NHS reform – a game of three halves

There were three articles in yesterday’s UK Sunday Times which nicely summarise the state of play for the NHS right now

‘Battered Lansley certain of victory in NHS fight’ is the first headline.  The article states that 65% NHS workers want the Bill withdrawn, 66% believe that it will make the NHS worse and 84% are concerned about the role of the private sector. Nothing new there. And as I, and many commentators have written – this Bill is an unpopular, poorly thought out piece of legislation. But as the article also states – it almost certain to become law.  As the newspaper piece goes on – history shows that most changes recommended by any UK Secretary of State for Health are unpopular but have been implemented anyway. But of course Lansley’s weak narrative and lack of concrete evidence to support his radical shakeup don’t help and a piece of legislature in itself doesn’t create change. It’s the people at the coalface who make things happen. Or not.

‘NHS told to reduce weekend deaths’ is the next headline as Lansley has ordered a ‘fundamental rethink’ on how hospitals are run at weekends due to concern over patient death rates. He states that ‘hospitals should be truly 24/7’ as currently diagnostic facilities, some operating theatres and treatments are unavailable and junior doctors take on additional responsibilities on Saturdays and Sundays. This follows research by the organisation, Dr Foster, which estimates that hospital mortality rates are up 20% at weekends. These figures beg further investigation but highlight a key point. It’s not just the ‘big picture’ that needs attention, it is the way hospitals function on a day to day basis that really need close scrutiny. Policies and practices, pathways and procedures all need review.

And finally another hot potato – ‘Rippon tears into nurses for lack of care’ reports how the well-known broadcaster Angela Rippon, who is now vice president of the Patients Association criticised the ‘minority of nurses who were not compassionate and caring’ The story started with a disappointing tale of a group of nurses huddled round a shopping catalogue at the nurses’ station saying they were ‘too busy' to attend to patients pressing their buzzers and calling for help. There are sadly all too many reports like this to ignore the fact that standards of care are falling not only in our hospitals but in clinics and health centres.

So what about this game of three halves?

One: Let the politicians, unions, medical associations and all other interested parties continue to debate the merits or otherwise of the Health and Social Care Bill. It will become law and then it’s up to all NHS workers to pull together and somehow make it work.

Two: Bill or no Bill – hospitals must be better organised, leading to measurable improvements in clinical and operational practices.

Three: Standards of care must be reviewed and transformed. Now. Leaders must lead by example. Managers must manage performance. Nurses, therapists, receptionists, doctors, ward clerks; anyone associated with patient contact must demonstrate a calm, caring, courteous attitude or suffer the consequences.

Now that’s what I call reform.

Andrew Lansley is a lone voice in a wilderness of his own making

It doesn’t take a management consultant, healthcare expert or even brain of Britain to work out that the radical restructure of an organisation at the same time as introducing stringent cuts is a tricky assignment. Add into the mix that the organisation has an annual spend in excess of £100 billion, over 1 million staff from a multitude of disciplines, and 60 million potential customers and the project gets a whole heap tougher. Then throw in unrealistic timescales and take away the support of the majority of that 1 million staff and you are on the road to hell.

You don’t need to be Sherlock Holmes to see the link between this scenario and the current state of the NHS as the Health and Social Care Bill continues to de-stable an already unsteady ship.

No surprises either to hear that the report of a cross party commons select committee chaired by former health secretary Stephen Dorrell voices serious concerns about the effect of ongoing debate about reform, saying they were ‘complicating the savings process’ because they were acting as a ‘disruption and distraction’.

Stephen Dorrell and his committee are the voice of reason, stating that the ‘need to achieve efficiency savings in the NHS was paramount, and that the bill must come second’.  Dorrell continued ‘The priority is to deliver more efficient care, in order to meet demands placed upon the system - and the implementation of the bill has to fit in around that’.

This point is key. We should be creating savings by developing cost effective, high quality integrated care pathways. Just the goal of 4% savings, year on year, should be sufficient to generate some of the behavioural changes required and alongside this goal, some long term strategies for sustainability of state funded care could be explored.

But back to Andrew Lansley, current UK secretary of state for health. I say ‘current’ because I cannot see how much longer he can dig in, hanging on to his precious Bill, despite all those around him, wiser, more experienced and the majority not politically motivated who believe he is over-complicating an already complex issue.

I listened to a radio interview with Lansley earlier today as he was asked to respond to the growing cacophony of opposition to his reforms. As usual, he continued to tow his own special party line, ignoring his detractors and sticking to his polemic – his ritualistic support of his own brand of reality. He still chooses not to hear the combined chorus of the majority of medical and therapy organisations, charities and independent think tanks.  He rejects the findings of the committee in the same way that he ignores any other report failing to support his one man mission.

This Bill has now become a bigger problem than the issues it seeks to repair. It is, as Dorrell quite rightly says, a distraction. Lansley’s commitment to this flawed reform is admirable but misguided.

Lansley is alone in his wilderness – I would rather he came back into the fold and started to respond to the wise people around him. Failing that – Cameron should release him into the wild to roam free – as far away from the NHS as possible.

What a difference a year makes – not.

A year ago, 19^th January 2011 I posted a blog entitled NHS Reform – The Titanic has now hit its iceberg. I commented that as the Health and Social Care Bill was published that day, I had a growing sense of foreboding.

Exactly one year on have my concerns eased? Of course they haven’t.

A few months later I published a blog entitled The List. This included 29 organisations and influential individuals who had spoken out against the Bill. Despite 12 months of lobbying, pausing and listening, and, let’s be frank, a degree of bullying by Andrew Lansley, UK Secretary of State for Health, I’m not aware that anyone on that list has changed their minds.

Today, on the anniversary of the Bill another two major organisations have come off the fence. The Royal College of Nursing and the Royal College of Midwives have announced that they feel continuing to work with the government to implement the reforms is no longer the best way forward. In a powerful statement Peter Carter, general secretary of the RCN, which represents 410,000 nurses, midwives, support workers and students, said: "The RCN has been on record as saying that withdrawing the bill would create confusion and turmoil, however, on the ground, we believe that the turmoil of proceeding with these reforms is now greater than the turmoil of stopping them’

Like everyone else with an investment in the NHS (approximately 60 million of us) I accept that the NHS needs improvement. In fact – 18 months ago I worked with an organisation called just that - NHS Improvement. It was one of the most satisfying and rewarding times of my life. My daughter also came on board to work on a project and we used to bore the rest of the family with our passionate recounting of working with committed and talented clinicians and managers, overcoming cultural and institutional barriers to achieve real progress. The improvements the team implemented impacted directly on patients’ survival and quality of care. Reform was going on in pockets throughout the UK. That is what the Bill should have built on.

But instead of watering the green shoots of new growth, the pin has been taken out of a grenade and the explosion from within is wreaking its damage through the core of our state funded system.

Influential organisations are demonstrating continued and unremitting opposition to the Bill. NHS workers seem to be unreasonable in their expectations of job for life and unsustainable pension contributions. Maybe this perceived intransigence is down to their genuine concern for the patients in their care and the discomfort of a stressful and confusing working environment.  The public/private healthcare sector divide is also widening as it was announced a few weeks ago that 49% of NHS hospital incomes could be gained from private patients.

As predicted – the Health and Social Care Bill is a divisive vehicle – busy going nowhere and dismantling previously good working relationships along the way. Confidence in Andrew Lansley is at an all time low. Bad news stories about the NHS are now the norm rather than the exception. It has not been a good year. Lansley has had 12 months to win the hearts and minds of over 1 million NHS workers. He has failed spectacularly and key relationships are now significantly worse than they were when the Bill was published.

Back to the shipping metaphor. We have all been shocked by the horrific spectacle of the Costa Concordia cruise liner grounded on the rocks off the coast of an Italian island. The captain has confessed that he steered the liner along the wrong path, with devastating results. Worse than that – once he realised his mistake, the actions to protect the massive vessel and the precious lives on board were grossly inadequate.

If only they had had a different captain steering that path...

Reasons not to be cheerful in the UK this week.

Oh dear – it’s difficult to for me to maintain my usual sunny outlook and optimistic nature this week.

Psychologists have dubbed 16^th January as ‘Blue Monday’, in the UK labelling it ‘the  most depressing day of the year’ (post-Christmas gloom, credit card bills coming in, new year’s resolution already broken etc. etc.)

There’s plenty of depressing news this week too. The new high speed rail link, HS2 has been approved by the government. Cutting a swathe through beautiful countryside and disrupting urban communities, apparently the £33 billion price tag is worth it to reduce the travelling time from London to Birmingham to 49 minutes. Living in the Chilterns (for my overseas readers, unspoilt rolling green hills and picture postcard villages), which is in the path of this development, I could be accused of nimbyism (Not In My Back Yard). Lucky for me, I live some distance from the route, but even if my outlook was affected, I would like to think that if this investment (that will bring no financial return until 2026), was for the greater good, I would support it. But I really don’t understand how anyone can justify this huge spend on a tiny part of the UK travel infrastructure, when there are so many more worthy recipients for the public purse.

Another cause for concern is the push for a referendum in Scotland to vote for complete independence from the UK. My father was Scottish and my mother English so I have a genuine affection for both countries and hate to contemplate the break-up of the UK. One bonus of devolution would be the health statistics for what would be left of the UK would improve. The Scots are the least healthy of the ‘home countries’ with higher rates of heart disease, obesity and diabetes. They drink more, eat less healthy food and smoke more north of the border with England. But, my Scottish cousins, despite your unhealthy habits I’d still rather have you as part of the UK, and the English have little cause to be smug about the state of their health either.

What really depressed me this week was a story told me by my friends who live in Manchester, the home of my favourite football team. They were in restaurant recently and saw a very young baby, in a high chair, being fed a cheeseburger by her obese mother. Yes – a cheeseburger! Barely old enough to eat solid food, this poor unsuspecting tot was probably being set on a path to an unhealthy existence and a life blighted by substandard wellbeing. If public health predictions are right, she is likely to be overweight by the time she goes to school, obese in her teen years (currently 20%) and possibly smoking (20%) and binge-drinking (50%) to add insult to injury.

I would feel so much happier if an additional  £33 billion was spent on finding ways to educate, encourage, bribe, whatever is needed to persuade parents to do the right thing by their children and start healthy habits from day one.

Now that would be a good investment.

What do nurses really need?

As usual, there have been several stories in the British press about nursing standards in our NHS hospitals. David Cameron announced that nurses will be told to do regular ward rounds, suggesting that they should check on their patients hourly to ensure high quality care.
In another report, the NHS future forum stated that nursing training has become ‘too academic’ while at the same time reporting that some nurses lacked basic skills, have a poor grasp of maths and do not understand the values of the health service. The report goes on to say that ‘selection in nursing …. has moved away from selecting students on their ability, capacity for compassion and caring and desire to work in nursing’

None of this will come as a shock to anyone associated with the NHS. But what is strange is how government, watchdogs and ‘health leaders’ seem to be going about addressing the issue.

I find it a little odd that the Prime Minister should get bogged down in such detail as a ward round. In fact – I suspect he isn’t even clear on what a ward round is.

I have written before about the farce that is a ward round in many facilities - a hotchpotch of ‘health workers’ with neither badge nor recognisable status, standing at the end of a poor patient’s bed, discussing them as though they don’t exist and even getting their name wrong.

Likewise the NHS Future Forum suggesting that nurses should be assessed for their capacity for compassion. How do you measure that?

Nursing is a profession. It is a profession that requires intelligence, physical ability, emotional strength and a genuine interest in the health and wellbeing of the people in their care. Nurses’ pay in the NHS really isn’t that bad. Truly. It’s not. But it’s not an easy job, particularly in the current NHS environment of limited resources, proposed cuts and most of all, uncertainty. It's a job that can be physically and emotionally draining and I can completely sympathise with nurses who bemoan their lot. It must be very tough right now.

So what do nurses need? I had a very interesting conversation with a senior nursing leader who has worked in the public, private and community care sector and I absolutely agree with her. She reckons that what nurses need most of all is support and leadership.

It’s not for the PM to decide how often a nurse should check a patient. It should be down to a ward sister, matron or whatever you wish to call the leader of the unit. That leader should nurture a culture of care and compassion, of good customer service and excellent medical practice. That leader should discipline the work shy, weed out the bullies and encourage those who need and want to improve. But most of all, the leader in charge of the ward should take personal responsibility to nurture the nurses and carers. Like a good parent, they should be firm but fair, lead by example with resilience and treat everyone with kindness and professionalism.

Come to think of it – that’s what patients need too….

Faulty breast implants – this isn’t just about silicone.

Silicone implants have been a big news story in the UK for the past few days – and not because just about every female contender in the latest series of ‘celebrity’ big brother appears to be sporting a pair of ‘plastic’ appendages.

A recent report has confirmed that PIP implants, currently nestling in 40,000 chests in the UK, are faulty, could possibly rupture and consist of  ‘non-medical’ grade silicone, of the type normally produced for mattress stuffing.

The really interesting bit is what happens next. How would the government react? Would the private sector step up to the plate (95% of these implants were fitted privately) and accept a level of responsibility? And what about the women walking around with a potential ticking time bomb lurking within what they clearly believe to be their greatest assets?

This is a situation about culpability, blame and ultimate responsibility. I wasn’t actually going to blog about this story until I received an email from one of my followers, a normally easy going lady of measured opinion. ‘Ok blogger lady...no idea if you have an opinion on the issue …. I do not feel that it’s right that the NHS foots the bill for the exploding boob saga! Surely the private companies who stuck them in should have to replace them?’

Nicely put – ‘angry from Amersham’!

Authorities in France, Czechoslovakia and Germany have recommended that the implants should be removed. Andrew Lansley, UK secretary of state for health, wisely took some time to ponder his recommendations. If he agreed that all PIP implants should be removed – who should pay for this? Only 5% of the implants were funded by the NHS, presumably for sound clinical reasons, such as reconstructive procedures following surgery for breast cancer. No-one could deny that these patients deserve fully funded support and replacement of the faulty inserts. But what about the remaining 95% who chose the surgery for cosmetic reasons? Where do you draw the line for the NHS to ‘mop up’ complications following procedures undertaken privately?

I fully agree with Andrew Lansley’s recommendations (and it’s not often you hear me say that in this blog). Anyone who received the implants under the NHS should be offered replacements. I also agree with his comments – ‘We believe that private healthcare providers have a moral duty to offer the same service to their patients that we will offer to NHS patients - free information, consultations, scans and removal if necessary’

So far the private sector is making all the right noises, with the clinical director of one group, Spire Healthcare saying ‘We have a duty of care to our patients’ and Nuffield’s group medical director saying ‘We believe there is a strong case for the private healthcare industry to pull together to resolve this matter in the interests of patients’.

One could argue that this rather tiresome tale of a faulty medical device that will only affect 0.07% of the UK population is occupying too many column inches and too much airtime. But it is the bigger issue that is being questioned here – the fine line between responsibility and ownership of patients when they are treated in both the public and private sector.

I would like to see two outcomes from this recent problem.

Firstly, if treatment which takes place privately is not eligible within the NHS, such as for cosmetic purposes, these procedures will normally be self-funded, as they are unlikely to be covered by private medical insurance either. In these circumstances, I would like to see a mandatory indemnity insurance payment, to be made by the patient, to enable funding to reimburse the costs for emergency or follow up treatment, wherever it takes place.  Yes – this will make cosmetic surgery more expensive but it will introduce a safeguard against future controversy like the PIP implant dilemma.

Secondly, and this is a personal view, it would be good to see fewer women, whatever age, with fake bosoms. Stick to what Mother Nature gave you and be grateful for your good health.

Assisted dying

This is a tricky subject, and one that I have avoided so far, but the UK news today is full of the report of the Commission on Assisted Dying. According to the report, doctors should be allowed to help terminally ill people to kill themselves. The report goes on to say that strict guidelines should be introduced to ‘protect the vulnerable’.

The report states that current law on suicide in the UK is ‘inadequate and incoherent’  and needs reform. The commission was not supported by the British Medical Association (BMA) who refused to take part stating ‘The BMA believes that the majority of doctors do not want to legalise assisted dying’

I was chatting to a colleague earlier about this topic and he very wisely said  ‘I don’t think anyone can really  comment about this subject unless they have direct experience of someone close to them being terminally ill’  Wise words indeed. The problem is, of course, that if you have had such experience, your views are likely to be highly polarised and passionate.

And this is where, as a hopefully rational commentator, I must be careful. Sadly, according to the above criteria, I do qualify to comment on this topic, after my beloved husband, Bob, died of cancer. It is this personal experience that means that the report from the commission angers me greatly. The report states that a person first of all would have to be terminally ill to be considered for assisted suicide under its proposals. The group has defined that to ‘qualify’ for assisted death, a patient who has less than 12 months to live.

And thereby lies the first, insurmountable hurdle. 12 months to live according to who? In July 1999, my husband was given 6 months to live. Shocking, devastating and very frightening for a man literally in his prime with a family and to enjoy and so much living still to be done. Luckily, Bob chose not to accept the time limit suggested and lived for a further three and a half years. Most of that time his quality of life was good, and during those years he kept his business going, celebrated the birth of a new grandson, saw his girls blossom and walked one daughter up the aisle. This story is not unusual, and sadly there are also cases where survival is actually much less than expected. But who really knows?

The report goes on to suggest that a patient who chooses assisted death ‘should  be acting under their own steam and not be mentally impaired in any way’.  This is an equally unworkable recommendation. Who could differentiate between a frail and elderly patient with all their faculties who chooses to die from one who is privately under great pressure from their family for a convenient passing? And how do you define mental impairment in these cases?

I fully support the comments of Baroness Finlay of Llandaff, who chairs an all-party parliamentary group that opposes legalised euthanasia, ‘It is one thing to define the end of life for treatment purposes, quite another to do so for supplying lethal drugs for suicide’

I applaud the courage of any person, body or group who attempts to address the difficult and emotive issue of assisted death. But I would prefer to see more effort, publicity and resource focussed on end of life care.

The phrase ‘die with dignity’ saddens me greatly. A better phrase, normally used in end of life care circles is a ‘good death’. Like a ‘good life’ – this can mean very different things to different people. Palliative care is vastly improved and following  a patient’s wishes regarding level of sedation an pain relief, whether they are at home or elsewhere and a whole host of other considerations is paramount. Knowing how to speak to terminally ill patients and their loved ones also requires training and expertise. These areas would benefit greatly from investment, funding and recognition. But for a clinician to ask ‘do you want to die?’ is a bridge too far in my opinion.

Let us focus on assisted life, not assisted death.

A year in the life of the NHS

Regular readers will know that I’m generally an optimistic soul but I must confess that I face 2012 and another year of observation on healthcare and the NHS with a heavy heart. Before I look forward, I thought I should review 2011 – through the eyes of my blog and its readers.

There is clearly an appetite for news and opinion on the NHS and Finchers Health blog is now followed in 75 countries – Kyrgyzstan, Albania and Vietnam are the most recent to come aboard. I shall continue to attempt to provide rational and fair commentary although I make no secret of my reservations regarding the content and application of the NHS reforms proposed by the Health and Social Care Bill.

How can I summarise the NHS in 2011? Turbulent. Upsetting. Disappointing. Shocking. Worrying. Exasperating. That pretty much covers the care scandals, job cuts, waste, political posturing, and worst of all back-biting a cross the medical disciplines. Has the NHS moved forward in the past year? I really don’t think so.

No-one can deny the need for a significant shake up of cost management and quality assurance, but a top down radical reform was never going to be the best way forward.

At the end of 2010 I wrote about the fear factor in the NHS as the Health and Social Care bill loomed. One post which struck a chord nationally was where I quoted a young NHS employee who had left a note saying ‘I’m worried that I’ll lose my job and I’m scared that I won’t find another’. Alas in 2011 a significant number of very able staff have left the NHS and the phrase ‘brain drain’ has been echoing in the corridors of many a strategic health authority and primary care trust. It is expected that over £1bn will be paid in redundancy settlements to over 20,000 staff in the next couple of years.

What were my most popular posts in 2011?
‘The list’ - 22^nd March: I produced a (then) almost definitive list of organisations and influential individuals who had spoken out against the Health Bill. This proved to be one of my most popular posts of the year.
‘My dream team for the NHS future forum’ – 18^th April: I listed the perfect combination of the great and the good, past and present who could help shape the new NHS. These included Florence Nightingale, Mother Theresa, Albert Einstein, Lord Robert Winston, Joseph Lister, NHS founder Aneurin Bevan, and - to ensure he hears everything first hand without the political spin - David Cameron
'What do patients really want?’ – 25^th April: Concerned that patients were being forgotten in the political melee, I posted a simple list of ‘must haves’ for patients. This included information, choice, to be listened to, easy access to GPs, decent out of hours primary care cover, courtesy and kindness and continuity of care. This post was very popular in the USA.
‘Another view from the front line’ – 9^th May: An impassioned plea from a GP who asked me to write about a colleague of hers who died suddenly– and she was convinced it was due to the stress of reform.
‘NHS Future Forum’ – 18^th -21^st May: I was fortunate to attend a future forum seminar and wrote in some detail about the varying views of consultants, GPs and politicians. A fascinating event which failed to reassure me that the ‘listening exercise’ involved much actual listening.
‘View from an inpatient bed’ – 10^th -12^th June: Finchers took research to the next level – as an inpatient! Grateful for emergency care and life-saving treatment, I still had to comment on the poor organisation, lack of ownership, waste and poor time management among the ward staff – shocking in some cases.  
‘My birthday wishes for the NHS’ - 5^th July: My list of gifts for the old lady’s 63^rd birthday included clarity (sadly lacking throughout 2011), rejuvenation (we could all do with a bit of that) communications training for all staff, tolerance, innovation and performance management.

'Who really has power in the NHS?’ – 4th August: A fascinating study outlining the disconnect between doctors and nurses.
‘Clinical commissioning groups – time to face reality’ – 21^st September: I reported (admittedly a little smugly) that GPs are now facing the reality of their commissioning responsibilities as an advocate of extra GP powers, Dr Michael Dixon states that he doesn’t want to have to decommission services’. Tough.
'Ministers behaving badly must go’ – 14^th October: This post enjoyed multiple re-tweets, possibly because I came right off the fence and stated that it was time for Andrew Lansley, UK Secretary of State for Health, to go. He sneered openly at a health worker during a BBC political discussion programme, showing his contempt for the very people for whom he has responsibility.
‘How to win a healthcare argument’ – 17^th November: one of many posts outlining the challenge of educating and persuading the public on what’s best for them

And finally ..
‘The NHS – with a little help from Charles Dickens’ – 23^rd December: The ghosts of NHS past present and future ponder on what has been, what is and what may be…

Which brings me nicely to 2012.

With my thanks to all my readers for your support, robust discussion and frank comments. I look forward to continued stimulating and enjoyable engagement for another 12 months and wish you all a happy, healthy and prosperous New Year.