most sensible plan for NHS funding comes from the National Health Action Party, who are fielding just 12 candidates (including 6 practising doctors) The NHAP manifesto proposes a 1p rise in basic rate of income tax to raise around £4.5 billion/year. It would scrap the market within the NHS, which also costs around £4.5bn a year to run. It would renegotiate PFI deals – hospital trusts currently spend £2bn/year on hugely over-priced repayments – and cut the cost of locums (£2.5bn/year) and management consultants (£ 640m/year). It would invest in disease prevention, impose stricter controls and taxes on tobacco, alcohol, sugar and unhealthy foods. It would integrate health and social care, and invest in social care to divert pressure from the NHS. It would use the purchasing power of the NHS to secure better deals on drugs and medical equipment. And it would try to crackdown on tax avoidance and evasion. It argues not just that a healthy NHS requires a healthy economy, but that the opposite is also true. Higher investment in healthcare stimulates economic growth, ensures a healthy workforce and encourages spending in local economies.

The NHAP is unlikely to win any seats but has received a lot of media exposure because its policies are more based on evidence than ideology. Perhaps the biggest lie of all in this election is the government’s claim that NHS bureaucracy has been reduced. The number of managers on the NHS payroll may have been cut, but the staggering complexity of the Health and Social Care Act, and all the new organizations that have to be involved in commissioning and contracting services in a healthcare market has meant vast amounts of time, money and outside support from management consultants and lawyers have been used to try to make sense of it all.

Any change to NHS services, such as transferring more care into the community or providing enhanced services in a GP practice now requires an absurd amount of paperwork and negotiation involving multiple organizations (e.g. CCGs, local area teams, NHS England, Public Health England). The NHS struggles enough getting the contracts right, but has no hope of ensuring that, say, services outsourced to for-profit providers will provide safe, high-quality, good value care1. It has enough trouble trying to ensure its own services are high quality in the current funding crisis. As the Health Service Journal reported, more than 80% of acute hospitals in England can’t meet their own targets for safe nurse staffing levels. That £4.5 billion a year currently wasted on turning the NHS into a market needs to go to the frontline, and soon.

My bidet revolution in the NHS, from the bottom up, is here

Damage limitation

Which party would do least damage to the NHS? The Coalition has increased NHS funding by 0.9% a year in the last five years, when the previous average increase has been 4% a year. Unsurprisingly, given the cuts in social care, many services are now hideously overstretched. In England 3 million people are now waiting to see a specialist with 250,000 more patients needing treatment who are not on the official waiting list. But had Labour won in 2011, it seems unlikely they would have been able to fund the NHS any more generously given the economic circumstances.

The Coalition’s biggest error has been the Health and Social Care Act, not just because it destroyed trust in breaking a key pledge not to have a massive structural reorganisation of the NHS, but because it has lead to a rapid expansion of the role of commercial companies in the NHS. Outsourcing is rarely the answer to anything, and the record in the NHS thus far is woeful. Many of Labour’s early PFI schemes for hospital development have been eye-wateringly expensive, with some trusts lumbered with payback fees more than ten times the original build cost. The withdrawal of NHS services provided by Circle, Serco, UnitedHealth and other private companies when they have been unable to make a profit has not stopped vital clinical services being put out to tender. Excellent, well-established NHS sexual health services have lost out to private contractors and Virgin Care has just won a £280 million contract to provide care for the elderly and those with long term conditions in East Staffordshire (Eye last), with £1.2 billion of specialist cancer care also up for grabs.

The danger for patients of outsourcing the NHS is not just that services may disappear if they can’t be made to be profitable, but also that services may not be of a high standard if staff don’t want to work for private providers. Nottingham University Hospitals NHS Trust has had to stop its acute adult dermatology service after senior consultants left when the contract was awarded to the Circle Partnership. The consultants had made it very clear well in advance that they would not work for a private company and with so many consultant dermatology jobs in the NHS remaining unfilled, they will find it easy to secure work elsewhere.

This would be excellent ammunition for Labour, had they not started it all. And the reopening of GMC case into Dame Barbara Hakin is a timely reminder of the idiotic top-down ‘targets uber alles’ enforcement that existed under Labour (as well as the incompetent tardiness of the GMC). MD and Eye journalist Andrew Bousfield referred Dr Hakin to the GMC in in July 2012 to investigate if she put patients at risk in her role as CEO of the former East Midlands Strategic Health Authority by insisting non urgent targets be met when Gary Walker, the then chief executive of United Lincolnshire Healthcare Trust, told her that the hospital was so overcrowded that it would not be safe to adopt such an approach.

In October 2014 – 27 months after the original referral – the GMC decided not to take any action against Dr Hakin. MD and Mr Bousfield were so appalled at the failure of the GMC to grasp the basics of patient safety, particularly in the light of the disastrous effects that the mandatory target culture, over-crowding and under-staffing had on Mid Staffordshire hospital – that we mounted a detailed challenge of the GMC decision on January 6, 2014. On April 1 (sic) 2015 – nearly 3 years after the original referral – we were informed that the GMC will be undertaking a review of the ‘patient safety’ aspects of the original complaint because the original review “may have been materially flawed” and that a “review is necessary for the protection of the public or otherwise necessary in the public interest.” MD is almost certain that the GMC will take no action against Dr Hakin who says she was following the orders of her chief executive (Sir David Nicholson) and the Labour government. But whoever is in charge of the NHS on May 10 needs a far more intelligent, compassionate, honest and collaborative approach to patient safety – and a change in culture that is entirely alien to adversarial party politics. The omens are not good.

The most sensible, sustainable evidence-based NHS policy is from the National Health Action Party

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