Archive for the ‘National Health Service’ Category

skeletal-debate

Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community.

Aneurin Bevin

The ability to provide safe, cost effective health and social care, across the National Health Service (NHS) England, and other recognised agencies, is continually being driven further into an abyss.  Contribution to this situation is seen through numerous factors: the change in societal expectations of what treatments should be available on the NHS; the historic failing of successive governments to create mechanisms within general taxation, and additional charging to facilitate the continuing demands on these services; poor leadership by the Department of Health-a direct result of short-termism and political ideology-cascading down to hospital management teams.  The private funding initiative (PFI) projects that have been demonstrated have a phenomenally catastrophic impact on patient care.  Outsourcing of services to the private sector which are integral to patient care, for example portering, and domestic services.  And more recently a drive, initiated through a shared myopia of government, and hospital managers, to blindly follow a culture of “more for less”, to name but a few.

Making savings ad infinitum with the objective of maintaining the same standards, is detrimental to an organisations ability to be efficient and sustainable.  Savings are a tool used by accountants to achieve short-term gains.  Whilst “Lean” working is a viable proposition in health care “lean” is not anorexic.  The long term effects of short term savings are to drive down standards, to force errors through the cutting of corners, and to cost the organisation dearly in the future.  “Speculate, you can’t accumulate, if you don’t”: true leaders in the NHS will see the value in this proverbial saying.

Hospitals are finding themselves in such financial dire straits, that with no apparent means of raising capital for investment, in the very basic infrastructure to make them viable propositions, under any  other circumstance they would be bankrupt.  It is possible to put a plug in the bath, even if it is a round(ish) plug in a square hole; and to at least turn the flow of the, money, taps down so they are running at a steady flow and not gushing.  But this requires long term policies, more freedom from government control, and leadership: not crisis managers.

It is time for hospitals to look at becoming shrewd financial investors; to speculate wisely.  If £25million in the red, to continue saving will only drive debt.  Speculate and invest to drive productivity over the long term, bringing the debt down.  If it is a system allegedly good enough for the government to implement, then why not Hospitals?

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Managers do not inspire doctors or clinical staff but good leaders do. NHS needs good clinical leaders.

Dr Umesh Prabhu

It is true, managers do not inspire doctors or clinical staff; it is also true that the NHS needs good leaders. 

However, even good leaders will fail to inspire the diversity of professional groups within healthcare, even though they share common objectives. Professionals, who with their own opinion toward hierarchical importance within the organisation, are but a barrier to progress.

Recognition needs to be given to the real and present danger within health care. One [danger] so great that the power it wealds will lead to the conclusion of the self fulfilling prophecy, based on the negative implications, of a failing NHS. This danger to healthcare, and leadership within healthcare, is the short-termism afforded to financial savings imposed by accountants, on the behest of others.

What is required, is for NHS Trust boards to be represented by members of all parties with intrinsic and extrinsic vested interested in the provision of healthcare, each with parity of voice. 

NHS Trusts must be empowered to raise funds: but not held captive by the shackles seen imposed through Private Funding Initiatives (PFI); to facilitate long-term investment. There is real truth in the addage, “speculate to accumulate”.

NHS Foundation Trust Hospitals are in a position whereby they no longer have the facility, ability, to progress.

The role of an agency has historically been to provide a source of labour to bridge short term vacancies, through sickness or maternity leave etc., within permanent establishment numbers.  Naturally, due to the nature of the short notice required to fill these vacancies, the cost to the Hospital, and the remuneration to the agency staff, is higher than a basic payment.  However, more so now-a-days, agency staff are found to be in post, in the same hospital, for years, enjoying higher rates of pay than their permanent colleagues; having to add here with less security and benefits.  But is this their fault; that agency staff can find themselves in such a position?  The answer is a resounding no.

There are reasons as to why agency staff, from all professions, find themselves in long term posts.  These reasons have remained unchanged over the years and include, but are not limited to:

  • High turn over of permanent staff – either out of health care completely, or on to the agency; tempted by the flexibility brought about through agency work.
  • Stagnation in the employment market – unless there are substantial benefits to moving, most staff remain at the same place of employment for considerable periods of time.
  • Inability to recruit experienced staff into permanent positions
  • Develop good working rapport with department – flexibility

On the 23rd November 2015 Monitor and the NHS Trust Development Authority (TDA) introduced price caps relating to the total amount Trusts can pay per hour, across all professional groups of agency staff.  The reason being that due to the existing pressures on health care budgets managing agency costs could allegedly save considerable sums.

Jeremy Hunt had indicated that such an action could save approximately £1 billion over a three year period.  A secondary, less publicised objective of the price caps being the eventual forced migration of agency staff  back in to permanent posts within the health service.

Introducing capping of the gross amount payable to an agency provider, thus in effect capping the remuneration of agency staff, at a time of year when people are at their most vulnerable, is a deliberate crass act by Jeremy Hunt.  Obviously a sanction timed with deliberate intention; reducing the potential risk of rebellion by the agency staff, withdrawing their labour.  Moreover, the timing of such an act would appear to be a deliberate attack on Junior Doctors in retaliation to their planned industrial action.

For clarity, the how and why of capping:

4. How have the proposed price caps been calculated?
4.1 The caps would determine the maximum total hourly rate trusts can pay an agency for an agency worker.  The cap would apply to the total charge and therefore would include:
 worker pay
 worker holiday pay
 employer national insurance
 employer pension contribution
 administration fee/agency charge
 any other fixed or variable fees or payments to the worker or agency or bank (e.g. travel, accommodation, finder’s fee, bonuses)

http://bit.ly/1LS1Nvo

1.10 The price caps are intended to support trusts when they procure from agencies and to encourage staff to return to permanent and bank working.  They should enable trusts to manage their workforce in a more sustainable way, reduce reliance and expenditure on agency staffing, raise quality and improve the working environment for their staff.

The effect of the capping for Band 5 and Band 6 on maximum AfC rate, most typical of Nursing and Operating Department Practitioners (ODP) can be seen here (on page 17).  An agency shift rate calculator can be found here.

This is not the first time there has been an attempt to address the high cost of agency expenditure, with the introduction of NHS Professionals.  An agency provider, owned by Government.  Professing to be the primary provider of healthcare professionals in the country, NHS Professionals does not appear to achieve the objective of having a positive impact on overall agency expenditure.

The continuing use of agency staff will inevitably remain a thorn in the side of NHS expenditure, as safe and effective health care provision is a catch twenty-two situation. The provision safe and effective health care is man power dependent.  If the provision of health care has to be pared-down to a minimal work-force in order to save money, to re-invest in other area’s, then the money saved will never reach those other areas: it will be needed to pay for mistakes made.  Invest in a work-force and whilst it will cost more to get the provision of health care right the first time, the savings made in the future will be rewarding and significant.

Effective work-force planning in health care, as with education is compounded by the lack of fluidity within the professions.  It is difficult to plan ahead for recruitment and retention in these areas and therefore there is, and will continue to be, a need for agency staff. And the capping of agency rates, to draw staff away from agencies into permanent positions is not the resolve.  It will only serve to move experienced health care professionals away from the NHS.

Dear Mr Hunt

Let us not beat about the bush.

Your attempt to save the National Health Service (NHS) £1 billion over three years, by way of capping agency spending bills, to re-invest in frontline patient care, is nothing but bravado in the face of a public who knows no better; and intimidation of hard working professionals who have to tread daily through sludge of government induced bureaucracy in order to deliver high levels of patient care.  To implement this aggressive policy at a time of year when individuals are at their most vulnerable clearly demonstrates the disdain this government has toward public sector workers.

Jeremy, the ignorance to the true potential of damage to health care demonstrated through your action is incomprehensible.  It is evident that there is already considerable loss of income across the NHS through the inability of hospitals to meet, in a timely manner, contracts with commissioning trusts.  On-the-day cancellations attributable in part to the inability of NHS hospitals to staff substantive vacancies with permanent staff; and a reluctance to employ short term agency staff, compound loss of income with the addition of  fines imposed by the commissioning trusts for failing to meet standards.  The perceived cost to prevent the cancellations, through the employment of short term agency, is an additional expenditure of small significance in the grand scheme of overall patient experience and outcome.

It must be asked Jeremy whether National Health Service Professionals (NHSP) ltd, an agency for healthcare professions set up by the Secretary of State for Health Alan Milburn in 2001; which was still owned in whole (all though not centrally funded) by the Secretary of State for Health in 2011, is included in your harsh opinion of, “agencies ripping off the NHS“?  In the very own words of NHSP:

We typically recruit more than 1,000 flexible workers every month, making NHS Professionals the largest recruiter in the NHS. http://www.nhsprofessionals.nhs.uk/nhsp/Pages/default.aspx

Is NHSP Ltd going to flourish through your anti-competitive attack on the private companies supplying agency staff?

Based purely on empirical data there is sufficient, substantive, evidence to be able to be explicit in saying the ratio of permanent staff (doctors, nurses, Operating Department Practitioners (ODP)) in post, on any one day, is far greater than that of agency.

Jeremy, if you are serious about making substantive savings in the NHS, remove the barriers of the internal market implemented by Thatcher post the Griffith Report.  Healthcare in silo’s creates financial waste.  Put some meat back on the carcass of a health care system made too lean by the blind followings of an inappropriate management system.

Regards

Richard

 

Silos444pxThe Labour Party are as guilty as both the Conservative and Libdem parties when it comes the privatisation of healthcare in the UK.

Privatisation of healthcare, without doubt began with Margaret Thatcher’s creation of the “internal market” in the mid 1980’s, using recommendations made by Sir Ernest Griffiths, in his earlier report “NHS Management Enquiry”, 1983. The report implied that healthcare should be run in line with the practices incorporated within supermarkets; Griffiths’ background was director and deputy chairman of Sainsbury.

Within the microcosm of healthcare provision [hospitals], the effect of the internal market was to create silos: separate within the whole. Unfortunately, because systems within the existing NHS ethos were not not geared up to facilitate Thatcher’s ideology; moreover, non-NHS managers could not comprehend why their management systems could not, on the whole, work within healthcare, the NHS continued to flounder like a supertanker embedded on a sandbank.

The silo effect of healthcare provision has continued through successive Governments, Labour and Conservative alike. Therefore it is unreasonable for Labour to continue to argue against the privatisation of healthcare when they themselves have done nothing to prevent progression of the privatisation of health care.

Cameron, Clegg and Milliband, all in it together.

 

A friend introduced me to the thoughts of Jared Diamond, during a conversation at work, in particularly to a  lecture he presented titled “Why societies collapse“.

In his lecture he presented an interesting analogy describing contributory factors associated with the collapse of societies; an analogy relating society, to bacteria in a Petri dish.

As bacteria grows within the confined space of a Petri dish there comes a point where there is a balance between “resources” within the Petri dish (nutrition) and “resource consumption”.

Diamond suggests, to prevent collapse within an evolving society, a balance between resources and their consumption; as much as a balance between economic outlay and economic potential to prevent collapse.

“Mismatch between available resources and resource consumption” will bring imbalance due to continuing growth of bacteria. As society expands beyond the available resources and systems of economy available, as with the bacteria, society collapses.

Taking Diamonds bacteria analogy to macroscopic level in everyday life, brought me to the state of the health service in the United Kingdom (UK). Taking this to microscopic level (that is hospital level) one can begin to appreciate why hospitals are failing.

It is clear that boundaries have been reached when the “Petri dish” represents the confines of the hospital. Attributable to an ageing, expanding, population available resources are not keeping up with consumption nor is the required economic outlay to maintain the service provision being met by the economic potential available. Simply there are not enough people contributing enough to the pot.

Resources in this instance means service provision within the hospital.

Accident and Emergency departments failing to meet the four-hour targets set by Government, where-by “no-one should wait more than four hours in accident and emergency from arrival to admission, transfer or discharge“. Or the increase in waiting times for operations due to the availability of level two and three facilities and ward beds.

In order to address the collapse of this micro-society one has to look at resources and resource consumption in tandem with economic outlay and economic potential.

What can be done to delay, if not prevent the collapse of this society?

As the Government of the day used public funding to save the banks from collapse, the health service is employing private companies. And whether this is liked or not, there is little that can be done about it.

Some hospitals are having to utilise facilities at private hospitals because they do not have the resources available within their “Petri dish”. We are already seeing private companies investing in health services. Richard Branson’s “Virgin Care” investing in community health services: Circle Partnerships investing in “Hinchingbrooke Hospital“, are providing the economic outlay.  This investment is bringing back an equilibrium to resource availability against resource consumption.

Whether one agrees with the thought that these companies have entered the market to make a “quick buck” or not; the question do we want healthcare or not, needs to be asked. There will never be enough people contributing to the pot, so we will all have to pay more in the long run no matter how healthcare is provided.

I apologise now for any referencing errors contained within this article.

On July 5th, 1948, the National Health Service (NHS) was established by the Labour Party. The central principle, a health service available to all: provided free at the point of delivery; financed entirely from taxation. However, it did not take very long before flaws were identified in Labours grand plan, in fact only seven months.

In an article published in the British Medical Journal (BMJ), February 19, 1949, titled, “The cost of the National Health Service”: Ffrangcon Roberts, M.D., [Roberts] clearly identified why the NHS was flawed; the areas identified, being as relevant today, some sixty three years later.

. Ageing population
. Expansion of hospital practice
. Misconceptions about the nature of disease

Other areas of relevance identified by Roberts include:

. Social and economic conditions
. Disease and working capacity
. Standard of living
. Moral implications
. Medicine considered as a commodity

Perhaps the NHS would be far different today if his points had been taken seriously in 1949.

The central principle of a health service available to all, provided free at the point of delivery, is how we would wish to see the NHS maintained. Having worked with many international staff involved in the provision of healthcare, the principle of the NHS is envied the world over.

The question of how this ideology can be financially maintained is one that divides the political spectrum. Roberts made reference to “The Beveridge report”: that full prevention and curative treatment must be available “without economic barrier at any point”; (P.162). How can this be possible with a system based on taxation? “Without economic barrier at any point”, suggests taxation would provide infinite funding for the NHS; yet in 1948, as now, there was and never would be sufficient numbers contributing to the health care coffer.

Roberts concludes,

“I believe that through ignorance and miscalculation in its preparation the cost of the Health Service has been grossly underestimated, that when in full operation it will be not less than £500 million, and that in future years it will rise to an even higher figure. Whatever the exact figure, I am firmly convinced that at the present rate of expenditure it will involve us in national ruin.” BMJ (1949).

“The alternative is hardly less comforting. It is that a limit will beset by shortage of personnel and materials. This means (mark it well!) that medicine will be rationed and controlled, and there is no reason for supposing that nationalized medicine possesses any moral superiority rendering it immune from the vices which rationing and control invariably bring in their train.” BMJ (1949).

Sixty-five years on and Ffrangcon Roberts words ring true; and the implications to the resolution of the health care crisis remain obvious…