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The tangled truth about the GP contract and out of hours
- May 21, 2013 posted by John Murray
There’s an almighty spat growing about the demand for A&E services and the part played by the demise of GPs’ responsibility for out of hours services as part of the contract negotiated ten years ago. Inevitably, given that the contract was negotiated by the last government not the current one, the debate has a pretty florid political complexion too.
In the nature of the NHS, it’s almost impossible to prove matters one way or the other, though the fact the debate is taking place demonstrates that you can’t make changes in one bit of the system without risking consequences in another. The same applies to the replacement of NHS Direct with 111. The consequence of more admissions through A&E will in turn start to be felt in elective surgery, with waiting lists starting to lengthen just as the next General Election comes into plain view.
So back to the GP contract. Legend has it that one of the BMA’s main negotiators couldn’t believe his luck when the then government generously offered to let GPs shuffle off their out of hours responsibilities for a mere £6000. Quite apart from the historical impact of those responsibilities on GPs’ quality of life, it was immediately apparent that several times the purchase price could be recouped and the cost of a holiday to the Caribbean earned by working a few Saturday or Sunday nights during the year. Equally, GPs’ days have become more demanding, partly as a result of bureaucracy related to QOF, while night duty now involves challenging triage for patients drawn from a wide catchment area.
Patients frankly haven’t come into it but there can’t be many who wouldn’t prefer to maintain the much vaunted relationship with their practice 24/7, especially when in extremis. Having myself dutifully gone to an out of hours service some miles away to wait for three hours before then being referred to A&E several miles in the opposite direction, I would hardly be surprised that the net effect has been an increase in people going directly to the latter and, judging by his interview on the Andrew Marr show on 19th June, Jeremy Hunt would seem to agree.
In these austere times and in the interest of a customer-orientated service, it would make eminent sense for one of the historical strengths of general practice to be restored and be touching if the BMA didn’t demand a King’s ransom for doing so, and pigs will be flying shortly too.
Media and medicine
- May 16, 2013 posted by aknight
The actress Angelina Jolie has talked publicly about her decision to have double mastectomy after discovering she carries the defective gene BRCA1. Ms Jolie was told that her risk of developing breast cancer was 87%. Having seen her mother die after a long battle with cancer, she made what she describes as a ‘strong choice’ which has reduced her risk to 5%.
Campaigners have praised her decision to speak about her experience, which she says she hopes will encourage others to seek gene testing, and raise awareness of the options for those at risk.
High profile cases can have mixed results for health campaigns. The sad death of Jade Goody from cervical cancer in 2009 led to an increase in women presenting for screening. However the NHS Cancer Screening Programme had to withstand a sustained tabloid-led campaign to lower the cervical screening age, despite the lack of any medical evidence to suggest this would save lives. And 13 years on, the effects of the media frenzy around the MMR jab are being seen in the measles outbreaks in Wales and London.
In the case of Angelina Jolie, the science seems sound: the genes BRCA1, BRCA2, TP53, and PTEN, combined with family history, do suggest a high risk and patient groups have been quick to provide information about screening and prevention options on their websites to support women who may be concerned. The NHS offers this sort of gene testing for women with a high risk.
On a wider policy level, £100m has been dedicated to a genome mapping project, announced in December last year as part of the Government’s Life Sciences Strategy, to sequence the genes of up to 100,000 patients with cancer and rare diseases. The aim of the project is to better understand patients’ genetic makeup, lead to better targeting of medicines, and to support the development of innovative new treatments.
And that would be good news for everyone.
Outcomes, car parks and a patient-led health service
- April 12, 2013 posted by Andrew Wilkinson
Even in a health service as saturated with buzzwords as the NHS, ‘patient choice’ stands out as a particularly tired refrain. In part, this is due to the elasticity of the phrase. Patient choice can relate both to sensitive decisions about treatment options and to the details of how and where to access health services. Some use the same phrase to advance a euphemistic discussion of privatisation.
Yet behind the lazy language on patient choice, a great deal of policy activity and structural change is being undertaken within the NHS with the explicit purpose of increasing the system’s ability to hear and act upon patients’ views. From the creation and promotion of independent Foundation Trusts competing for patients’ preferences, to the new duties upon Monitor, the health sector regulator, to protect patient choice and competition, a consistent focus has been put upon ensuring that discerning patients have, at the very least, the freedom to influence their health services.
There is a danger, however, that lazy language breeds complacent thinking. Often the choices desired by patients bear little relation to those enacted in their name. On the (hopefully) rare occasions that patients and their families come into contact with the NHS, their demands are often the same. Clean beds, friendly staff, decent food and lower car parking charges – these are the concerns of patients in hospitals across the country and they are barely reflected in policies and outcomes frameworks at all.
This is not to suggest that NHS resource should be redirected towards car parking subsidies at a time of financial pressure on the health service. Rather, it is to highlight the risk posed by the disconnect between patients’ wishes and the policies claiming to address these. This is symptomatic of a broader problem, whereby the commissioning and delivery of care is too far removed from those experiencing services on the front line. At its worst, this disconnect can contribute towards travesties such as those seen in Mid Staffordshire. While such events are mercifully rare, the less damaging signs of the gulf between patients and true decision-makers are seen far more often.
There are early indications that policymakers are attempting to redress the balance. The NHS Constitution was reinforced in March with stronger wording around patients’ rights and the friends and family test is set to roll-out across the health service by next year, offering a crude approximation of patient satisfaction.
These are welcome initiatives, but there remains some way to go. In the meantime, perhaps alongside Patient Reported Outcomes Measures, the extent of patient choice in the NHS can just as well be judged by the quality of hospital food. Until they both align, it might also be best to view the rhetoric of patient choice with a little more caution.
The new NHS: keeping track
- April 2, 2013 posted by aknight
As Secretary of State, Andrew Lansley struggled to convey the reasoning behind structural reform of the NHS. However he was clear on one point: it would cut the number of administrators in the NHS, releasing savings to be spent on patient care. On the evidence so far, he seems to have been right.
In health politics, ‘administrator’ tends to mean anyone who is not performing a clinical role. From hospital managers to switchboard operators, all are captured under one term that conjures up images of clipboards and typing pools.
In this case ‘administrators’ mostly means commissioners – those responsible for deciding what healthcare is needed and who should provide it, putting contracts in place and ensuring the quality of provision. No-one wants a bloated bureaucracy, but commissioners do an important job.
Even so, with 70,000 people employed by the outgoing PCTs and SHAs, it was easy to make the case for slimming down the system. That said, there are more bodies in the new system than the old, so how does the collective payroll look?
Let’s keep track: we now have NHS England itself, with around 4,000 staff, including four Regional and 27 Area Teams. Commissioning Support Units have been a surprise gift to the employment market, with 19 CSUs expected to employ around 500 people each or about 9,000 in all. The Clinical Commissioning Groups themselves (212 of them) are expected to employ about the same again. Then it begins to get a bit murky, with teams administering Clinical Senates and Strategic Clinical Networks across 12 larger geographies, while significant staff are being re-deployed to local authorities with their new responsibilities for public health. The likes of Public Health England will also be a big employer with around 5,000 staff but these largely hail from the Health Protection Agency, which has ceased to exist.
Comparing like with like is fiendishly difficult. The numbers thus far seem to bear out the government’s intentions but we can be sure that critics of the reforms will be keeping a beady eye on developments.
Will local authorities meet the public health challenge?
- March 13, 2013 posted by Alice Briceño
Local authorities (LAs) take the reins on public health from 1 April, assuming responsibilities that have sat within the NHS since 1974. With potentially better knowledge of their local populations and the close relationship that exists between public health and other LA controlled services, such as housing, there is real potential for local government to deliver cohesive health programmes that do not operate in isolation from other factors that contribute to health and wellbeing. The intention is that this approach will deliver superior outcomes.
However, the service transfer deadline is approaching rapidly and there have been worrying signs that local authorities may not be adequately prepared to take on their new responsibilities. For example, earlier this week, a survey conducted by The Hepatitis C Trust shone the light on the 75% of local authority respondents that did not know how many people in their area are ‘living with or at risk of hepatitis C’. Failure to recruit Public Health England key appointments to schedule and the late announcement of public health budgets in January are likely to have exacerbated the situation.
So, although LAs are well placed to join the dots between public health and the wider determinants of population health, if their current understanding of population needs related to the array of services falling into their remit is lacking, effective commissioning of public health will remain elusive. Luckily for local authorities, there is an army of experts from across the health economy vying to ensure that they are equipped to deliver quality services and superior outcomes for patients. If local authorities successfully separate the wheat from the chaff, they may yet surprise us all. Their success in doing so will also have direct relevance to Andy Burnham’s much more ambitious ideas for the integration of health and social care in LA hands.
Francis, nursing care and the truth that must speak its name
- February 11, 2013 posted by John Murray
A catalogue of cruelty as catastrophic as that documented at Mid-Staffordshire NHS Foundation Trust has many causes. Such casual cruelty is, however, by no means isolated to one hospital. Anecdotal evidence from patients, their friends and families suggests that it is pretty rife throughout the NHS.
Clearly, there are factors which might contribute to such behaviour, including management failings, staff shortages and the increasing number of frail and confused patients. In the case of Mid-Staffs, however, it is worth recalling that these events coincided with the most generous increases in funding and improvements in pay the NHS has ever seen.
The new Secretary of State for Health has rightly laid great emphasis on the importance of care in the NHS and this has been combined with qualities such as compassion in alliterative catalogues of the kind which so delight policy-makers but often obscure the point. The implication is that care is a quality which can be retro-fitted. In truth, care provides the vital underpinning without which medicine becomes purely technocratic, overlooking our needs as sentient beings, flesh and bones.
As a child, I recall the enormous relief accorded by nurses applying a flannel to the forehead, raising me up the bed, plumping pillows, taking an interest in my welfare. As an adult, while not decrying the continued existence of good care, too much of what I’ve seen and heard has involved a cavalier disregard for the needs of the individual; patients manhandled without consideration, left in a contorted heap for hours on end, denied assistance with eating and drinking.
So how have we reached this sorry pass? The truth is that as part of a major overhaul in the late 20th Century, nursing fatally lost its way. Up to the that point, nursing began with care and was learned from the outset by doing. Less academic State Enrolled Nurses underwent two years of training and were recognised for their qualities as excellent nurses. State Registered Nurses received three years of training with a more academic bent but founded on the same principles of care. Crucially, training was only briefly restricted to the classroom and rapidly transferred to the ward, recognising that the profession was about tending for people in distress with all that entails and ensuring that those less suited to the task could make their escape sooner rather than later.
Project 2000 was hatched in the early 1980s with the laudable intent of raising the status of the profession and tapping the potential of nurses more effectively. In many ways this has succeeded, with erstwhile nurses now to be found at the highest reaches of the NHS. The nature of nursing itself, however, has been crucially transformed, and for the worse. In particular, the technocratic part of the job has been largely disconnected from care. This is exemplified by the fact that nursing is now taught largely in the classroom with a significant amount of experience on the wards involving seeing rather than doing. I am told it is possible to qualify as a nurse having scarcely encountered vomit and diarrhoea, blood and guts. Furthermore, while the technical aspects of nursing have been upgraded, the vocation of care has been shuffled off to largely unqualified care assistants. The founding principles of nursing have been lost in the process.
Culture takes a long time to change, for better and for worse. If true, there will be no quick fixes for the problems underlying the scandalous events at Mid Staffs and elsewhere. The sooner we recognise the need for fundamental change the better, not with a view to re-inventing nursing as it existed before Project 2000 but to restoring care to the very heart of what it means to be a nurse, from the first day of training onwards.
Ian Dalton, Clare Balding and the NHSCB exodus
- February 7, 2013 posted by John Murray
By happy coincidence, different bits of BT recruited Clare Balding, everyone’s favourite commentator and Ian Dalton, Deputy Chief Executive of the NHS Commissioning Board on the same day last week.
While it is hard to see much in common between these two, it’s likely that their new found affiliation with BT had one thing in common – money and, in the case of Ian Dalton, this begs potentially troubling questions about the upper echelons of the NHS.
During the fat years prior to the financial crisis, top salaries in public service became a non-issue with ministers and departments being able to hire pretty much whoever they liked at whatever was necessary for the purpose. Since the 2010 General Election, the environment has turned nasty, with newspapers regularly inveighing against fat cats in the civil service with the Prime Minister’s salary taken as an arbitrary benchmark of what is reasonable (below) and unreasonable (above).
In the case of the NHS, the result is a very curious compression of differentials where large numbers of managers with very different levels of responsibility command salaries which are not so far apart. For example, Area Directors for the NHS Commissioning Board are currently being recruited at salaries circa 140,000, while members of the top team on the Board itself are, with the exception of Sir David Nicholson, capped at 170,000. By comparison, Ruth Carnall’s salary as Chief Executive of NHS London was 260-265,000 in 2010-11.
As a rule, a Prime Minister’s remuneration increases considerably on their departure from office. NHS managers who stay the course are in a rather less favourable position. Given the pressures of the job and the almost prurient nature of media and public interest in pay, is it therefore any surprise that Ian Dalton has followed hard on the heels of Jim Easton in heading off to the private sector, where a markedly higher standard of living awaits?
The worry must be that Ian Dalton will not be the last and that recruitment and retention of top talent to the upper echelons of the NHS will becoming increasingly fraught until more sensible differentials are re-established.
Here we go again?
- January 29, 2013 posted by John Murray
Andrew Lansley famously entered the last General Election saying that there would be no top-down re-organisation of the NHS. When his White Paper on Equity and Excellence was unveiled there was almost universal amazement, which his anarchic vision of a CCG on every street corner assuaged not at all. The suggestion that the intentions of the White Paper could have been achieved without primary legislation was batted away with breezy condescension but that was the view held by just about everyone outside Andrew Lansley. And the final shape of the reforms has made the view even more persuasive, though now entirely academic.
So when Lansley’s successor as shadow secretary of state for health repeats the mantra that the NHS can look forward to a period of stability regardless of the result of the next General Election, we are right to be a little sceptical. Labour is embarking on a review of its health policy which will doubtless be designed to maximise the Party’s room for manoeuvre for as long as possible. Nevertheless, it is hard to see Andy Burnham’s opening brushstrokes requiring anything less than a new canvass.
The intention seems to be to retain much of the nomenclature we are just starting to grasp, so CCGs, HWBs and so on would remain but with the money flowing to local authorities rather than CCGs, who would assume a purely advisory role, while HWBs would become the cockpit of decision-making, perfectly poised between health and social care. But the nomenclature relates to legal responsibilities and those are laid down in primary legislation making this kind of change inconceivable without another sizeable health bill.
Furthermore, people will need to follow the money, so if local authorities were to assume budgetary responsibility for health services a massive migration of management from the NHS would ensue. Notwithstanding some welcome noises about the new arrangements for specialised commissioning, the NHS Commissioning Board would also surely find itself wound up.
In classic fashion we may be in danger of heaping pelion on ossa if we think that local government represents some panacea for the ills of the NHS, though the intention of bringing about better integration between health and social care is entirely laudable. As for the prospects for more top-down reorganisation, it would be nice to hope that we learn from recent history but probably mistaken.
Old wine in the 2013 bottle?
- January 4, 2013 posted by John Murray
Old wine in the 2013 bottle?
Veterans of NHS reform understandably cast a jaundiced eye over the new arrangements taking effect on 1st April and wonder what the upshot will be of all the midnight oil being burned in preparation for D Day? It is certainly easy to be sceptical but differences this time just might bring about some genuine change, including:
1. The NHS’s financial predicament – the Nicholson Challenge was originally cast as an unprecedented middle distance belt-tightening event but is rapidly turning into a marathon. Short term expedients like pay freezes or bashing suppliers will not suffice. The NHS is going to have to do things differently and that means hospitals and the people they employ. In the past, a form of Mexican stand-off has ensured that very little happens, as the party or parties in power fear the consequences of change on their electoral fortunes while those in opposition wreak havoc at their expense. For the future, those who believe in the NHS may be coming to realise that the choice is no longer between reconfiguration and no reconfiguration but between reconfiguration and the viability of the NHS coming into stark relief. So, maybe, some of the nettles will now be grasped;
2. The NHS Commissioning Board – the paradoxical nature of the reforms is made manifest in the Board, a body that is pledged by statute to uphold the autonomy of the wider NHS but by instinct as likely to thwart that autonomy. As a body with a national remit for England and enormous budgets and responsibility to commission services, the Board is in a hugely powerful position to exercise leadership and make things happen where they have previously languished, not least in areas like innovation. The combination of this power and the NHS’s financial predicament could prove an effective catalyst in cutting through the thicket of bureaucracy which largely characterises the reforms.
There are plenty of familiar faces populating the newly re-fashioned NHS but they frequently share the frustration of outside observers and, given the luxury of some time to evolve, things just might turn out better than the Jeremiahs have foretold.
NHS transition – from policies to people
- September 19, 2012 posted by Andrew Wilkinson
As Andrew Lansley fades into the memory at Health, one of the big questions is whether his successor, Jeremy Hunt will continue to put as much space as possible between Ministers and the running of the NHS or accept that taxpayers’ money entails inevitable political baggage?
April 2013 is fast approaching, and the new NHS organisations that began as policy ideas in a 2010 White Paper are gearing up to take on their formal responsibilities. The Department of Health finds itself in a dual role, helping to establish the new NHS architecture while also adjusting to its new backseat position, with the NHS Commissioning Board taking the wheel.
As it does so, tensions will emerge. The relationship between the Board at national level with its 27 ‘Local’ offices, and with the hundreds of Clinical Commissioning Groups and Health and Wellbeing Boards across the country will once again raise the longstanding debate on centralisation versus localism in the health service. The implications of this go beyond the question of integration. For example, if the Board demonstrates an inclination to centralise ever more power from April 2013, there could be louder calls for the Department to develop a tighter grip on its activities. Local grievances will be channelled through MPs, who will bring pressure to bear upon Ministers for substantial answers. If Ministers find themselves stuck between a centralised, autonomous Board on one hand and disgruntled parliamentary colleagues on the other, something will have to give.
It is at this stage that relationships will be brought to the forefront. Now that much of the recruitment to senior Board posts has been completed, and the Ministerial reshuffle has taken place, the relationships between the new staff and organisations will become far clearer. The tone and spirit of these personal and institutional relationships will have a significant bearing on how well integrated and efficient the new arrangements will be.
Relationships within the Department of Health will also be important to monitor. For example, Norman Lamb, the Liberal Democrat on the Health team, was an ardent localist in opposition and during the passage of the Bill. This may contrast with David Nicholson’s view of how the Board will need to function to be effective.
In part, these tensions will be played out through formal documents, such as the Framework Agreement covering the Department’s working relationship with the Board, and the draft Mandate to the Board which is currently being consulted upon. A number of other questions, however, might only be resolved as new staff bed in over the coming months.
Despite the formal work already completed, there remains much to monitor as attention turns increasingly from policies to people.
Views expressed are those of the author, not JMC Partners.
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