Crisis? What crisis?

I haven't posted anything on here for a while. That partly because I'm not sure that anyone reads my musings anyway, but also because my morale has been so low that I just couldn't bring myself to put things down on "paper". I figured that it would just be a stream of vitriol aimed at Ivory Towers.

You see the lot of the NHS Manager is not a happy one at the moment. The NHS has a financial crisis and if you listen to the musings of Comrade Hewitt then this is all the fault of the managers, consultants, GPs and the current beau - Sir Nigel Crisp. Can you spot the obvious omission from that list?

I can, politicians.

There is no doubt that finances in the NHS are not being managed well. When you are about to declare that you have an overdraft approach ten figures then it's probably time to take a good hard look at yourself. Naturally, rather than look at the centralised control and command approach, the politicians are taking the usual step of pointing fingers at any moving target.

Recent diktats from the central committee have informed (should that be "educated"?) us all that there is a new deadly sin next year. The Devil himself is going to pay a visit to any Trust which declares an overspend next year. In fact, so determined are the Govt to look good in time for the succession of Prudence come in under budget, that we are all going to have to plan to underspend by 3% of our budgets. As we are due to get a 9% increase in funding, this shouldn't be a problem really. Apparently.

However, as with all Govt screw-ups plans, the various departments aren't talking to each other centrally, so God only knows how we are supposed to sort this mess out in the mushroom farms [kept in dark and fed on shit] of the front line.

What the financial wizkids have missed is the costs which are being imposed on us from on high. Let's start with Anywhere NHS Trust and look at their high level accounts.

Their budget last year was £150m, with the 9% increase this increases to £163m. So we start by taking off the "top slice" which is going straight back to the DOH - 3%. In effect therefore the PCT now has £9m more for this year.

From this they will have to pay:
£3.5m for Herceptin
£1.2m for New Enhanced Services (previously mentioned here)
£5m for "market forces factor" (explained here)
£0.6m for the new Dental contract
£0.5m for the GP QOF achievement (underfunded by the Ivory Towers)
£0.5m for OOH services (also underfunded by the Ivory Towers)

And those are just the obvious examples which can be costed easily. That doesn't take into account the cost of reducing waits to 18 weeks (hence more activity and therefore more tariff prices), or the cost of implementing the white paper on community services.

I'm sure it won't take a maths degree to work out that, just to stand still, the PCT will be looking to employ the services of this man. Or better still, see if we can do better than the crew who pulled off this little job.

At the same time as making these breathtaking announcements, we had the debacle of the DOH withdrawing the tariff prices for 2006/7. A feat which ultimately caused the "retirement" of Sir Nigel Crisp - is it a retirement if the PM sacks you? - and which has undermined the whole planning and financial structure of the NHS. Months of work down the drain and many an NHS Manager considering if the NHS is really the place for them.

Still, we are also supposed to be saving 2.5% of the management budget next year, so maybe there is a divine plan after all...

Bring Out Your Dead...

... because we're not going to collect them.

At least this seems to be the position of some undertakers.

You'd like to think that in the event that someone dies in your house, whether expected or not, your friendly undertaker would pay you a visit and collect the body. Well if you want this "service", then please have a doctor on standby.

Because, so determined are they to ensure that the person is actually dead, some undertakers are demanding that a doctors verify that the person is doing an impression of the Norwegian Blue Parrot. Unfortunately, under UK law this isn't actually necessary.

According to "the beak", anyone can verify a death provided that they are deemed "competent". In effect this means that anyone reading this post can be shown how to look for signs of life - suffice to say if you don't see any then chances are that the person is not "resting", "stunned" or even "pining for the fjords". Marie Curie nurses, who look after terminal patients, are generally trained to do this, and because they are exposed to deaths on a regular basis are likely to have honed their skills somewhat.

But in these days of risk aversion, undertakers aren't so sure. Neither does it appear that they are willing to have their own staff to carry out this task. Just to add a nice twist, there is no obligation on doctors to do it either.

In fact, as a result of the changes to out-of-hours services the situation has just got worse. With GP cover at a minimum, they do not have time to verify deaths whilst they could be treating someone who isn't just "nailed to the perch".

So, at the point that relatives and carers are at their most vulnerable what will their lasting memory of a loved one be? That final breath, the fun times they shared, or the dead body in the marital bed. At the point when we need them the most, the very services there to assist you, won't.

My advice therefore, if you are reading this and you know someone who is terminally ill is please ask them not to die tonight. Unless that is you have already checked with your chosen undertaker that they will collect regardless of who has verified that the person has indeed died.

You could end up with a dead body to look after - until the next refuse collection that is.

Post generated with thanks to the genius that is Monty Python.

Sending The Boys Round...

It won't come as a surprise to you, given the amount of recent publicity, that this post is about NHS overspends. In fact the situation is so bad that it is reported that Trust could record a total debt of £1bn and as a result Lady Hewitt of Ivory Towers has decided to send the boys round to a few Cheif Executives Offices to apply the thumbscrews.

As interesting aside to this decision is the reaction of Chief Execs from across the country who have told the Health Service Journal that they don't have much faith in this concept, in fact 87% of them don't have much faith. Whilst one Trust has publically stated that it "welcomes" the move, you have to wonder if this is more a result of political necessity (and if I am to be cynical the CEO wanting to keep his job) than it is because they believe it will help them. Of course, they might welcome the chance to show the DoH that they are actually doing all they can to keep costs low.

In recent statements our Lady has commented that it isn't the Government's fault that finances are reporting poor returns. Having said that, one could ask why they do not appear to be supporting those Trust who had to deal with the victims of July's terror attacks, nor do they seem to be taking any responsibility for the fall out from the new contracts for GPs and Consultants or the additional costs of the Agenda For Change initiative (commonly known as f**king Agend for Change by staff) or for the fact that they have massively underestimated the costs of the agreements which have to force upon PCTs and Trusts.

Just looking at GP contracts, my PCT faces an underfunding of in excess of £500k for the Quality and Outcomes payments (because the DOH didn't expect our GPs to be so good at hitting targets), another £600k plus for the new out-of-hours on-call GP service (because the DOH didn't realise how expensive it is to persuade GPs to work unsociable hours) and next year a further £800k for new "services" which are non-clinical (see previous post on this issue). So, somewhere in the region of £2m will be spent on things which the PCT doesn't actually want to do or at least didn't plan to do themselves. All of this are central dictats.

It's hardly surprising then that this whole issue is seriously demoralising staff. Again, the HSJ reports that 99% of CEOs believe that these changes were not costed properly centrally and are having a huge impact on their organisations financial position and that 83% believe that the government is trying to "dodge it's own culpability". Instead they seem happy to play a game of "blame the manager", funnily enough this comes at a time when the opposition parties are starting to recognise that maybe it isn't actually the "bean counters" who are to blame.

Just to bring additional joy to our lives those same CEOs, or at least 87% of them believe that the situation will actually be worse next year.

Perhaps "the boys" would like to take a trip to Ivory Towers?

Smokeless Fools

Today the BBC is reporting about the upcoming debate and vote on Smoking Bans. Particulary this story relates to the voting intentions of the Secretary of State on a policy put forward by her predecessor and her department. Basically it looks like she will vote against it.

Ah, the machinations of the political process. Why not just withdraw and admit that the original plan was unworkable and fundamentally wrong? More to the point, how embarassing is it to vote against the department which you head?

Smoking represents on of the biggest causes of the world's fourth largest killer - COPD - which is soon to become the biggest if the W.H.O. are to be believed. Now I'm not usually one for the "nanny" approach to such matters but there comes a point where we have to accept that it isn't just the smoker who is affected and that we have a duty to protect those individuals.

In other news the BMA is suggesting that Doctors ahould stand up to NHS managers decisions to hold waiting lists at their maximum level in order to cut costs. Apparently it is not clinical appropriate to deny routinew treatment in excess of six months - in some cases I presume. I like this stance being taken by the BMA. Especially when you consider that doctors being told that no patient should breach this standard is also against clinical advice. In part they are correct, it is the managers responsibility to make sure that the books balance. How about a cut in pay then chaps?

Contradictions are what make my life so much fun. If it's not the DOH being undermined by it's own political master, then it's the BMA saying that patients should not wait for surgery, except when they should or saying that books should be balance while pushing for increase pay for their members.

There is a story which I can agree with though, and for once I also seem to agree with some MPs. The "Fit for Purpose" review is underway, the 23rd major reorganisations in the NHS since 1974. It's looking at changing the configuration and role of PCTs and Health Authorities. The Health Select Committee has stated that the review is ill thought out. I couldn't agree more. PCTs have finally got to grips with their role and are staring to make inroads. So of course we must be disbanded. As the report suggests it takes about three years for any changes to bear fruit and, by coincidence, PCTs were created three years ago. Another excellent advance from our "masters". We all know it's about money, not efficiency or effectiveness. Apparently PCTs can survive with less staff, even though most of us are just as overworked and stressed as the front line services we are supposed to commission and performance manage. Just a thought, will the DOH staffing number be reduced also?

A Good Union

I don't konw, weeks go by and nothing, then two posts in the same hour.

This one is about my desire to have the BMA negotiate my next pay review.

You see, the GP contract has been reviewed again, as was the plan. Coming out of that process are some new "Enhanced Services", the theory behind these is that they are supposed to offer practices a chance to address some of the patients clinical needs, which aren't covered by the GP "normal" work pattern. Fair enough I hear you say.

I'd agree with you too, generally, because Primary Care has been ignored for the past few years and hasn't seen the same level of investment that secondary care services have.

However, what are these new "enhancements"?

IT, Commissioning, Patient Choice and GP Access.

Can you spot the clinical one?

Me neither.

In fact when you add up the costs of these new "services" it comes to just over £300m. None of which goes to address clinical needs. I don't hear many doctors bleating about that funding "not going to the frontline". In fact the BMA, in a recent letter to members, actually trumpets their success. Ignoring the reality that the money will come from somewhere else and that usually means the very clinical services which many would like to see more of.

In one respect perhaps they could tell me which service I should "cut" inorder to fund it - perhaps the Counselling enhanced service, or the anti-coagulation one. Perhaps we could look at reducing the care we give the homeless or reduce the Flu jabs we give. In another,I have to say "well done" to the BMA. It is looking after it's members interests.

Now, if they could just look at Agenda for Change for me, I'll be a happy man.

A Free Press

Oh the joys of having a free press, singing the praises of the NHS at ever opportunity. Not.

I suspect that the media pukes who forms this age old profession have forgotten that alongside the benefits of freedom comes the responsibility of "truth". But hey, when have journalists ever let facts get in the way of a damned good headline?

Take this one, for example, from the BBC today:

"Hospital cuts "low-priority" surgery".

A good headline, underlining how the increased investment in our service hasn't actually brought many benefits. Except there is a little problem with that headline. Firstly, not cuts have actually been made and secondly it isn't a hospital considering the option of "cuts" anyway.

So let's look at the story in a little more detail. The patient who is the basis of the story is going to have to wait five months for her surgery. Not good IMHO. But hang on, a few years ago she would have waited eighteen months and no-one would have batted an eyelid. In fact back in 1995, clinical priorities would have meant that her surgeon would have considered it perfectly acceptable. Oh, how times have changed. And for the better. But is there any mentioned of this dramtic change in expectations? Of course not.

Then let's look at the patients comments. She apparently "believes" that the decision is because of "a shortage of money at Northampton General Hospital", but the acrticle doesn't make it clear that it isn't actually the hospital which is suggesting that she shouldn't be treated earlier. It's the PCT, the purseholders. They would rather direct their money to what they consider their clinical priorities (or possibly the new GP contract, but more of that later) and so they are suggesting that as waiting times for routine surgery can be a maximum of six months then that is what they will be.

Now I don't defend that delay, personally I would love to see everyone treated within days like they are abroad. But the NHS has been massively underfunded for years (even the Tories will admit as much now) and we are trying to play catch=up. We'll get there but until then some patients will have to wait. Galling as that is.

Having said that, I am a little disappointed that the spokesweasel for the PCT is using the current review of PCT configuration as an excuse. Sorry guys, doesn't wash.

In other news, I see that Mr Cameron (or Blair-lite) has stolen some of Labour clothes. Lots to say, little of it substantive. i smell more political interference on it's way, should he get elected...

Protectionism or patient focus?

I'm never sure what to make of BMA comments about change in the NHS. Sometimes I wonder if they are just trying to run a protectionist agenda, sometimes I wonder if it's just fear of change but on other occasions I can see their point.

When they start denegrating the abilities of their colleagues I get a bit annoyed. Drug errors are a fact of life, doctors are not immune to them, contrary to what they might think. A development like proposed here is actually a good thing, in fact it would do the doctors good to think back to their days as a houseman & SHO and remember who it was that taught them about the reality of being a doctor...

Sure I can see the arguments against, such as "doctors on the cheap" but anything which gives patients greater access to trained health professionals cannot be a bad thing.

On a separate couple of issues, it's a shame that 1,100 more dentists have joined the NHS because the Minster's intervention in the Herceptin case has apparently left the NHS "toothless"...

The curse of foresight.

I'm getting a little worried about my ability to see into the future.

I must admit though that I hadn't anticipated that the Herceptin review I talked about yesterday being resolved so quickly today. It appears that the PCT in question had now had a change of heart and has agreed to fund the lady's treatment.

Does raise a question though, either the original decision was indeed incorrect and therefore the people involved in that decision should take a look at how they decide such matters, or they were entirely right and the only reason they have changed their mind is because of political pressure.

I know which I think it is and it's not like politicians (of all parties) ever play politics with people's health is it?[/sarcasm].

Looks like The Lancet has concerns too...

Women's Health

Two issues caught my eye today.

Firstly is the Herceptin debate. What can I say? A PCT makes a decision, based on all the evidence before it and the Minister intervenes. Not necessarily because she thinks they are wrong, but because of the media focus on this drug at the moment.

I have real concerns about how this seems to be playing out. Firstly is the expectation that because a drug exists then it should be offered automatically. Regardless of the fact that this is an unlicensed use of the drug. If we ignore that aspect, even though it's very important in this debate, then we have to also look at the huge price tag. For the same money a PCT could fund the treatment of, say, three other patients with cancer. Sadly for them their disease doesn't carry the same emotive aspect and so they will not get the same media and political attention. They might as well not exist.

The there is the political aspect generally. Who is accountable here and if the PCT decision is overturned as a result of politics, who will fund the treatment and carry the legal responsibility? The PCT have already made an informed decision for themselves. What impact does something like this have on their other "Exceptional Treatment" cases? Previously decisions have been made purely on the basis of medical advice and cost, should they also now check with the Minister?

The second issue to catch my eye has been the Abortion Case which is currently in front of our learned friends. Or should that be "friends"? I can only hope that they make the correct decision and uphold the right to confidentiality. It's the cornerstone of much of the work which we carry out in the NHS and is particularly relevant in cases like these. We must ensure that the actions we take do not place people in danger.

Now I am sure that in the vast majority of cases, telling a parent is not going to cause the young girls in question any real harm and that her parents will be as supportive as I'd like to think I would be.

However, there is a minority for whom that step would be disastrous. At best they face homelessness, at worst death. We have an obligation to offer access to a service which will offer the best medical care possible, without the fear that we will breach the confidentiality of any consultation. Should this lady get her wish, then we face the prospect of children not having anyone to turn to for support and guidance, worst still we face the possibility that we will return to the "backstreet" approach which brought about abortion laws in 1968.

It's quite telling though that she doesn't have the support of her own daughters though.

Personally, I think that tells us more about their relationship that she cares to admit. If my children didn't think that they could talk to me about something like this, then I think that marks me out as a parental failure. More so if I had to resort to the courts to get my way....