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.