Good care doesn't have to be complicated.

The tragic case of Kane Gorny is a dramatic example of what can and does, go wrong in a hospital ward. Kane was just 22 when he of dehydration in a London hospital. He was so desperate for fluids and so upset that the hospital staff ignored his pleas that he dialled 999 and called the police who took his call seriously enough to come to the hospital ward to find out what was going on. They were sent away by the staff and Kane later died, for lack of water.

The case isn’t as straightforward as it would first seem, that patients were dying in the NHS simply for the want of a drink of water. This unfortunate young man was suffering from a medical condition which meant that he needed regular medication and constant top up of fluids to ensure that his organs received the hydration they needed. Add into the mix that Kane had suffered a brain tumour a year earlier which meant he could be prone to bouts of aggression. None of this was unmanageable and his post-surgery care after a hip operation should have been routine as long as the staff responsible for his care understood his medical history and specific needs.

The coroner investigating Kane’s death ruled that he was ‘undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, …a culture of assumption’

It is truly shocking that the many clinical and support staff who came into contact with Kane failed to ascertain the exact needs of their patient. Why was this? Because they didn’t care? I hope not. Because they were too busy? Maybe. Or because there was insufficient ownership and unclear responsibilities? More likely.  They all made assumptions regarding his condition and behaviour. Not one person ‘owned’ the wellbeing of this vulnerable young man. The highly desirable side effect of ownership and responsibility is communication, and good communication between clinical staff would have probably have saved his life.

I have just read a synopsis of the 37 page mandate for commissioning laid down as a result of the
Health and Social Care Bill. It talks about ‘improving recovery of illness’ and that the commissioning board will have a role in ‘maintaining or improving performance’. The government is ‘committed to extending the range of choices at every stage of patient care’. Would any one sentence in the 37 page mandate change the outcome for Kane Gorny? I doubt it. I suspect that he wasn’t so much worried about choice. His needs, and the needs of most patients, are pretty basic. Give me the right treatment at the right time with as much kindness and compassion as is humanly possible.

How can we ensure that quality of treatment and care in our hospitals? Through strong management at ward level. Through clearly defined responsibilities. If one person in that ward had personal responsibility for Kane, then hopefully they would have read his notes and made sure that they understood what was needed. And if they didn’t understand any element of his care there would have been other clinicians on hand to answer their questions.

When I worked in hospitals three decades ago there was a system where at the beginning of each shift the ward sister would allocate a number of patients to each nurse. Those patients would be their responsibility for the duration of the shift and the handover to the next shift was also their responsibility. They ‘owned’ those patients. I hope I’m not being naïve in believing that this simple method could still work today as long as you have enough qualified nurses on duty at any one time.

Why change basic principles. Good care is cost-effective care. Strong leadership, performance management and sufficient hands-on qualified staff create good care.  It doesn’t need 37 pages to explain that simple fact.

NHS Reform – what next?

As predicted, Andrew Lansley, UK Health Secretary has had his way and the Health and Social Care Bill has been passed.

It was interesting to watch Mr Lansley being interviewed on TV over the weekend. With the legal mandate safely secured, he was much less defensive and more confident in trying to explain just how the reforms will improve patient care and save money. One has to admire his resilience and self-belief, and his absolute determination to push ahead with this top down reorganisation of the NHS despite so much vociferous opposition from powerful adversaries.

Maybe it’s the pseudo petrol crisis, the hoo-hah about tax on hot pies or just the prospect of unlimited chocolate on Easter day, but all seems very quiet on the NHS reform front at the moment. A lull before the storm? I don’t think so – possibly the reverse. The storm has blown itself out and the lull follows.

After all the excitement (the debate has kept the pages of this blog busy for over a year), it all feels like a bit of a damp squib. The posturing and politicing, pausing and reflecting, debating and demonstrating, letter writing and voting has all been to no avail for the anti-Bill lobby. Just for the record, anti – Bill is not the same as anti-reform and I suspect that the majority of those closely involved with the NHS would agree that some improvements and efficiencies were badly needed.

As extensively reported, many of the changes listed in the Bill are already underway. Hospital managers are looking at ways of controlling increasingly tight budgets and coming up with constructive ways to work with the private sector to make best use of resources and reduce costs or increase income. Some GPs are either engaged in learning more about the commissioning game and enjoying some new found power while others are suffering in silence and struggling to balance patient time with administrative burden. Other GPs, possibly an alarming number, will be seriously considering early retirement to avoid the new regime. Health workers will be an unwilling audience as some layers of beaurocracy are deconstructed and replaced with other, unfamiliar ones.

What does this all really mean for the millions of stakeholders directly affected by NHS reform? Only time will tell.

And what about patients? They will be the real judges of what happens next.

The Health Bill isn’t the death of the NHS, but it will delay recovery.

As expected, the controversial Health and Social Care Bill is now set to become law within the next few weeks. The UK press have sensed that the public are fairly bored with the protracted political wranglings and in the wake of the Chancellor of the Exchequer’s budget announcements yesterday, the Health bill passed the finishing line with little ceremony.

Only one newspaper, Daily Mirror, seemed to prioritise the story and dedicated its front page to the NHS reforms with a picture of a tombstone headline ‘RIP NHS 1948 – 2012’

As Mark Twain (very much alive at the time) said after seeing his obituary prematurely published ‘Reports of my death are greatly exaggerated’, this is not the death of the NHS. But it’s certainly not very well. The comedian Spike Milligan’s grave stone reads ‘I told you I was ill’ (really – it does!) and this would have been a more appropriate headline for any newspaper. It isn’t competition that will do the most harm, it’s giving GPs too much money, too much responsibility and too much power. It’s ignoring the importance of quality nursing care and the value of performance based targets for both staff and clinical regimes. It’s the loss of priceless expertise in Strategic Health Authorities and Primary Care Trusts and introducing new layers of beaurocracy, despite claims to the contrary.

We know that it’s not just the patients in our hospitals and health centres who need treatment, we know that the health system needs fixing. No-one argues with this fact. This Bill won’t kill the NHS but although Andrew Lansley’s diagnosis was right, his recommended treatment and his unrealistic prognosis is way off course.

Why giving GPs £80 billion worries me – straight from a horse’s mouth..

Opposition to the Health and Social Care Bill is becoming old news and even the Royal College of GPs has offered an olive branch to the government in an attempt to make the inevitable reforms somehow work.
Despite ongoing bewilderment as to how legislation is being implemented before it reaches the statute books, the reforms are well under way.  Some GP’s are knee deep in commissioning plans, primary care trusts have accepted their fate as they shed staff and hospital trusts face a confusing and cash strapped future.

A BBC interview with an apparent supporter of the Bill polarised all my fears about these changes in the space of just three minutes this evening. As I was listening to the interview with Dr Rishabh Prasad, a GP from a Leicester medical centre, for just a few moments I was nearly swayed into thinking that perhaps giving GPs a very large slice of the NHS cake could work. The enthusiastic doctor explained how he believed that the reforms could promote innovation and how frustrated he had been previously in trying to set up a local study into deep vein thrombosis. But then he admitted that patients may not be happy with the changes that GPs’ new responsibilities may bring

The BBC health correspondent mentioned in her report that practices were already having to provide extra cover to free up GP time for commissioning projects. Dr Prasad then continued (and I quote) ‘As we pull GPs away from front line clinical work, there may be a disruption of service, not less of a service, but you may not be able to see the doctor you want or you normally see because they will be doing other things…..as a GP I can’t be in two places at once… I can’t be chairing some meeting and be here seeing patients. It will be interesting to see what happens in the next 5 years’

Mmm, chairing some meeting or seeing patients? – I know how I would rather my GP spent his or her time.

I do agree with Dr Prasad on one point though.  It will be interesting to see what happens in the next 5 years. Very interesting.

NHS Risk Register: To publish or not – which is the biggest risk?

I am a Prince 2 practitioner, trained in running projects using the ‘process based method for effective project management in controlled environments’ so popular in the public sector and favoured by the NHS. Much of the training course is plain old common sense, but the formal structure given to key elements of project design ensures that errors and omissions can be avoided and, most important of all, risk is managed.

Within the Prince 2 manual, the purpose of the risk theme is to ‘identify, assess and control uncertainty and, as a result, improve the ability of the project to succeed’. Just the sort of actions one would take when restructuring or re-forming a major institution such as the NHS.

The training goes on to help project managers:

Identify risks that could affect the projects objectives
Assess likelihood, immediacy and impact of each risk
Control responses to the risk, assign risk owners, execute and monitor responses. (i.e. take remedial action)

As the Information Commissioner placed an order to the Department of Health (DOH) to publish the Health and Social Care Bill risk register, it is reassuring to know that such a document exists. However Andrew Lansley, UK secretary for State for Health still won’t confirm that the register will be published and despite the fact that a recent tribunal has rejected the DOH’s appeal against this publication, the Coalition continues to drag its heels.

I have some sympathy with the view that it is not ideal for risk registers in general to be made public. To the ill-informed eye, such a document could be misinterpreted and the risks overestimated. But with such a major political and social issue, surely refusing publication will do more damage than exposing the flaws of a Bill that is already so blemished and devalued.

So one must ask – why? Why doesn’t the ‘nothing about me without me’ mantra apply to the risk register? The risks of top down re-organisation have already been discussed ad nauseam. Any change involves risk and as long as this risk is ‘identified, assessed and controlled’ then the likelihood of success will be greater. So shouldn’t the publication of the risk register reassure us that all bases are covered?

I suspect that the risk register won’t tell us anything new, but it will probably prove one thing. That Andrew Lansley was fully aware of the identification and assessment of major problems with his legislation even before the Bill was presented to parliament. But he went ahead without taking the controlled responses required to actually succeed and achieve the ultimate project goal. To improve the NHS.

What does compassion really mean when it comes to improving the NHS?

In one of his more obtuse replies to opponents of the Health and Social Care Bill, David Cameron is apparently going to tell the Tory faithful that ‘true compassion means taking tough decisions’.

As cliché’s go - that’s right up there with ‘no pain no gain’, ‘you always hurt the one you love’ and ‘it isn’t you, it’s me’. Compassion is a strange choice of words to explain what should be a decision based on fact, evidence, expert opinion and realistic forecasting. Unfortunately, just because a decision is tough, it doesn’t mean it is right.

And what about ‘true compassion’? The Oxford English Dictionary defines compassion as ‘sympathetic pity and concern for the sufferings and misfortunes of others’. I guess therefore that true compassion must mean true sympathy.

But what should compassion really mean in the context of NHS reform?

For patients: To be treated with dignity, care, courtesy and respect by every member of the medical profession, allied health professions and administrative staff.

For NHS staff: To be valued, informed and supported. To have your voice heard and your views respected noted and considered within the planning process.

For GPs: To recognise that not all GPs support the Bill. For those who want to form Clinical Commissioning Groups , clear guidelines, soft control, information, education and support. For those who don’t, to be valued for their expertise and commitment to patients, even if they don’t support the Bill

For Medical Colleges (such as Royal College of GPs and Royal College of Surgeons): To stop patronising them or ignoring them and to listen, note and act on their recommendations and concerns.

For consultants: To recognise that they are a vital part of the care pathway, that they are experts in their field and, like most GPs, care deeply for their patients and their clinical teams.

For Andrew Lansley:To accept that he means well but let him down gently and give him the tools (i.e. an experienced, pragmatic and influential team) to sort out the mess of his creation.

For David Cameron: To acknowledge that he thought he was doing the right thing when he handed a £100 billion budget to an intransigent Minister of Health, without realising that he would pass most of it on to just one link in the healthcare chain.

For the general public: To be reassured that their loved ones will be cared for properly, that budgets will be allocated sensibly and that quality will be the driver in every change applied to their state funded health system.

Maybe this on-going conflict between politics and care explains why compassion fatigue is high on the list of contagious diseases right now.

The NHS Reform sitcom - in homage to Blackadder goes forth

This week there’s been yet another debate on NHS Reform in the commons, BBC’s Newsnight programme did a Healthbill special, and just about every political programme continues to follow the tale of misinformation, misery and mayhem. Yes the Health and Social Care Bill is taking on the persona of a confusing sitcom, with three of the key players, The PM, Deputy PM and Health Secretary sticking true to character throughout.

The Health Bill sitcom scripts aren’t great and the characters not particularly appealing but I can see some similarities to the brilliant satire, Blackadder, especially series 4, based in the trenches during the first world war. Captain Blackadder, a battle weary, worldly wise leader struggles to keep his troops in line, fighting a war he doesn’t understand and facing a particular battle that he knows he is unlikely to survive unscathed. Captain Darling, similar in rank but lacking is good sense and paying lip service to his paymasters away from the front line is an unwelcome but compulsory presence in the trenches. And then there’s the unpalatable batman, Private Baldric – who has his own warped version of reality - diligent, loyal but, to be frank, living on a different planet to his colleagues. A good example of Baldric’s ‘brilliance’ is to shoot a pigeon so that Blackadder will have meat for supper. The only problem is – he shot the carrier pigeon used to relay vital information to and from the command post…

I shall leave you to decide who should play each character in my version of this tale…

Blackadder: ‘We need to improve the NHS – it’s too expensive, badly run and unsustainable. I have pledged that there will be no top down reform but we need to improve services and efficiency’

Baldric: ‘It’s OK Captain Blackadder – I have a cunning plan…’
Blackadder: ‘Good – I’ll leave it to you then.’
Baldric: ‘The patient will be at the heart of everything we do. The lion share budget will go to GPs. Nothing about me without me…’
Blackadder is distracted and doesn’t really listen - ‘Good, good …. Carry on…’

 A year passes and the troops don’t seem to like the Health Bill very much. They decide to try a new tack..

Blackadder: ‘No-one knows more about the NHS than Baldric’

Darling: ‘No-one knows more about the NHS than Baldric’

That doesn’t seem to rally the troops – in fact – it seems to irritate them.

Blackadder: ‘Baldric – this doesn’t seem to be going very well – most of the NHS staff, the medical colleges and even GP’s themselves don’t seem to be very keen, even your cunning plan of pausing and reflecting doesn’t seem to have distracted the troops enough, there might even be some desertions – what do you have to say?’

Baldric: ‘…many, many GP’s I’ve spoken to support the Bill…’
Blackadder: ‘Great! Where are they…?’
Baldric: ‘…nothing about me without me…. The patient at the heart of everything we do….’
Darling: ‘Can I help?’
Blackadder and Baldric look round to see where the noise has come from and at last realise that it’s Darling who doesn’t really say or do very much in the trenches.
Darling: ‘Why don’t I write a letter to all my troops and advise that I want a few more amendments and then we can discuss the Bill again in the commons and then I can pledge my support for the Bill and…’

That plan, which was carried out this week, didn’t work very well either.

The series ends with our three heroes preparing to go over the top to fight a major battle. As haunting music accompanies freeze frame shots of our characters leading their troops into the abyss we know how this is going to end….

Badly.

A word game that just isn’t funny anymore

I’m sure that many of you will have played the business word game. The one where you give a presentation or speech and are tasked by your colleagues to include an incongruous word into the mix. Failure to meet the challenge usually means that the first round is on you next time you’re at the bar. When I was an account manager with a major health provider there was a wide scope for potentially ridiculous words to weave into the conversation – I seem to remember that ‘chronicity’ was a firm favourite and one of our customer service managers somehow managed to include ‘wheelbarrow’ into a placatory call to a disgruntled customer.

I’m sure that David Cameron is far too busy for silly games but I can’t help thinking that some wordplay is underfoot within the Coalition.

‘No-one knows more about the NHS than Andrew Lansley’ said Andrew Mitchell, Secretary of State for International Development, looking very uncomfortable when questioned by Andrew Marr about the Health Bill on the BBC today.

‘No-one knows more about the NHS than Andrew Lansley’ said William Hague, Foreign Secretary, looking very uncomfortable when questioned by Andrew Marr about the Health Bill on the BBC a week ago

‘No-one knows more about the NHS than Andrew Lansley’ said the Prime Minister as reported in the Guardian newspaper last year.

If this is a word game – they’re not very good at it. For a start, the phrase or word is supposed to believable within the context in which it’s used. If this is the only argument the government can muster in reply to Health Bill opponents then they clearly are running out of arguments. If ‘no-one’ knows more about the NHS than Andrew Lansley then let’s give ‘no-one’ the job of UK Secretary of State for Health. Clearly Lansley’s ‘in-depth knowledge’ hasn’t stretched to understanding how to engage the support of most of the people he needs on side to make his reforms work.

Or is this a cunning ploy to personalise the Bill in Lansley’s name? Has the cabinet been instructed to pin the Bill indelibly to the hapless Health Secretary’s mast so that when it all goes horribly wrong he will be the only scapegoat? I wonder.

But back to word games – chronicity means …’of long duration, lasting for a long period of time or marked by frequent occurrence, subject to a habit or pattern of behaviour for a long time’.

Perhaps the choice of word for our silly game a few years ago was strangely prophetic….

Tobacco - the enemy within..

Let me start with a story…

There was once a village where the local people faced a grave problem. Every morning – exhausted and weary villagers were to be found drowning in the fast flowing river that ran through their village. The local community set up an elaborate and expensive alert and rescue system which enabled every drowning man and woman to be dragged out of the water, resuscitated and saved.

For years the village community struggled on, but they were poor because all their resources went into the daily lifesaving process. Then one day, a wandering minstrel happened by, and suggested that rather than saving the villagers – wouldn’t it be a good idea to find out why they were in the river in the first place?

I could continue the story with giants, goodies and baddies and elaborate plots but suffice to say, as soon as the locals realised what was causing their comrades to be in the water in the first place, they fixed it and the rescue and repair system was no longer needed.

My recollection of this well-known fable was prompted by a startling report published in the British Journal of Cancer announcing that 40% yes – 40% of cancers diagnosed in the UK each year are caused by avoidable life choices such as smoking, unhealthy eating and excess alcohol. Tobacco continues to be the most significant cause, accounting for a risk factor of 23% in men and 15% in women. I would like to optimistically assume that these figures would drop as public knowledge and understanding increases but there are no indications that this will be the case.

At a time when we are desperately seeking not only cures for cancer but also trying to reconfigure our health services to ensure that we can afford to treat an increasingly unhealthy population surely we should be doing more to stop people developing illnesses in in the first place?

The smoking debate is long running and emotive. There have been accusations of ‘nanny state’, ‘destroying human rights’, ‘restricting personal choice’ and the  pro-smoking lobby even disputes the extent of the dangers of tobacco. In medicine there is a measure known as the Therapeutic Index – which is the ratio between the toxic dose of a drug and the therapeutic dose (i.e. a dose that works). This is a useful measure of the safety of a drug and if the therapeutic dose is the same as the toxic dose then it is likely this drug will never get a licence. Even the rarest of side effects may stop the development of a drug in some cases and yet a massively toxic substance is freely available, with only an age regulation associated with it’s distribution and consumption.

In the UK you can be fined for not wearing a safety belt and even imprisoned for holding your mobile phone while driving (quite rightly). Children are no longer allowed to play with conkers in school without safety goggles. The same children at just 16 years of age can smoke a small piece of paper wrapped around a lethal substance responsible for 100,000 deaths annually and possibly twice as many people suffering life limiting disease. As soon as they are 18, they can buy this lethal substance in packs of 10 or 20 throughout the UK. Even that piece of legislation is crazy – you can smoke at 16 but can’t buy cigarettes until you are 18. I’m sure that makes a big difference to teenage smokers – not.

How can this madness be stopped or at least reduced? Yes, if the substance was banned it would drive smoking underground but surely the number of smokers would reduce dramatically. Yes tobacco -growing economies would be severely damaged but surely alternative crops could be grown? Yes, the UK government would in the short term lose significant taxation income and face huge pressure from the powerful tobacco companies’ lobby but in the long term, healthcare costs from smoking-related diseases would be massively reduced.

At a time when the Health and Social Care Bill is concentrating on the minutiae of who commissions what, disbanding and reconfiguring the beaurocratic process we continue to allocate massive resources on fishing the villagers out of the river. I can’t help but wish more time and resource was spent on stopping them jumping into the water in the first place.

Is any of the Healthbill protocoligorically correct?

There’s a great line in The Slipper and The Rose, the Hollywood version of Cinderella, where the autocratic King announces ‘Kings don’t cheat – they adapt to circumstances!’

As David Cameron calls an NHS summit today, adapting to circumstances - or changing the rules as you go along - seems to be the modus operendi when it comes to The Health and Social Care Bill. Plans for this summit, called by the Prime Minister ‘to discuss the implementation of the NHS Reforms’ were leaked by the Health Services Journal on Friday and more details emerged via social media over the weekend. Firstly we hear that the Royal College of GPs hasn’t been invited. Then we find out that the British Medical Association (BMA), Royal College of Midwives and Royal College of Nursing are also snubbed. Spookily all these organisations have been vehement in their opposition to the Bill. There’s even a rumour that Larry, the Downing Street cat has been banned from attending this hastily called meeting as his support cannot be guaranteed…

Yet again the coalition PR machine have got it so wrong with the Health Bill. When I first read of the summit – my immediate reaction was positive - maybe Cameron is going to get the key players together not just to talk but to plan a workable way forward? And yet again I, and literally millions like me, have been let down. As the BMA so politely put it ‘It would seem odd if the major bodies representing health professionals were not included’. Considering previous form on this legislation, this is not odd at all. Restructure of the NHS has already started, without mandate. The future forum came and went but still the reforms have been pushed forward.  Consensus of key stakeholders appears to be neither required nor valued.

Downing Street have, in a move smacking of autocracy and not democracy, refused to release the invite list and have quickly re-positioned the summit as ‘part of an ongoing dialogue’ . Simon Burns, health minister continued that this was a meeting with ‘those constructively involved in improving the reforms’

Mmm … ‘ongoing dialogue’ appears to mean ‘think as I think, speak as I speak’.
‘Constructively involved’  translates to ‘those who are empire-building, currying political favour or stand to gain financially, professionally or personally from the reform without consideration of the greater good and the NHS as a whole’

The coalition have defied protocol throughout – which brings me to a song from the Slipper and the Rose, as the head of court questions the king about his tunnel-vision approach to leadership...

‘And when the treasure is tapped of it's treasures
Are the tapestries stripped from the walls?
No, the court carries on with it's pleasures
Inquisitions and banquets and balls

But they must be protocoligorically correct
Good form must never suffer from neglect
The rules and regulations we respect
Must be treated circumspect

Else the kingdom will be wrecked
We've a system to protect
Checked and double checked and protocoligorically correct’

Oh how I long for the NHS to be shaped in a protocoligorically correct way…and where is Prince Charming just when we need him?

Why Miss Piggy is bigger news than Andrew Lansley

As the Health and Social Care Bill struggles its way to the statute book (or maybe not), it has to be noted that this has not been one of the Coalition’s finest hours. The Bill has become a political embarrassment and therefore a PR disaster.

When the fabulous David Beckham fell out with the equally fabulous (but in a very different way) Alex Ferguson, manager of Manchester United football club, Beckham had to go. Why? Because in Ferguson’s words ‘no-one is bigger than the club’. This puts me in mind of some of the issues facing the Health Bill. Andrew Lansley, UK Secretary of State for Health, is making more headlines than the reform itself. In the past week alone we have read:

‘Lansley will have to go, says top Lib Dem as party faces revolt’

‘Tories turn ‘toxic’ as health bill falters and reshuffle approaches’

‘Andrew Lansley right man for NHS Reform – Nick Clegg’

Lansley and the coalition PR machine have got it all so wrong. A good definition of public relations is ‘The art or science of establishing and promoting a favourable relationships with the public’.  Lansley’s ‘public’ includes over 1 million healthcare workers, a multitude of charities, care organisations and clinical practitioners. Not forgetting the powerful clinical bodies, colleges and unions. The lack of convincing and coherent narrative and Lansley’s inability to sway from his fixed, flawed vision are the two greatest contributing factors to this debacle. Another golden rule of PR – adapt to circumstances and sadly, flexibility is definitely not one of Lansley’s fortes.

It is widely accepted that reform is needed and some of the content of the Bill makes sense. But the message has been consistently off the mark.

My first job in healthcare marketing and PR was to promote a new private hospital in North London. State of the art medical facilities, cooperative working with the NHS and a high standard of care was of absolutely no interest to the local press, who we were very keen to get on side. We knew that a bad news private healthcare story would hit the headlines but any positive press releases were ignored. And then I got a front news story. A lifesaving heart transplant? Ground breaking technology? No. A baby. We sent pictures to the press of the first baby born in the hospital and the adorable little tot and her proud Mum graced the front page of every local rag.

There just haven’t been any good news stories about how this Bill will actually work. Poor Lansley, who according to his colleagues is ‘a decent man’, will ultimately have to take the rap for not only his, but his party’s failings. They really have made a pig’s ear of this.

Which brings me nicely to the title of this blog. Earlier this week I was flicking through the Metro newspaper (a free circulation newspaper with over 3.5 million readers) as always looking for health news stories. A large headline on one of the early pages caught my eye ‘Miss Piggy wants to start a family with Kermit’. About 10 pages later was a much smaller article entitled ‘Andrew Lansley rules out resigning over NHS reforms’

No contest.

NHS Reform – Has the penny finally dropped for Cameron?

The signs are all there when a relationship starts to falter. He doesn’t look you in the eye, won’t sing your praises in public anymore, avoids direct questions about your future together and doesn’t even let you sit next to him at Prime Minister’s question time in parliament….

Andrew Lansley, UK secretary of state for health is certainly feeling the cold – and not because it’s snowing outside. It’s the cold shoulder that will be providing the chill as he is increasingly sidelined while the political argument supporting the Health and Social Care Bill slowly unravels.

There seems to be a significant shift in commentary on the Bill recently, as it faces the next report stage in the House of Lords next week. There have been some cracking debates on TV and in the press as informed stakeholders become increasingly frustrated with the blinkered view of the Coalition health ministry.

On BBC’s Newsnight, the Health Minister Simon Burns was made to sit in silent agony as Jeremy Paxman read out the very long list of professional organisations opposed to the Bill. Burns, who in my opinion always has something of the pantomime about him, had to quash his usual flamboyance as he shifted uncomfortably in his seat, clearly desperately formulating some sort coherent repost to this growing list. The best he could manage is ‘If you talk to the GP’s - the people on the ground doing the commissioning, you will see the support for this Bill’.  He failed to comment on the fact that the Royal College of General Practitioners, who represent 50,000 members are vehemently in opposition. He ignored the question on why the majority of medical bodies rejected the Bill but claimed with great glee that the Royal College of Gynaecologists was in support of the radical NHS reshuffle. (There has to be a joke there but I can’t think of one I can print). Burns repeated the same mantra in other interviews this week as Lansley remains strangely absent. Mr Burns, please, change the record.

So Lansley is heading for the dark recesses of Prime Ministerial rejection, but sending another minister into the fray with equally weak argument and who clearly struggles with supporting this tragic Bill is not a good strategy.

The language surrounding NHS reform is becoming emboldened. A headline in the UK Times yesterday reads ‘Tories turn ‘toxic’ as Health Bill falters and reshuffle approaches’  reporting that the atmosphere within the Tory benches is ‘toxic’ as it dawns on them just how damaging this Bill could be not only to the NHS but to the party. Zoe Williams, the Guardian journalist summed up the situation beautifully on a politics show earlier today saying ‘It’s a car crash’

I wonder if David Cameron realizes now just what a car crash this is. As another journalist, Andrew Pierce commented. ‘This could be Cameron’s Poll Tax’ (referring to the local taxation policy Thatcher introduced which was the beginning of her downfall). But what can he do? Hope, as Pierce suggests, that The Lords will let him off the hook by rejecting the Bill? But the equivalent of a motorway pile up has already started. Despite the lack of legislature to back it up – the existing structure of the NHS is already changing beyond recognition. PCTs and SHAs are dismantled or merged, NHS Trusts are panicking as they scrabble to achieve Foundation status, staff are disengaged, Clinical Commissioning Groups are struggling to rise to their new challenge, the private sector has become totally vilified and patients are confused.

Yes, I think the penny has dropped, but removing Lansley or even stopping the Bill won’t avoid the metaphorical car crash. Fasten your seat belts – it’s going to be a rough ride.

NHS Reform – Is it too late for the public to take notice?

‘You’re scaring me now – can we change the subject please?’  Was this the recounting of a tale of horror – a scary film, gory story? No – it was me having dinner with a friend a year ago. She is a teacher, mother of three, with a semi-retired husband, elderly parents and a blind faith in the sustainability of the NHS to be able to care for them all. Conversation had turned to my blog and I shared my concerns about the Health and Social Care Bill. An intelligent and socially aware individual, she had until that point assumed that a radical reshape of the NHS would automatically produce a better state funded health system – until I shared some of my personal views on this flawed piece of reform.

I was reminded of this conversation reading Benedict Brogan’s excellent Daily Telegraph blog (@benedictbrogan) today where he comments ‘Mr Cameron is now opposed by the nurses and doctors in a way that the public might begin to notice’

To those of us with any inside knowledge of the NHS and how it works (or doesn’t),  the shortcomings of the Bill have haunted us daily – but the public so far have been oblivious to the realities of this top down restructure. In our press they see horror stories of inadequate care, limited resources and nightmare scenarios for hospital patients. They read of waste, poor standards and treatment rationing. Yes, most of these stories are true, but the situation is unlikely to be improved by these reforms. How can ‘the man in the street’ possibly understand what’s really going on?

Although I try to avoid politics in this blog, this coalition government has shown some weakness in a desire to please everyone. I wonder how long it will be before public opinion starts to sway Westminster on the Health Bill. Unfortunately this is where the opponents to the Bill have made their biggest mistake. The public are not impressed with strikes by NHS workers demanding that their pensions and jobs are protected in a way that those outside the public sector can only dream. Although Andrew Lansley, the UK Secretary of State has failed spectacularly in his narrative to clinicians and NHS administrators, his sound bites have, so far, persuaded the public that giving GPs the lion share of power and budget control is the way forward (even though the Royal College of Physicians do  not support this Bill).

One of the comments on posted by a wise reader of this blog states that the public are too concerned with paying their mortgages and riding the recession to be bothered with the arguments offered by the Bill’s detractors. This is where Lansley has got it right and the Bill’s opponents have missed their chance.  The Coalition is still backing the Bill. It may have a rocky ride through the Lords and the Commons but, again as Brogan writes ‘Cameron has shed too much blood to back down on health reform’.

I hope I’m wrong but I believe it is too late to muster public support.

Lansley will have his way.

Baffled? Moi?

Opposition to the coalition’s NHS Reforms has stepped up a pace again this week. The Royal College of General Practitioners (RCGP) has released a statement calling for the Health and Social Care Bill to be scrapped. Clare Gerada, chairman of the RCGP stated ’We cannot sit back. Instead, we must once again raise our concerns in the hope that the prime minister will halt this damaging, unnecessary and expensive reorganisation which, in our view, risks leaving the poorest and most vulnerable in society to bear the brunt.’ The Chartered Society of Physiotherapists joined the fray with ‘the views of patients and professionals had been ignored’

These two professional bodies alone represent 84,000 clinicians. They aren’t talking about pay or pensions – they are concerned with patient care.  Add the British Medical Association, Royal College of Nursing, and Royal College of Midwives and the growing body of evidence that this Bill remains unpopular becomes stronger than ever.

Then consider that the editors from three prestigious journals (British Medical Journal, Health Services Journal and Nursing Times) in an unprecedented joint editorial stated that the reforms were already creating ‘an unholy mess’. They agreed that ‘the resulting upheaval has been unnecessary, poorly conceived, badly communicated and a dangerous distraction at a time when the NHS is required to make unprecedented savings. Worse, it has destabilised and damaged one of this country’s greatest achievements’

This all adds up pretty powerful commentary by respected individuals and organisations. The sort of commentary that surely deserves some reasonable and carefully worded response from the architects of this ‘unholy mess’.

Not so. Health Minister Simon Burns said he found the criticism from GPs 'baffling' and in defence of the Bill his best shot was that the RCGP had previously supported some aspects of the Bill. He went on (or should I say whinged on?)  ‘Now we have this constant criticism and I find it in one way baffling, because it's not representative of what I hear GPs up and down the country saying, now that they're beginning to engage in having the powers to determine the care that needs to be commissioned for their patients.’

Hardly a well-considered response and still no real justification or explanation of how these reforms will actually improve the NHS while achieving a 4% saving year on year.

Burns’s boss, Andrew Lansley, has remained remarkably quiet this week, and it would seem that he still finds it incomprehensible that anyone would dispute the validity of his brainchild, despite over 12 months of dissent, growing more vehement by the day.

I agree with the three editors when they suggest that the Bill will no doubt become law and the way forward is that ‘Parliament should now establish an independently appointed standing commission, to initiate a mature and informed national discussion on the future of our national health system. Let us try to salvage some good from this damaging upheaval and resolve never to repeat it’

But back to being baffled – even though everyone involved with the NHS may have to accept that these reforms are now unstoppable there are still some questions that really warrant a decent answer.

 
Why has David Cameron not intervened to at least improve the quality of ministerial statements around this top down reform?
Why has Lansley been allowed to continue with his intransigent rhetoric surrounding key elements of the Bill?
Why have so many independent, intelligent and experienced voices been ignored?
Why was such a drastic, complex, top down shake-up of the state funded health system planned to coincide with major savings demands?

Baffled? It’s not you, Mr Burns who should be baffled. It’s the rest of us…

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...

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.