Politicians must focus on NHS big issues

We are entering (in case you hadn’t realised it) a general election campaign. As far as the NHS is concerned it is going to be the bitterest and most tragic election campaign ever. This is the first time the NHS is being argued over without consideration of any underlying principles of any kind. At the last election the pattern was set for the future by the naked lie about not seeking any major reform. The promises offered by David Cameron in 2010 about the NHS built upon valued principles but have proved to be as shallow, short term and shabby as the failure to mention planned reform. Now it is only about money.

No-one can deny that there should be budgets and management should pay full regard to its financial obligations. But this is a public service and should be run for the benefit of the public. The balance has been twisted by short-term thinking about the politics of deficit. This has twisted almost every area of public life. Lets look at some problems in the NHS and think how politicians with a proper public interest might act.

We find that the financial deficit in about half of all Foundation Trusts is less than what they collectively spend on agency staff, mostly nurses. They need the nurses to meet their performance and safety targets. One of the problems with nurses is that they have not had a real pay review for some years so leaving and joining an agency, or going abroad, is an attractive route forward. Somewhere or other in all this there is an answer based on sensible principles which respects nurses, patients and budgets.

Another big issue is so-called bed blocking. Once upon a time local authorities ran care homes. That was stopped and it was left to market forces to provide care for the elderly. There is no centralised view of care needs, that’s left to the market. At any one time this winter there have been thousands of NHS beds occupied by people who should be in a more appropriate care environment but there are not enough care beds available. This is market failure and the public is paying through the NHS. One answer is to increase the number of publicly funded care places so that the winter peak can be handled. Blindingly obvious. The principle should be that discharge into a non-hospital place must be guaranteed at the time it is needed. Why cannot hospitals invest in care units part-funded through care charges.

The bean counters had a field day with PFI. The idea was simple. We need new hospitals so get the private sector to build them and run the buildings while the NHS occupies them and runs the healthcare service, paying a service charges for the privilege of doing so. It moved hospital construction off the government’s balance sheet and piled it onto the NHS’s annual budget. NHS hospitals now owe £80bn in PFI loan unitary charges – in other words, the ongoing costs of maintaining PFI hospitals and paying back the capital (on a formula which benefits the PFI ‘partner’). More than one NHS Trust is paying 15% of its annual budget in such charges – that’s 15% of its budget which is ring-fenced, immune from cuts or economies. PFI needs re-negotiating, if necessary through legislation.

That’s three areas where the politicians and the NHS need to do some re-thinking. Its not about a couple of hundred million here or there to massage public opinion, probably funded through some poorly identified saving which has knock on side-effects no-one has spotted yet. All these are big areas where public service core principles should apply. However no-one is bothered about core principles, they are all looking for where a pound spent can be paid for by a pound saved and, most importantly, a headline won.

Look after the principles and the pounds will appear in the system. Fail to do so and the NHS will fail.


NHS Future – trust innovators not profiteers

The NHS has faced some difficult moments over recent years which combined with a major reorganisation and real financial challenges create an aura of doubt over its future which the current political atmosphere is feeding on. I have just spent four weeks lying on my back. This gives some time for reflection and the hope that underneath all this doom and gloom there is more than just a glimmer of hope.

The announcement of Manchester as a quasi-autonomous region in the NHS closely followed by the naming of 29 ‘vanguard’ areas where local services will be given the freedom to create the service structures which suit their needs are being credited as the first big result of Simon Stevens arrival as Chief Executive of NHS England. This is the first dusting of common sense action at a major strategic level in the NHS for donkey’s years. If it is Simon Stevens arrival into post less than a year ago that triggered this we should cheer loudly.

It is a striking contrast with the high value but largely secretive attempts to put swathes of the NHS into private sector control. Nothing that has been announced in the last month could not have been done before the major changes which the NHS has been forced through. They all rely on innovation in the publc sector. Four years have been wasted. Or have they?  I think they have shown us some key indicators for the future.

  • the previous regime at the most senior levels was not capable of committing to such huge challenges for whatever reasons
  • the political agenda created diversions based on trivial dogma which we can now see will be disastrous if they are allowed to proceed
  • Stafford was not an isolated incident and what happened there (and in similar hospitals) is connected to that leadership issue

Lets look at that previous regime from another angle. Stafford looms large in that picture. The recent condemnation of NHS complaints handling was long overdue and still requires action. The ‘disciplinary’ actions taken against whistleblowers – many probably illegally – needs explanation. The  stories of bullying at various levels and the resulting waste of talent and opportunity that involved also need unravelling.  The sad postscript is that those whistleblowers and victims of bullying probably include many real innovators the NHS now needs.  For ten years the senior management of the NHS ignored the issues. We can suspect that it did so because that was its own management style, dictated from the top.

Whatever the truth, and no doubt someone will write it up in due course, we seem to be moving forward at long last. It may seem like four years wasted but if the political and executive arms of the NHS were frozen into incapability by the inertia they had built up and by the sheer scale of the politically driven unnecessary change they faced, revitalising them with new leadership and fresh ideas can only be beneficial.

The big issue to learn from is the foolish experiment of Hinchingbroke Hospital. We can see now that it was doomed from day one. Some people said so at the time but the evidence is now inarguable. Merging private sector management, the frontline of patient care, profit targets and the NHS financial system was never going to work.

Bringing in private sector expertise in focused areas can work, especially when you are developing a new service. The provision of PET/CT scanning in the NHS has been privatised for five years and the new ten year contract will go to one of the two previous providers. However this time the contractor will be working closely with an NHS provider, the Christie Hospital, whose role will be standards, skills and knowledge at a national level to support the provision and operation of equipment in cancer centres. It is a clean focus, few distractions. Is this a model to learn from?

The Guardian’s revelation this week that all cancer and end of life care in Staffordshire is to be outsourced to one private sector contractor looks like the lessons of Hinchingbroke are to be ignored. Front line care, quality services and profit hived off from local budgets has no ring of viability to it. By contrast the devolution of Manchester looks chaotic but such is the will to make it work in the public sector it stands a decent chance of success, though no doubt it will be a turbulent road.

So my weeks of enforced rest have arrived at two conclusions.

There are areas where some degree of privatisation will work. They need carefull analysis and planning. Front-line responsibility for patient care is not among the areas where it will work. There is a direct line betwen public money and patient care which should not be broken. I am also struck by the fact that the PET/CT contract decision involved patient representatives and that the contractor Alliance Medical is taking that message on board too.

But the second conclusion is possibly more important. Innovation in delivering NHS services is not dependent on private sector involvement. The ideas and the will are there in the local NHS, all they need is the freedom to demonstrate their viability. The 29 vanguard projects were chosen from over 260 bids, hopefully they are the first of many which will be the engine of change.

Compassion, care and a fried egg

Three weeks silence has been forced by a repeat visit of acute back problems. Spinal stenosis in the lumbar back was eased last summer by an injection at L4/5. Now the acute focus is at L3/4. The last three weeks have been dominated by morphine induced woolliness and extraordinary gymnastics to achieve simple tasks such as visiting the loo.

The comparison between ten days of hospital care and returning home to the care of my wife Sheelagh, is interesting. In hospital there is no shortage of manpower (sorry personpower) (womanpower really – should I get more PC in my thinking), to help get all these tasks done. There is also a store of equipment and good practice experience. At home the lack of resources is made up for by the familiarity of the surroundings, undistracted love and care, and the provision of food which comes high up my favoutites list. You also feel that you are working together towards a beneficial end. Even though I get “dont even think of trying that” at home, it is delivered with sympathy and the hint of possible negotiation.

There is no negotiation where Sister Helen is concerned. After some four stays on her ward in the last four years Sister Helen has got the measure of me. To be fair her team are superb and I only have praise for Ludlow Ward at the Robert Jones & Agnes Hunt Orthopaedic Hospital at Oswestry, and that includes Mo, who is every bit as formidable (and kind) as her boss. On such wonderful people is the real NHS built.

The hospital has one other call to fame. I have to admit that I have not done any research to estbalish whether RJAH is unique, the first, or one among many, but freshly cooked eggs and bacon for breakfast ! Brown or white toast, warm on the plate ? A pot of real coffee ? Yes this is a hospital breakfast which humbles many hotel breakfasts. I had my first egg and bacon with some trepidation. Long term recall of what hospitals can do to food vanished. It was hard to resist every day thereafter but I had to. The constipatory side-effects of eggs topped up the similar characteristic of morphine and other strong pain-killers. My earlier comment about extrordinary gymnastics has a deep rooted origin.