FrontPoint Systems Ltd

I came across this in the letters page of the Telegraph today:

Sir - Recently, I came up against the full might of our proud nation’s new NHS computer system (Letters, April 19). We all, our dear leader tells us, want choice. I was offered “Choose and Book”, which is supposedly a part of the system that is actually beginning to work.

I was given a password and went as instructed to nhs.healthspace.

That was the first problem. I use a browser that is chosen by all who have tried it in preference to the one that comes with the computer. But although the NHS began working on its system in the past century, it is still under construction. The first response I got was that the system could not cope with my decent browser.

So I downloaded the old-fashioned browser. Did that help? Not a lot.

“Choose and book your appointment,” it said on top of the document that I was given at the local surgery. But as soon as I tried, the NHS website went into a sulk from which it never recovered.

Nothing was having any effect. So I resorted to the telephone. A surprisingly cheerful woman explained, as though to a toddler, that I could get no further because there were no appointments.

What none at all? At any of the hospitals within a day’s train ride? None at all. If there is no such thing as an appointment, it was not very polite of the NHS to offer the temptation to try to get an appointment. It hardly seems like £12 billion well spent.

John Ticehurst, Chard, Somerset

The problems do not lie just within the provision of IT services. The integration of information systems into the delivery of healthcare is also one of the largest change management programmes in the world. It has however not been given more than lip service in that direction & any number of lost opportunities litter the field.

IT is an enabler, not an end in itself. Something that appears to have been forgotten by CfH & the people making the decisions.

The HSJ for one is asking for Richard Granger to go.

Rather than Connecting for Health gathering forces for a final push, a limbo is developing. Mr Granger is expected to leave soon yet everyone must maintain the fiction that he is still influential.

PAC chair Edward Leigh wants someone to ‘get a grip’ but there is no clear hand on the tiller during the vital transfer of responsibility to strategic health authorities. It is time the programme, and its pugnacious boss, retired to the sun.

There is more interesting news from the HSJ:

Comparative analysis of patient safety using a set of US indicators has heightened concerns about the quality of NHS trust coding, according to a Dr Foster Intelligence study.

The company had planned to publish trust-by-trust comparison of performance on patient safety against nine of the US Agency for Healthcare Research and Quality indicators. But returns from trusts revealed such variance and lack of confidence in secondary level coding that Dr Foster plans to work with a selection of trusts on a study of how to improve safety reporting.

Something that I have been saying for a while. It is not just the safety data however but also the rest of the data infrastructure. It is not a solid foundation to rely on for the development of an internal NHS economy.

Which brings us to Payment by Results:

Earlier this year the professional and patient lobby on dermatology got together and warned of a threat to their specialty.

Given that this was the height of the NHS financial crisis, it was tempting to dismiss their letter to The Times as special pleading, except for one important fact: they appear to be right. The law of unintended consequences from payment by results is making itself felt.

At least one hospital trust - Newham University Hospital trust in London - has declared its department financially unviable; others have come close.

The Times letter was signed by 350 dermatologists (that is pretty much all of them, by the way), the Skin Care Campaign, the British Journal of Dermatology and the Royal College of Physicians joint specialty committee.

NHS deficits and the government’s health reforms were damaging the care of people with skin diseases by removing choice, it said. GPs were being forced to treat patients themselves or divert them to services not run by specialists. As a result, specialist teams were being dismantled.

Didn’t Bedford Hospital dismantle it’s dermatology department too? I seem to remember Barry Monk standing for parliament opposing the changes.

In a survey by the British Association of Dermatologists last summer, just over half the 100 consultants surveyed said their primary care trust was setting up a clinical assessment and treatment service for dermatology. These were expected to divert up to 50 per cent of patients; meanwhile PCTs were commissioning fewer referrals from the hospital departments, in some cases slashing the number in half.

A third felt this would lead to financial instability and redundancy was under discussion in a quarter of trusts. As BAD clinical vice president David Shuttleworth put it: ‘Those departments which are unable to demonstrate financial viability in trusts trying to claw back a deficit are particularly at risk.

‘Under PbR a relatively small reduction in referrals may be sufficient to attract the attention of an embattled finance director, who may feel that “outsourcing” dermatology into the community will reduce losses on the balance sheet.’

It is hard to argue with that assessment based on present evidence.

Nor is it just dermatology that is threatened in this way. Rheumatology faces the same pressures, says the British Society for Rheumatology.

Take, for example, BSR president Andrew Bamji. He says he is currently under pressure to reduce his new follow-up ratio from 1:3 to 1:1, a move that is not clinically appropriate, would place him outside professional guidelines and see him discharge nearly half his caseload overnight.

As has been stated before, the underpinnings of the tariff are based on little more than myth.

But the tariff is based on an average; divert the simple referrals to a clinical assessment and treatment service or GP with a special interest and it no longer covers the more expensive cases left to the hospital department.

Or, as Dr Holden puts it: ‘That means bankruptcy. You cannot be paid for Minis and build Rolls Royces.’

I would have to agree & that argument has been put forward to oppose the transfer of patients to the ISTC programme as well, only to be ignored by the Department of Health.

NHS Confederation policy director and PbR supporter Nigel Edwards agrees. The idea is in the latest PbR discussion document, although only as an idea. ‘I am concerned that the PbR team’s approach is to unbundle, unbundle and unbundle and put a price on everything,’ he says. ‘They seem to recognise the problem but not do anything about it.’

Things have got to be bad then if the NHS Confederation comes out publicly against it.

‘This is an area where services have to be very carefully designed, where “good enough” will not deliver.’

I concur but I would also extend that statement to the rest of the health service.

Which leads us to the the effects on the wider system:

The Department of Health has drawn up a list of acute trusts that will be closed, merged or broken up because they will not survive under payment by results.

The list follows health secretary Patricia Hewitt’s request earlier this year for strategic health authorities to find ways of salvaging acute trusts struggling under the government’s new financial regime for the NHS, possibly mirroring the take-over of Good Hope Hospital trust by Heart of England foundation trust last month.

Sussex-based Frimley Park foundation trust is exploring whether it could merge with or take over the running of some services from the financially failing Surrey and Sussex Healthcare trust.

Other foundation trusts considering mergers include King’s College Hospital, and Guy’s and St Thomas’ in London, which are understood to be examining whether a takeover of Sidcup’s struggling Queen Mary’s trust is feasible.

HSJ have come out with corrections to the list with strongly worded letters of complaint from the chief execs of the trusts in question.

Forced mergers between organisations with very different circumstances do not work. There is plenty of evidence for that. You only postpone the inevitable.

And you end up with things like this:

The Department of Health has been asked to explain where the ‘missing millions’ that should have been spent on sexual health have gone.

PCTs were given £300m of money to be spent on public health under the Choosing Health white paper, but it was not ringfenced.

So we end up paying more in a few short years.

And there is also trouble out in the community with the BMA advising GP’s to ensure that atleast 70% of savings under Practice Based Commissioning are returned to the practices as promised by the Department of Health. A very good illustration as well of how a minimum level ends up becoming a maximum target very soon.

The British Medical Association’s GPs committee has recommended to members that they do not agree to commission through PBC unless their PCT will guarantee in writing 70 per cent of any savings they may make. The ability to use savings for patient services was announced, as an incentive for GP practices, when PBC was introduced two years ago.

The GPs committee guidance says there is ‘an absolute necessity for practices not to enter into any commissioning arrangements without written and signed confirmation from the PCT, in advance, that they will get their share of freed up resources at the end of the financial year, regardless of the PCT’s financial situation’.

But NHS Confederation PCT network chair David Stout said the BMA’s stance could cause problems for cash-strapped PCTs.

‘PCTs and practice-based commissioners should agree on service redesign but I think the GPC’s suggestion of a contract shows a real lack of trust, although I do think agreements should be documented.’

What trust? You just had all those stories about GPs being overpaid & how the DoH would re-negotiate the contract. Did no one see this coming?

A DoH spokesperson said guidance it published in November last year said it was ‘imperative‘ for practices to be allowed to use a minimum 70 per cent of any freed up resources for reinvestment in care.

The NHS Alliance can’t get away by saying

‘The 70 per cent savings figure is guidance and at the end of the day a statutory duty outweighs guidance.’

Watch out for more of the same.

NHS Employers says there is now no need to employ staff from abroad, following the increase in home-grown healthcare staff, but the Royal College of Nursing said the move was ‘wrong and muddle headed’. The British Medical Association said that while there had been an expansion in doctor training in recent years, ‘that doesn’t necessarily mean there are more doctors than needed’.

I am sorry but there is no workforce planning worth the name in the NHS. And NHS Careers is not really very credible.

Besides, I wonder what the DoH will have to say to that, given the rules on “additionality” which necessitate the employment of non-UK staff only by the various IS providers under the ISTC schemes.

Which brings us to the shake-up in the Department of Health:

Bill McCarthy, director of policy and strategy, director general of commissioning Duncan Selbie and director general of health and care partnerships Professor Antony Sheehan have all left recently.

Departmental sources denied that any interviews had been carried out for a rumoured new chief medical officer post, dedicated to the NHS and separate from Sir Liam Donaldson’s DoH post.

There is simply very little credibility left in the medical establishment. Recruiting in secret from within that segment of the profession will not be an improvement.

One trust chief exec explains what life is like for his trust:

Our experience is common. We are confronted by an almost continual stream of advice, instructions and demands. Almost any external event, such as a front page story, guarantees a new set of instructions. We hear of some initiatives from the media. Often what we are told to do by one part of the NHS clearly conflicts with another; giving the perception that there is no coherence at the management layer above our trust’s. A plan reached after months of negotiations can be only weeks old before it is invalidated by decisions external to our trust.

This conflicts with the experience of successfully managing large complex change programmes. You need clarity of vision - everyone needs to know what they will get as a result of all the effort and upheaval, and it has to be worth it. You need leadership who personify the vision, and have not only the capabilities to deliver the programme but an ability to reach people on an emotional level. And you need clarity in the structures for accountability and responsibility for day-to-day delivery as well as the change programme. I suggest the NHS falls well short on all of these.

Oh dear, someone has strayed off the reservation!

The NHS is managed badly. It has neither the capability nor capacity for the efficient management of so many component sub-organisations, especially during a period of change. Some would add it does not have the right culture either.

Or has he? The remedies he suggests are redolent of a “business focussed approach”. Repeat after me “The health of the public is not a business.” You are not there to improve circumstances just for your organisation alone.

After all, the land of opportunity has its own set of troubles with poor healthcare management, not to mention the fact that UnitedHealth is in the spotlight again.

Hermes, one of the biggest European pension fund managers, has for the first time put forward a proposal requiring a shareholder vote on executive pay at a US company – a move that reflects the increasing activism of foreign shareholders pushing for boardroom reform.

UK-based Hermes plans to introduce its resolution at next month’s annual meeting of shareholders of UnitedHealth Group. The healthcare insurance company has been hit by a stock options backdating scandal.

You might remember the $1.6 billion paid out to the chief exec over the past decade.

Oh dear, more trouble:

Proper public consultation on the National Health Service will be undermined by “vague and woolly” legislation passing through parliament, the Commons Health Committee said today, criticising government proposals to limit public consultation on healthcare changes to “significant” proposals and decisions.

The proposed changes are contained in the Local Government and Public Involvement in Health Bill, which is nearing the end of its passage through parliament.

Consultation on NHS changes, such as the closure of maternity wards, was already a sham in some cases, the committee said. “Elsewhere, NHS bodies have sought to evade their duty to consult entirely,” it added.

“The Department of Health needs to take a lead and make it clear that such behaviour will not be condoned.”

MPs said the planned replacement of the country’s 400 Patient Forums by 150 “Local Involvement Networks” (LINks) only four years after the volunteer-run health watchdogs were created was unnecessarily disruptive, and might push volunteers to leave.

Uncertainty about the role of the new LINks would create “confusion and inactivity”, the MPs said.

The government says the forums, which themselves replaced the 30-year-old network of Community Health Councils, have too narrow a membership.

But the Health Committee said the forums should have been allowed to merge to form the new LINk bodies.

“Once again the Department of Health has embarked on structural reform with inadequate consideration of the disruption it causes,” the committee said.

The MPs said the health secretary — currently Patricia Hewitt — intervened too often in decisions after extensive local consultation, leading to illogical conclusions and undermining public confidence in the consultation process.

Wasn’t there a Department of Health report just recently urging better consultation?

Does one hand know what the other is doing?

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This entry was posted on Friday, April 20th, 2007 at 9:30 am and is filed under Clinical, Economics, Management, Medical Informatics, NHS, NPfIT, CFH, Politics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.