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Armando Iannucci in the Observer

Last month, a young mother in Brighton unexpectedly went into labour at home. When she rang up the midwife unit for someone to come out, she was told: ‘We’re shut for home births today.’ She was then asked to call back later. The interesting and frightening revelation comes in the subsequent statement by a spokesperson for Brighton and Sussex University Hospitals NHS Trust who said it was ‘totally committed to providing all women with a choice of where they give birth’.

That’s it. This is a statement of aspiration rather than an apology for reality. It’s like if I were to hit you in the face with a hammer and, instead of apologising afterwards, merely said: ‘I remain firmly committed to not hitting people in the face with a hammer.’

My contention is that it takes a very special development in the mental synapses to respond to a story like this without apologising. What we’re seeing is a creeping inability on our part to say we made a mistake.

Have I mentioned before how much I hate PR double-speak?

The medical profession is still awaiting an apology from the architects of the MMC / MTAS muddle.

Dr Crippen pulls together a number of threads to this story in the Britmeds.

As are we all for the cynicism and / or naiveté exhibited by those who fell for the Trap.

We already have a system - the free market - under which consumers can vote every day for what they want, instead of every five years as in politics! And that’s not only more democratic but also cheaper, because it means we can get rid of all those bureaucrats, who as we now know have just been (rationally) feathering their nests at our expense! There is no such thing as society! Order out of freedom: no wonder it looked like the end of history, the final triumph of democracy and free markets.

One of the revelations of The Trap is that Alain Enthoven, the guru behind Thatcher’s internal market NHS reforms of the 1980s, was US assistant secretary for defence under President Johnson, and before that - one guess - nuclear and game theory strategist at the Rand Corporation. ‘Consumer choice, competition and strong incentives to modernise’: no, not Brown, but Enthoven’s NHS prescription for New Labour, circa 2000.

The Trap’s bringing together of a number of strands, including psychiatry, medicine, politics, economics and management, is wide-ranging and controversial. But a virtue of its broad historical context is to bring into sharp focus otherwise-puzzling aspects of the agenda that New Labour has pursued since 1997 even more zealously than the Tories before them.

In this perspective, the assault on professionalism - teachers, doctors, lecturers, police - suddenly appears not an unfortunate by-product of policy: it is the policy. Ministers want doctors and lecturers to be motivated by money and league tables. It is only by ridding them of pesky notions of doing good or knowing best that game theory and public choice can be made to work.

Left to themselves, humans obstinately refuse to be bad enough for these grotesque theories to come true. When Nash tested his system games on Rand secretaries, he was bemused that they insisted on co-operating instead of betraying each other every time. Only later did it transpire that Nash himself was suffering from paranoid schizophrenia, believing everyone, including work colleagues, was out to get him. In fact, it turns out that the only people to reliably exhibit the behaviour required to make the equations work are psychopaths and economists.

That sounds bleakly funny, until you consider the implications. As the economists’ experience suggests, self-interest can be learned. The trap is that this is what organisations in both public and private sectors, all based on the same reductive assumptions about human nature, are teaching us. Slowly but surely, organisations are remaking us in their own stunted and cynical image.

More about the Trap in the Times with Simon Jenkins who argues for greater local democracy:

A tradition of the public realm once built round autonomous institutions, elected leaders and public accountability has been overtaken by the demons of quantification and control. The means by which the Treasury regulates public money has become the means by which the centre controls everything on which money is spent.

To every activity is attached a pecuniary value and thus a performance. To every performance is attached a target and to every target a league table. The targets may seem to be guided by what people say they want in focus groups, but in reality they are “negotiated” by power blocs within the public service. Their enforcement depends on matrices of budgets, feedbacks and incentives, covered by quasi-contracts and internal pricing systems. Orwell’s future, depicted as “a boot stamping on a human face for ever”, is now a computer mouse implanted in the brain.

Quantification makes computers honey-traps for ministers. John Reid and Patricia Hewitt are putty in the hands of their salesmen. Yet a 2005 survey showed that, of seven comparable governments, Britain had the highest computer “scrap rate”, the weakest contracts and the most uncompetitive market, quite apart from the poor value added of many of the machines. Yet these computers now have a validity of their own, blighting the NHS budget, farm payments, child support, ID cards, criminal records, tax credits and, most recently, doctor recruitment. They do not measure value but are a surrogate for it, so that what the computer cannot measure is valueless.

After all, these voices are not worth listening to, since what do they know, being professionals who have a vested interest & anyway, the special advisers know better.

Medics will face a “stark choice” between carrying out operations for which they are not trained and simply abandoning dying patients, according to a joint paper by the British Association of Emergency Medicine (BAEM) and the College of Emergency Medicine.

The professional bodies representing A & E doctors say the new system - which could see casualty departments operating without back-up services such as intensive care, paediatrics and surgery - is too dangerous.

The Royal College of Paediatrics and Child Health and the Royal College of Surgeons have raised similar concerns, warning that hospitals with an A & E but no surgery could struggle to keep enough intensive care staff on their books to support patients who suddenly fall critically ill.

I have worked in a few hospitals where cuts have led to situations like these & it is part of the reason why I no longer work in A&E or indeed the acute sector.

The DoH asked for recommendations for a new system for acute hospitals after David Nicholson, the NHS chief executive, revealed that the NHS must agree about 60 “reconfigurations” across England within a year.

The elephant in the room that no one will admit is that the reason is money. Just what are your lives worth? Any claims that there are not enough doctors to maintain services will now be laughed out of court but that was the excuse used all these years when the plans were being developed.

The plans to downgrade district general hospitals were drawn up by the Academy of Medical Royal Colleges, an umbrella body representing a number of doctors’ specialities.

Even it admits there are problems to overcome if its proposals are to work. It cites a lack of evidence showing what the outcomes are for patients who travel longer distances, but insists “big is not necessarily better” when it comes to hospitals.

Unfortunately as demonstrated by the past few months, the Academy & the senior members representing its constituents might be said to have lost touch with sanity.

One of the other reasons for my move into the primary care sector was the framing of unrealistic duty rosters which pretended that staff were machines. The scientific evidence behind shift patterns that ask you to do a few day shifts followed by an afternoon shift, then to be followed by a night shift, on consecutive days with just one day before you go back to the grind of day shifts again or indeed any other similar scheme escapes me. A look at the genetics of sleep.

This Doctor appears to be sticking it out:

I am not a consultant, but I feel that the term ‘junior doctor’ requires a little qualification. I started at medical school in 1992, qualified as a doctor in 1998, and have worked as a registrar (middle grade doctor) since 2003. I am junior in that I am not yet a consultant, but I have been around for a few years and seen a lot of disease.

Midwifery comes under scrutiny again in the Independent, after the recent front page article.

The most important factor in labour was one-to-one continuous care - this came from midwives, obstetricians, the National Childbirth Trust and natural birth gurus. In other words, mothers should be attended throughout by a devoted birth professional - ideally, a trained midwife. In reality most maternity units were woefully understaffed and it was commonplace to hear of midwives running between four women in labour. The Royal College of Midwives said forlornly (and still does) that at least 10,000 extra practitioners are needed to bring the maternity services up to scratch.

But I am afraid I have no sympathy with the argument that insurance is not required. I would support mechanisms of providing that cover however it might be structured as not many insurance companies are going to consider a few hundred midwives in a high risk occupation a viable business.

The Times looks at claims of the increasing medicalisation of labour & again pushes independent midwives.

Patricia Hewitt, the health secretary, is preparing to announce a new drive to improve maternity services.

There will be a promise that every woman will have a named midwife to care for her throughout pregnancy and a guarantee of one-to-one care by a midwife during labour. How long that promise will take to be delivered is anyone’s guess.

Since 2004 the government has been promising women “real choice” over where to give birth. In reality mothers face not a choice but a dilemma: home or hospital?

Last week the government watchdog Nice (the National Institute for Health and Clinical Excellence) issued a warning that babies born at home have a higher risk of dying if serious complications occur. But last week, too, a health department study found that the NHS is letting down new mothers in hospital, treating many like “meat on a conveyor belt”.

So the NCT have a good PR department. However safety comes first and if the practitioners are not able to keep their knowledge up to date & to accept responsibility for their mistakes, they have no business providing care. So the focus should be on the means of obtaining insurance & proving competency, not denying the need for it.

As for this, the best gloss that can be put on it is a wilful blindness to criticism & a lack of interest in a range of views, preferring sycophants. Much worse has been claimed. No wonder so many schemes run into trouble.

Claims made in Liam Halligan’s Dispatches programme of a few weeks ago are re-examined in this article in the Times.

Cancer patients who have had tumours removed are dying because they are waiting so long for for follow-up radiotherapy that their tumours return, a government report has found.

After surgery, patients should receive radiotherapy within 28 days, according to the Royal College of Radiologists. However, in some areas, patients are waiting three times as long. In Kent, for example, the waiting time for breast cancer patients who have had tumours removed by surgery is three months.

Dr Michael Williams, vice-president of the Royal College of Radiologists and co-author of the report, said that, in addition, some patients were not receiving enough radiotherapy.

Williams said: “One problem is delays in some areas of the country and the other is that, when patients are treated, they receive fewer fractions [doses] of radiation than they would receive elsewhere in Europe and America.”

It is understood that the report, co-authored by Mike Richards, the government’s “cancer czar”, also says that the NHS is administering only about half the amount of radiotherapy needed to treat British patients properly.

The government report has been subject to repeated delays. A draft was ready in August and the document has been with health ministers since February. Critics suspect the Department of Health (DoH) will suppress it until it is ready to announce a new plan to improve cancer services in the autumn.

Healthcare in the private sector makes an appearance in the Telegraph with a profile on General Medical Clinics but I wonder how the restrictions on private screening will impact on other parts of the industry.

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From the letters page of the Telegraph:

Sir - As an NHS manager, and partner of a doctor, I have witnessed first-hand the past two months of shambolic hell that my medical colleagues have been through, under the Modernising Medical Careers (MMC) procedures, in many cases merely to re-apply for their own job.

Imagine if this was suggested in any other profession - a one-off, once in a lifetime chance to continue your career, to achieve what you have aspired to since childhood. It would be ridiculed.

Chris Edmond, Belfast City Hospital

Let us face it, the new proposals will not work & only have lawyers rubbing their hands in glee.

Sir - Ten years ago, the NHS was on its knees, with staff shortages, recruitment difficulties, and widespread vacancies. We’ve eliminated recruitment difficulties and rewarded hard-working professionals.

Patricia Hewitt, Secretary of State for Health, London SW1

Yup, I saw them dancing in the streets for joy last Saturday.

Sir - I have yet to meet a single experienced doctor who thinks MMC benefits trainees or the public. It will produce fewer experienced specialists, to the detriment of the general public.

I am convinced this is a manifestation of Labour’s old hatred of consultants, seeing us as pin-striped buffoons, as portrayed by James Robertson Justice.

MMC is designed to reduce the influence of the royal colleges and indeed of the medical profession. The sub-plot is to create unemployment in the medical profession to control the labour market.

Dr Andrew Lawson, Warborough, Oxfordshire

Not that the Royal Colleges deserve to escape much of the blame either.

The Daily Mail runs a thoughtful piece on the flight of junior doctors.

It’s not ingratitude that has driven them to take their skills (learned at a cost of £250,000 a head, paid for by the taxpayer) abroad.

Rather, this brain drain is being driven by the incompetence of their political masters.

The introduction of the changes has created a “bottleneck” of applicants which this year will see 32,000 junior doctors chasing just 23,000 vacancies.

Dr Claire Cooke, 28, who spent five years at medical school at St George’s Hospital in London and who has undergone five years post-medical school training, is one of them. She currently works in a hospital in south-east England and refused to take part in the MMC application process.

“For the last five years I have always wanted to be a surgeon but this whole shamble has made me reassess that,” she said. “The type of doctor this system is attempting to create is not the type of doctor that I or any of my colleagues want to be.”

She adds that she refused to apply because “after all the hard work I have done to get where I am, I just wasn’t prepared to beg for the scraps from the table“.

Of course, half a billion pounds a year has nothing to do with it either. Remember CFISSA. Where do you think some of the 3938 million to the SHAs & 5574 million to the PCTs went?

Not a lot I can say about these.

Atos Origin was brought in by NHS North West last December as part of a pilot project aimed at cutting waiting times for patients needing scans.

They were given two pilot contracts for ultrasound and MR scans. But regional health bosses suspended them last week and are now reviewing a five-year contract with Atos to diagnose conditions including hip, knee and back problems in 12 centres across Greater Manchester and in Merseyside and Cheshire.

Hmm, I wonder what went on within the DoH during negotiations.

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Ok, I was mistaken & something did happen.

This statement from the Review Group appeared on the MMC website.

Version 1.0
STATEMENT BY THE REVIEW OF RECRUITMENT AND SELECTION FOR SPECIALTY AND GP TRAINING – THURSDAY 22 MARCH 2007

Building on last week’s announcement, at a minimum, every long listable applicant who applied through MTAS and meets the eligibility criteria for their relevant specialty will be invited for an interview. Under this guaranteed interview scheme, candidates will be able to choose which of their preferences to be interviewed for in light of geographic specialty-specific and ST level-specific competition ratios which will be available on the MTAS website. We are in discussion about the implications of this for the timetable.

The recruitment system has worked satisfactorily for General Practice and this will continue. In other specialities, there is evidence that the shortlisting process was weak and we will therefore eliminate this part of the process immediately. In contrast, the interview process has been working and therefore the revised approach will ensure that all long listable candidates will be interviewed. The Review Group believes that this new approach is the most equitable and practical solution available. The Group also recognises the enormous effort by the consultants, service and deans that has already taken place to ensure that the interview process has worked. The time and effort required for further interviews is recognised by the service and the time required will be made available. Therefore first choice interviews that have already taken place should not need to be repeated.

In accordance with the advice already issued, we reiterate that all interviews will be informed by the use of CVs and portfolios and probing questions.

I have been informed by the Academy that the new interviews will be less structured & will take account of all information including CVs. The scoring system & weightage given to the components are still being worked out along with the logistics. This is expected to be made available soon.

In broad terms, this means that all eligible applicants at every stage of their training, whether or not they have already had interviews or interview offers, will be able to review their stated first choice preference and have the opportunity to select the one for which they want to be interviewed. We will be discussing operational details over the next week and these may differ between specialties and between different parts of the UK dependent on local circumstances. We will also consult widely. Exact details for how applicants will be able to do this will be available week commencing 2 April on the MMC website at www.mmc.nhs.uk. In the meantime, interviews will continue and applicants should attend unless they are confident that this will not be their preferred choice.

This bring up the question of inequitable treatment as those candidates interviewed under the MTAS format are at a disadvantage compared to those who will attend the new round of interviews. I do not see how this can stand up to legal challenge. It would be far better to bite the bullet & re-interview everyone again.

No job offers will be made until all these interviews have taken place. Discussions are taking place on the implications of this for the filling of General Practice training places. We expect that the majority of training places will be filled through these interviews. Unfilled vacancies will be filled through further interviews.

The Review Group has recommended the development of a programme of career support for applicants at all stages of the process. Further details to support applicants, deans and selectors through this process will be available next week on the MMC website. Future work will explore what the possibilities might be for doctors to change specialties.

Professor Neil Douglas
Review Group

I have to make this clear that this is work in progress but the current interpretation is:

Essentially everyone will now get ONE interview, and one interview only. Even those previously given 4 interviews will have to select only their top choice to be put forward for consideration.

Interviews will continue until all posts are allocated.

What were the Review Group thinking? One chance to get a job or leave medicine in the UK!

The competition ratios currently available from MTAS are inadequate for the purpose of trainees choosing appropriate posts. The format used by Wessex Deanery is better but an improvement would be to add the names of the hospitals making up the posts to the table. Particularly as trainees should be able to apply to them individually as opposed to a wide geographical area.

According to a spokesperson from the Academy of Medical Royal Colleges, the Department of Health has been unwilling to release information regarding the MTAS process such as the numbers of applicants, posts, statistics regarding the percentages of trainees who obtained interviews according to their rankings of choice etc. No information has been forthcoming regarding ethnicity & immigration status monitoring either.

The spokesperson was unable to tell me whether this information had been made available to the Review Group.

I have requested that the Academy release copies of the evidence assessed by the Review Group as well as the records of its deliberations in the interests of transparency. As quite a few stake-holders were not invited / allowed to submit their evidence, it will also help to draw attention to matters that might not have been considered by the review.

I would also suggest to the AoMRC that to avoid being left holding the bag for this catastrophic failure of medical workforce planning, they need to avoid taking taking any decisions on their own & also be as open as possible to other opinions. Defensiveness is not a viable strategy.

With reference to the offer from the Review Group & the Academy to consult widely, I am willing to offer technical solutions to facilitate such consultation.

An interesting blog offering personal experience of MTAS, especially the GP assessment process. Please note however that the shortlisting for this is not based on brain dead questions as far as I am aware.

Coverage in the Telegraph.

The MTAS website has since been updated with more detailed stats but these still are not as detailed as I would like them to be. This information was correct as of 17:00 today (23.03.2007). Please check both the MTAS website & here for updates. Also, remember that FTSTAs are included in the numbers of posts listed here. A very large pinch of salt is required.

Compiling them into an Excel spreadsheet has taken a while but am also uploading the national stats by region & also by specialty.

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Not a lot appears to have been happening with both the Independent & the Times covering the report of the Health Select Committee on workforce planning I mentioned yesterday.

The HSJ has snippets about Out of Hours services (deadlines for providers to improve services), joint commissioning with social services (a few PCTs have started recruiting) & the perversity of PbR (another round of consultations was launched recently) but no revelations.

Tom Reynolds over at Random Acts of Reality highlights another “reform” of staffing levels. Penny pinching changes that endanger patient care are not limited to hospitals. Now the ambulance service is at it too.

The FT ran a couple of articles in the aftermath of the policy initiatives re-spun at the beginning of the week touting the lack of enthusiasm among retailers for the GP surgery plans, but being charitable, these are early days & the hoped for outpouring of interest will happen like manna from heaven. Or maybe not. At-least Virgin are touting their GP property division.

Alliance Boots, Tesco,J Sainsbury and Asda delivered a mixed reaction yesterday to Tony Blair’s proposal that they run GP surgeries, with most appearing to see only limited opportunities for public-private tie-ups.

Tesco, Britain’s biggest supermarket chain, said it had no plans to open doctors’ surgeries in its 600-strong estate of supermarkets and hypermarkets, while Asda said it was exploring a limited service. The second-largest supermarket chain was assessing the feasibility of offering out-of-hour GP services in a handful of stores.

All eyes are on London with the new executive team employing Lord Warner, Paul Corrigan & Anthony Sumara. The private sector appears to be waiting to see what they come up with once in post.

The FT also covered the first official hints of restricting the services offered on the NHS, hidden in the small print as it is too divisive a topic to raise publicly. So not a debate then, more whispered conversations in the corridors of power with the role of public whipping boy being played by NICE.

The prospect that the National Health Service might provide only core services, with patients forced to pay for any other treatment or meet it from private insurance, was raised by the government yesterday.

News that ministers were examining the possibility of defining the services that the NHS is obliged to provide free to everyone was disclosed in the small print of the public services policy review launched yesterday by Tony Blair, the prime minister, and Gordon Brown, the chancellor.

It says the government should “look at the possibility of drawing up a package of services that all users are entitled to”. NICE, the National Institute for Health and Clinical Excellence, could be asked to do that.

And from the entirely forgettable Healthcare Computing 2007 exhibition, not much happening either. At-least, that appears to be the view of those who bothered to go. Contrast that to the situation across the pond where they did not go down the monolithic central procurement route.

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It appears that the report of the Health Select Committee regarding Workforce Planning in the NHS is out though I doubt it covers the recent turmoil surrounding the MMC / MTAS process, having gone to press on 15th March. (Pdf versions 1 & 2)

70% of NHS funding is spent on staffing costs.

It was too easy to throw new staff into the task of meeting targets rather than consider the most cost-effective way of doing the job.

Unfortunately, cuts in the training budget threaten what successes there have been.

There has been a disastrous failure of workforce planning. Little if any thought has been given to long term or strategic planning. There were, and are, too few people with the ability and skills to do the task. The situation has been exacerbated by constant re-organisation including the establishment and abolition of Workforce Development Confederations within 3 years. The planning system remains poorly integrated and there is an appalling lack of co-ordination between workforce and financial planning. The health service, including the Department of Health, Strategic Health Authorities (SHAs), acute trusts and Primary Care Trusts (PCTs), has not made workforce planning a priority.

The contribution of clinicians to managing health services must be improved. Clinical training should contain a larger management element and senior clinical staff should be better supported to take on general management roles.

At the end of the day I do not see this report as particularly insightful. A number of people gave evidence but workforce planning is symbolic of the failure of imagination in the system as a whole.

The BBC is quick to cover the report but has few specifics.

The Guardian adds a few quotes.

Dr Sam Everington, deputy chairman of the BMA, said he felt the committee’s criticism was misplaced.

“While agreeing wholeheartedly that integrated workforce planning must be a priority for the health service, we do not agree that the expansion of the medical workforce was reckless and uncontrolled and that pay increases for doctors have not seen a return in productivity,” Dr Everington said.

Meanwhile, staff go to Australia or anywhere else they can make a better life.

There is more in the Telegraph on MTAS.

In the meantime, I have set up a Wiki to collect contributions to the critique of Patricia Hewitt’s statement in the Commons on the 19th of March. The video of the appearance is available as well.

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Well, yesterday was budget day & the whole production takes up most of the coverage.

With reference to healthcare, there are a few announcements but no real surprises so far.

The reduction of VAT on anti-smoking aids from 17.5 to 5% is an useful public health measure.

From the Independent

Spending on the NHS in England will rise by £8bn in 2007-08 in what is certain to be the last of the years of plenty.

The future after that looks bleak. Mr Brown declined to do for health what he did for education and announce the allocation for the years from 2008 to 2011 in advance of the Spending Review later in the year. But the growth rate for the health service is certain to be much lower than it has been in the past. A figure of around 3 per cent is widely expected.

Despite its lack of prominence in yesterday’s Budget, the NHS is likely to be a key battleground as Mr Brown goes head to head with David Cameron in the run-up to the next election. With one third of NHS trusts in debt facing a cumulative gross deficit of more than £1bn, the health unions in militant mood over job cuts, local communities mobilising to oppose hospital closures and expensive new cancer drugs coming on to the market, the health service has a torrid time ahead.

The political reaction, again from the Indy

David Cameron tore into the Budget for “wasting money on an industrial scale” as he mocked the Chancellor as the pilot of a sinking New Labour ship.

The Conservative leader derided Gordon Brown’s 10 years at No 11, telling MPs: “His great experiment in tax and spending has failed. He is an out-of-date politician wedded to state control. The question everyone is asking is, ‘Where has the money gone?’”

“All he has done is re-announce this year’s money which we already knew. He has got the figures for the future - why won’t he tell us?”

The Times

Mr Brown said that financial allocations for 2008 to 2011 would be made in the spending review later this year, but did not elaborate. The general expectation is that future settlements will be far lower than in the past five years.

The supporting documents for the Budget suggest an “envelope” for these increases rising by 1.9 per cent in real terms per year — significantly lower than the NHS has recently enjoyed.

The Guardian is more positive though again details are lacking.

Mr Brown said cash for investment and reform in the NHS in England would rise by £8billion this year, representing a 10% increase, or 7% in real terms.

In the whole of the UK, total additional NHS expenditure is to rise by almost £10 billion this year, the chancellor said.

He added that with efficiency savings of 3% each year, the government could release £26bn a year by 2010-11 for frontline public services - which would receive 75% of all new spending.

Those efficiency savings are nebulous.

From previous records, Where the money was actually spent.

2005-6, Centrally Funded Initiatives and Services and Special Allocations (CFISSA) was over 6 Billion pounds over budget out of a total budget of less than fifteen billion pounds.

Significant Underspends (2004-2006):
Cancer -77 million
CHD -37 million
Mental health -34 million
Reducing health inequalities -169 million
Workforce -667 million

Significant Overspends (2004-2006):
Older People +165 million (interesting this: an overspend of +374 million, followed by a dramatic underspend of -209 million)
Improving patient experience +68 million
IM&T +696 million
Specialist health services +1065 million (audiology, dentistry, ophthalmic < -- already privatised)
Modernisation agency +63 million
Primary care +4153 million
Residual budgets (eg to SHAs) +3938 million
PCT allocations +5574 million

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There has been a fair amount of comment in the papers on various NHS plans & I would like to highlight a few of them here.

Death by 1,000 cuts: NHS budgeting laid bare
Patricia Hewitt’s budgeting may have made the NHS healthier in a financial sense, but at what cost? An A&E doctor reveals all…

My department is under such extreme pressure to help the hospital meet its financial targets, that no one can seriously argue that patient care is not being compromised.

I think this is a sentiment I have expressed often enough here.

“They”, the managers, don’t talk of cutbacks, but of “rationalisation”. In the Alice-in-Wonderland world they inhabit, replacing two or three trained nurses per shift with cheaper, unqualified assistants is not about saving money, but about extending roles and enabling stakeholders in the client-care pathway.

The managers are the politicians’ foot soldiers. Usually, they are not around to see the results of their decisions. These range from minor annoyances, such as not being able to spend as much time as you should with a bereaved family to the potentially catastrophic; the missed septic patient, nearly sent home because someone had forgotten to check their temperature.

As said before, short-term compromises lead to larger bills in the longer term.

While the trust I work in has more financial problems than some, it is hard to believe that practices similar to those I have witnessed are not being repeated throughout the country. Indeed, we are far from the top of the list of “overspent” trusts.

With those in charge deaf to our concerns, but mindful as ever of the daily numbers game, increased “breaches” of the four-hour target may be the only way we have of trying to demonstrate how unacceptable things have become.

Desperation is the only way I can characterise the writers feelings. These sentiments are replicated in most parts of the NHS up & down the country, not just in A&E. For a view from the community services, ask the district nurses.

The letters section of the Times has a couple. One regarding MTAS:

We urge the Department of Health to listen to doctors and to invite the royal colleges to produce an alternative system that is acceptable, transparent and, above all, valid. The NHS needs our talented young doctors and they deserve far better than MTAS.

DR SUSAN BURGE, President, British Association of Dermatologists

PROFESSOR CHRIS BUNKER, Chair, Specialty Advisory Committee, Joint Royal Colleges of Physicians Training Board

DR DAVID EEDY, Editor, British Journal of Dermatology

And this one making a point I raised a few days ago.

Sir, Recently 1,000 lawyers protested outside Parliament against reforms to the legal aid system. On March 17 12,000 junior doctors marched through the streets of London.

To judge by the media coverage of this unprecedented event, the general public would be forgiven for not fully understanding the threat that Modernising Medical Careers poses to patient safety.

Maybe the lawyers captured the attention of the media because many of them have been working to rule since last year. What do we doctors need to do to get our message across?

DR GEORGE BOSTOCK, Truro, Cornwall

From the letters page of the Independent:

The Public Accounts Committee deem doctors to be responsible for overspending in the NHS. The truth is entirely the opposite - it is because the medical profession do not have enough influence in spending decisions that health service finances are in such a mess.

And a column from Mark Steel

There’s splendid news about the Health Service. It seems last year it made £95m profit from car park fees at hospitals. What an example of modern spirit and enterprise, and a contrast to the old “anti-business” ideology that allowed people to park at hospitals for free. These dinosaurs would never have had the imagination to say “Hmm, they HAVE to come by car as they’re limping - we can charge them as much as we like.”

A cynical comment but nearly true enough as decisions are not being examined for impact. As long as criticism can be spun away or deflected by layers of management.

Every corner of a hospital has been studied for its marketing potential. Bedside telephones are on offer at premium rates, and televisions can be hired for £16 a week. Surely with that combination on offer there ought to be an investigation into whether our hospitals are being run by ITV. Maybe the premium rates are in place because they discourage people who are not using the hospital from feigning a hernia in order to sneak a cheap phone call.

Hospitals as “profit centres”, yes, that was the term.

So far, they’ve only gone part way down this route, for example by placing a series of businessmen from companies such as Deloitte and Touche on NHS boards. This is why the police should be discouraged from pursuing the “cash-for-peerages” scandal. At least that way businessmen are only buying themselves a robe and the right to sit among some dribbling Lords, but in this case they’re buying the opportunity to run a bloody hospital.

This is all a consequence of the Health Service being subordinated to the Private Finance Initiative, and you can study the details if you like but you ought to be able to tell from the title whether its purpose is to encourage a) health or b) private finance.

Outside experience is useful as long as it is tempered with practical knowledge of the service in question.

I am waiting to see what gets dredged up today.

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The Public Accounts Committee report on Financial Management in the NHS is out (pdf)

Spending on the National Health Service is the fastest growing area of public expenditure. The NHS budget for 2004-05 was £69.7 billion, rising to £76.4 billion in 2005-06 and will be £92.6 billion in 2007-08. Despite the increased resources, the NHS reported an overall deficit of £251 million (including Foundation Trusts) in 2004-05, the first time since 1999-2000 that the NHS as a whole had overspent. In 2005-06, the overall deficit increased to £570 million (£547 million excluding Foundation Trusts). There was an increase in both the number of NHS organisations—Strategic Health Authorities, Primary Care Trusts, NHS Trusts and NHS Foundation Trusts—reporting a deficit (up from 168 to 190) and the proportion of those bodies reporting a deficit (up from 28% to 32%).

The Committee took evidence from the Department on three main issues: what factors had led to the deficits, what the impact was on organisations in deficits, and what steps were being taken to recover deficits.

We found that there is no single reason why NHS bodies are in deficit, but that a number of factors are at work. Those reporting a deficit tended to have had a deficit the previous year. Excluding foundation trusts, of the 159 bodies reporting a deficit in 2004-05, 117 (74%) also recorded a deficit in 2005-06. The NHS has also been under significant financial pressure to meet the costs of national pay initiatives which the Department had not fully costed. Some NHS bodies have coped better than others in managing these cost pressures, indicating that the standard of financial management expertise varies across the NHS, as does the level of clinical engagement in financial matters. Bodies already in deficit looking to turn their financial position around can also be disadvantaged as they are expected to recover that deficit in the next financial period.

NHS bodies in deficit face the challenge of maintaining and improving the level of healthcare services whilst managing and recovering their deficit, during a period of significant reform and rationalisation within the NHS. To manage their deficits, NHS bodies have needed to cut the size of the workforce, with 903 compulsory redundancies in the six months to 30 September 2006; reduce the number of open hospital wards; and defer significant capital projects. It has also become much more difficult for recently qualified clinical staff to find work in the NHS.

The NHS is aiming to return to financial balance in 2006-07 and to produce a £250 million surplus in the subsequent financial year. In order to achieve balance in 2006-07, the Department has top-sliced the budgets to create a strategic reserve of £450 million as at the end of September 2006. Bodies with large deficits are required to produce financial recovery plans which are reviewed by the Department. Whilst some plans have been successfully designed and delivered, others have been based on unrealistic assumptions or short-term measures.

The recommendations are as follows:

1. The in-year financial information produced by some NHS bodies for management and reporting purposes does not allow the Department to manage the national finances of the NHS in the most effective manner. The Department should require NHS bodies, at regular intervals during the year, to produce and interpret balance sheet information as well as robust income and expenditure and cash flow figures. All figures should show the year to date as well as the forecast position. Local NHS bodies would then be able to identify and address emerging problems promptly and Strategic Health Authorities and the Department could manage the national picture better.

Nothing to argue with here though it a gargantuan task.

2. The Department does not have an overall picture of the impact of deficits on the NHS’s capacity to deliver services, and was only able to provide us with information about the number of redundancies, closures and abandoned capital programmes after our hearing. Decisions on structuring and staffing in individual organisations are taken at a local level, but the Department should collect this information as part of its wider performance management arrangements so that decisions affecting the capacity of the NHS to deliver its objectives are properly informed.

As discussed previously in other posts, the DoH is in flux with poor organisation & very little input from clinicians. At the moment financial considerations seem to trump any other priority.

3. There is a lack of financial management expertise in the NHS, and a need to strengthen communication between those responsible for the finances and for the delivery of local health services. Measures to bring about financial balance need to stem from a partnership between financial managers and clinicians to enhance both the efficiency and the effectiveness of healthcare. The Department should identify models of successful joint working between financial and clinical management, and promote them across the NHS.

Edward Leigh MP is mistaken if he thinks that clinicians do not take in interest in finances. I will return to this in a separate post.

4. Errors in the costing of the Agenda for Change pay initiative, General Practitioner and consultants contracts meant that in 2005-06 individual NHS bodies were required to fund a £560 million shortfall in resources to pay for these central initiatives. The Department of Health should analyse the original costings to determine where lessons can be learnt so that local NHS organisations are not required to meet the ongoing cost of these schemes without sufficient funding.

A lot of assumptions were made about doctors & other staff working practices such as claims that most consultants spent their time on the golf course. The DoH has learnt to its cost that most staff do more than their contracted hours. and Agenda for Change has not made non-medical staff very happy either.

5. Decisions by Strategic Health Authorities on whether deficits incurred by NHS bodies should be repaid in the next financial year, and on the amount of financial support for NHS bodies in deficit, are not being applied consistently across the NHS. And while Strategic Authorities need some flexibility to take account of local circumstances, the Department should give a lead in determining the tolerable range of variation in financial regime. The accounts of NHS bodies should be enhanced to clarify the various sources of income, including financial support, which those bodies receive, to give a more transparent picture of their financial performance.

The RAB accounting regime needs to be extensively modified or to go. There has so far been no clear indication of this. And PbR is perverse as admitted by the Health Secretary.

6. The arrangements for disseminating best practice arising from the work of turnaround teams are not sufficiently robust to maximise the impact such findings can have. The Department should set up a formal process for sharing turnaround reports both internally and publicly, allowing all NHS bodies to consider whether they too could achieve efficiency savings by adopting the actions identified. The Department should also establish a failure regime setting out the consequences of falling into significant deficit and formalising the required recovery procedures.

Some of the causes of deficits are well understood & there is no evidence that turnaround teams have been able to make much of a difference without savage cuts to clinical priorities. In others, improved financial management has indeed helped. But the decision to call for extra help must be based on evidence. And any changes must bear clinical priorities in mind.

Most of the outlets lead with this.

The Telegraph takes aim at NHS management including the DoH.

A devastating insight into financial mismanagement at all levels of the NHS - from Government ministers down to hospital bureaucrats - is provided by a committee of MPs today.

The report by the all-party public accounts committee exposes how billions of pounds of taxpayers’ money is being poured into a health system with inadequate financial controls and low levels of accounting expertise.

The MPs conclude that NHS structures are so inadequate that the Department of Health has no idea what the effect of last year’s total deficit of £570 million is having on patient care.

The BBC says doctors must be more closely involved.

Doctors must be more closely involved in budget decisions if the NHS is to solve its financial problems, say MPs.

Edward Leigh, PAC chairman, said: “There is no excuse for clinicians to distance themselves from money matters as if the quality of healthcare delivered by an organisation has nothing to do with whether it has to dig itself out of a deficit.”

Dr Jonathan Fielden, chairman of the British Medical Association’s consultants committee, said the NHS had financial problems because reforms had been ill thought out and incoherent.

He said: “It is totally untrue to claim that clinicians show a lack of interest in financial matters.

“Doctors could not have been more vocal about the looming financial crisis and have become exasperated by the lack of funds and the devastating effect this has had on the patient care.

“Clinicians are being deliberately disengaged by trust managers who instead prefer to employ costly management consultants to come up with solutions already suggested by NHS staff.”

The Independent adds its voice to the chorus.

Doctors have refused to help NHS trusts cut their spending, leading to a massive cumulative deficit of more than £1bn, a committee of MPs says today.

The reluctance of the medical profession to consider the cost when proposing treatment is singled out by the Public Accounts Committee as a key reason for the poor financial performance of the NHS. The report’s emphasis on the role of doctors signals rationing of care may be inevitable if the NHS is to balance its books.

There is a lot of waste to be cut out of the system before we need to consider rationing but the current policies are not the way to go about doing so.

More comment in the Independent.

One of those close to Brown tells me that for certain there must be no demonstrations against hospital closures in the run up to the election. The anger must have been addressed by then. They do not rule out some policy changes.

In the meantime, there will almost certainly be a new Health Secretary this summer. For Brown, this will be the most important appointment of the lot, more significant than the new Chancellor or the next deputy leader. The current occupant, Patricia Hewitt, who has managed to provoke the ire of nurses and doctors when they were being paid more than ever, will not be there much longer.

The Government’s policies are also moving broadly in the right direction. Some of the current short-term crises arise because several hospitals are poorly managed, spending carelessly in the knowledge that they will be bailed out by the better performing hospitals, a perverse arrangement that encourages inefficiencies and penalises well run institutions.

Part of the problem is that the new financial rules are being applied too indiscriminately, failing to take account of expensive policies imposed by the Government. So some hospitals face big bills as a result of Brown’s Private Finance Initiative and yet are being punished for spending excessively. This is where the politics of the NHS lapses into silliness: You must pay for this and we will penalise you for doing so.

Niall Dickson from the Kings Fund writes in the Telegraph.

Another select committee report, another stinging rebuke of the financial management of our health service.

Today’s report by the Public Accounts Committee paints a grim picture for our national health service and warns the prognosis for its financial future is poor.

Edward Leigh MP and his colleagues are right to be concerned - as the NHS approaches the financial year-end it is hard to find a single organisation not having to resurrect at least some of the desperate tactics to reign in spending last deployed in the 1990s.

Desperation leads to bad decisions. Cuts in services that will end up presenting a larger bill than the usually small sums of money saved immediately.

Charging over and beyond reasonable costs to people who are forced to use private vehicles in the absence of suitable public transport alternatives is simply exploitation & in this group I include both staff and patients. But everything is a profit centre these days. The media reports illustrate just what is happening.

Also in the Times, scrutiny of PFI costs.

The Department of Health (DoH) is facing claims from public finance initiative (PFI) consortia after its national review of hospital schemes, Contract Journal (March 14) reports.

The DoH has issued guidance to help primary care trusts (PCTs) to assess claims arising from ten revised or cancelled PFI schemes. The costs will be shared by the DoH and PCTs. A DoH spokesman says that the department has “appointed forensic accountants to work with trusts to verify the reasonableness of any claims by bidders on cancelled or scaled-back PFI schemes”.

The Department of Health is an evidence free zone.

I have discussed the lack of evidence behind walk-in centres & plans to shift services into the community. The Times lets rip.

TWO of the Government’s flagship health policies appear to be listing badly after broadsides from researchers.

And yet we see a push for personalised public services. Can we provide safe and adequate services before we aspire to Ebay style ratings & frills and extras please?

The Telegraph

The first of the policy reviews commissioned by the Prime Minister to leave his imprint on Labour policies concluded that people wanted services more tailored to their needs.

And stop making up neologisms like “contestability”!

The Independent

The Chancellor committed himself to bringing in more “personalised” state-funded services - including a greater role for private firms and voluntary groups in providing them.

The BBC

To help “empower” people, schools and hospital league tables may include satisfaction ratings like on eBay.

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1 Based on data current at 14 March 2007
2 Applications per post is the ratio of applications to posts.

And some enlightened souls provided more detailed information. Step forward Wessex deanery.