Media watch
Today’s HSJ has a few more choice quotes as it follows though with the second of its 3 part series on NHS opinion. This time the comments are from PCT chairs.
“I am loath to say this but it’s a bit like the Iraq war - it’s very easy to do the big military thing but the follow-through and the consequences are not given sufficient attention, and you can see that again and again.”
“We have lost good people, killed the organisation’s memory and are constantly on the back foot in getting to grips with the day job of improving health.”
Asking the leaders of primary care trusts for their views on the NHS after 10 years of Labour, one opinion crops up repeatedly: thanks to ministers, organisations have wasted far too much time coping with the fallout from structural change.
100 per cent of PCT chief executives surveyed said managers felt “battered and bruised by constant reorganisation”. A further 88 per cent said high turnover of chief executives made it hard to speak out about poor decisions.
All of those who spoke to HSJ believed the policy had been driven through the Department of Health far too quickly without being properly tested or costed.
One chief executive from the North gives the example of the fitness for purpose programme which started two weeks after the new PCTs were set up. “As the DoH had already paid the consultants McKinsey to carry out the work, they had to go through with it. I only had 10 people in place at the time, the thought of being assessed was ridiculous”.
“We are trying to do everything at the same time. Blair and others have become impatient with the NHS for not reforming fast enough, so they have quite deliberately cascaded reforms - many of which are incompatible - in the hope that by putting a huge amount of pressure on the NHS the ones that survive will be the ones that work.”
I think these stand by themselves but the sentiments are not a surprise to anyone who has more than a passing interest in the NHS.
There is mention of a report from the Institute for Public Policy Research.
The Future Hospital: the politics of change, is based on interviews with clinicians, managers, the public and patients in areas facing hospital shake-ups.
The report also recommends that more clinical staff be used to convince the public of the need for change. Front-line staff - the most trustworthy group in the eyes of the public - were not fully engaged in the process, the research found.
And often, only the most senior clinicians were drafted in for back-up at community meetings and to front consultation leaflets.
Without the support of other staff, the changes were widely perceived to be motivated solely by financial expedience. ‘Clinicians are more trusted than managers but the tendency is to engage senior clinicians such as the medical director,’ said Mr Farrington-Douglas.
‘The public and patients are also sceptical about top clinicians and feel they might have their own motives for changing hospitals.’
‘The engagement needs to be with frontline staff, who are a much more effective conduit of public opinion.’
Except frontline staff are more likely to tell you just what is wrong with the idea of the day & it is not pleasant hearing to most management ears.
The NHS Confederation primary care trust network also complain about top-slicing .
More than £1bn has been taken from PCTs during this financial year through the top-slicing regime. This money is then held by the SHAs in their reserves to offset the region’s deficit. The impact of this top-slicing has been to throw a large number of PCTs into apparent deficit, when without the top-slice they are delivering a surplus. When the effects of top-slicing are taken into account, the number of PCTs in deficit falls from 71 (47 per cent of PCTs) to 29 (19 per cent of PCTs). Or to put it another way, 42 PCTs have been sent into deficit because they have been top-sliced.
Dr Foster’s again comes in for some stick for its links into government.
MPs accused the government of having ‘very cosy relationships’ with Dr Foster. They examined the role of Matt Tee, who was seconded to the DoH as acting director of communications while in Dr Foster’s employ, and the relationship between Jake Arnold-Forster, chief executive of the Dr Foster joint venture, and Josh Arnold-Forster, who was John Reid’s special adviser from 2005-06, when former health secretary Mr Reid was defence secretary.
Salary trends for Chief Execs are looked at with a suggestion that they are doing well out of the reviews revealing a broad salary range for NHS trust chief executives, with the highest at £190,000 and the lowest at £83,500. The median basic pay was £126,561 - a rise of six per cent since 2006. Tell me again about that 0% pay award for GP’s & 1.9% overall for the NHS including for nurses, doctors and AHP’s, especially given the complaints about Agenda for Change & the new doctors contracts.
My attention was caught however by an insert from the NCCSDO which summarises the evidence for different approaches to reducing demand for outpatient treatment.
Four types of intervention aimed at reducing demand on hospital outpatient services were reviewed:
â—Transfer of services – traditionally delivered by hospital clinicians – to primary care practitioners
â—Relocating specialist outpatient care to community premises
â—Liaison between primary care practitioners and specialists
â—Professional behaviour interventions to change GPs’ referral behaviour.
The study questions some of the key assumptions about hospital & community care and shows the questionable evidence base behind a number of buzz word laden reforms.
Transfer:
Transfer of minor surgery - Dependent on the skill of the surgeon & can be variable. The study finds little impact on hospital waiting times suggesting that GP’s are picking up unmet need. So little or no cost saving.
Primary care clinics for chronic conditions - Reasonable results but cost benefit unknown as is impact on primary care workload.
GPSI’s - Very limited research. Lack of uniformity, variable cost, acute trust hostility. No evidence of effect on demand. (Trying to use GPSI’s in referral management centres is part of the problem as they have no evidence to support them.)
Changes in discharge procedure including no follow-up - Little evidence, queries about GP workload & reduction in quality of care. (So no more silly ideas about cancelling all follow-up appointments in outpatients.)
Direct access to investigations - Improves care & waiting times, cuts costs. (A good idea but GP’s need training to order & interpret some of the tests.)
Relocation:
Moving secondary services to primary care - Ineffective in reducing demand. More expensive. (Add disruptive to that list.)
Tele-medicine - Tele-dermatology plausible but more expensive than outpatient clinics. (I blame the poor IT set-up’s which over specify the equipment. Also very few specialities can really benefit.)
Liaison:
Liaison between primary & secondary care improves communication & quality of care but has little effect on outcome. And is more expensive.
Professional behaviour change - Can be effective in improving referral quality. (Something that happens organically at the moment & is being hit by squeezed budgets.)
So are we going to see these findings inform changes in policy at the DoH?
March 15th, 2007 at 11:11 am
[...] reviewed the study by the SDO last week which covered similar ground & pointed out the fallacies underpinning a number of initiatives. [...]