Jeremy Hunt may win the battle but he will lose the war with the Junior Doctors

 Come on Jeremy – take a leaf out of George’s book.

One good thing has come out of the recent welfare budget debacle. George Osborne   demonstrated how a government minister can quickly change their mind in the face of irrefutable arguments against a bad decision.

 

Oh if only Jeremy Hunt would do the same thing. The junior doctor’s opposition to the Health Secretary’s new contract has now reached a previously unthinkable stage as they plan a ‘full withdrawal of labour’ between 8am and 5pm on April 26 and then 8am to 5pm on April 27. This conflict must stop – and it is down to Hunt to make the pain go away.

I use the word conflict advisedly – this is much more than a dispute  now – it is more akin to a bloody civil war – where the blameless victims are anyone who may need the state health service now or on the future. And maybe the doctors are victims too. When the arguments started in earnest around this new contract in 2014 I felt sure that clinicians wouldn’t jeopardise the wellbeing of their patients, and as a healthcare professional myself, felt that I could never condone strike action. But two years on – no-one can doubt the strength of feeling among these doctors and their desperation that has lead us to this sorry state.

 

Hunt insists that the doctors ‘don’t understand’ the contract. Come on Jeremy – it may have escaped you, but you actually have to be pretty intelligent to become a doctor. The British Medical Association doesn’t just employ doctors, they will have had lawyers look at the contract too – and I am confident that they do understand it. And they don’t like it. Never will.

I have been privileged to have worked alongside many junior doctors and have been treated as a patient by several too and I have never come across a lazy doctor. They work their butts off. They care about their job, they care about their patients and they always do more than their contracted hours. Yes, there may be some need for cost cutting and reshaping in the NHS but if you are going to bash anyone- do not bash the doctors.

 

 

Savings must be found elsewhere and the planned changes to the NHS working week must be reformulated. If the doctors do finally give in - which is clearly what Jeremy Hunt believes they will do – he won’t have won. The battle will be momentarily over but the war will still wage. In a great little memoir on power – Robert Greene states ‘Any  triumph you think you have gained through argument is really a Pyrrhic victory: the resentment and ill will you stir up are stronger and last longer than any momentary change of opinion. It is much more powerful to get others to agree with you through your actions, without saying a word. Demonstrate, do not explicate’

 

 

So Mr Hunt, take heed. Please do not beat these hard working, dedicated decent human beings into a grudging submission. Less of the explanations, more of the demonstration. Withdraw the contract – redraft another one in close association with the BMA – and then everyone can get on with what they do best – looking after patients.

 

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

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

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

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

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

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

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

1.     Think about the logistics. How will it work? Where are the pitfalls, or weak link in the chain? What will a successful outcome look like? Does the expertise and resource exist and if not – how is this generated?

2.     Assess the benefits. Will a successful outcome mean either a better or more efficient service, better clinical outcomes and/or more cost effective care? Basically – undertake an independent and transparent cost benefit analysis.

3.     Create a robust procurement process. ‘Screwing’ a provider down to an unacceptably cheap price means that you either have an unsustainable model or you will receive substandard delivery. Either can ultimately lead to disaster and expensive damage limitation further down the line. Use the considerable procurement expertise available within the NHS. Good, sustainable contracts are born out of the premise that every party is satisfied with the deal.

4.     Ensure that robust monitoring is in place. Just because something starts well, you can’t guarantee it will continue that way.

5.     Create and implement an effective communications strategy. I have no doubt that one of the biggest failings in the 111 service is lack of clarity for the public.

6.     Keep politics out of it. I know this is a fantasy rather than a realistic possibility, but our politicians and key NHS leaders should focus on the job in hand, not play a politically expedient game.

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

Ah well – a girl can dream…

Good public health policy takes courage

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

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

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

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

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

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

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

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

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

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

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

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

We need to see that courage from the government now.

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

Who should watch the watchers?

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

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

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

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

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

Thirdly – the regulatory and monitoring landscape following last year’s health and social care act is very confusing. In a poster created by NHS Employers the section entitled ‘Monitoring the NHS’ describes the 3 key areas as follows:

Care Quality Commission: ‘..is the independent regulator of all health and social care services in England. Its job is to make sure that the care provided meets national standards of quality and safety’

Monitor:  ‘..promotes the provision of healthcare services which are effective, efficient and economic and maintains or improves the quality of services’
Healthwatch England:  ‘..is the independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatches, it ensures that the voices of patients and those who use services reach the ears of decision makers’

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

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

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

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

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

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

And, most important of all….

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

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

How can you measure care?

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

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

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

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

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

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

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

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

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

I shall leave the last word to Tom’s wife – who used her own personal benchmarking system:

‘You could feel the care the minute we walked in the door’

 

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.