A very quick question for Richard Granger (Where is he? Where also is the rest of that self-serving article in CIO magazine that came out a couple of months ago? ).
Given the posturing about the NPfIT procurement exercise & how successful it was, perhaps he would like to tell us why we are now told that Lorenzo will be with us in 2011. I suppose the mass extinction of numerous innovative local software projects was worth the wait. Perhaps he would also like to explain why SHAs are having to migrate GP systems to those provided by the LSP just to avoid penalties. GP Systems of Choice anyone?
The Penfield strategy is the latest in a long-line of plans for delivering Lorenzo that stretch back to 2004, none of which has so far resulted in completion or delivery of the next generation software. One of the procurement principles behind the NHS IT programme, led by NHS Connecting for Health, was claimed to be only buying proven product that had been shown to work after exhaustive expert testing.
Would incompetent contracting be an explanation?
And I am sorry to see the same state of affairs in the US as exists here though there appear to be a few bright spots. Do we have to suffer the same poorly designed crap that passes for software?
An eventful few days with reports galore from various quangos.
The Healthcare Commission reported on the 2007 NHS healthcheck, assessing the state of the 394 trusts that make up the NHS in England. These performance ratings make for uncomfortable reading, a reminder that things are not as rosy as they are made out to be.
There was then the Health Profile of England 2007 report telling us that the north of England was much worse off than the south, a fact that makes last year’s raid on public health budgets even more disturbing.
Almost one in 10 (8% of trusts and PCTs, or 27 of the 335 total) scored poorly on use of resources but also on financial management, financial standing and value for money.
A total of 27% of trusts and PCTs performed well or strongly on use of resources - up from 12% in 2005/06.
A total of 77% of NHS bodies achieved year-end financial balance in 2006/07, compared with 67% in 2005/06.
Some of what the Audit Commission says is a bit disingenuous. Telling trusts that they will have to reconsider the range of services they provide is all very well but in reality it is patients that will suffer. And the expensive patients are the elderly, the very ill, the ones that there exists no alternative provision for.
One of the trusts locally is not in financial balance & has been buffeted by various reconfiguration plans. Their immediate priority is to get back into the black. So how do they do this? Wards are closed & staff are cut, especially cover for absent or ill nurses & doctors. Dozens of patients are spending the night in A&E because the Medical Admissions Unit is understaffed & they have closed whole bays as there is no money to pay for locums. So while this might bring the books into balance, it does not seem to be good medicine.
And yet the DoH predicts that the NHS is nearly a billion pounds in surplus. Perhaps they should shut it down altogether & there would be no worries about deficits at all.
Healthcare Renewal suggests a mid-Atlantic conference of medics to fight the perverse incentives developing in healthcare provision. Am always willing to meet for coffee guys, as long as you are buying.
After all this story makes our 4 hour waits look ordinary.
So James Lee, the chairman of Maidstone and Tunbridge Wells NHS Trust falls on his sword but not before releasing a “astonishing” letter to Alan Johnson.
“We have been struggling with a state pretty close to bankruptcy,” he said. The trust’s clinical income last year increased by 1.5% in cash terms when staff pay rates were rising by over 5%. “We knew the Treasury was pumping money into the NHS, but quite frankly none of this seemed to be getting to the coalface.”
As income fell, hospital activity rose by 11%. The trust cut costs by more than £40m in an attempt to break even. It struggled to cut maximum waiting times to 18 weeks. But this was “never really achievable”.
“The NHS is run on the basis of command and control. I personally have never experienced such centralised or detailed control … This way of managing things is fundamentally incompatible with the whole concept of independent trusts … I have done my best.”
Not really Mr Lee, your best was not good enough, especially since you did not oppose at the time the unreasonable diktats you decry today.
So do the architects of the “creative destruction” over the past few years have anything to say for themselves? PbR, ISTCs, reconfiguration, PFI, 4 hr waits, targets …… not a lot of room left for clinical standards to play a part.
And for Alan Johnson to stand in Parliament & deny any responsibility on behalf of the DoH was not very edifying, especially when there are 20 trusts in worse straits. Not that there is likely to be such a high death toll in each of them but blaming poor management is only going to go so far.
At this rate, I can’t blame GP’s for threatening to quit. Are we going to see a revival of proposals to set up doctors chambers, especially given the plans from NHS Employers to gain control of General Practice too by creating a sub-GP grade & employed doctors? One would have thought that they would get their own house in order first.
A(nother) senior civil servant bemoaned the way the machine was run “at full pelt†while the election decision was pending. “What was the point of bringing Ara Darzi’s report forward? We all thought No 10 was taking a serious look at the NHS and Darzi was sincere,†she said.
“But look what happened.
It was all brought forward and Darzi recommends that GP surgeries open at weekends. Big wow! It’s hardly ground-breaking research into how healthcare should be structured for the next generation, is it?â€
I’m glad to see the civil service paying attention. Now if they would actually do something useful …
Meanwhile, elsewhere in the NHS:
Cases of C diff began to rise at the trust in 2004, and in the three months between October and December 2005 alone, 144 patients were infected. The trust, ……, did not declare the outbreak of infection. They did not even take any measures to contain it.
Instead they concentrated on saving money on patient care, cramming in beds inches apart - thus increasing the chances of the infection spreading - and cutting the workforce. While patients were dying, the trust spent almost £700,000 on “turnaround†consultants, to advise them on how to cut costs.
The Healthcare Commission also reported that too much management time was concentrated on plans to build a new hospital under the private finance initiative.
Its more telling criticisms were practical, however. Bedpans were left covered in faeces; bins of dirty needles were left overflowing on wards; patients were “hot-bedded†in as soon as a previous occupant left, allowing no time for cleaning. Nurses told patients to “go in their bedsâ€, rather than finding them a bedpan.
Experts, however, point out that, while politically eye-catching, the benefits of such cleaning programmes last only until the next contact with infection, which can be at the next human touch. Their solution is simpler.
“You wash your hands, you wash the beds after the patients have been there, you have the laundry services working and everything should be okay,†said Mark Enright, a specialist in hospital-acquired infections at Imperial College, London.
Not much for me to say, is there? Start with the basics & the rest will follow. And for people tempted to use this as an example of the failings of “socialised medicine” there has been enough from the care home sector both here & in the US to demonstrate that the NHS does not have a monopoly on sweating assets & neglecting patients.
Almost a fifth (19%) of those questioned in the biggest patient survey of its kind revealed that they had missed out on dental work they needed because of the cost.
Almost three fifths (58%) of dentists themselves said new contracts brought in last year had made the quality of care worse and as many as 84% thought the changes had failed to make it easier for patients to get an appointment.
The stark findings came in research carried out by the members of England’s Patient and Public Involvement (PPI) Forums - special feedback bodies covering every NHS trust in the country.
This isn’t a compendium of bad news. It is about it being time for the DoH to accept that it has made quite a few mistakes & that its pet policies do not work. Given the reputed state of British teeth & the increasingly poor reputation of the NHS, perhaps sooner rather than later.
As I roll up to work in my now officially recommended short sleeved shirt (and jeans that are not, recommended that is, have been wearing both for years, non-conformist that I am), what I think about politicians & the senior management of the health service would land me in a lot of trouble if written down. Actually it has been, though in not so many words & I’m sure I have lost out commercially as a result. Well, am not one to care, so will continue shining light on dark corners.
One of the prime duties of a manager is to say no when appropriate. But the simple fact is that too many people take the path of least resistance to asinine diktats from those above them in the pecking order. “I was only following orders” did not work at Nuremberg & there is no reason why it is acceptable here though I notice that the rules are being redefined at Haditha & Abu Ghraib. And when the lines of accountability are so diffuse that it is difficult to pinpoint one person or team for specific failures, you will have the same situation repeated throughout the land. Things must be really bad if the Economist calls for more regulation & compares the relatively larger (60 times larger for an industry double the size) regulatory capacity in the USA favourably with that in the UK. Sacrificing the odd chief exec & withholding their severance pay is a joke.
LIKE Agatha Christie’s “Murder on the Orient Expressâ€, a whodunnit in which clues implicate all the main suspects, investigations into the sad tale of Northern Rock are turning up so many potential culprits that no one of them, it seems, can be held responsible for Britain’s first bank run in more than a century. On October 9th lawmakers quizzed Sir Callum McCarthy and Hector Sants, the bosses of the Financial Services Authority (FSA), Britain’s financial regulator and supervisor of its banks. With public money underpinning Northern Rock, parliamentarians wanted to know who had let the bank get into such a sorry state, and who managed its bungled rescue. Instead they were led on a merry dance through the Kafkaesque world of bank supervision, in which fiasco marks success, no one is in charge of anything and the net of culpability is cast meaninglessly wide.
This could also have been written for the health service or indeed any other large govt department. DEFRA comes to mind with its handling of the Foot & Mouth crisis.
Maidstone came to light because they were put under the spotlight. Do the same to any other trust & you will find similar results, though probably not on such a scale. But when you are dealing with a hospital that is running at 110% occupancy, where ambulances queue on a daily basis to offload people but the AE dept breaches the 4 hr limit (!!@*&%*$*%**£*£) a few times a day and the managers are running around like mad trying to find beds for these patients, where the doctors struggle to do the basics before the patients are pushed to a ward in the outer reaches of Mongolia, where every shift is at-least a few nursing staff short (from an already stretched roster) & not infrequently short of doctors too & where there is no money for training but where the PCT was keen to close the hospital down to cut beds last year in order to save money & this year having magically found a few million that puts it in the black is now keen to stick to the status quo but not fund any improvements that would help the hospital run like mad to keep its place on this mad conveyer belt, then you might begin to think like I do. And this is just from an A&E that I occasionally help out at. I could go on about the rest of the place but it is early & I don’t want to have a cloud over my head for the rest of the day.
“Seek & you shall find” is right but just how much appetite is there for a search party?
10 years of misdirected funds, of spending levels that do not even begin to correct historic deficits but are touted as bringing us up to the European average when we try to do a lot more on a lot less but with one hand tied behind our backs, of more than 20 years of idiots with less than one brain cell between them braying to the gallery.
Well, they will get their way, slowly but surely, egged on by the asses in the media who parrot the messages they are fed by corporate masters looking to raid the kitty (Camilla Cavendish in the Times yesterday really got me angry), the break-up & privatisation of the NHS is happening & then let us see what good healthcare really costs.
One thing I can assure you is that it will cost a lot more than the £53 your GP gets to treat you for as a whole year or the £1200 (range £900 to £1700) that the PCT receives per person to cover your entire medical costs. In comparison, U.S. per capita spending in 2004 was $6,037, compared with $3,094 in the Netherlands, $3,169 in Germany, and $3,191 in France. When you consider that by Purchasing Power Parity (PPP) £100 is equal to 120 US dollars, the real consequnces of a shift to the US model become clear. Yes, there is waste & poor performance in the NHS, just as there is in any other large organisation. Just find me another healthcare insurance policy that will cover you to the same extent for these amounts of money & then I will listen.
Another take from the Economist on setting up a new healthcare system in China makes for interesting if predictable reading for those with experience of places where patients simply do not have the money to pay.
One of the themes that has emerged from the chaos of the past few years has been the call for people to take personal responsibility for their own health. I agree that insulating patients from decisions regarding their healthcare & the consequences thereof does them no favours but wonder why the same rationale does not apply to those making decisions detrimental to the state of the healthcare system.
I refer you then to the claim that “light touch regulation“, a hallmark of most government policy these days, is the responsible course of action & not an excuse for the abdication of responsibility or an enabler for a “free for all”. Surely this excuse has been discredited by the events of this summer, ranging from the failure of the Financial Services Authority to manage the banking industry (with that embarrassing run on Northern Rock caused in part by the regulators themselves) to that of Mattel which having outsourced its manufacturing facilities decided that quality control was beneath it. On a similar note, there is the matter of the Commercial Directorate overseeing the award of a major contract to Atos Origin that had to be publicly cancelled within a few months with the consequent delay in awarding a whole raft of other contracts & yet I am told that an investigation has not revealed any failures. Just how thorough was this investigation then?
“You have a situation where there is often no incoming inspection of raw materials, and no outgoing inspection of finished goods. This is about business people displaying poor business practice,†she says. Of course, low-cost sources of production are attractive. But that price arbitrage has to be handled carefully.
Exactly the same situation applies in the services sector with the quality control procedures being very deficient.
Outsourcing does not allow you to abdicate responsibility for failure!
Do the advisors & decision makers who played fast & loose with their responsibilities not bear any of the costs of this & why do we not hear of consequences for more than a token sacrificial lamb? And when it comes to government, hardly any price is paid in the first place & the mistakes are repeated time and again in a cynical “wash, rinse & repeat” cycle
NHS may be sick, but this won’t cure it
Nigel Hawkes: Analysis (in the Times)
Take a blank canvas. Talk to 1,500 NHS staff. Spend 12 weeks thinking hard. And then come up with the ideas you first thought of.
That, in a nutshell, is a brutal but not inaccurate summary of the review of the NHS by Lord Darzi of Denham, published yesterday.
Astonishingly, it identified as problems exactly the same things the Prime Minister and the Health Secretary have themselves been talking about for months: access to family doctors out of hours (Gordon Brown) and MRSA (Alan Johnson). Surely, in a system that now costs £90 billion a year, employs 1.3 million people and treats a million patients a day, Lord Darzi might have identified issues not already flagged up in a hundred tired political speeches?
Oh yes, those “citizens juries”, don’t we all know how those turned out?
The NHS does not change because the incentives are not there. Managers who innovate take risks. If they go wrong, cost money, or produce headlines in the newspapers, the Department of Health can be relied upon to provide no backing. The trick of survival as a NHS manager is to change nothing and balance the books.
You forgot to add Nigel that survival skills also include the ability to be seen to support every misguided diktat that is handed down from on high. Saying “No” can be detrimental to the health of your career.
Lord Darzi also correctly identified stroke as a disease where the NHS has failed, miserably. He might have added allergy, liver diseases, osteoporosis or a host of other equally deserving conditions. The system is fundamentally unresponsive unless it is kicked. And kicking is no longer in fashion, so heaven knows how change will occur in future.
Perhaps we ought to stop this customer malarkey then & look at the situation from the patients perspective, at what will genuinely improve their health & is needed. Most of the 1.3 million people working in the NHS do so because they genuinely want to help the sick, not just to feather their own nests. System redesign should not mean “open season” on the staff.
In the new NHS, which is supposed to be evidence-based, Lord Darzi has ignored all this evidence, which points to the need for better education, nutrition and ante-natal care, among other things. Instead we will have GP clinics open 12 hours a day, seven days a week, to satisfy the Prime Minister, while the gaps between rich and poor in expectation of life continue to widen.
Perhaps the most depressing thing of all is not what the report says, but the reaction to it.
Almost all the great and the good who have backed every half-baked initiative for the past decade emerged to say how pleased they were.
Not only has the NHS stifled good healthcare; it has bought off those who are supposed to act as candid friends, and made them complicit in perpetuating its failures.
I couldn’t agree more!
As has been stated before, the DoH exists in an evidence free zone.
Well, that honeymoon didn’t last long & we are back to hearing the same rubbish about choice, this time aimed at GP’s. The lack of evidence for polyclinics & extended opening etc. has already been mentioned & debunked, including by NHS organisations themselves and yet we hear about them in the media ad-nauseum.
I have been otherwise engaged in trying to shine some light on a particularly murky situation & am now considering my options given the entirely predictable stonewalling that has taken place. But am not about to let things go by the wayside, even if the state of affairs is entirely too depressing.
Secretary of State - Alan Johnson MP
NHS and social care delivery and system reforms; finance and resources; strategic communications
Minister of State for Health Services - Ben Bradshaw MP
Finance including: Spending Review; Resource allocation and Financial policy; NHS Financial management; NHS Estates, Capital, Private Finance Initiatives (PFI) & Local Improvement Finance Trusts (LIFT); NHS Performance management; NHS efficiency
Policy & Strategy including provider policy, demand side reform, Payment By Results (PbR) policy & system architecture regulation
18 week patient pathway
System management & regulation and Professional regulation including the 3rd session Bill
Workforce Capacity
Commissioning capabilities & programmes
Commercial policy, solutions and procurement
Connecting for Health / NHS IT
Urgent Care & emergency care
Primary care
South West Strategic Health Authority (SHA)
London SHA
Ben Bradshaw is more of an unknown quantity with his brief covering NHS IT as well as PFI, Commissioning & the 18 week target. I guess he will be the one to watch.
Parliamentary Under Secretary of State for Health Services - Ann Keen MP
Healthcare quality
Patient Safety including Cleaner Hospitals / Healthcare Associated Infections (HCAI)
National clinical directors and programmes including: Cancer services; Cardiac services; Stroke services; Diabetes; Renal services
Dentistry and fluoridation
Partnership, experience & involvement
Optical
Chronic Diseases and long term conditions (including neurological)
Workforce including: Employment models and contracts; Education & careers; Pay; Nursing policy / Chief Nursing Officer (CNO) people strategy
Reconfigurations
Children’s health services and maternity
Yorkshire & the Humber SHA
North East SHA
North West SHA
At the very least Ann Keen can be said to have some knowledge of the state of affairs in addition to Ara Darzi though of course a clinical background is not a guarantee of sound judgement. But having sat on the Health Select Committee till now, she should atleast be able to display a grasp of workforce issues.
Minister of State for Public Health - Dawn Primarolo MP
Public health including Regional Public Health Groups (RPHGs), WHO and Children’s public health
Health improvement national programmes including: tobacco & smoking, alcohol, diet & nutrition, physical activity, drugs & drug treatment, obesity, sexual health, accident prevention, abortion, rural health, and Deep Vein Thrombosis (DVT).
Health Inequalities
Fertility, including IVF, Human Fertilisation and Embryology Authority (HFEA) and draft Bill, Regulatory Authority for Tissue and Embryos (RATE)
Food Standards Agency
Health protection including: Emergency preparedness; Scientific development; Pandemic flu; Immunisation; International health
International & EU business
Research and Development (R&D): National programme, R&D workforce, systems, Infrastructure, Innovation & Industry relations
Medicines & Pharmaceuticals industry including Medicines and Healthcare products Regulatory Agency (MHRA)
National Institute for Health and Clinical Excellence (NICE)
Departmental Management
West Midlands SHA
South East Coast SHA
We know all about Dawn from her time at the Treasury, thank you.
Parliamentary Under Secretary of State for Care Services - Ivan Lewis MP
Social care, local government & care partnerships, including: policy & innovation; finance; strategy; workforce; inspection; Partnering & alliances; Regional presence; Older people; Learning / physical disabilities; Disabled children
DH’s relationship with local government
Mental health including Child and Adolescent Mental Health Services (CAMHS)
Prison/offender health
Allied health professionals
Third sector including section 64 and social enterprise
Carers
Dignity & respect
Sustainable development
Equality & Human Rights
End of life care
Audiology
East of England SHA
South Central SHA
East Midlands SHA
An old hand at this, hopefully one capable of learning new tricks.
Parliamentary Under Secretary of State - Lord Ara Darzi
NHS Next Stage Review - Terms of Reference as announced
Hmmm, the fig leaf of respectability or something genuine?
The Scarborough and North East Yorkshire trust will shed 600 jobs under the proposals, which managers say are the only way to make “immediate and essential” cuts in their ballooning budget.
The trust, which is the biggest employer on Yorkshire’s North Sea coast, has accumulated debts of £20m, with a £7m deficit this year. It covers one of the largest areas of any NHS trust in the country and has a large, mostly retired, elderly population.
The finance director, Sandy Hogg, said the trust needed to save £15m immediately, and the trust had some leeway to close wards and reduce non-clinical support. Patients were staying in hospital for shorter periods and more health care was provided at home, which would help to maintain service provision with fewer staff.
I do not know the details of the situation in Yorkshire in detail but I can confidently proclaim this to be tosh. Provision of services at home will need an expensive short term investment in staff, not something that the trust are likely to do at the moment.
The Healthcare Commission said it could not assess independent sector treatment centres because of a lack of data.
It said there were reassuring signs but called on ministers to rectify the “cock-up” which meant performance data was not comparable with the NHS.
I must remind readers here that a patient opinion survey is not a very reliable or useful measure of quality.
Anna Walker, the commission’s chief executive, said the contracts the Department of Health drew up with the private companies were not adhered to as the emphasis was on setting them up quickly to treat patients faster. Data collection was overlooked. She said: “I believe it was a cock-up. The contracts lacked clarity.”
I lean towards the cock-up explanation as well rather than conspiracy theory but when the faults have been predicted well in advance & stridently warned against, I find it rather difficult to excuse the strikingly poor performance. And is there no penalty for repeated & utter failures? Failing upwards maybe?
British Medical Association research carried out among its members found that 62 per cent of clinical directors working in NHS hospitals were concerned about the quality of care provided by the centres.
A quarter said medical notes were never made available and half reported patients who had developed complications needing emergency admission to an NHS hospital following operations in treatment centres.
And what is worrying is that the CD does not appear to be interested in collecting data to verify or refute this & other claims.
But “they are not adequate for monitoring the quality of care given to patients”, said the commission, and more work was needed to ensure that in future data could be compared more easily. The same information should also be collected regardless of the part of the county in which patients were treated.
I could comment about KPIs & the curious lack of interest the Commercial Directorate has in them.
At least £1 million has been paid to a private health-care company for operations on NHS patients that have not been carried out, a leaked letter shows.
Derbyshire County Primary Care Trust has a £2.7 million contract with an “independent sector treatment centre” in Chesterfield to provide orthopaedic operations. But more than a quarter of the procedures paid for were never carried out because patients opted to go to NHS hospitals. Health managers have written to GPs trying to persuade them to send more patients to the Barlborough treatment centre, run by Partnership Healthcare Group.
To readers from far & wide:
The server logs make for interesting reading, telling me just who is visiting the site & the topics that interest you.
So can I invite you to participate in the discussion, by telling me why I am wrong if indeed I am so & generally shedding a little light on this brave new world we inhabit.
It is more fun that way, honestly!
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