Tuesday, 30 July 2013

The NHS Direct/111 confusion epitomises the problems with government health policy.

If ever a snapshot was needed to illustrate that a plan isn’t working, the recent news that NHS Direct are withdrawing from 111 contracts provides just such an unwelcome image. Originally running around a third of 46 regional contracts to run the 111 telephone helpline service, NHS Direct has now pulled out of the ‘financially unsustainable’ arrangements. That leaves eleven regions with no provider to run this fledgling service. The reasons that NHS Direct (itself an NHS Trust) cited for the withdrawal was that projections reported earlier this month showed they had lost £2.8m since April and were "heading for a deficit of £26m if we continue to run the same volume of 111 services until the end of this financial year".

This is a new embarrassment for the embattled coalition health team as another plan fails to quite come together as predicted.  Interestingly, but not surprisingly when this story broke – news items included Andy Burnham, shadow Health Secretary as he said it was a "mess of the government's making" which had led to nurses being replaced by computers

During a debate in the House of Lords, the Lib Dem peer, Lord Willis of Knaresborough gamely tried to defend the service: ‘My Lords, may I try to redress the balance? There is a real sense that very significant numbers of people calling the 111 service get a good service. On 9 June, I had reason to call 111 because I was having a heart attack. The response from 111 was excellent, in York. At the same time not only did the service call the paramedics but it had me in hospital within 25 minutes to an absolutely superb accident and emergency service. If York can do that in such an efficient and superb way, why cannot we guarantee that service throughout the country?

With a spectacular own goal the venerable Lord demonstrated that 111 is a confusing and potentially dangerous option facing the man in the street with a health issue. No Lord Willis – you should not have called 111 – you should have dialed 999! 111 is billed as the service to call ‘when it’s less urgent than 999’ and NHS Choices website advises the public to call 111 ‘if you urgently need medical help or advice but it's not a life-threatening situation’. What was, in theory, a good idea has now sadly deteriorated to farce as a money saving, efficiency enhancing idea is spoiled though poor procurement, poor communications and poor implementation.

Which brings me to my checklist for Jeremy Hunt to use when trying to move the NHS forward.

When you have an idea for an NHS service redesign or enhancement:

1.     Think about the logistics. How will it work? Where are the pitfalls, or weak link in the chain? What will a successful outcome look like? Does the expertise and resource exist and if not – how is this generated?
2.     Assess the benefits. Will a successful outcome mean either a better or more efficient service, better clinical outcomes and/or more cost effective care? Basically – undertake an independent and transparent cost benefit analysis.
3.     Create a robust procurement process. ‘Screwing’ a provider down to an unacceptably cheap price means that you either have an unsustainable model or you will receive substandard delivery. Either can ultimately lead to disaster and expensive damage limitation further down the line. Use the considerable procurement expertise available within the NHS. Good, sustainable contracts are born out of the premise that every party is satisfied with the deal.
4.     Ensure that robust monitoring is in place. Just because something starts well, you can’t guarantee it will continue that way.
5.     Create and implement an effective communications strategy. I have no doubt that one of the biggest failings in the 111 service is lack of clarity for the public.
6.     Keep politics out of it. I know this is a fantasy rather than a realistic possibility, but our politicians and key NHS leaders should focus on the job in hand, not play a politically expedient game.

This really is very basic stuff, but I suspect that if these simple rules had been applied, we would not be facing the confusing and worrying situation regarding our emergency and non-emergency NHS services right now.

Ah well – a girl can dream…

Saturday, 20 July 2013

Good public health policy takes courage

I was sitting in the Friday afternoon rush hour traffic yesterday and glanced to my right to see the epitome of a public health nightmare sitting in the car next to mine.

A hugely overweight man was driving his executive car with the cabriolet roof down. He looked hot and sweaty and his balding head was bare to the 33 degree heat. He was (I kid you not) smoking a cigarette, occasionally drinking from the large MacDonald’s branded container. The hand that was on the steering wheel was tapping furiously as he was clearly stressed at the crawling traffic. The one safe thing he was doing was wearing a seat belt.

This poor man is a real life caricature of the ‘ticking healthcare time bomb’ so often referred to by healthcare leaders and politicians. I suspect that when my hapless subject got home he poured himself a large gin and tonic or similar to ease the hassle of is day. Diabetes, respiratory problems and heart disease, let alone joint and musculoskeletal issues are knocking firmly at his door as the grim reaper will held at bay by medical professionals who will try to fix him as the inevitable happens.

Is this man a lost cause? Possibly. Does he know that his habits are life limiting? Probably. Will he do anything about it? Who knows.  I am in no position to judge as I am far from saintly when it comes to healthy eating and drinking habits so I do have great sympathy for Mr Cabriolet Man. But how interesting that he has at least vastly increased his chances of surviving a road traffic accident by wearing his seat belt. And why does he wear a seat belt? Because it’s the law.

Of course we can’t make unprotected sunbathing, alcohol, or even getting stressed against the law. But surely those charged with protecting the health of the public should take every reasonable action they can to not only educate us, but strongly guide us towards healthy behaviour. Especially the impressionable young.

We know that educational programmes help enormously as at least the general public now know that smoking kills, excess alcohol ruins lives and healthy eating and exercise are the route to longevity. We also know that despite these programmes, there are generations in the UK making very unhealthy choices.

A study reported yesterday regarding early death rates due to liver disease in young women is truly shocking. For women born in the 50s , the death rate due to alcohol related disease is 8 per 100,000, for those born a decade later the rate rises to 14 per 100,000 and those born in the 70s, women only in their 30s right now, are dying at a rate of 20 per 100,000. Various causes have been cited, but cheap booze must play a part in this yet the government shies away from minimum pricing for alcohol.

Smoking is an equally depressing story as although statistics show that smoking rates are decreasing, we still see young children and teenagers smoking even though they know it’s bad for them.

Controlling the smoking habits of a population is potentially one of the biggest public healthcare challenges a nation can face. We know that, apart from the human loss and suffering, smoking costs the NHS and estimated £2bn a year.

How disappointing, then that the government have decided to postpone a decision regarding plain packaging for cigarettes – a move that had been expected to reduce young smokers. In a strongly worded letter to the Guardian Newspaper, a group of chest physicians, paediatricians and public health specialists make a powerful case for plain packs saying.

The tobacco industry targets young people because it needs to replace the 100,000 people in this country who are killed each year by smoking related diseases. Every day roughly 570 children aged 11-15, nearly 30 classrooms full, start smoking. Tobacco packaging is designed to manipulate perception of risk. For example, even though terms that dishonestly imply relative safety in cigarettes like "light" and "mild" have been banned, research shows that smokers continue to believe that cigarettes in lighter colour packs are less hazardous.The government must now either bring forward legislation or allow parliament a free vote on what is an urgent child protection issue.’

It is equally disappointing that the coalition will also delay a move to introduce a minimum unit price for alcohol.Protecting the health of the public while maintaining their right to personal choice is a tough job. Introducing unpopular measures can a poison chalice for health ministers and legislators. Like the brave move to make the wearing of seat belts in cars compulsory for drivers in 1983. This was a contentious issue for several decades before it finally became law and has saved thousands of lives, while creating a behaviour that is now automatic and part of everyday life.Good public health strategy needs to be backed up by legislation where possible. Legislation that is designed to limit choice and change behaviour takes courage.

We need to see that courage from the government now.



Tuesday, 16 July 2013

How do we stop the bad news coming from the NHS?

Regular followers of this blog may have noticed that it has been a few weeks since I last posted any commentary. I could use the excuse that a heavenly week in Devon and Cornwall, followed by some speaking engagements intervened, but the truth is that I have been at a loss for words.

Bad news and the NHS are now synonymous. Horrific stories of poor care, failing hospitals, commissioning teams in panic mode, financial meltdown of Trusts and most frightening of all, unexplained high death rates make for very upsetting reading. I don’t want to be another purveyor of doom adding to the cacophony of despair but it is hard to find some positive insight into the disarray of our state funded healthcare system.

Most distasteful of all is the political interference, name-calling and finger pointing, not forgetting a hefty dose of arse-covering into the bargain.

In my opinion, the recent review of the Liverpool Care Pathway epitomises the current crisis. Medicine, and many related functions, is an inexact science. Clinical decisions have to be made on the best advice available at the time, backed up by robust evidence and those decisions monitored through clinical governance which is best delivered by clinical peers. Sadly the human element can override good science and even worse, a culture of poor care totally undermines good medicine.

It is absolutely right that a review was instigated into the use of the pathway, originally created to ease suffering of those near death, but absolutely wrong that this review was needed in the first place. How dreadful to learn that this carefully designed set of guidelines was in many cases distorted and recreated by badly trained or badly managed staff with little or no consideration for patients or their loved ones. Yet again, we have been shocked to hear of staff displaying ignorance, callousness and in some cases, downright cruelty all in the name of ‘care’.

The review, led by Rabbi Baroness Neuberger, was originally set up to research the use of this pathway but en route uncovered significant shortcomings in the treatment of the dying, notably at weekends when senior clinicians were absent.

How on earth did we get to a state where a nurse felt it was acceptable to shout at a relative for trying to give a patient a drink? Is the stress of the job turning good people bad or are they just the wrong people for the job in the first place? And how do good managers, senior clinicians and medical leaders turn this mess around?

I have just been watching some news footage from the House of Commons with the current Secretary of State for Health Jeremy Hunt lobbing salvos a cross the House aimed at the previous Labour Health Minister, Andy Burnham who with equal vigour retaliated. The headline for an article by Sean Worth in the Telegraph today shouts ‘Labour must bear the blame for the shameful decline of the NHS’ and the BBC has reported that Professor Sir Brian Jarman,  ‘an independent expert on mortality rates has suggested that ministers have suppressed details of NHS failings to avoid losing votes’.

Maybe Professor Jarman has the key and maybe he’s right when he advises us that we should take heart that following Sir Bruce Keogh's report, 14 Hospital Trusts have been identified as failing and 11 will now be subject to closer scrutiny and urgent service improvement activity.

I also agree with his premise that ‘a "basic problem" with the NHS was that the government both provided health services and monitored them’

Maybe that’s the answer. Let independent and wise individuals such as Baroness Neuberger review specific areas of concern and let us find an independent, non-political means of monitoring quality of care. Let there be zero tolerance for cruelty or poor clinical practice. A cruel or incompetent nurse, doctor (and that should include GPs) or healthcare assistant should be suspended pending investigation and poor clinical practice should be offensive not just to patients but to staff with no exception. Let clinicians have the final say on clinical issues and most important of all, keep politics out of it.

Improve from within and then maybe the bad news will stop.

Saturday, 22 June 2013

Who should watch the watchers?

Like many others, I believe in the ultimate goodness of the majority of people, especially those involved with the care and protection of others. So of course I, like many others, hoped that the tranche of scandals emerging from a closer scrutiny of the NHS would now be over.  But we were wrong. This most recent disclosure of the failings of the Care Quality Commission (CQC) is perhaps the most shocking lapse of morality of all.

Although full details and allocation of blame are yet to emerge, it would appear that the regulatory body designed to protect the wellbeing of patients and maintain standards in UK care facilities have failed spectacularly in their duty. Not only have they failed to monitor standards in an efficient and robust manner, the former Chief Executive, Cynthia Bower, plus her deputy Jull Finney and the media manager Anna Jefferson stand accused of actively covering up damning information regarding their investigation of the high death rate of babies at the University Hospitals of Morecambe Bay NHS Trust.

There have been concerns over the CQC for some time and there is no suggestion that the new Chief executive was in any way involved but this latest scandal puts several major issues (again) under the spot light.

Firstly – just what has happened to the moral compass within pockets of our state funded health system? The Francis report, investigating the Mid Staffs scandal where up to 1000 patients may have died as a direct result of poor care was supposed to be the beginning of the end of these tragic stories. This latest shocker regards the maternity unit at the Morecombe Hospital Trust where a high baby death rate prompted investigation. Babies were possibly dying as a direct result of poor practice. It is now suggested that senior CQC officials covered up information which could have saved other tiny babies. And yet, it would appear, these people put their own jobs and personal interest above the care of the very people they were supposed to protect. At the risk of being over-dramatic, if they were guilty – how do they sleep at night? Is this because they were working in a poisoned environment, immersed a blame culture, with perverse team ethics or no collective emotional responsibility? This is heavy stuff.

Secondly – this demonstrates in blazing clarity the enormous task that faces the CQC. An impossible task in fact. How can a team of experts (I use the term loosely) monitor and investigate over 40,000 health and care facilities throughout the UK? Professor Julian Le Grand, from the London School of Economics stated today that the way the organisation was set up it was ‘daft’ by creating a generalist organisation and merging health and social care for this monumental remit.

Thirdly – the regulatory and monitoring landscape following last year’s health and social care act is very confusing. In a poster created by NHS Employers the section entitled ‘Monitoring the NHS’ describes the 3 key areas as follows:
Care Quality Commission: ‘..is the independent regulator of all health and social care services in England. Its job is to make sure that the care provided meets national standards of quality and safety’
Monitor:  ‘..promotes the provision of healthcare services which are effective, efficient and economic and maintains or improves the quality of services’
Healthwatch England:  ‘..is the independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatches, it ensures that the voices of patients and those who use services reach the ears of decision makers’

This poster also describes NICE, Health Education England, Department of Health, NHS England, Clinical Commissioning Groups, NHS Trust Development Authority, and Health and Wellbeing Boards. All with some level of responsibility for standards. Confused? Who wouldn’t be?

How should we be monitoring our health and social care services? And who should watch these watchers? What needs to be done?

Clarify where the buck starts and stops: Well defined areas of organisational and personal responsibility, measurable standards and a simplified regulatory framework are needed

Give relevant experts the appropriate powers. In my opinion, one of the reasons that the cardiac and stroke networks were so successful in improving standards was that specialist units were awarded accreditation by appropriately qualified clinical specialists. It has emerged that lay people, fireman and other generalists within the CQC were tasked with inspecting hospitals – no wonder significant flaws were missed.

Neutralise conflicts of interest. It has been suggested that the newly formed Clinical Commissioning Groups should bear the burden of regulatory monitoring responsibility. No they shouldn’t – they have enough to do and there is already a risk of blurred lines between poacher and gamekeeper.

Separate health monitoring from social care monitoring. We don’t have joined up care yet so it doesn’t make sense to have joined up monitoring. If the CQC remains, specialist teams must be created.

And, most important of all….

Recognise that monitoring alone isn’t enough to create high quality care. Measuring only does that – it measures. Investment of time, energy and money are still required to build strong leadership within the NHS and support a culture of honesty, transparency, decency and clinical excellence.

I believe (and hope) that there is sufficient intellect, expertise, commitment and skills already within the NHS to make this happen. They just need gathering up and pointing in the same direction.

Sunday, 2 June 2013

How can you measure care?

It has just been revealed by the Health Services Journal that Sir Mike Richards has been appointed as the new Chief Inspector of Hospitals. The purpose of this unenviable role has been described by David Cameron to ensure that “a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking”.

The ‘clean and safe’ bit is relatively simple to monitor. There are a multitude of matrices available to set and measure performance standards, clinical outcomes and achievement of targets. But it is the care bit that’s tricky.

The new Chief Inspector, whose team will become part of the Care Quality Commission (CQC) has said that he ‘will champion the interests of patients’. This laudable aim fails to provide a definition of how to measure those interests so I looked to the CQC for clarification. Their website states their aims related to hospitals and GPs as:

‘We check all hospitals in England to ensure they are meeting national standards, and we share our findings with the public…..We inspect GP practices and other primary medical services in England to check that they are meeting the national standards of quality and safety’

It is absolutely right that national standards of quality and safety are met and monitored on a regular basis. But we still don’t have a benchmark for care.

Emotional intelligence is becoming an accepted principle for describing individuals, departments and organisations. One model to assess emotional intelligence is based on the three I’s – Intention, Interpretation and Impact. If you imagine a ward or GP surgery environment it is logical to project the three I’s to measure care and I would like to see this explored on a more formal basis for the NHS.

In the meantime, of course patient feedback and the ‘friends and family’ test are a valuable tool, albeit a subjective one. But then – care is subjective isn’t it?

Always happy to hear good news healthcare stories I am pleased to have two to report this week. One of my daughter’s colleagues is facing the agony of a very premature baby, born at 26 weeks, fighting for survival in a hospital in Portsmouth. The baby’s father has said that the one thing he doesn’t have to worry about is the care. A nurse is by the baby’s incubator at all times and the precision and intensity of each procedure (such as taking blood samples form underdeveloped veins) is enhanced by the palpable desire of each doctor, nurse and therapist for the baby to survive and thrive. The baby’s parents are in no doubt of the genuine commitment and care of the team who hold this precious life in their hands as medicine and care are combining to give this little mite the best possible chance.

Another example of care is much more low-key. Regular readers of this blog may recall my account of a gentleman (Tom) who was receiving poor care in a ward after breaking his hip. (‘Good care is about personal responsibility’ 21 April). Suffering bed sores, missing meals because he couldn’t reach his food, and becoming more frail by the day, the poor care received was having a direct impact on his will to live. I am pleased to report that Tom’s wife arranged for him to be moved to another hospital where the ward delivered the sort of care every patient should suspect. The medical treatment was the same, but the emotional and physical care was clearly far superior in this second hospital. Little things like making sure his cup of tea was just how he liked it, alongside scrupulous cleanliness and appropriate treatment for his bed sores. Tom is now home – working hard on his exercises and looking forward to walking his beloved dogs again before too long. What a difference moving from an environment with a poor emotional intelligence to one which embodied positive physical and emotional support.

I shall leave the last word to Tom’s wife – who used her own personal benchmarking system:
‘You could feel the care the minute we walked in the door’


Saturday, 18 May 2013

Public and private can make excellent bedfellows, especially in treating cancer

I was recently asked to write about the future for my latest blog in Health Insurance Magazine and I included a plea for increased cooperation between the public and private sectors. As I wrote ‘There are still some Neanderthals out there who subscribe to the public good, private bad mantra’

I experienced a fantastic example of private and public partnership a few weeks ago when I attended the launch of a molecular screening laboratory in London’s University College (UCL) Cancer Institute. The technical detail of this collaboration between Sarah Cannon, the cancer arm of Hospital Corporation of America (HCA) International and UCL Advanced Diagnostic, part of the UCL Cancer Institute is described in more detail in their press release:

This is the coming together of an NHS Hospital (UCL) and an American Healthcare company (HCA) to research and treat a range of cancers. The mission of this venture is to enable patients to ‘live with cancer’ through a patient centred approach. No this isn’t the ‘patient centred’ sound bite often quoted by politicians and health officials – this is personalised medicine - the patient focussed analysis which identifies the genetic drivers for specific cancers. In a nutshell, the genetic abnormality which triggers the cancer is identified through molecular profiling undertaken in this joint venture laboratory. The techniques used can now sequence multiple genes in the fraction of the time previously required. Traditional biopsy assessment can be supported with genetic pathway analysis leading to individual treatment regimes saving time, money and lives.

Multiple clinical trials will establish the appropriate treatment pathways and this cancer screening unit gains its income from a variety of sources including charities, research organisations, government funding and drug company sponsorship.

Patients, often with little hope of cure or even a short term future, will be given the lifeline of this molecular screening to find the best possible chance of addressing their genetic abnormality to offer an improvement in longevity and quality of life.

This laboratory is targeting 11 (rising to 35 by July) genetic abnormalities using samples collected from a traditional biopsy. Patients will be admitted to clinical trials from a variety of sources (NHS, research establishments and the private sector) and the initiative is, in my opinion, a significant good news story.

Several major points struck me as I attended this press launch.

Firstly, the genuine passion and commitment of the key clinicians and executives. If you have to face cancer, I can think of no better individuals to join your armoury for your personal battle. Backing professional conviction with hard facts and a heavy dose of realism, the clinical team from UCL and HCA and senior executives from Sarah Cannon seemed to find the right words to inspire and convince. Professor Chris Boshoff saying ‘the future is now available in this laboratory’ managed to avoid sensationalism in his tone and Dr Howard Burris, president of clinical operations at Sarah Cannon referred to this speeding up of tailored diagnosis as a ‘game changer as we speed up the development of novel therapies’. Exciting stuff.

The second key point was the space, manpower and technology available in the pristine laboratory premises. These impressive facilities simply could not have been provided by the public sector alone.

Thirdly, with disappointment I noted that one journalist (but only one I’m pleased to report) was intent on finding the downside of this development. She started her questioning with the comment ‘I’m sorry to be cynical but…’  Of course she wasn’t sorry at all as she harped on about the NHS not being able to fund this initiative and suggested that NHS patients would not be referred to the facility. Regular followers of healthcare news will know the high-circulation tabloid well – it constantly sensationalises health reports and often focusses on the bad, rather than good news stories. The speakers responded to her with courtesy and patience. The point which she chose to miss was that eligible NHS patients presenting with one of the cancers under investigation at the unit will be enlisted in clinical trials as appropriate. Their cancer tissue, collected from traditional sampling techniques can be sent to this laboratory for testing and their tumour signature identified within 7 days. The cost of this is marginal compared to the amount of money saved though inappropriate treatment and the human cost of repeat biopsies and wrong pathways. Add to this the income generated from funded research and additional sponsorship and this is a laudable public private venture.

Dr Burris struck a chord with me when he said that the biggest cost in drug development is time. This is also the most precious currency of any cancer patient. The ground-breaking molecular screening speeds up the voyage of discovery for cancer diagnosis and tailored therapy and can buy precious days, weeks and years for cancer sufferers.

As one patient who, after ten years of toxic therapies, has benefitted from newly targeted drug treatment for his rare cancer said ‘I feel like a normal human again’. However mealy mouthed or cynical you may be about public private partnerships in health – this is a powerful testimony in favour.


Saturday, 11 May 2013

NHS managers could learn a thing or two from Sir Alex Ferguson

As Manchester United fans across the globe prepare themselves for the ‘end of an era’ and mourn the retirement of Sir Alex Ferguson, it is worth reflecting on why he has been one of the greatest football managers of all time.

Regular followers of this blog will be familiar with my penchant for combining two of my great passions – football and health - so of course this landmark is just too significant to go without comment.

Non-believers may wonder why a football related subject should dominate headlines worldwide but Ferguson has his hands on the rudder of a 1 to 2 billion dollar enterprise, equally beloved by the stock market and football fans alike. Why has he been so influential and why have so many column inches been dedicated to this recent news? Because Ferguson is not only a great manager, he’s also a great leader and it’s quite rare to have both in one package.

Much has been reported about the lack of leadership and management in the NHS, both from a macro and micro perspective. Progress, service improvement and high quality care CAN be achieved in our hospitals and primary care facilities, if the teams have some decent leadership. And I’m not just talking about the boardroom, I’m talking about the doctor’s surgery, the bedside, and even the operating theatre – each department needs strong management. So NHS managers and leaders, please read the list below and take note.

Why was Sir Alex Ferguson so successful in managing a diverse group of individuals, each with their own agenda, but with, in theory, a common goal?

Discipline: I’m not suggesting that the hairdryer technique (where Ferguson blasts anyone who displeases him with a nose to nose tirade) but teams do need to play by the rules. Boundaries should be clear, rules well defined and bad behaviour should be noted and censured.

Reward good performance, address bad performance. The two golden words that could go a long way to fixing the NHS – performance management. Many have seen examples of incredible commitment and dedicated care alongside laziness, complacency and cruelty. For every individual failure there was a manager who either missed or ignored bad behaviour and practice. Performance management requires integrity and courage.

Instil pride in the brand and the team. Ferguson made it clear that when a player behaved badly on or off the pitch, he was damaging the Manchester United brand. The NHS has a fantastic brand and yet so many managers ignore this fact. I have seen brand loyalty (to almost a pathetic degree) in workers within the private sector which benefits customers, staff and the organisation in equal measure. Staff should wear their uniform with pride and be encouraged to honour their own teams.

Manage egos and personalities bigger than the brand. Cantona, Keane, Ronaldo – Ferguson had a knack for channelling genius and is probably responsible for saving the career of many an upstart. His controversial sale of David Beckham still smarts, but maybe he was probably right in recognising that the Beckham circus could have unbalanced the team dynamics. One of the biggest challenges facing NHS leaders is how to manage clinical teams. The clinical card is often produced to win a work stream argument. These days, I have found that the big egos aren’t just the consultants (historically the most difficult to manage, especially orthopods and heart surgeons) but therapists, GPs and nurses sometimes inappropriately use their clinical qualifications as a type of diplomatic immunity. Their clinical concerns must be heard and carefully balanced with the harsh reality of health economics.

Earn your stripes. Ferguson worked his way up and was a player himself. The best NHS managers either have a clinical qualification or at least worked within a clinical environment. Jeremy Hunt, the Health secretary, is suggesting that prospective nurses spend more time on the ward before embarking on their training but I think it would be more effective to insist that every manager spends some time either observing or assisting patient care so they really understand the stress and pressure that clinical teams face.

Lead by example and encourage a healthy work ethic. Even at the age of 71, Ferguson is first at the training ground for early morning sessions. Too many NHS managers stay in their ivory towers and should spend more time in committee than at the coalface.

Celebrate success! Ferguson’s ‘dad dance’ at every goal leaves something to be desired, but no-one could doubt his pleasure. There is so much good in the NHS and it should be celebrated.

For senior leaders only – manage the press. Ferguson was criticised for blacklisting several organisations and reporters during his career. But he is a canny Scot and he knew that he needed to control the message. I was at a launch of a new joint NHS/private venture on cancer research the other day. It is potentially a fabulous collaboration, and I shall be writing about it soon. But there was one reporter there, from a newspaper that famously overdramatises health stories and so often gets the facts wrong. She kept chipping away at the potential negative elements of the venture, and even her questions demonstrated that she didn’t quite get it – but these bad news stories dominate the UK press and undermine improvement efforts. Yes, it’s important that the public know about catastrophic events such as the unnecessary deaths at Mid Staffs and flaws in government reforms but the NHS PR machine needs to work harder in sharing the good news too.

I wish you every happiness and good health in your retirement and many many thanks for the hours of pleasure you have given millions Manchester United fans for over a quarter of a century.

Just one thing – could you consider postponing your retirement and replacing Sir David Nicholson as Chief Executive of NHS England? It’s about time the NHS had a premier league manager.

Sunday, 28 April 2013

The ‘bed blockers’ who can make or break the NHS - practical pathway mapping urgently needed.

Andy Burnham, Shadow Secretary for Health has now outlined his ‘ideas’ for additional healthcare reform if Labour should win power at the next election. He was quick to state that these are just ideas at this stage but confirmed that he is identifying a ‘clear direction of travel’ for his policies.

The main thrust of his ‘direction of travel’ was to merge social care with the NHS. It would be hard to disagree with Burnham’s assessment that ‘Councils and the NHS don’t work well together’ and most involved with care would endorse a ‘fully integrated system’. His concept of one owner for the responsibility physical, mental and social wellbeing is worthy. But is it workable? What does fully integrated care mean? And how can we make this a reality?

Burnham is absolutely right that a major challenge facing NHS hospitals are the elderly patients who need ongoing care but have no current need for the acute care for which most hospitals are designed. This vulnerable section of the community make up between a quarter to a third of hospital occupancy at any one time which explains why they are sometimes referred to as ‘bed blockers’.

In the same way that that increasing the number of lanes in a motorway can only ease traffic congestion if the slip roads lead somewhere, so NHS improvements can only work if there is a suitable onward referral route for patients ready for discharge. Many patients stuck in acute hospital wards no longer need hospital care but need to continue their convalescence with ongoing care in the community. This care can take place either in their own homes with additional support or in a community care facility.
When I was working on stroke improvement initiatives in North West London, we made fantastic progress on providing specialist targeted care for stroke patients. The London Stroke Model defined that stroke patients should be admitted to hyper-acute stroke units within stringent time limits from the initial call for an ambulance. After up to three days of intensive treatment and therapy these patients would be transferred to stroke unit where the specialised care would continue. This system works extremely well, with every stroke unit in North West London reaching the required standards for accreditation and additional funding within a few months. Stroke patients received world class diagnosis, assessment and urgent treatment, vastly improving their chances of not only survival, but retention of a good quality of life.
An additional bonus was that each hospital that reached and maintained the required admission times would earn significant uplift in their tariff. Every stroke patient not admitted directly to the specialist unit would count against the hospital. As part of the accreditation process, I joined inspection teams in hospitals to ensure that these stroke units met their targets for accepting stroke patients. The most challenging aspect of applying this stroke model was freeing up beds in these units to enable new patients for admission. Time and again, a patient who no longer required specialist care but needed community support would languish in their hospital bed because there simply was nowhere else to go. In one stroke unit, we had a patient, a homeless man, who was well rehabilitated and no longer needed intensive therapy, but had been in the unit for 66 days (the average length of stay in a stroke unit is around 20 days) because he simply had no home to go to. (We actually threw a leaving party for him when he finally had somewhere to stay). This bed blocking creates a damming effect (and damning for that matter) on the entire system, back to the moment when an unfortunate patient first has a stroke.

Burnham’s ideas of an integrated system are coming from a good place but his direction of travel is fundamentally flawed. Burnham’s ideas are:
·        NHS leads on the physical, mental, and social wellbeing of patients
·        Councils should hold the budget and define the health and wellbeing strategy to make a better link between health and social care
·        NHS should lead on provision, council lead on strategy and commissioning

Opposition is a luxury in politics. You can make bold statements without actually providing an explanation of how highfalutin’ claims can be made real. Burnham’s plans sound like a rehashed, but even less workable solution than the current Health and Social Care Bill, currently being led by The Health Secretary, Jeremy Hunt.

Yes we need more integration between health and social care.  But let’s not make life even more complicated than it is already. Councils are NOT the right bodies to set strategy for healthcare but they should lead social care, and maybe public health. Integration is needed at the interface between the two. To try to reform all at once is terrifying and unworkable.

What we need is multidisciplinary pathway mapping – from cradle to grave, from diagnosis to cure, from acute to chronic care. Individual responsibilities to be defined for each area of care and ownership identified for coordination and cooperation.

Mr Hunt and Mr Burnham – if you would like a lesson in clinical and social pathway mapping, I would be more than happy to oblige.

Sunday, 21 April 2013

Good care is about personal responsibility

What is the best way to take the temperature of the NHS? Ask the patient’s relatives. This is why the Cure the NHS organisation has such a powerful voice – or at least it should have,

I try to avoid hysteria and over reporting of bad news stories about the NHS in this blog but every so often I have to share a ‘tale from the front line’

A friend’s husband, a fit and active 70 year old (I’ll call him Tom), recently fell and broke his hip while walking his dog. Two weeks later, he is a frail, broken elderly in-patient with bed sores and a post-operative infection. The care he has received in the hospital in Hampshire has been poor – very poor. Tom’s wife, we’ll call her Liz, is a retired nurse, so she knows something about care and standards. Liz was horrified to note that Tom had bed sores, nasty places on his back and ankle, and challenged one of the nurses about how this could happen. Surely he was being turned regularly – the essential protocol to avoid the breaking down of thin skin due to pressure, lack of movement and poor circulation. ‘Ah’ said the nurse in charge, ‘that would be the agency nurses’. A cheap shot and a poor example of ownership, leadership and responsibility.

Liz also noticed that untouched food was left out of reach from Tom and now makes sure she is there at meal times so she can make sure he eats.To add insult to injury, Liz noticed that the floor beneath Tom’s bed was filthy, with unidentified stains and dust. It was clear that this was of no concern to the nurses when Liz pointed out that this dirt could be an infection risk, so she asked if she could borrow a mop and bucket and clean the floor herself. She was advised that there were no cleaning materials kept on the ward (apart from antiseptic solutions and wipes), as the contract cleaners were in charge of that. Liz enquired whether the contract cleaners could be called to undertake this task and was advised that they only appeared on the ward on pre-arranged times.

Have we learnt nothing from the Mid Staffs scandal? How come if you drop a bottle of tomato ketchup in a supermarket a cleaner appears within minutes? How often have we all heard ‘could a cleaner please go to platform 1’ at our stations but not so in a hospital?

A visit to the NHS choices website gives this particular hospital some reasonable ratings. 8.9/10 for cleanliness, 7.74/10 for overall care and 4.5/5 for patient feedback. Perhaps Tom has been unlucky – maybe an unfortunate set of circumstances has led to this isolated, but nonetheless, unacceptable lapse in service? But this is a very personal crisis and Liz fears that Tom, a normally robust and positive personaility, has given up and may not survive this episode.

Professor Don Berwick, the man tasked in improving patient safety in the NHS, says that redesign of service delivery is needed to make ‘zero harm a reality’. He lists seven imminently sensible criteria to be assessed and improved:
  •  Identifying aims for improvement in quality
  •  Building capacity through training and education
  • Oversight, accountability and influence
  • Patient and public involvement
  • Measurement, tracking, transparency and learning
  • Impact for legal penalties and criminal liability on patient safety
  •  Leadership
I absolutely agree with all of the above and will be fascinated to see the outcomes of this initiative. But in the meantime, let’s try to keep this real. Behind the jargon and theory, there are two key players – the care givers and the care receivers. If you ask any patient or their relatives what they want out of the care givers I would guess that their number one request would be simple. Ownership and responsibility. Don't blame agency nurse, contract cleaners, the doctors, targets, budget cuts, reform, phase of the moon or anything else. Ultimately – whoever you are, if you are caring for a patient, it is your responsibility to be the best and do the best you possibly can.

Or am I being naïve?

Saturday, 6 April 2013

Damned if you do and damned if you don’t.

I have a great deal of sympathy for Sir Bruce Keogh, Medical Director of the NHS and anyone else tasked with the challenge of interpreting patient safety figures. Like it or not, (and most of us don’t) – medicine is not an exact science. The nearest we can get to certainty is clinical governance - assessing outcomes and constantly monitoring effectiveness of treatments, surgical interventions, procedures and the departments providing these services. Clinical governance relies on statistics and as with any such analysis, validity and relevance needs to be verified and there is still room for error with interpretation.

The accepted wisdom that centres of excellence are the best way forward for specialist services and that there can only be a limited number of these special units in the UK means that some very tough decisions have to be made. None more tough than selecting centres of excellence for children’s heart surgery.

When it comes to NHS units, the natural human reaction is the absolute opposite of the NIMBY (Not In My Back Yard) response for unwanted local development or activity. In fact – we are all most likely to be YIMBYs (Yes In My Back Yard) for most NHS services on offer.

But patients, clinicians and parents must get real. Funds are limited, special skills are limited and high tech equipment is too expensive to be used only periodically. Specialist centres are the practical and cost effective way to ensure that the very best of outcomes are achieved. Of course, it is so much more convenient to take your child for life-saving surgery to a local centre, but if the quality of that local centre is in doubt, however lovely and committed the staff may be, then parents must take heed.

It is in this context that Sir Bruce suspended surgery at the paediatric heart unit in Leeds last week. Initial indications from figures recently acquired suggested that the mortality rate at the unit was unacceptably high. There was an immediate reaction from clinicians and families refuting this claim but Sir Bruce took, in my opinion, the only sensible decision that was open to him – to temporarily suspend surgery. The spectre of Mid Staffs Trust where statistics as early as 2007 that highlighted concerns were ignored (or even worse, covered up) and 1200 unnecessary deaths later, action was finally taken, continues to define the way forward for decision makers in the NHS. We simply cannot allow another Mid Staffs horror to happen. In the same way that a car manufacturer would be widely criticised for failing to recall vehicles with potentially dodgy brakes, so must NHS managers police care facilities, review statistics and act accordingly.

A spokesman from the hospital Trust said: "As we have stressed, the data and other information raise questions. They do not provide answers. These are for the Trust's review to determine. It must be right to put the safety of children first. It was therefore a highly responsible step to suspend the service. We hope that Leeds will shortly be in a position to restart children's heart surgery secure in the knowledge that everything is OK."

Sir Bruce has quickly reversed his decision on the Leeds unit and paediatric heart surgery will resume shortly as the figures have been proved to be erroneous and no doubt the staff, patients and parents will all be relieved and delighted.

This reversal of decision also took courage. We must trust that the majority of those involved in decisions regarding patient safety really do have the best interests of those patients at heart. If we don’t believe that premise, and that politics and personal grudges are creating bias and misinformation, then the NHS faces an ever bigger challenge than we all feared.


Saturday, 23 March 2013

Commissioning – we must keep the fox out of the chicken coup

It is only natural that the most commercially minded General Practitioners will become actively involved in Clinical Commissioning Groups (CCGs). It’s also logical that these commercially minded GPs will already have some involvement with private companies delivering care to both private and NHS patients. There is, I believe, nothing wrong with that, especially as we must not forget that GPs are, after all, privately contracted to the NHS in the first place. This only becomes a problem when GPs are given the power to choose providers for their patients and may have a financial interest in one or more of the providers being selected.

According to a recent report, more than a third of GPs on the boards of new NHS commissioning groups in England may face potential conflict of interest in the commissioning process. The investigation, undertaken by the British Medical Journal, estimated that 426 out of 1,179 (36%) GPs surveyed who are in executive positions on NHS Commissioning Boards have a financial interest in a for-profit health provider outside their practice.

This entirely predictable predicament now has to be subject to guidance to be issued by the NHS Commissioning Board.

However honourable and decent these GPs are, (and I have no doubt that most, if not all, are) – to be faced with a choice of the best provider for a particular treatment pathway, knowing that you have an intimate personal or/or financial relationship with that provider can be at best challenging, at worst, impossible. If you exclude a provider on the grounds of conflict of interest, you are at risk of reducing appropriate choice. If you exclude a commissioning GP on the grounds of conflict of interest, you may be denying a population of patients of an expert opinion. Catch 22.

I am pleased to see a growing number of recruitment adverts from CCGs and Commissioning Support Groups for pathway mapping, service redesign and cost reduction experts to enhance the whole process and deliver an effective and independent commissioning service. Considering the high proportion of GPs with declared private interests, each CCG may need to appoint additional independent advisers to redress the balance and maintain an impartial majority.

Ideally – there should be an independent organisation to commission clinical services in a region.
Ah yes – there used to be. They were called Primary Care Trusts, and they are due to be abolished next month.


Saturday, 16 March 2013

As predicted – NHS reform is proving to be divisive.

 Perhaps it’s because I was brought up as the difficult middle child, but I love a good spat – it gets issues out in the open and can often clear the air. If only it were that simple with all the siblings of the complex NHS family, a family that appears to be more dysfunctional by the day as the Health and Social Care Act is implemented.

No-one could doubt  the good motives of the former Health Secretary Andrew Lansley as he formulated the transfer of power to give General Practitioners not only the lead when it comes to commissioning of services, but the key to around £60 billion. But as many of us are already aware, the consequences of these changes are not all beneficial.

As predicted, GPs appear to fall into three camps. Those who don’t want all the hassle, paperwork, responsibility of balancing commissioning with face to face patient time and therefore vote with their feet through early retirement. The second group are probably the silent majority who either take an active role in a commissioning group because ‘if you can’t beat ‘em join ‘em’ or maybe take a lesser commissioning role while trying to spend as much time with their patients as possible. And the third, possibly more vocal and active group are those who favour the changes, relish their new found spending power and appear to be planning world (or at least UK) domination.

Those GPs who embrace the additional responsibilities placed on their shoulders by NHS reform are to be congratulated and supported and I have no doubt that many of the clinical commissioning groups will do an excellent job in difficult circumstances, especially when they have the good sense to bring in the appropriate commissioning and clinical pathway mapping experts. But I fear that the side effect of the bullish comments by, for example, the NHS Alliance could do much to damage interdisciplinary relationships and ultimately the patient experience and clinical outcomes.

Without doubt, the priority for any health professional must be joined up care for patients – literally from cradle to grave. Forgetting this awesome timespan, let’s just focus on a patient needing some non-urgent care that may involve some sort of surgical or specialist led intervention. In an ideal world, the clinical pathway for the patient’s condition has already been agreed within the local CCG and this pathway entails full cooperation between primary and secondary care. But according to a letter to The Times newspaper by Drs Michael Dixon and Chris Drinkwater and some of their colleagues ‘hospitals are dangerous places’ and they must ‘as an immediate imperative, shift all non-urgent care into the community’ One could argue that this makes sense but it must be viewed in context. Services can only be shifted into the community if the infrastructure creating the desired capacity is there.
It isn’t.

The letter goes on to mention the NHS Alliance Manifesto which is ‘formulated by frontline doctors, nurses and professionals in primary care’ Manifesto? A manifesto can be defined as ‘a published verbal declaration of the intentions, motives, or views of the issuer, be it an individual, group, political party or government’. This very much suggests a group in isolation of the whole NHS family. The NHS Alliance manifesto spells out some worthy aims but is positioned in a political, territorial way. There is more than enough bad press about hospitals without such powerful GPs proclaiming what dangerous places they are – just imagine how a Times reader with a visit planned to hospital this week must feel?

Needless to say, two days later, a response from a surgeon was printed in the newspaper and he politely points out that one of the issues with non urgent care is that over the years he ‘has witnessed a derogation of out of hours care, exacerbated by the GPs contract in 2004’ and doctors deputising services are often ‘staffed by doctors who do not have requisite skills’.

Fair point well made.

So there we have it – just one small, but potentially significant spat between primary care and secondary care siblings generated by the parent who didn’t think things through when dividing the spoils of his inheritance.

What a sad reflection of a familial relationship that should engender the very best for the patients in our care. It has  generated some unwanted side effects for professionals, trying to do their best for their patients but having to win ground and hold position all at the same time.

Friday, 8 March 2013

What a difference a week makes – not.

It really is same old same old at the moment in UK health.

David Nicholson hangs on:
With the tenacity of a desperate mountain climber teetering above a crevasse, the Chief Executive of the NHS grips to his position. Insisting ‘I am the right man to lead the NHS’ his performance at the parliamentary select committee hearing this week served only to confirm that this man is either seriously lacking in a layer of human emotion and humility, or is incapable of showing that he really does care. Either way, this is not the type of persona that the NHS needs right now. Word on the street is that he will be gone by August, so if that’s the case, why not let him go now? Apparently he has a ‘tight grip on the NHS’. If his grip was as tight on the organisation to achieve the right balance between quality and cost as it is on his job maybe there would be some hope. This man ain’t for shifting. No change there then

Julie Bailey and Cure the NHS continue to impress:
And long may she continue to voice the concerns of millions. Speaking outside the Houses of Parliament with her comments on Nicholson’s culpability, the compelling Ms Bailey was, as always, calm, eloquent and convincing. Her late mother, Bella would be proud of her – and so should all of us. Keep doing what you are doing Julie and all your friends and colleagues at Cure The NHS.

‘Billions in extra cash fails to stop the rot in the NHS’ (Daily Telegraph)
A report in the UK press this week told how Britain is slipping down the ranking in public health, compared to other Western countries. Life expectancy is increasing – which in itself could be depressing as our pension pots run out – but we are now 14th in the list of 19. I would be more interested to see a table listing quality of life and health and wellbeing – just being alive doesn’t tell the whole story. But the key point is that spending has increased from £46 billion in 1990 to £122 billion this year but we are not seeing an improvement in the health of the Nation. The effects of a past generation of smokers, and a new generation of the obese and inactive who eat junk food continue to pile on the pressure for our struggling state funded system. How do we stop the rot? We are still looking for answers.

Jeremy Hunt attacks 'complacent' hospitals (BBC)
Apparently Jeremy Hunt, the Secretary of State for Health will announce during a speech today  that ‘too many hospitals are coasting along, settling for meeting minimum standards’ He will ‘attack a culture of "complacency" and "low aspirations", which he believes is holding the NHS in England back’. Mmm – so that would be a culture led by a Chief Executive who has a ‘tight grip’ on the NHS? So that’s another thing that doesn’t seem to be changing – the disconnect between logic, good sense and NHS reform.

Change for change’s sake is bad. Change to improve, innovate, rationalise and consolidate is good. What a pity - it’s mainly the things that need to change that are staying the same.

Saturday, 2 March 2013

What a difference a year makes as NHS Reforms become real.

How interesting… Michael Dixon, Chair of NHS Alliance and Interim President of NHS Commissioners has warned that doctors would "start getting bogged down" in dealing with competition and would end up taking their "eye off the ball". He is concerned that the wording on competition in the Section 75 of the Health and Social Care Act will mean that doctors could get "bogged down" in the process of commissioning and distracted from patient care.

Reality is really beginning to bite for a GP who has been a huge supporter of NHS Reform, which transfers the shift of power to give GPs the majority of the NHS budget to commission care and services. Dr Dixon has been a bullish proponent of GP led commissioning and last year relished the new powers to be endowed on GPs, but his ardour now appears to be waning. What a difference a year makes. Less than a year even. Last May, I attended an NHS Futures Forum and struggled with Dr Dixon’s enthusiasm for this shift in power. An extract of my blog that week follows:

May 18th 2012
‘…..Oh dear oh dear oh dear. I must be very careful how I put this but Dr Dixon’s presentation fuelled my worst fears about the effect of these NHS Reforms. He started his talk with ‘I am an independent contractor, like a plumber’. ….…..Michael is massively in favour of GP Commissioning and leads a pathfinder GP practice. He was in my opinion (I must be careful not to upset my lawyers) positively salivating at the prospect of complete control of a big chunk of the NHS budget. I found his talk of a café in his practice, his views on specialist representation and his apparent lack of empathy with secondary care quite worrying……He made no secret of the fact that a desired outcome of the reform and GP led commissioning was to migrate services away from Hospital Trusts. He continued – and I quote, as near as my notes allow, ‘I’ll be moving stuff from hospital to my practice and I’ll get money for it, therefore there needs to be total transparency’.  Baroness Young (the chair of the event) was brilliant as a devil’s advocate with her careful wording. She asked Dr Dixon his view on the fact that many patients, especially those with long term conditions do not wish to be ‘discharged’ from the care of their specialists to be handed over to a general practitioner……I asked Dr Dixon if perhaps that figure [that 30 -40% hospital admissions are avoidable] could be due to the fact that patients couldn’t get in to see their GP and how would GP commissioning improve this state of affairs. For a moment I thought he had morphed into Andrew Lansley as the question was effectively side stepped. When I queried the impression that he didn’t want specialists on ‘his’ commissioning board, he clarified that he doesn’t want hospital specialists on the board who are ‘trying to protect their budget’.  A phrase that springs to mind includes ‘pot and ‘kettle black…….’

Back to the present…
There is some merit in Dr Dixon’s demand that the wording of section 75 of the Health and Social Care Act should be changed as it appears to encourage a scatter gun approach to opening up competition for services which could be unsuitable for private involvement either due to expertise, location or supply issues. Commissioning isn’t easy. If it was, the NHS would be in a better state than it is. I would much prefer seeing GPs looking after patients, directing their care and referring them on to appropriate specialist services. But the nitty gritty of preparing tenders, assessing responses and monitoring contracts is a full time job.

I believe that carefully managed competition in targeted service areas can be a good thing for the NHS. But commissioning is a specialised, time consuming, detailed and burdensome job. Being a GP is a specialised, time consuming, detailed and burdensome job. How can GPs realistically be good at both? Dr Dixon continued in his interview with Pulse magazine that offering the tendering process for most NHS services to private firms could mean that the reforms are ‘a complete waste of time’ and that ‘GPs will walk’.

Last year, referring to his desire for autonomy and lack of interference, Dr Dixon famously said ‘GP’s don’t want to be managed – we want to be seduced’

Fun as seduction may be, it often results in consequences that aren’t always positive. I am tempted to say ‘I told you so’.

Instead I shall settle for ‘Be careful what you wish for….’