Who wants to be leader?

Whatever the result of junior doctors’ July ballot on their proposed new contract, they will continue work shifts and hours that wouldn’t be tolerated in any other safety critical industry. The central issue was always that we don’t have enough junior doctors to staff the NHS safely, but then we don’t have enough at any level. NHS Employers produced a tactless report with the Nuffield Trust last week, inviting senior nurses and others to ‘fill in the gaps in the medical workforce’. Quite where theses senior ‘medical infill’ nurses would come from is unclear. From September 2009 to January 2016, the NHS dispensed with 2,293 nurse consultants and matrons.

On June 8, High Court action by the junior doctor group Justice for Health was due to start to determine whether health secretary Jeremy Hunt can legally impose the latest version of the new contract, as he has repeatedly threatened, if junior doctors and medical students vote to reject it. This has now been postponed until after the junior doctors ballot result is announced on July 6. Any contract is only as safe as the staff available to work it, and we’ll find out in August how many rota gaps need to be filled by imaginary nurses. Junior doctor campaigners have at least been given a good taste of how NHS politics work, how unpleasant, inaccurate and unaccountable the top of their organisation can be, and whether they want to be part of it.

Many NHS chief executives are pondering precisely those questions. One described the current state of the NHS in England as ‘the last days of the Roman empire. NHS England and the army of regulators brutally demand accountability, compliance with targets and ever more savings, and yet are completely unaccountable themselves. Try complaining about them and they make your life even worse. As for all Vanguard sites and all those bloody stupid new models of care they keep imagining, it would be far quicker to just burn the money At least with Jeremy Hunt, you can vote him out.’

The King’s Fund recently produced a report based on interviews with NHS CEOs at or near the end of their careers. It is not pretty reading. The mean tenure of an NHS CEO is less than three years, and the job is so unpalatable that many posts are either vacant or filled by interims. This lack of interest in being an NHS leader means that some truly shocking and incompetent CEOs are still in post, as well as some truly outstanding ones who have somehow managed to survive. Despite Hunt’s claims to the contrary, the NHS is going through by far the longest period of restrained growth in its history. Since 2010, allowing for population growth, spending has risen by 0.1% per annum and is likely to be stuck there until 2021. In 2009, we spent 8.8% of our GDP on health, now we spend 6.3%, and you get what you pay for. Social care services have collapsed, and there is still huge variability in access to, and quality of, NHS services. Try finding emergency dental or mental health care.

All this would be bad enough were in not for the Health and Social Care Act on top of the austerity. As the King’s Fund report observed; ‘There was barely a good word said for the 2013 reorganisation of health and social care…. The changes were ‘disastrous’ and ‘catastrophic’. Tim Smart, former chief executive of King’s College Hospital NHS Foundation Trust declared; ‘I think the system was broken by the Health and Social Care Act. And that’s a real shame.’

When MD first met Jeremy Hunt on January 8, 2013, he said ‘When I look under the bonnet of Lansley’s reforms, I’m pretty impressed with what I see.’ Hunt is now the longest serving health secretary in the history of the NHS, and yet not nearly enough good leaders want to work under him, in a chaotic competitive market where no-one understands how the system works, no one is overall charge and too many organizations are concerned with their own survival, rather than the survival of patients. For thirty years, the NHS has been run like a business and failed spectacularly. In the NHS, the more business you attract, the more likely you are to go bankrupt because there is no money to pay for it. And yet you aren’t allowed to close for business, and the regulators and commissioners can punish you for treating too many patients, especially the sick ones. Time to admit commissioning has failed and ditch the market. That alone would attract good clinical leaders to stay in the NHS.

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It’s the Capacity, Stupid

It’s painfully clear to anyone works in or needs the NHS or social care services that we don’t have the capacity – equipment, technology, beds, staff – to cope with the demands placed on us. This is down both to lack of investment – the UK spends less of its GDP on health and social care than other Western European countries –, an ageing and expanding population, and massive waste, particularly on political reorganisations and reforms that are not evidence-led, cost a vast amount in time, money, effort and goodwill – and end up making little or no difference to the length or quality of people’s lives, and may even cause harm.

90% of consultations in the NHS occur in general practice, for a fraction of the funding. If general practice fails, the NHS fails. The belated bung now promised for GPs – £2.4 billion extra a year by 2020-21 – is not new money and may not stop the service collapsing. Sadly, much of it is likely to be wasted on non-evidence based political vanity projects such as opening surgeries for 12 hours on a Sunday when no one wants to be there, useless well person checks which only serve to make well people anxious, and ill thought out screening that doesn’t have a proper evidence base and hasn’t been approved by the National Screening Committee. Money will be thrown at faddish technological fancies that haven’t been properly evaluated, all GPs will be ‘accelerated towards a paper free environment’ and if there’s any money left over, it might be used to treat people who are genuinely ill. It might also be too late.

Research from the King’s Fund has found that the number of GP consultations has increased by 15% in 5 years, three times the rate of increase in the number of GPs. Consultations among the over-85’s were up 28% and many were too complex to be completed in ten minutes. The job is so stressful that five years after qualifying, only 1 in 10 new GP trainees plan to be working full time. Between 2009 and 2014, 46 per cent of GPs leaving the profession were under 50; between 2005 and 2014 the proportion of GPs aged between 55 and 64 leaving doubled. In addition to the stress of seeing more complex, demanding patients, GPs also have to cope with an absurd administrative burden. As well as individual appraisals and revalidations with the GMC, GP practices have to be inspected by the CQC which – driven by the fear of missing the next Harold Shipman – impose a hugely bureaucratic and stressful inspection procedure with little evidence base that it improves the quality of care.

Ruling the NHS by fear and bullying is a highly corrosive error that all governments make. Under Labour, access targets were brutally imposed and fear of failure was so great that figures were fiddled and patients were ignored, most notably in Mid Staffs hospital. Hospital inspections and targets are not in themselves a bad thing – inspections could focus on learning and development, targets could help provide quicker care for many patients but allow enough leeway to prioritise sicker patients at busier times. And yet both tend to be inflexibly enforced with no evidence or empathy

Nearly Four years ago, MD referred Dame Barbara Hakin – National Director of Commissioning Operations at NHS England – to the GMC for unilaterally raising the 4 hour casualty waiting time target from 98% to 100%, and insisting that it had to be met ‘whatever the demand’. In Hakin’s fantasy world, every single patient who turns up to an emergency department must be seen, treated, admitted or discharged within 4 hours no matter how busy it is. That the GMC is still considering whether this impossible imposition was unsafe suggests either a very limited understanding of patient safety or a chance for the second most senior doctor in the NHS to retire safely before reaching a decision. The fact that record numbers of hospitals are now missing a reduced 95% target shows what an unworkable demand it was. There will always be patients who can’t be seen within four hours when an emergency department lacks the capacity to deal with the demand, and there will always be patients who need to be kept longer than 4 hours because it is not safe to transfer or discharge them. Brutal imposition of such non-evidence based nonsense costs money, lives and careers in the NHS. Jeremy Hunt risks repeating the error by imposing an untested junior doctors’ contract without evidence he has enough doctors to cover extra shifts across seven days. Whatever way the vote goes on the junior doctors’ contract, many will continue to work dangerous hours and shifts come August, and there aren’t enough consultants to safely extend seven day services either. Does Hunt have the capacity to understand capacity? Or is he wilfully blind?

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Free the Canaries

‘It is deeply ironic and paradoxical that we are killing, through work stress, the very people who are charged with caring for us.’ So said Professor Michael West, a Senior Fellow at the King’s Fund, to a meeting of London GPs and their staff last week. West highlighted the stark contrast between the values of the NHS – compassion, collaboration, treatment according to need – and the reality. The NHS has the highest levels of work related stress, staff illness, bullying and discrimination of any organisation he has studied in over 30 years. 26.8% of NHS staff have significant anxiety and stress – 50% higher than in the general population. And long-term, unremitting stress can kill.

Not investing in the NHS is disastrous not just for patient care but also for the economy. Prompt, high quality healthcare returns patients and their carers to work. The NHS employs 1.4 million people – a huge benefit to the economy – and is crying out for more doctors and nurses. Any yet disastrous workforce planning means many great potential doctors are refused entry to medical school, and many great nurses may be put off nursing by the abolition of bursaries. At least fund the NHS to the GDP average of other European countries, staff it safely and then see how it compares.

Professor West cited unsurprising evidence that showed the key to improving the NHS was engaging and including staff rather than bullying and enforcement. There is strong research to support fact that staff happiness and job satisfaction are strong predictors of not just absenteeism and staff turnover, but patient satisfaction, mortality rates, safety and even CQC ratings. Staff are happiest when those at the top of the organisation share the same values as those at the bottom. Unfortunately for the government, NHS staff believe in evidence as well as empathy.

Handing statistics to Jeremy Hunt is like handing a flame thrower to a hyperactive child. The harm done by his misinterpretation – deliberate or otherwise – of weekend mortality rates and stroke outcomes has destroyed trust in his ability to think critically. In answering an urgent Common’s question about the all-out strikes, Hunt set about the BMA like a man demolishing a watermelon with a sledgehammer. Even more alarming is that the BMA did not fight back. Hunt has been briefed that those at the very top of the BMA do not share the goals of the junior doctors and is hoping the organisation will implode. Chair Dr Mark Porter has been suspiciously silent although he was flushed out to appear in front of the Department of Health and the empty chair reserved for Hunt. Junior doctors have kept this vigil for two weeks in the hope Hunt will return to talks as every sane authority has pleaded for him to do. But Hunt would not reopen negotiations with the BMA if you kidnapped his children. He’s trapped in a macho mind-set that could do incalculable damage to the NHS.

Ironically, Andrew Lansley may be the person to take down Hunt. His ‘sell off the NHS’ Heath Bill removed the legal responsibility of the secretary of state to provide universal NHS care. Lansley saw himself floating above the market chaos as an SoS for public health, telling people to lose weight whilst Virgin et al picked over the profitable NHS services. When the junior doctors behind Justice for Health take Hunt to the High Court over the legality of his imposition on June 8/9, he may find Lansley has neutered his power.

Whoever wins, the NHS has hit the wall. It’s now in the sixth year of a decade of flat line funding and rising demand. Patients are suffering, managers are drowning in complaints, whistle-blowers are still silenced. Excellent FOI work by whistle-blower Minh Alexander has found that many trusts are still using super-gag clauses to silence departing employees. Over a year after Sir Robert Francis’s report into how NHS whistle-blowers are treated, there has been no meaningful change. Not a single sacked whistle-blower has been found comparable re-employment. The national whistleblowing guardian, Dame Eileen Sills, resigned before taking up her post, as did her deputy. The Health Service Ombudsman service is in total disarray after yet more accusations of cover up. Junior doctors at least have the bravery to speak up about work-related stress, poor training and unsafe staffing. They are the canaries in the mine. If we silence them, the lights go out on the NHS.

Blood on the Tracks

When David Cameron and health secretary Jeremy Hunt refuse to listen to the pleas of just about every doctor and patient safety expert worth listening to, you have to ask why. The Academy of Medical Royal Colleges (the AMRC) – which represents all of the 22 medical royal colleges and faculties – is the latest to urge the government to suspend imposition of the junior doctors’ contract and return to negotiation as the BMA is keen to do, but Hunt is not for listening. ‘That train has now left the station. The matter is now closed.’ Although it clearly isn’t.

Either Hunt and Cameron are living out the conspiracy that the NHS must be irreversibly harmed to break it up for a sell off. Or they refuse to be beaten by the BMA whatever the cost to patients. Or they’re in denial about the fact that the NHS has run out of time and money to recruit, train and pay sufficient staff to provide compassionate, competent care around the clock. Staff are already working dangerous hours to cope with vacancies, rota gaps and record demand, and the service is only just held together by altruism and good will. So to prolong an avoidable war with doctors in training represents one of the greatest acts of political idiocy in the history of the NHS.

The AMRC describes an ‘unprecedented crisis’ and is also against the all-out strike planned by the BMA for April 26-27, which includes withdrawal of emergency care. This will be covered by consultants, non-trainee doctors, nurses and trainees who don’t support an all-out strike, or who will come in if the consultants can’t cope with the demand. If the government still refuses to listen, the BMA could escalate to an indefinite strike, probably scheduled after the European referendum. Hunt is supporting Cameron and his job looks safe until June 23 unless serious patient harm occurs during a strike, which would also harm the BMA and could lesson public support for doctors. If Cameron wins, he may yet replace Hunt with – say – Michael Gove or Boris Johnson as a punishment. Few politicians get out of the NHS alive.

Hunt has at least published his proposed imposed contract, which has allowed the legal action to start. The BMA’s legal challenge over the government’s failure to undertake a timely EIA (equality impact assessment) is likely to be swatted away, although the EIA made interesting reading when it appeared with the final terms and conditions on March 31. The government admits that features of its contract may ‘disadvantage’ and ‘impact disproportionately’ on women, particularly those working part time, but believes it is lawful and ‘comfortably justified’ as a proportionate means of achieving the legitimate aim of ‘a truly seven day NHS’ – whatever that is. The majority of trainee doctors are women and many may simply refuse to work under a discriminatory contract.

Many male doctors (MD included) also end up working part time in the NHS because the workload is so unremitting it simply isn’t safe for them or their patients to practice full time in the long term. Many full time staff put in over 80 hours a week, part time can be 30-40 hours. The stress can be unremitting and tired doctors make mistakes. Most believe they can’t be stretched more thinly than they are by the new contract. MD and the Patients’ Association are supporting the more widespread legal challenge of Just Health, an independent group of NHS workers committed to a publically owned NHS. It crowd sourced £100,000 in donations in 4 days for a challenge by Bindmans LLP.

Bindmans has sent a 41 page letter before claim to Hunt arguing that he has no legal power to impose a contract on most junior doctors as he is not their employer. For the minority of those he can be said to employ (who work in non-Foundation Trust hospitals), he did not consult with relevant parties prior to announcing imposition. And the decision itself is legally flawed and will not achieve the aim of a 7 day NHS. Bindmans have also sent a letter to NHS Employers advising them they may seek an injunction to restrain them from recommending the contract whilst its legality is being challenged. The contract includes a clause 22 that would allow Hunt and NHS Employers at their ‘absolute discretion’ to ‘review, revise, amend or replace any term or condition of this contract and introduce new policies and procedures, in order to reflect and respond to the changing needs or requirements of the NHS.’ Clause 22 is a catch 22. Sign the contract and sign away control over your terms and conditions. Don’t sign it and don’t work in the NHS. Small wonder applications for junior doctor training schemes are at an all-time low, and applications for certification to work abroad are at an all-time high. Thousands of treatments have been cancelled but the public remains broadly supportive of junior doctors. It seems only the High Court or blood on the tracks can stop Hunt’s train. Serious patient harm would also derail the BMA. And yet all this harm could be avoided by returning to negotiations. It’s utter madness.

Mind the Rota Gaps

The NHS is facing a £30 billion black hole in its finances by 2020, caused by 10 years if flat-line funding and a 4% year on year increase in demand for its services as people persist in living longer that they used to. Prior to the last election, NHS England chief Simons Stevens said – in the best case scenario – the NHS could recoup £22 billion in efficiency savings without damaging patient care, something MD (amongst many others) said was highly unlikely. This would leave the government with just £8 billion extra to provide over £5 years, enough to just about keep the lights on. Lib Dem expenses expert David Laws is now alleging Stevens asked for £16 billion from the government and was sent packing. True or false, the NHS is now being sucked into a huge black hole of debt and services and waiting times are suffering.

The demand on the NHS is made worse by 20% cuts in social care as patients can’t be discharged from hospital or stay well outside it. Poverty causes ill health too, and cuts in welfare payments add to the burden on the NHS. A sure sign the NHS isn’t coping is the chaos at its front door. General practice has faced huge funding cuts and is short of at least 5,000 GPs in England. But there aren’t enough doctors wanting to be GPs even if there was the money to pay them. Cameron made an inane manifesto pledge that ‘everyone over 75 will see a GP on the same day if they need to’, when in fact anyone should be able to see a GP when they need to. But with a dire shortage of GPs, many can’t.

The knock on effect on emergency departments is equally alarming. The emergency medicine workload is so unremitting that it has the greatest attrition rate of any medical specialty in the NHS, with almost 50% of year three and four registrars resigning. Dr Clifford Mann, president of the Royal College of Emergency Medicine, has warned of ‘unprecedented levels of pressure, overcrowding and a desperate shortage of medics’, with 20% of posts unfilled. He has asked for doctors from other specialties to be diverted to A&E to keep the public safe. ‘There have been some reports to harm to patients, and a collapse in the morale and resilience of the medical and nursing staff.’

The lack of safe staffing levels for nurses was a key finding of the Mid Staffs review, and NICE were given the task of gathering the best evidence for the safest ratios of patients to nurses in different healthcare settings, with the intention of moving onto other staff groups. Alarmingly, this work was pulled by the government and NHS England, who then tried to bury NICE’s finding before being forced to publish them under FOI. It seems the government wasn’t prepared to commit the funding to safe staffing, making a mockery of its manifesto promise to make the NHS the safest health system in the world. So many nurses are left caring for more than eight very sick patients at once.

Unsafe staffing levels are clearly bad for patients, but so stressful for staff having to cover rota and shift gaps that they either give up themselves after a few years, or decide that part time working is all they can cope with. In the annual census for the Royal College of Physicians, 21% of respondents said that gaps in the trainee rotas were so frequent ‘such that they cause significant problems for patient safety’. This problem is greatest for specialties that provide emergency cover for the NHS. Further up the ladder, the picture is equally bleak. Across the UK 40% of advertised consultant appointments could not be filled. Almost all were due to there being a lack of trained applicants, and many jobs attracted no applicants at all. Vacancies are most acute in the North West and West Midlands.

Ever determined to balance the books in the impossible hope of making £22 billion efficiency savings, the government has capped the rates of NHS locum pay, and locums are simply refusing to do the most stressful jobs for less money. Hospitals have now been forced to reduce medical cover on wards at night and reduce training for junior doctors. Out of hours care is flying by the seat of its pants and the government knows it simply doesn’t have the staff for its fantasy pledge of an extended ‘truly 7 day NHS’ even if it was able to bully the junior doctors into submission. Which it can’t.

As with every other policy in the NHS, workforce planning is driven by the need to save money, not what patients need. Despite the challenges of an ageing population, the NHS is training 19 per cent fewer nurses in 2014-15 than it was in 2004-05. Unsurprisingly, there was a 25% growth above inflation in temporary and agency costs between 2013-14 and 2014-2015. The solution is to train and retain more staff, not spread the existing staff thinner until they break. The National Audit Office found that in 2014, the NHS in England was short of 50,000 clinical staff. The latest estimate is a shortfall of 70,000 clinical staff. The twin obsessions of austerity and profitability will only make this worse. Far from being the safest health service in the world by 2020, the NHS is fast becoming the least safely staffed.

MD is performing at the Edinburgh Fringe and is supporting an independent legal review of the imposed contract.  We all need to know if Jeremy Hunt’s actions are safe and legal.