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This is no time for an amateur. Burnham must become Secretary of State for Health.
Andy Burnham MP (@andyburnhammp), Shadow Secretary of State for Health, was interviewed this morning by veteran broadcaster, Andrew Neil (@afneil) on #BBCSP.
The question is how well the NHS is prepared for the winter period this time around. This is no time for an amateur. Winter staffing levels and bed capacity are going to be vital planning considerations.
According to Richard Vautrey (Deputy Chair of the BMA GPs committee), “Doctors and all healthcare professionals are hugely frustrated… The political knockabout is hugely frustrating.”
Neil asked Burnham what one move he would implement to relieve the crisis in A&E forecast for this winter.
“I would immediately halt the closure of NHS walk-in centres”, announced Burnham.
There has been much criticism over the NHS 111 ‘rolled out’ by the Coalition, and indeed Keogh this week signalled that he wished to extend the powers of NHS 111 in the next few years in a reconfiguration of A&E services.
Burnham himself has much attacked how people are not clinically trained have to stick to their algorithms, which invariably end with ‘Go to A&E!’ for difficult problems.
“I would put nurses back on the end of phones, and restore the NHS Direct-type service”.
Of course, many people in English health policy feel that the A&E problem has been exacerbated with sometimes inappropriate ‘social admissions’. Burnham cites often that the ‘whole person’ was a founding principle of the National Health Service under Bevan. Therefore it was unsurprising that he should bring up this flagship policy of Labour in this brief interview.
“I want to rethink how the NHS works – the full integration of health and social care.”
Neil then went onto explore other interesting issues currently confronting English health policy.
Should the NHS brace itself for another ‘top down reorganisation’ under Labour after May 8th 2015?
“No it shouldn’t. I will repeal the Health and Social Care Act. Moving forward, it’s all about making the current structures do different things. I will work with the health professions.”
At this point in the interview, Andy Burnham started ‘talking back’ (politely).
“Why don’t you spend time talking about £1.5bn NHS reorganisation?”
GPs have been put in the firing line by Jeremy Hunt, especially the 2004 GP contract. Accessibility to GPs has therefore become a political ‘hot potato’.
Labour has been much criticised for the ‘target driven culture’. Indeed, the political manifestos in 2010 had appeared to signal a shift from this culture. Managers being driven by targets keep on resurfacing in the news headlines; as for example, the recent furore in Colchester.
This, however, was a positive opportunity to talk about a beneficial target which had been scrapped.
“We brought in evening and weekend opening. This has been reversed too.”
“I welcome a move to bring back named GPs. But I want to be clear. It’s got harder to get a GP appointment, as the 48 hour target – which we introduced – has been scrapped.”
The Health and Social Care Act (2012) is fundamentally hinged on a competitive market and its regulation.
It is clear now, however, that competition, heavily touted by some think-tanks, has become a massively flawed plank in policy.
Referring to David Nicholson’s recent evidence in the Health Select Committee, Burnham opined, “Only last week the CEO of the NHS is bogged down in a ‘morasse of competition law”.”
Furthermore Burnham signalled that he welcomed a right for patients to come under GPs outside of their catchment area, as he had indeed promised before the last election.
On the general issue of how GPs are performing, Burnham added quickly, “I think every political party supports transparency.”
This week is likely see a number of proposals from the current Government in response to the latest Francis report about Mid Staffs, which had really put patient safety in the NHS into the public spotlight.
“‘Wilful neglect’ was a recommendation of the Francis Report. You can’t ‘pick and mix’ the recommendations. It is an entire package. It must be implemented in full. This includes safe staffing levels. The Government has a responsibility to staff as well.”
Is the GPs Contract of 2004 to blame? ‘Our survey’ of Stephen Dorrell and Alan Milburn “say no”.
Milburn even called it ‘nonsense’, saying though he felt Jeremy Hunt’s “pain”.
“[The Contract] got changed every year from 2004. There are a lot of myths which have built up around the contract. The 2004 Contract was responsible for the A&E crisis is just spin of the worst kind.”
Then veteran broadcaster Neil started talking about other issues.
“I can’t believe you’re talking about those emails on a national programme. You’re really scraping the barrel.”
They both chuckled and ended the brief interview.
This is no time for an amateur.
He may drive the Tories “nuts”, but yesterday was a virtuoso interview from Burnham.
Andy Burnham MP must become the Secretary State of Health.
Keogh: Is the solution to failed outsourcing more failed outsourcing?
Sir Bruce Keogh has published a report on the first stage of his review of urgent and emergency care in England. You can read more about the review as it progresses on NHS Choices.
There are various potential causes of the current A&E problems. One reason might be that many people anecdotally seem to have trouble in getting a ‘routine’ GP appointment.
Labour says the crisis has been made worse by job cuts under this Government — such as the loss of 6,000 nursing posts since the election, and decisions to axe NHS Direct and close walk-in centres.
Sir Bruce says the current system is under “intense, growing and unsustainable pressure”. This is driven by rising demand from a population that is getting older, a confusing and inconsistent array of services outside hospital, and high public trust in the A&E brand.
Invariably, the response, from either those of are of a political inclination, or uneducated about macroeconomics, or both, is that “we cannot afford it”. This is dressed up as “sustainability”, but the actual macroeconomic definition of sustainability is being bastardised for that purpose.
Unite, which has 100,000 members in the health service, said this year that it wanted the “Pay Review Body” to “grasp the nettle” of declining living standards of NHS staff. “The idea behind the flat rate increase is that the rise in the price of a loaf of bread is the same whether you are a trust chief executive or a cleaner. Why should the CEO get a pay increase of more than ten times that of the cleaner, as would be the case if you have a percentage increase,” said Unite head of health Rachael Maskell.
According to one recent report, the boss of a failing NHS trust was awarded a £30,000 pay rise as patients were deprived of fluids and forced to wait in a car park because A&E was full. Karen Jackson, chief executive of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, is reported to have accepted a 20% increase last year, taking her salary from £140,000 to £170,000.
Even if you refute that the global financial crash was due to failure of the investment banking sector, it’s impossible to deny that the current economic recovery is not being ‘felt’ by many. Indeed, some City law firms have unashamedly reported record revenues in recent years. Many well-known multi-national companies have yet further managed to avoid paying corporation tax in this jurisdiction.
Sir Bruce Keogh has himself admitted that extra money and “outsourcing” of some services to the private sector will be used to attempt to head off an immediate crisis, but will say the whole system of health care needs to be redesigned to meet growing long-term pressures.
This is on top of an estimated £3bn reorganisation of the NHS which the current Government has denied is ‘top down'; in their words, it is a ‘devolving’ reorganisation; similar to how the ‘bedroom tax’ should be a ‘spare room subsidy’ according to the Government and the BBC.
A poet who uses language far better than either the current Coalition or the BBC is Samuel Taylor-Coleridge. One of his poems, “The Rime of the Ancient Mariner”, relates the experiences of a sailor who has returned from a long sea voyage.
The poet uses narrative techniques such as repetition to create a sense of danger, the supernatural, or serenity, depending on the mood in different parts of the poem.
Water, water, every where,
And all the boards did shrink;
Water, water, every where,
Nor any drop to drink.
Like the manner of this poem, the mood of the NHS changes with the repetition of certain language triggers such as ‘sustainability’.
More than £4bn of taxpayer funds was paid out last year to four of Britain’s largest outsourcing contractors – Serco, Capita, Atos and G4s – prompting concerns that controversial firms have become too big to fail, according to the National Audit Office.
But according to the National Audit Office, increasingly powerful outsourcing companies should be forced to open their books on taxpayer-funded contracts, and be subject to fines and bans from future contracts in the event that they are found to have fallen short. The report estimates that the four groups together made worldwide profits of £1.05bn, but paid between £75m and £81m in UK corporation tax. Atos and G4S are thought to have paid no tax at all.
“[This report] raises some big concerns: the quasi-monopolies that have sprung up in some parts of the public sector; the lack of transparency over profits, performance and tax paid; the inhibiting of whistleblowers; the length of contracts that taxpayers are being tied into; and the number of contracts that are not subject to proper competition,” said Margaret Hodge, chair of the public accounts committee, who commissioned the NAO to carry out the study.
As for the NHS, Keogh describes it as ‘complete nonsense’ that his proposals are a ‘downgrading’ or ‘two tier system’. As an example, Keogh says there has been 20% increased survival rate in major trauma by treatment in a specialist treatment on the basis of his 25 designated trauma centres. Keogh’s focus is on major trauma, stroke or heart attack.
This is a perfectly reasonable observation, in the same way that the existence of the tertiary referral medicine centres for clinical medicine, such as the Brompton, the Royal Marsden or Queen Square, for highly specialist medical management of respiratory, palliative and neurological medicine should not be interpreted as the NHS Foundation Trust ‘tier’ offering a second-rate service on rare conditions. Developed after an extensive engagement exercise, the new report proposes a new blueprint for local services across the country that aims to make care more responsive and personal for patients, as well as deliver even better clinical outcomes and enhanced safety.
Keogh advocates a system-wide transformation over the next three to five years, saying this is “the only way to create a sustainable solution and ensure future generations can have peace of mind that, when the unexpected happens, the NHS will still provide a rapid, high quality and responsive service free at the point of need.”
But it is highly significant that this ‘beefed up system’ is building on the rocky foundation for the NHS since May 2010, where the Coalition has ‘liberalised the market’. Far from giving the NHS certainty, the Health and Social Care Act (2012), as had been widely anticipated, has liberated anarchy and chaos.
There are many more private providers delivering profit for their shareholders.
However, the National Health Service has been propelled at high speed into a fragmented, disjointed service with numerous providers not sharing critical information with each other let alone the public.
Only this week, Grahame Morris, Labour MP for Easington, warned yet again about how private providers are able to hide behind the ‘commercial sensitivity’ corporate veil when it comes to freedom of information act requests. This wouldn’t be so significant if it were not for the fact that ‘beefing up’ the NHS 111 system is such a big part of Keogh’s plan.
NHS 111 was launched in a limited number of regions in March 2013 ahead of a planned national launch in April 2013. This initial launch was widely reported to be a failure. Prior to the launch the British Medical Association – affectionately referred to by the BBC as “The Doctors’ Union” – had sufficient concern to write to the Secretary of State for Health requesting that the launch be postponed. On its introduction, the service was unable to cope with demand; technical failures and inadequate staffing levels led to severe delays in response (up to 5 hours), resulting in high levels of use of alternative services such as ambulances and emergency departments. The public sector trade union UNISON had also recommended delaying the full launch.
The service has run by different organisations in different parts of the country, with private companies, local ambulance services and NHS Direct, which used to operate the national non-emergency phone line, all taking on contracts last year. The problems led to the planned launch date being abandoned in South West England, London and Midlands (England). In Worcestershire, the service was suspended one month after its launch in order to prevent patient safety being compromised. The 111 non-emergency service has faced criticism since a trial was launched in parts of England last month. Some callers said they had struggled to get through or left on hold for hours.
Andy Burnham, Labour’s shadow health secretary, at the time accused the Government of destroying NHS Direct, “a trusted, national service” in an “act of vandalism”. “It has been broken up into 46 cut-price contracts,” he said. “Computers have replaced nurses and too often the computer says ‘go to A&E’.”
Clare Gerada, also at the time, said that the introduction of 111 had “destabilised” a system that was functioning well under NHS Direct and called for non-emergency phone services to be operated in closer collaboration with local GP services.
“The big problem about 111 is of course money,” she said. “It was the lowest bidders on the whole that won the contracts… If you pay £7 a call versus £20 a call you don’t have to be an economist to see that something’s going to be sacrificed. What’s sacrificed is clinical acumen.”
Keogh is keen to put a different gloss on the situation now. He admits that people wish to talk to clinician if they are worried, rather than an “unqualified call handler”. He says that this is possible ‘but we need to put the infomatics in place’. 40% of patients need reassurance, according to Keogh. Keogh then argues that, if there is a concern, an ambulance can be called up, or a GP appointment can be arranged.
However, for this system to work, people offering out-of-hours services will not just be dealing with a third degree burn in the absence of any previous medical history at all. There will be patients with long-term conditions like diabetes, asthma and chronic heart disease, who might not have to use A&E services so frequently if they were supported to manage their health more effectively.
Some of these patients will be ‘fat filers’, where it’s impossible to know what a medical presentation might be without access to complex medical notes; e.g. a cold in a profoundly immunosuppressed individual is an altogether different affair to a cold in a healthy individual. Likewise, individuals with specific social care needs will need to be recognised in any out-of-hours service.
The aim of ‘beefing up’, as Keogh puts it, the ‘National Health Service’ was to make it a coherent service across all disciplines, with clinicians – as well as top CEOs – adequately resourced out of general taxation.
As it is, it is pouring more money into people who have not delivered the goods thus far.
The solution to failed outsourcing cannot be more failed outsourcing. As one interesting article in ‘Computer Weekly’ explained recently, the “NHS 111 chaos is a warning to organisations outsourcing”.
The report has also made a case for improved training and investment in community and ambulance services, so that paramedics provide more help at the scene of an incident, with nurses and care workers dispatched to offer support in the home, so fewer patients are taken to hospital. This can work extremely well, provided that resources are allocated to such services first, and there is a proven improvement in quality (which seems very likely.)
And if somebody tells you it’s all about sustainability – tell them there’s water water everywhere, and there’s not a drop to drink as this recent event provoked.
Jeremy Hunt fiddles while Rome or A&E burns, and a smear campaign continues
There is nothing as inevitable as death and taxes, apart from Channel 4 ‘scoops’ on the NHS and Conservative smear campaigns against Andy Burnham.
Ed Miliband’s narrative in the last few weeks or so has been about ‘facing up to bullies’. In this context, it is hard to imagine that he is going to reshuffle Andy Burnham MP out of Health. It is well known that Burnham knows this brief backwards, and is considering how to throw forward the issues about NHS financing with introducing innovative ‘whole person care’ to remould the design of primary and secondary care services.
You would have thought that Channel 4 and the Conservative Party would be more interested ‘in the national interest’ about the fact that cuts in the NHS are leading to over-pruned staff, and this can risk patient care. You would have thought that they would have been interested in a debate about a £3bn top-down reorganisation and £2bn ‘efficiency savings’ pumped back to the Treasury (not frontline care). This issue of pay unsurprisingly has demoralised NHS staff in comparison to NHS managers who have received a formidable pay increase.
This has struck a raw nerve with some people especially:
It is all part of a relentless campaign of attacks on the NHS, in the name of ‘investigative journalism’ where the evidence is either missing or distorted to suit the purposes of the broadcaster.
Dr Jacky Davis said of the previous Channel 4 programme, not the report last night, on the “Our NHS” blog:
On September 11th Channel 4 news broadcast a lengthy piece on the NHS, ominously entitled ‘Death on the Wards’. It presented new figures from Professor Sir Brian Jarman about alleged high mortality rates in UK hospitals. There was a clear intention to shock the viewers. The ‘s’ word was repeatedly used by the two presenters and after describing Jarman’s figures as ‘absolutely shocking’ Victoria Macdonald then attempted to put the words into the mouth of Sir Bruce Keogh (Medical Director of the English NHS) when she asked him ‘When you saw those data were you shocked?’ To his credit Sir Bruce sensibly claimed that he needed ‘to think about it’, a basic precaution that the broadcasters would have done well to emulate.
The piece was peppered with worrying claims including one that ‘the NHS is fundamentally failing’ along with claims about patients’ likelihood of dying in a UK hospital as opposed to one in the USA. Finally the presenter compared the average UK hospital with the Mayo Clinic in the US (one of the world’s most prestigious hospitals with an annual revenue of over $8 billion) without any suggestion that comparing a Mini to a Rolls Royce might be ingenuous at best and negligently misleading at worst. This was followed by a panel discussion involving Professor Jarman, Tory MP Charlotte Leslie and [Corrected: this should have read a 'a representative'] of Cure the NHS which was set up after the Mid Staffs disaster. Not a single person to speak up for the NHS or question the data.
Instead, all of this gives an appearance of a message which is being controlled very strongly from Conservative Central Office, though media outlets will of course strongly deny this. Many viewers are sick of reporting of this which is either inaccurate or misses out half of the relevant evidence, with the obligatory appearance from Brian Jarman whose research has been strongly criticised in the medical press. It is common knowledge that the BBC is accused to have devoted hardly any time to accurate, complete and balanced reporting of the acceleration in NHS privatisation, as shown in minimal coverage of a rally in Manchester recently which had attracted 60,000 people.
And yet the true facts are disgusting as to what has actually happened to acute care under this Government’s watch. The number of A&E units missing targets has trebled in a year, as the Government was accused of presiding over an unprecedented “summer A&E crisis”. Between July and September, 39 departments failed to meet the Government’s key target of seeing 95 per cent of patients within four hours, new quarterly figures from NHS England show. Last year only 14 units missed the target for the same period.
It is reported that the Shadow (and former) Health Secretary “Andy Burnham is facing calls to quit after claims he tried to “block” the publication of a devastating report into hospital neglect before the last election”, but in fact these “calls” have come from Tory MPs and a very unpleasant media campaign from certain recurrent protagonists in the media. Nothing would give these people greater delight than ‘gaining a scalp’ when they should be sorting out the mess of service provision of acute medical care in England.
It is also reported that, “Britain’s most powerful civil servant Cabinet Secretary Sir Jeremy Heywood was last night examining whether he needs to set up a Whitehall investigation into whether civil servants breached their code of conduct.”
However this is only because he has been written to. If Heywood has read the letter, he will indeed be considering this issue. He has not decided to investigate this issue yet.
A set of emails were released after Conservative MP Stephen Barclay made a Freedom of Information request to the Care Quality Commission, relating to the Basildon and Thurrock University Hospitals NHS Foundation Trust. Barclay has campaigned on this issue vocally in the past (see for example his article in the Telegraph “The only way to cure the NHS is to change the way we police failures”). The terminology of “cure the NHS” is also striking given the name of the campaigning group “Cure the NHS“, the leader of which was indeed cited by Jeremy Hunt in parliament in one of his numerous speeches demoralising current staff in the NHS. This patient campaigning group – like Channel 4 and the BBC – has also been keen in the past to quote Brian Jarman’s statistics which have received widespread criticism in the academic press. Mid Staffs Foundation Trust is now set to ‘dissolve’. All the sensationalist bravura has actually achieved absolutely nothing in itself.
The awful spectacle of this whole political debacle is that in English health policy this is all incredibly important. Phil Hammond (GP not Secretary of State for Defence) and Heather Wood have both been instrumental in bringing to the fore what had tragically happened to this Trust, and what does need to be remedied in parts of the NHS, for example.
Isabel Hardman, in a narrative which now sounds like intensely boring stuck record, reports that:
The knives are clearly out for the Shadow Health Secretary – and if MPs are calling for him to resign just before a reshuffle, it suggests they want to leave him wounded in the run-up to the 2015 election, rather than leave his post.”
But reporting malicious gossip rather than English health policy is clearly not going to benefit the patients of NHS England.
The problem, is that the central claim – that Burnham himself personally engaged in a ‘cover up’ – might well be potentially legally defamatory on the balance of probabilities under English law.
On the information publicly provided by Andy Burnham in a ‘Labour List’ post, provided as he was totally fed up with the gun-ho nature of the smears, it appears that there is prima facie no evidence of a cover-up. There is only evidence that there was anger at CQC/DH protocols not being observed. (THIS IS NOT AN OFFICIAL LEGAL OPINION).
Indeed, there are wider issues about the legitimacy of the need to publish potentially defamatory information in such a hurry, ahead of a reshuffle, under the “Reynolds Criteria”.
But there is currently a long-running dispute in the law whether such comments should be covered by defences such as legal parliamentary privilege. Hence Burnham’s litigation experts are asking Jeremy Hunt to ‘put it to proof‘.
A Conservative health spokeswoman, and countless people in the past ad nauseam, is reported to have said there was “overwhelming evidence that Labour ministers leant on the quality watchdog to tone down and cover up NHS failure for political purposes”.
In the absence of knowing what the civil service were ‘up to’ at the time (and many of these staff might have moved on) at the Department of Health, it is actually impossible to make this claim.
The irony is that, when the PM addressed Parliament originally over the Francis Report into Mid Staffs, he said categorically that he ‘did not want scapegoats’, despite patient campaigners having a hit list or ‘wall of shame’ of those people which they wished retributive justice to be administered on.
In his centrepiece Conservative party conference speech this week, Hunt lambasted Burnham for “covering up” poor care during his time as health secretary yet again despite the fact these smear tactics have failed to impact any polling on the NHS for Labour and the Conservatives. And in the meantime performance of A&E actually has been reported to deteriorate.
Hunt repeated the narrative of Channel 4, in regurgitating Jarman’s statistics which many have panned in the academic press, and ratcheting up the pace on Twitter. It has long been appreciated he does his own tweets, in the same way that Andy Burnham does.
Burnham insisted that those “damaging emails” showed only that he was concerned that rules about disclosure had been broken.
In a furious open letter, Burnham wrote:
It is impossible to see how you can claim this mounted to a cover-up. I therefore ask you, by the end of today, to provide me with evidence to substantiate your assertion.If you fail to provide such evidence, I will require a full retraction and public apology. If that is not forthcoming I will consider further action.
However, Baroness Young, who is now chief executive of Diabetes UK, last week was at the Conservative Party conference in Manchester, and responded to Mr Hunt’s claim at a debate held by the think tank “Reform”:
BY:
“I just want to put the record straight because within your speech today, Jeremy, particularly the press release that accompanied it, you continued to misrepresent my evidence to the Francis inquiry and to misrepresent that the situation the letter from Andy Burnham to me and I really am very angry about it.
“I have already written to you and the prime minister previously to point out the fact that the way that you are abusing my evidence to the Francis inquiry in a partial manner misrepresents entirely the situation that existed at that time.
“I think it’s unfortunate that you’ve used a partial quote from me to imply that the CQC was pressurised into concealing this because it simply was not the case. If I was pressurised at all either politicians or by civil servants it was about the process by which CQC went about its regulatory work. At no point was I ever asked to or indeed did tone down the evidence. I really do find it very unsatisfactory on a number of counts that this continues to be pedalled in public and in newspapers. I’m not sure what it is that you don’t understand about me saying I was never put under pressure to subdue the findings of the CQC as a regulator.
“The most distressing part of this is that we are constantly harking back to what the political classes were doing rather than looking forward and giving CQC and others involved in healthcare as much support as possible in improving and building on the problems of health systems rather than constantly undermining the work that was done in the past.”
JH: “I really do need to respond to that. Do you have the words that you said under oath to the Francis inquiry?”
BY: “I have a full copy of the Francis inquiry.”
JH: “Will you read out the words you said to Francis inquiry.”
…
BY: “I was paraphrasing the best bit about the pressure coming from civil servants rather than ministers and I’m now quoting ‘it was primarily because what we wanted to do (ie our regulatory processes) not so much what we wanted to say because I don’t think we were really under a lot of pressure not to say things’. That cannot be clearer, that was from my Francis evidence a long, long time before this hoo-ha arose.”
JH: “First of all I think it was deeply wrong that you should have been under pressure from civil servants, who are under the orders of ministers, in terms of what you do in connection to the whistleblowing issue.
None of this is helping with the morale at the current situation in Staffordshire, especially with regards to recruiting excellent staff to work in their units. Mid Staffs and surrounding areas have also in the meantime embarked on successful programmes of cultural change, and therefore this slamming of Mid Staffs in the media can only be seen for petty nasty electoral reasons. And, most significantly, many people in Staffs themselves are now very upset. It is said that Sir Hugo Mascie Taylor, involved in the current Staffs reconfiguration, has repeatedly made the point that the key reason for the propsals to change services here are because of the reputational damage inflicted on Mid Staffs, and the way this has made recruitment more difficult.
It also very much emerges that, if there is anything to investigate, it is the civil service culture of the Department of Health. And meanwhile none of this helps the current crisis in A&E. Despite the government’s pledge to protect frontline services with real-terms increases in funding, Monitor, the NHS watchdog, has proposed that in 2014-15 hospitals should be paid 4% less for operations than they were the previous year. While hospitals were braced for a cut of about £1bn in funding, the Foundation Trust Network, which represents all 160 hospital trusts in England, calculates that Monitor is now asking for another £500m in savings – roughly £3m from each trust.
Chris Hopson, chief executive of the Foundation Trust Network, said cuts to frontline services would be deeper than expected and questioned whether the NHS could invest in much needed changes to the way hospital services work, as had been recommended by the Francis report into failings at Mid Staffordshire NHS Trust. The need to correct funding shortfalls was also identified in the Keogh report on mortality, recently, in 14 NHS Trusts. Indeed, countless studies have shown a link between unsafe levels of staffing and poor patient safety, and this is the real debate. He is quoted as follows:
The level of efficiency savings the NHS has delivered over the last three years is unprecedented, but this level of performance cannot be sustained year on year till 2021. We need a reality check here – in the end you get what you pay for, and trusts can’t perform miracles out of thin air.
And actual staff are totally sick of it all now.
The head of health at the union Unite, Rachel Maskell, is reported to have said:
Jeremy Hunt is responsible for either undermining the Treasury position or trying to act in an even more draconian way than the Treasury with regards to staff who work across the NHS. He blames the staff on a regular basis; now he wants to further cut their terms and conditions.
Mark Porter, chairman of the BMA Council, is also reported to have said:
Doctors fully recognise the economic constraints the NHS is facing, but for the government to imply that unless NHS staff endure what is effectively another year of pay cuts they will put patient safety at risk is insulting at best, given doctors are working harder than ever before and have borne the brunt of the government’s efficiency drive.
Correction: Perhaps some other things are inevitable after all. The NHS ‘efficiency drive’ will continue, the smear campaign against Andy Burnham will continue, the malaise over what is happening to the NHS will continue for a bit, Brian Jarman’s methodologically problematic weak statistics will continue to get quoted on the BBC and Channel 4.
But – in a latest twist to the story, Andy Burnham’s (Labour) lawyers are completing the pre-action protocol for civil litigation against Jeremy Hunt on the law of the tort of defamation under English law.
If this all proceeds to formal legal proceedings, I will not be able to make any comment on it.
And Andy Burnham will still be in a job.
Is a banking crisis or an A&E crisis more important to English voters?
(c) Steve Bell 2008
link here
Comparing a banking crisis and an A&E crisis is comparing chalk and cheese. Likewise, potential English voters will have personal reasons for why they might think one crisis is more significant than the other.
It is said that James Carville, campaign strategist for Bill Clinton’s successful 1992 presidential run, posted a sign at campaign headquarters that succinctly set out the key messages: “Change versus more of the same; the economy, stupid; and don’t forget health care.” English voters in all probability do not do a direct comparison of economic performance and performance in the NHS, but it is easy for a right-wing dominated press to forget the impact of the NHS. Whilst the raison d’être of the current Coalition has always been to ‘sort out the mess’ from 2010, the facts are that a series of catastrophic mistakes by George Osborne has left the economy in a dire state when it had been recovering when David Cameron was bequeathed the keys to Downing Street even having not won the General Election. Not voting Labour, furthermore, has been seen as a punishment for “fiscal incontinence”, or “reckless spending” of the Labour Party whilst in Government 1997-2010. The issue there is that the Conservatives promised to match, at least, the spending commitments of the Labour administration last time around, and there is no conceivable argument for blaming public sector nurses or teachers on a global economic crisis.
What happened was that a £0.8 trillion cash injection was pumped into the “banking crisis”, for which Labour has never been given any widespread credit (and only blame for increasing the deficit.) As such, it did not receive much credit either for the highest level of public satisfaction recorded by the King’s Fund. And yet, even daily, Conservative supporters remind potential voters about ‘the lack of regulation’ in the financial sector, even though it was the Conservatives who felt the City of London was over-regulated compared to its competitors abroad. The Conservatives have tried through innuendo to pin the Mid Staffs blame tail on the Labour donkey, and latterly tried to the pin the A&E tail on the Labour donkey. What happened in Mid Staffs, certainly in terms of substandard clinical care (whether or not you agree on the precise mortality statistics), has never resulted in an electoral backlash against the Labour Party. In fact, the “NHS brand” of Labour has been very resilient, as demonstrated in the recent poll findings from Lord Ashcroft:
And yet there is barely a ‘cigarette paper’ between Labour and the Conservatives on an ability “to steer the country through tough times”. It could be, simply, that there is a ‘time lag’ – for example, Tony Blair supporters have often argued that Labour won a General Election, in spite of the dubious (allegedly) reasons for the UK to go to war against Iraq. Likewise, people may not instantaneously (or ever at all) blame the Labour Party for failings at NHS Trusts, or the current Coalition for the A&E crisis. Yet, the reasons for these failings matter immensely, and all parties are aware of the massive importance of finding reasons for these failings with a view to ensuring that these disasters do not happen again. There is concern about whether ‘the Mid Staffs experience’ was replicated elsewhere, hence the genuine organic support for ‘Cure the NHS’ led by the inspiring Julie Bailey. The Labour Party argue that the ‘banking crisis’ could have become a real crisis felt by members of the public, with people being seconds away from being unable to take money out of cash machines.
It is possible that the best days of the ‘National Health Action Party’ are yet to come, but it is likely that the Labour Party has more of a chance to getting into government than the National Health Action Party. That of course does not stop either Party from standing up for what is right. People generally have more affection for their hospitals than banks, and this could be one of a number of reasons why there was never felt to be a need for the ‘National Banking Action Party’. Without banking, as per without hospitals, England would collapse, except the fundamental problem for the Conservatives is that hospitals as yet do not “create wealth”. It is easy to measure the success of a director in generating profit for his shareholder, as he is legally obliged to do under the Companies Act, with regard to his environment, but it is very hard to quantify degrees of bad care. ‘Success’ in the financial sense, creating a profit, in the voters’ eyes may not be paralled by ‘success’ in quality-of-care, and certainly there have been reports of people having been reported to have been given very generous pay-offs despite poor clinical care in institutions with which they were connected.
The media’s obsession with Labour’s blame for the global financial crisis is indeed staggering, and its inability to cover accurately issues such as the Health and Social Care Act (2012) has been a scandal in its own right. Parts of the media have been trying to ‘rubbish’ the NHS brand, but have latterly discovered that private healthcare providers using the NHS brand, which has a lot of goodwill, can be very profitable. An argument which the media could have argued, which they did not, either due to stupidity or incompetence, is that the NHS overall was under-regulated, in the same way the financial industry allegedly was. There has been a notion that private companies are restrained from making profit by ‘legal red tape’, but it is worth noting that much of this legal regulation is there to ensure safe standards for workers. One only has to look at reports of corporates making profit out of collapsing factories in Bangladesh to understand the importance of corporate social responsibility, and it has been an on-running theme in healthcare that employee relations when bad in hospitals or in social enterprises can be very much to the detriment of the organisation.
It would be therefore be very convenient had the Health and Social Care Act (2012) addressed any of the issues which led Mid Staffs to be unsafe clinically. It did not. That is why even in their wildest dreams parts of the news media cannot argue that the £3 bn reorganisation which nobody voted for will do anything to prevent another Mid Staffs. If anything, even with a more fragmented market, regulation of healthcare providers will be harder. Much focus has been put into ‘breaking up the monopoly’ of the NHS, rather than defending the need for a comprehensive, universal service free-at-the-point-of-use (as far as is feasibly possible, of course). Labour does have a ‘head start’ in that it has a loyal following regarding the NHS, despite ‘controversies’ in policy, such as PFI or the introduction of NHS Foundation Trusts. Labour seems desperate to restore its ‘economic credibility’, even though it still has never won the argument, and is likely to do so in the near future. Labour politicians are lining up to establish their ‘pragmatism’ in managing the UK’s finances properly, but even the response to last week’s announcements of means-testing benefits has either been welcomed by those who would never vote Labour or derided by Labour ‘core voters’ for bringing Labour ever closer to the Conservatives.
England in my view will never learn to love Labour over its running of the economy, although it is probably fair to say that if Labour is considered economically incompetent it is unlikely to win a General Election. However, it does have an opportunity to lead on its running of the NHS. This takes real leadership from all involved in the NHS, and needs a very clear vision of what sort of society we wish to live in. This might include, for example, making Doctors, nurses, healthcare professionals, and other NHS staff feel valued, rather legally ensuring primacy of the shareholder. The A&E crisis is unlikely to get as many column inches as the banking crisis, and as such the A&E crisis hasn’t brought the country to its knees, but the thing is: in a non-financial sense, it has every potential to.
How not to lead in a crisis: Jeremy Hunt and A&E
Earlier this week the King’s Fund warned that waiting times for A&E patients had hit a nine-year high and the number of people waiting more than four hours to see a doctor had almost doubled since last year.
Jeremy Hunt is supposed to be the “leader” in the “A&E crisis“, having just been recruited to implement a £3bn reorganisation of the NHS which, historically, has been opposed by all the Medical Royal Colleges.
Mayor Mike Bloomberg, who won a third term, and is widely regarded as an adept city leader, but came under fire for inefficient snow removal in New York City. Most of the complaints came from residents in the so-called outer boroughs — e.g., the four that are not Manhattan. However, Newark Mayor Cory Booker has received acclaim for his response to his snowfall, despite accepting criticism on a host of other matters.
Some failures can be useful if leaders learn from them, according to Robert Mittelstaedt, Dean of Arizona State University’s business school. The three biggest causes of failures he sees are not believing data, disregarding new phenomena, and not taking responsibility for problems. Hurricane Katrina holds plenty of those lessons, according to Mittelstaedt. He points out that for years a wealth of information was available that New Orleans could not withstand a major storm, but officials didn’t act on the data. Officials then ignored information about the scope of suffering by those stranded in the city. He blamed President Bush and others for not taking responsibility and instead arguing about whose job it was to rescue people. “When you see people on rooftops, you don’t sit around worrying about whose responsibility it is,” according to Mittelstaedt.
Erika Hayes James, an organisational psychologist at the University of Virginia’s Darden Graduate School of Business,categorises five phases of crisis that require specific crisis leadership competencies in “smoldering crises“. Smoldering crises differ from sudden crises in that they begin as minor internal issues that, due to manager’s negligence, develop to crisis status. These are situations when leaders are blamed for the crisis and its subsequent effect on the institution in question. Each phase contains an obstacle that a leader must overcome to improve the structure and operations of an organisation. James’s case study on crisis in the financial services sector, for example, explores why crisis events erode public trust in leadership. James’s research demonstrates how leadership competencies of integrity, positive intent, capability, mutual respect, and transparency impact upon the trust-building process.
John Baldoni (2011) in the Harvard Business Review views that important lessons can be derived from how a ‘good leader responds to a crisis’.
- Take a moment to figure out what’s going on. The problem is that everything under the sun has been blamed for the crisis, apart from the current operations management of this Coalition, by Jeremy Hunt. Reasons cited by Hunt have included winter, “The UK Labour Party”, immigrants, women GPs, and targets. To compound the farce which has been “the blame game”, Stephen Dorrell, the Tory chair of the health select committee, very publicly disagreed with Hunt recently, over linking the crisis in A&E departments to GPs opting out of working nights and weekends.
- Act promptly, not hurriedly. A leader must provide direction and respond to the situation in a timely fashion, but acting hurriedly only makes people nervous. However, it is really in dispute whether Hunt in fact acted promptly. According to Jamie Reed MP, a recent Freedom of Information request submitted to the Department of Health shows that Jeremy Hunt had spent six months as Health Secretary before visiting his first A&E unit. When he finally got around to it, the A&E unit he visited was only yards from his own office.
- Manage expectations. When trouble strikes, people want it to be over right now — but seldom is this kind of quick resolution possible. It falls to the leader in charge to address the size and scope of the crisis. You don’t want to alarm people, yet do not be afraid to speak to the magnitude of the situation. Winston Churchill was a master at summing up challenges but offering a response at the same time. As he famously stated in 1940, when assuming office, he said,”You ask, what is our aim? I can answer in one word. It is victory; victory at all costs; victory in spite of all terror; victory, however long and hard the road may be, for without victory there is no survival.” However, the plan proposed by Hunt is neither decisive or prompt. He has announced a fundamental review of emergency care, conceding that “we have failed to give the public confidence that there’s anything between GP surgeries and A&E”. The review, which will result in action by next April, will focus on “vulnerable older people”, whom Hunt said were the heaviest users of the NHS. However, at least the review will not be a panicked response.
- Demonstrate control. When things are happening quickly, no one may have control, but a leader can assume control. That is, you do not control the disaster — be it man- made or natural — but you can control the response. This is a man-made crisis. Unfortunately, there’s an element that Hunt is still in denial over this crisis, with him having only a few hours ago tweeted:
- Keep calm. A hallmark of a crisis is its ability to change quickly: “your first response may not be your final response.” In these situations, a leader cannot be wedded to a single strategy. He or she must continue to take in new information, listen carefully and consult with the frontline experts who know what’s happening. However, his first response was to blame GPs, and this has been rebutted very robustly by the Royal College of General Practitioners. Hunt has been forced to back-track on this as the evidence to support him simply not there.
And above all Jeremy Hunt has offended the first rule of crisis leadership: he has not taken responsibility for the crisis personally, nor vicariously on behalf of the current government.
Jeremy Hunt says that ‘NHS 111′ is now “up-and-running”, but that targets should not be gamed
The reality is that the vast majority of hospitals in the NHS are currently failing to see 95% of patients within four hours. Jeremy Hunt was interviewed on the BBC ‘The Andrew Marr Show’ this morning in a wideranging interview which also covered membership of the European Union.
Jeremy Hunt first underplayed the severity of the NHS 111 fiasco, but claimed that things are better now. Of course, one tragedy in care is one too many. The NHS says it has experienced seven “potentially serious” incidents in the first few weeks of its 111 urgent care helpline in England. One case involved a patient in the West Midlands who died unexpectedly and there have been reports of calls going unanswered and poor advice being given. All the cases are being reviewed. Other organisations are also running 111 lines for NHS England and have been warned they must deliver good care or face financial or contract penalties.
In 2010, critics had claimed the change from NHS Direct to NHS 1111 would undermine the quality of the service by reducing the number of qualified nurses answering calls, but chief executive of NHS Direct Nick Chapman said that new helpline would be better and more cost effective.
Jeremy Hunt, meanwhile, this morning stated, “There are short-term pressures and long-term pressures. We did have teething problems with NHS 111. It is up-and-running now in 90% of the country. We need to have better alternatives in primary care, a better personal relationship between patients and their GPs”.
“Under the last government, we had a culture of ‘hitting targets at any cost’.” Hunt then went onto blame ‘the target culture’ for bringing about the problems which Mid Staffordshire NHS Foundation Trust had faced, leading to two inquiries by Sir Robert Francis QC.
Hunt further added that, “I would never blame GPs, because they work extremely hard. I have just been in one.”
Of course, nobody reasonable, seriously, would take the blindest bit of difference of Hunt comparing his brief time work experiencing in a GP surgery to seven years of basic medical training, including pre-registration training, even prior to specialist GP training.
GPs have experienced a number of contractual changes over time (described here), and latterly it has been mooted that the personal income of GPs, following the latest change, has been steadily eroded as funding levels have been frozen, whilst the running costs of surgeries and staff pay have increased.
Hunt further provided this morning, “That Contract is one of the contributing causes, because after hours and at weekends the service deteriorates. I don’t want to go back to those days where GPs are personally on call at 2 am.”
Hunt added that, “GPs should have responsibility that people on their list have a good service.”
It is difficult to see what exactly Hunt means by this, as it is hard to separate out the effect of a medical decision taken out-of-hours compared to a decision compared to during ‘conventional hours’, and one assumes that each Doctor is still responsible for his/her own medical actions to the General Medical Council, wherever he or she provides care.
Hunt then gave a response which managed to combine a welcome for targets in improving care, with direct criticism of those managers clearly gaming the system.
Regarding the A&E target, Hunt opined, “It is a very important target, and we have never said we do not have to have good targets. We don’t want people to follow targets at any cost.” However, he then described a series of measures how managers would then ‘game’ the system.
“We had beds which hadn’t been cleaned, ambulances circling hospitals before they entered the front door because they didn’t want the clock the start.”
