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

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

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

http://sarahcannonresearch.com/about/newsroom/new-genetic-sequencing-lab-creates-tipping-point-for

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

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

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

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

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

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

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

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

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

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

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In the same way that that increasing the number of lanes in a motorway can only ease traffic congestion if the slip roads lead somewhere, so NHS improvements can only work if there is a suitable onward referral route for patients ready for discharge. Many patients stuck in acute hospital wards no longer need hospital care but need to continue their convalescence with ongoing care in the community. This care can take place either in their own homes with additional support or in a community care facility.

 

When I was working on stroke improvement initiatives in North West London, we made fantastic progress on providing specialist targeted care for stroke patients. The London Stroke Model defined that stroke patients should be admitted to hyper-acute stroke units within stringent time limits from the initial call for an ambulance. After up to three days of intensive treatment and therapy these patients would be transferred to stroke unit where the specialised care would continue. This system works extremely well, with every stroke unit in North West London reaching the required standards for accreditation and additional funding within a few months. Stroke patients received world class diagnosis, assessment and urgent treatment, vastly improving their chances of not only survival, but retention of a good quality of life.

 

An additional bonus was that each hospital that reached and maintained the required admission times would earn significant uplift in their tariff. Every stroke patient not admitted directly to the specialist unit would count against the hospital. As part of the accreditation process, I joined inspection teams in hospitals to ensure that these stroke units met their targets for accepting stroke patients. The most challenging aspect of applying this stroke model was freeing up beds in these units to enable new patients for admission. Time and again, a patient who no longer required specialist care but needed community support would languish in their hospital bed because there simply was nowhere else to go. In one stroke unit, we had a patient, a homeless man, who was well rehabilitated and no longer needed intensive therapy, but had been in the unit for 66 days (the average length of stay in a stroke unit is around 20 days) because he simply had no home to go to. (We actually threw a leaving party for him when he finally had somewhere to stay). This bed blocking creates a damming effect (and damning for that matter) on the entire system, back to the moment when an unfortunate patient first has a stroke.

Burnham’s ideas of an integrated system are coming from a good place but his direction of travel is fundamentally flawed. Burnham’s ideas are:

·        NHS leads on the physical, mental, and social wellbeing of patients

·        Councils should hold the budget and define the health and wellbeing strategy to make a better link between health and social care

·        NHS should lead on provision, council lead on strategy and commissioning

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

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

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

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

Good care is about personal responsibility

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

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

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

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

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

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

Professor Don Berwick, the man tasked in improving patient safety in the NHS, says that redesign of service delivery is needed to make ‘zero harm a reality’. He lists seven imminently sensible criteria to be assessed and improved:

•  Identifying aims for improvement in quality
•  Building capacity through training and education
• Oversight, accountability and influence
• Patient and public involvement
• Measurement, tracking, transparency and learning
• Impact for legal penalties and criminal liability on patient safety
•  Leadership

I absolutely agree with all of the above and will be fascinated to see the outcomes of this initiative. But in the meantime, let’s try to keep this real. Behind the jargon and theory, there are two key players – the care givers and the care receivers. If you ask any patient or their relatives what they want out of the care givers I would guess that their number one request would be simple. Ownership and responsibility. Don't blame agency nurse, contract cleaners, the doctors, targets, budget cuts, reform, phase of the moon or anything else. Ultimately – whoever you are, if you are caring for a patient, it is your responsibility to be the best and do the best you possibly can.

Or am I being naïve?

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

Ideally – there should be an independent organisation to commission clinical services in a region.

Ah yes – there used to be. They were called Primary Care Trusts, and they are due to be abolished next month.

 

As predicted – NHS reform is proving to be divisive.

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

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

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

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

Without doubt, the priority for any health professional must be joined up care for patients – literally from cradle to grave. Forgetting this awesome timespan, let’s just focus on a patient needing some non-urgent care that may involve some sort of surgical or specialist led intervention. In an ideal world, the clinical pathway for the patient’s condition has already been agreed within the local CCG and this pathway entails full cooperation between primary and secondary care. But according to a letter to The Times newspaper by Drs Michael Dixon and Chris Drinkwater and some of their colleagues ‘hospitals are dangerous places’ and they must ‘as an immediate imperative, shift all non-urgent care into the community’ One could argue that this makes sense but it must be viewed in context. Services can only be shifted into the community if the infrastructure creating the desired capacity is there.

 

It isn’t.

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

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

Fair point well made.

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

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