George

I actually feel as if I know Danny Finkelstein from his Spotify choices – not giving anything away but we share a mutual ‘like’ of a ukelele song about cleaning windows. Also, I do sometimes wonder how our Man in Pinner can get away with stripy shirts and spotty tie combos on Newsnight.

It was with some incredulity that I witnessed an exchange on Twitter. But to be honest, I am often in awkward public Twitter exchanges, and invariably they appear much worse to the outsider than they actually are.

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Prof Liz Lightstone is well respected. That goes without saying. I know of the powerhouse that is renal medicine from Imperial – including Prof David Taube and Prof Charles Pusey. Renal medicine is well known to be one of the more demanding specialties for a physician.

As such, many people are expected to play their rôles, and I don’t deny that. But overall I think both parties in this Twitter conversation want a resolution to this crisis in the workforce.

I think part of the problem is the sheer level of distrust of Jeremy Hunt. As far as the medical profession is concerned, he appears to have gone ‘rogue’ like a ‘lone trader’ – like a dog who won’t let go of the bone of an unfair, unsafe contract. But it’s easy to underestimate the mass appeal he has within the Conservative Party, who view this dispute as standing up to “those evil unions.”

But Lord Finkelstein would be the first to admit, surely, that the current state of affairs on the NHS is not ideal. There are some people who’ve been closely watching the NHS policy for years, like me. And we feel that NHS policy is not being held hostage by the BMA, but by the private markets.

The cost of implementing the markets has gradually crept up from about 5% of the NHS budget to about 15-20% – if we go the full whack, it’ll be about 30% like America with the worst outcomes in healthcare.

The reason we’re in this mess is that the McKinsey report on NHS efficiency and productivity some years ago gave Sir David Nicholson, Simon Stevens’ predecessor, the license to impose efficiency savings of billions. Even a former Conservative Secretary of State for health, Stephen Dorrell, has expressed incredulity at how they could be achieved.

Anyway, the Labour opposition led by Andy Burnham MP stuck to the efficiency savings line – and so does Heidi Alexander MP – to my knowledge. Efficiency savings are cuts – and forced austerity on the NHS.

But the NHS is facing strong winds from elsewhere. One is fraud, and this is not just mega bucks corporate fraud against which the Health and Social Care Act does not produce any statutory protection interestingly. This is the same Act which abolished the National Patient Safety Agency. The current Secretary of State for Health has done nothing yet on the apparent loophole of lack of legal protection for junior doctors in whistleblowing.

The fraud comes from other areas, like GPs commissioning the same services they make money from, a known risk of the Health and Social Care Act. It includes “upcoding” – hospitals claiming for patients with “urosepsis” rather than “urinary tract infections” to make more money. Mega money grants siphoning off money for even more snazzy ways of gauging patient opinion.

The big one is the private finance initiative. Whilst gestating under the Major administration in a special department in 1993-6, Coopers and Lybrand were able to hit the ground running in 1997 with the Ascent of Blair. And the rest is history. PFI has gone full throttle under all subsequent administrations since, including the current Tory one.

Another huge ‘sink’ on resources is that the fact that every transaction is costed, with the disastrous ‘purchaser provider split’. Even the original architects of ‘activity based costing’, upon which the contemporary NHS purchasing system is based, warn against excessive administration costing money.

So against these immutable headwinds, Jeremy Hunt wants to slash the current staff budget. The cost of staff is a huge proportion of the NHS budget. The reason the NICE guidance on safe staffing is currently in the dustbin, from Jeremy Hunt, is that the aim is to reduce the staff costs through various means, such as employing less skilled staff and reducing the budget to pay Doctors. That drive to cut costs is for him ‘a price well worth paying’ despite the destruction of value to the overall service.

Of course, if older GPs fail to revalidate, there is a recruitment crisis in various specialties, or younger Doctors emigrate to Australia, that is one way for Hunt to control this staffing budget.

And with this fetish for being fettered by private markets comes the chipping away of universality and comprehensiveness from the NHS – “minor procedures” become out of scope, co-payments get introduced in obscure guises, such as contributions for expensive medications, and personal budgets where choice is restricted by the money simply running out.

It’s extremely tricky to spin it any other way – but Hunt lied about “the weekend effect”. Dr Fiona Godlee, Editor of the British Medical Journal, wrote to give a stark warning about the misuse in interpretation of that famous paper by Prof Nick Freemantle and colleagues.

But Hunt and Keogh are playing with fire. By refusing to lift the imposition on the contract, the Junior Doctors Committee are having to go ahead with a strike they don’t want either. And with the current Government refusing to negotiate, the Junior Doctors Committee’s hands are tied.

And there’s still plenty to discuss, for example how it can possibly be a legitimate purpose to increase the gender pay gap of female doctors under the proposals, or how it can be good for patient safety to remove ‘safeguards’.

There are plenty of ‘useful idiots’ on Facebook and Twitter who will tell you the contract is a good thing too. And they come in various guises. Some even write for the Guardian.

Michael Fallon MP said last Friday on BBC Any Questions that overtired doctors were the cause of the spike of deaths at the weekend, hence the need to revise the contract. He offered, by the way, no indication how the new contract would mitigate against this effect.

There’s a sense that it’s their party, and the Conservatives will simply lie if they want to.

@dr_shibley

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