Category Archives: Quality of care

For everyone who couldn’t make the Conference, here is Jessica’s speech to our Fringe meeting on the future of Women’s health that I referred to earlier in a members email.

Jean Hardiman Smith

 

Thank you for inviting me to speak to you today. My name is Jessica Ormerod. I run a research and information organisation called Public Matters with my lovely friend and colleague Deborah Harrington.
Although we write about all aspects of the NHS and other public services, I have a particular interest in maternity. I have been writing about maternity issues for seven years since I was the chair of the maternity services liaison committee for Lewisham Hospital which coincided with our fight to save our maternity services. We won that fight but we have by no means won the war because as you know maternity services up and down the country are being closed and downgraded.
But before anything else I want to paint the picture of what is happening to the NHS as a whole. Because every closed maternity ward, service or reduction in staff is the direct result of changes to the NHS that have been happening since the 2012 Health and Social Care Act. These changes are having a devastating impact on access to care. It is no exaggeration to say that we are witnessing the reversal of 70 years of universal, comprehensive and equitable care.
The 2012 Health and Social Care Act put into place all the major elements for a step change in the privatisation of the NHS.

A QUANGO called NHS England was formed as the Commissioner-in-Chief of the service, with over 200 subordinate local commissioning units. These commissioning units broke with the tradition of planning services, replacing it with buying in from public, private and voluntary sector providers. Areas of work are subdivided into contractable units and NHS public providers are obliged to compete. The loss of a contract means loss of income, which has a knock-on effect on the viability of the public sector, which is left with high cost acute care and a reduced income.

In 2014 a new CEO was appointed to run the NHS in England. He created a new plan for the NHS, the Five Year Forward View and this was greeted by the establishment as a welcome antidote to what was seen as the fragmented mess left by the 2012 Act (this was only a mere 18 months on from it being enacted). But it’s important to recognize that far from being an accident, the Act achieved the fragmentation necessary for privatisation to be embedded at an organisational level, including many major health industry players taking key roles in the commissioning and policy-making process.

At the heart of NHS England’s Five Year Forward View is the idea that the NHS in England will never again be funded to a level that maintains its services in the way they are run now. It puts together a series of proposals for change which are not just cuts but are about a fundamental reshaping of how services are provided. Expensive specialist and emergency care are relocated to centralised hubs and more care is to be delivered in the community via partnerships with local authorities. There is an aspiration for fewer emergency admissions with an improvement to overall health which it argues will lead to less dependency on NHS services.

We could say the scope of this aspiration is far reaching or we could say it is pie in the sky. It not only assumes the NHS can cope with a growing population without corresponding growth in services but that it will do so with a reduced service with much of the change becoming the responsibility of local authorities.

The process of transforming the NHS in England, is based on close co-operation between successive politicians and Department of Health managers over many years with the US Health Maintenance Organisation or Accountable Care Organization principles of managed care. This process is continuing without any checks and balances of substance within the formal organisational structures of government. Politicians go to great lengths to deny both privatisation and US influence on the current changes.

There is, however, a groundswell of resistance to the damage being done to the NHS and there is a lot of knowledge surrounding individual service contractions and closures, but little in the public domain about the overall programme of change. And that is what I am here to talk about today.

The National Maternity Review, aka Better Births – A Five Year Forward View for Maternity Care, is one of the Five Year Forward View’s New Models of Care. It emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets. Personal Care Budgets commoditise and monetise the system. They add layers of unnecessary complication, increase expense, fragment accountability and lead to an accounting nightmare.
44 Local Maternity Systems have been established. The systems have been introduced without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated Care Systems. Unlike the Integrated Care Organisations which are now under consultation, they have been put into place with very little fanfare or institutional opposition.
As with all the changes to the NHS currently taking place, there is a real problem that rhetoric about better care closer to home is not matched by real resources or access to physical structures like hospitals. NHS England consistently refers to services being more important than organisations but fail to fill in the blanks about how this works. They also insist that travelling in order to receive excellent care is not a concern to patients. There is no acknowledgment that time, expense and severity of health condition all very much effect the distance people are able to travel regardless of the excellence of the service at the end of the journey.
In the case of maternity, these questions of distance and the emphasis on community care run two different risks. The first being the potential for increase of emergencies outside hospital setting. The second is that mothers might be taken in to hospital for assisted birth or caesarean in order to pre-empt risk arising.
But what makes maternity different from other services?
Most people use health services most at the beginning and end of their lives. Pregnant women are the exception to this. During pregnancy women come into more contact with the NHS than they probably have ever done in their lives. This is particularly the case if they have a complicated pregnancy or birth. Healthy women can become profoundly unwell during pregnancy and they can be vulnerable to life-threatening complications during birth. That’s why it is so important that women have all levels of care within easy access.
Until now maternity services have been provided in the most part by the NHS. Women have always been free to employ a private midwife. But the NHS has a duty to provide a midwife at every birth even if a private midwife is also in attendance.
Maternity services are woven through the traditional structure of the NHS. Women see their midwife at home or at their local GP. They receive a minimum of two scans to check the baby’s progress and health at the local hospital. If they have a pre-existing condition or they develop a pregnancy-related illness then their specialist will work alongside the maternity team to ensure that the woman and baby are safe and as healthy as possible throughout the pregnancy.
Currently women can give birth at home, in a ‘stand-alone’ facility run by midwives, ‘co-located midwifery unit’ – that’s a midwife-run facility on hospital grounds, or in an obstetric unit which includes doctors and surgical theatre. Obstetric units can only be sited in hospitals with A&E because they require acute services which is blood, air and surgeons. A woman can become dangerously ill very quickly during birth so timely access to acute care is essential.
Put this into the context that since 2010 maternity services have been starved of funds and there has been a staff recruitment and retention crisis. Many maternity units have already been downgraded or closed, hundreds of GP practices have also closed so women already travel further to receive care. This means it costs more and takes more time to see a midwife, GP or hospital doctor. It also means longer emergency transfer times. The risk is this will only get worse once the STPs restructuring of the NHS is complete.
Who is driving the changes to maternity?
Surprise, surprise, Better Births panel includes private health providers and those private companies are working with government to re-write policy.
Although most current providers are NHS hospitals, private providers are now being strongly encouraged. Local Maternity Systems set their own payment systems. This means that they can choose whether they pay via their geographical population or they can pay per activity or service. However, they do not follow established budget areas; they do not share boundaries with CCGs or Local Authorities even though they rely on budgets from both. Across the country there is now a mish-mash of payment systems. The risk is that women will fall through the gaps.
NHS Trusts have been ‘incentivised’ to adopt Better Births by offering a chance to win ‘pioneer funding’ to speed up the transition to the New Models of Care. In November 2016, Seven ‘early adopter’ sites started to implement the recommendations – I don’t need tell you about this because you’re part of it! The sites were told to be bold and radical. Another incentive is ‘the maternity challenge fund’ which instructs successful trusts ‘to explore innovative ways to use women’s and their partners’ feedback to improve maternity services’. A pioneer site is not the same as a pilot test site.
LMSs are encouraged to work alongside private providers in order to offer women a wider choice. As most women have previously been cared for by the NHS this simply means opening the door to the private sector. In a climate of serious staff shortages, it is possible that some midwives may see the benefit of setting up an independent midwifery practice rather than staying in the NHS. Despite protestations to the contrary, this does actually reduce the ‘NHS offer’ and opens an income stream for public money to be handed over to the private sector.
Better Births tells us it is working on a new accreditation scheme for maternity providers. But in a publicly provided NHS service, this is unnecessary because the NHS trains staff to a professional standard.
Private providers are required to have a contract with the NHS in order to receive payment via a Personal Care Budget. It is claimed that the budgets (which are described as ‘notional’) will demonstrate to CCGs the kinds of choices women make during pregnancy, birth and postnatally. This will apparently encourage CCGs to respond to women by increasing their offer. The claim is that this will also empower women. But it is decidedly unclear about how this can be achieved. The guidance talks about using Personal Care Budgets for birth pools, place of birth settings or breastfeeding support but all of this should be available to every woman regardless of a personal care budget. In fact, all of these used to be available to women as part of the normal care given by the NHS.
Moreover, it precludes the notion that women become ill in pregnancy. No one chooses to get gestational diabetes, pre-eclampsia, HELLP or any other life-threatening condition. What happens when your health needs change but you’ve used up your £3000 on hypno-birthing? There should be real concern about the potential lack of access to obstetric care when women have serious complications of pregnancy. Or to return to the issue of financial balance, if £3000 is a notional budget for a normal birth which can be used up in a number of ways then the acute hospital will potentially have to pick up the cost of the emergency care without a matching budget.
What does this all mean?
Scale and pace have taken precedence over caution and evidence. Academic research will take years to catch up to establish the public health consequences of this new policy.
This is a top-down reorganisation of a national service with little to no consultation, pilot schemes, peer review, oversight or risk assessment. A Health Select Committee inquiry into the maternity transformation plan was not completed because of the 2017 election. It has not been re-opened.
The Vice-Chair of the maternity transformation programme finishes his report with the following advice to LMSs: Be Bold! Don’t wait for instruction!
Clearly long gone are the years of epidemiological study, of public health planning, of consultation with experts.
Better Births is based on consumer choice issues around personalised maternity care. There is a serious lack of evidence that this restructuring will give women the vital services they need. There are fewer services, obstetric departments are being stretched even further and technology is replacing face-to-face clinical care.

On the other hand, it embeds private care and fee-for-service. And, most importantly of all this is not how a national public service works.

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 Court of Appeal grants NHS campaign group permission to appeal against NHS England’s new Integrated Care Provider contract

Some very good news – which also means NHS England is consulting on an ACO contract that may be unlawful.

They knew full well that was a possibility, despite their protestations in the consultation document that both Judicial Reviews had ruled in their favour.

(They have rebranded the ACO contract the Integrated Care Provider contract and their consultation runs until 26 Oct.)

We shall be putting out more info shortly about this.

 

The Court of Appeal has issued an order granting campaign group 999 Call for the NHS permission to appeal the ruling against their Judicial Review of the proposed payment mechanism in NHS England’s Accountable Care Organisation contract.

The Accountable Care Organisation Contract (now rebranded by NHS England as the Integrated Care Provider contract) proposes that healthcare providers are not paid per treatment, but by a ‘Whole Population Annual Payment’, which is a set amount for the provision of named services during a defined period. This, 999 Call for the NHS argues, unlawfully shifts the risk of there being an underestimate of patient numbers from the commissioner to the provider, and endangers service standards.

In April, the High Court ruled against the campaign group’s legal challenge to NHS England’s Accountable Care Organisation contract – but the group and their solicitors at Leigh Day and barristers at Landmark Chambers found the ruling so flawed that they immediately applied for permission to appeal.

Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the Accountable Care Organisation contract – now renamed the Integrated Provider Organisation contract.

The consultation document asserts that the payment mechanism in the ACO/ICP contract is lawful, because:

“The High Court has now decided the two judicial reviews in NHS England’s favour.”

Steve Carne, speaking for 999 Call for the NHS, said

“It beggars belief that NHS England is consulting on a contract that may not even be lawful.

And a lot of public funds is being spent on developing the ACO model – including on the public consultation.

We are very pleased that 3 judges from the Court of Appeal will have time to consider the issues properly.

We shall shortly issue our stage 5 Crowd Justice appeal for £18k to cover the costs of the Appeal.

We are so grateful to all the campaigners and members of the public who have made it possible for us to challenge the lawfulness of NHS England’s attempt to shoehorn the NHS into an imitation of the USA’s Medicare/Medicaid system.

We will not see our NHS reduced to limited state-funded health care for people who can’t afford private health insurance.”

Jo Land, one of the original Darlo Mums when 999 Call for the NHS led the People’s March for the NHS from Jarrow to London, added,

“All along we have been warning about the shrinkage of the NHS into a service that betrays the core principle of #NHS4All – a health service that provides the full range of appropriate health care to everyone with a clinical need for it, free at the point of use.

Since we first started work two years ago on bringing this judicial review, there have been more and more examples of restrictions and denials of NHS care, and the consequent growth of a two tier system – private for those who can afford it, and an increasingly limited NHS for the rest of us.”

Jenny Shepherd said

“NHS England’s rebranded Accountable Care Organisation contract consultation is a specious attempt to meet the requirement to consult on a significant change to NHS and social care services.

We don’t support the marketisation of the NHS that created the purchaser/provider split and requires contracts for the purchase and provision of services.

Integration of NHS and social care services, in order to provide a more straightforward process for patients with multiple ailments, is not aided by a system that essentially continues NHS fragmentation.

This new proposed contract is a complex lead provider contract that creates confusion over the respective roles of commissioner and provider. It requires multiple subcontracts that are likely to need constant wasteful renegotiation and change over the duration of the lead provider contract. This is just another form of fragmentation, waste and dysfunctionality.

The way to integrate the NHS and social care is through legislation to abolish the purchaser/provider split and contracting; put social care on the same footing as the NHS as a fully publicly funded and provided service that is free at the point of use; and remove the market and non-NHS bodies from the NHS.

Such legislation already exists in the shape of the NHS Reinstatement Bill.”

The campaign team say they are determined in renewing the fight to stop and reverse Accountable Care. Whether rebranded as Integrated Care or not, they see evidence that it is the same attempt to shoehorn the NHS into a limited role in a two tier healthcare system that feeds the interests of profiteering private companies.

Steven Carne emphasised,

“It is vital that we defend the core NHS principle of providing the full range of appropriate treatments to everyone with a clinical need for them.”

999 Call for the NHS hope the 2 day appeal in London will happen before the end of the year. The Appeal will consider all seven grounds laid out in the campaign group’s application – with capped costs.

Details on the first instance judgment can be found here, and the judgment itself here.
David Lock QC and Leon Glenister represent 999 Call for the NHS, instructed by Rowan Smith and Anna Dews at Leigh Day.

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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Imagine the scenario. A 60 year old lady (she could be a relative of yours) undergoes a routine angioplasty for stable single vessel coronary disease. Unfortunately, shortly following the deployment of the stent into her 90% stenosis of her right coronary a dissection occurs, she suffers an acute myocardial infarction, and dies. She had signed a consent form prior to the procedure indicating that there was a 1% risk of heart attack, stroke or death but she had not been told that having a stent would not prevent a heart attack or prolong her life.  She had previously told her son that she didn’t want to have a heart attack implying that’s why she agreed to the have it done in the first place. Should the Cardiologist, who knew that the procedure would not provide any benefit for what mattered most the patient, and neglected to tell her, be prosecuted? Consent that is not fully informed is not consent at all. But rather than the exception such sequestering of patient important information is very much the norm.

One study revealed that 88% of patients believed they were having the procedure done for the very purpose of preventing a heart attack and 43% of cardiologists when anonymously asked said they would still go ahead and do the procedure even if they knew it would not benefit the patient. Monetary factors, enjoyment of performing the procedure and pressure to keep up numbers of cases for individual cardiologists and hospitals all contribute to overuse. But this is not in keeping with the practice of Evidence Based Medicine which is defined by the integration of individual clinical expertise, best available evidence and most importantly patient preferences and values.

When patient’s were explicitly told lack of prognostic benefit from angioplasty only 45.7% opted for the procedure versus 69.4% who were not explicitly given this information. It is estimated that such information given to patients with subsequent reduction in procedures could save US healthcare $864 million a year.

The Academy of Medical Royal Colleges state that doctors have an ethical responsibility to reduce waste because In a system with finite resources one doctors waste is another patients delay. In the UK approximately a third of coronary angioplasties, 30,000 a year are carried out for stable disease. For many this may be to alleviate symptoms which have not settled with medical therapy but studies suggest this benefit disappears after a year and the recent ORBITA trial suggests stenting offers no improvement in exercise capacity in patients with single vessel disease.

But “too much angioplasty” is just one symptom of a system failure where financial incentives trump patients at every level.

In the US it’s estimated that 20-50% of over $3 trillion dollars spent is inappropriate, wasting resources and/or harming patients.  In the UK Sir Bruce Keogh has suggested 1 in 7 of all medical and surgical treatments in the NHS should not have been carried out on patients.  The Academy of Medical Royal Colleges calculated that at least £2 billion is being wasted on treatments that have clear evidence of no benefit.  But this is likely a gross underestimate of billions more that could be saved/money that could be made better use of if patient preferences and values are taken into consideration.

A pioneering independent free website theNNT.com evaluates evidence based medicine with quick easy to read summaries according to patient important outcomes. It recently published a review that there was no mortality benefit in taking statins for those with a less than 20% risk of developing cardiovascular disease in the next ten years. This risk profile represents the majority of at least 40 million taking statins worldwide but how many of them are aware of this? My own anecdotal twitter survey of 144 respondents revealed 92% would not take a statin on this information. Greater transparency when communicating true benefits and harms of any treatment is an easy win to rapidly improve value in the NHS whilst simultaneously empowering patients with more choice.

Improving the system will also require commissioners to financially reward doctors for carrying out a simple shared decision-making conversation with patients, not on the volume of operations or prescription of more medication which is ethically dubious at best. Every patient should also be empowered by asking the following questions as per the Academy of Medical Royal Colleges Choosing wisely campaign. Do I really need this test, medication or procedure? What are the risks? Are there simpler safer options? What happens if I do nothing?

The system is broken and can be rapidly fixed not by pouring in more money but by adhering to the principles of practising evidence based medicine where patient preferences truly matter.

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Liverpool activist Greg Dropkin has weighed the claims of the RightCare initiative, and found them wanting.  (RightCare: wrong answers Journal of Public Health November 2017). RightCare is an NHS England programme that identifies opportunities for savings and quality improvements and describes itself as ‘a proven approach that delivers better patient outcomes’.

Greg Dropkin’s challenges the modelling assumptions made by RightCare (which have a flavour of a corporate consultancy about them), and the misinterpretation of dissimilar outcomes as opportunities for improvement. The difficulties of measuring unwarranted variation are well documented by Appleby and others in a 2011 Kings Fund report (Variations in health care: the good, the bad and the inexplicable). Unwarranted variation is a slippery notion, even though it appears to be endemic in clinical practice.

The RightCare approach has advantages for the NHS, giving NHS England, the DoH and the Treasury the results they want – the appearance of better quality care with the impression of lower costs. It contributes to the current magical thinking about NHS finances. Sadly, Dropkin’s argument is unlikely to dent this magical thinking much, the NHS being a centralised hierarchy within which conformity is highly valued.

Worse, from our point of view, is that faulty RightCare judgements may result in misallocation of resources through the allied CROC (Co-ordinated Reallocation Of Capacity) programme. For example, if the solution to unwarranted variation in cancer outcomes seems to be proton beam therapy, the NHS will have to invest in plant and machinery, or buy treatment time in the small but growing network of commercial proton beam treatment centres.

However, if RightCare did not exist we would have to invent it. It attempts to address variations in the five tractable conditions that drive secondary care use (heart disease, hypertension, COPD, CKD and atrial fibrillation), and it is interested in under-use as well as over-use of services. Given that pathway standardisations introduced by QOF seem to have only limited impact on clinical outcomes or service use, this makes sense.

An example is RightCare’s Falls and Fragility Fractures Pathway, which defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures. The NHS claims to be working on this, but other priorities have overshadowed falls and fractures, despite their huge cost. The Royal College of Physicians 2010 report Falling Standards, Broken Promises, documents the neglect of this problem. RightCare is right to pick up the problem, and its proposals for a pathway are appropriate and overdue.

The 2011 King’s Fund report recommended changing the focus of initiatives against unwarranted variation from achieving outcomes to fixing care processes (especially shared decision making). This favours pathways, which may be picked up by the Get It Right First Time initiative (GIRFT) as much as by RightCare. (Digression: Why does the NHS have two organisations trying to tackle unwarranted variation? Because they have both evolved from different NHS fiefdoms!)

Shared decision-making is a noble enough idea, but in the NHS’s current toxic climate it too can be warped. ‘Choosing Wisely’ is a programme that aims to discourage doctors from using interventions that are not supported by evidence, free from harm and truly necessary. (Malhotra A et al Choosing Wisely in the UK  BMJ 2015;350:h2308). The NHS in North West London recently asked the public their views on Choosing Wisely, a scheme which it said was “to help reduce waste”. Its proposals for consideration were: encouraging patients to buy medicines over-the-counter when they could; GPs to avoid prescribing medicines that could be purchased; and patients to collect their own repeat prescriptions rather than let pharmacies collect them. What begins as an attempt to improve the quality of care ends as a means to transfer costs to the user.

An incoming Labour administration should change RightCare without abandoning it. Duplication of effort is usually unhelpful, so RightCare and GIRFT should be merged. The emphasis on outcomes and the optimistic claims of savings could both go, to be replaced by evidence-based pathways that regulators could audit and evaluate. And campaigners could harry those in NHS middle management who try to sneak in service reductions or co-payments as part of a quality improvement drive.

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Yet another important figure in the health world adds to the concerns expressed by many others about the serious  situation facing NHS England this coming winter. Niall Dickson, chief executive of the NHS Confederation, which represents all health service organisations, said that there was “an even greater sense of foreboding” this year than last.

His comments came as figures revealed that the number of the most critically ill patients waiting more than an hour for an ambulance has doubled in a year.

Mr Dickson writes “A cash injection at this stage is unlikely to solve the winter pressures, but the chancellor must revisit the pencilled in figures for 2018-19 and 2019-20, which if left as they are, would guarantee more crises and further delays to the reforms that are needed. Mr Dickson added “there has also not been enough investment in community health and social care services”!.

Many health professionals are now facing dire problems resulting from insufficient funding and the government must be held accountable for the inevitable consequences.

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The BBC has revealed that seven NHS trusts missed their cancer, A&E and operations targets; with only two trusts in London meeting their latest A&E target (to see 95% of patients within 4 hours).

This is consistent with NHS data showing that in February 2017 almost all hospital A&E departments (excluding specialist and GP led urgent care centres) failed to see 95% of patients within four hours. Epsom and St Helier University Hospitals NHS Trust was the only London Trust to hit the target that month.

If you want to read more about these figures, you can find them here.

I am very concerned that this is no longer a winter crisis but a perennial crisis; a crisis of the government’s making. Health Secretary Jeremy Hunt’s uncompromising squeeze on Trusts’ finances is leaving London’s health services over-burdened and struggling to provide the best patient care. The strain is taking its toll, with low morale setting in across the workforce.

The government must recognise the need to meet increasing pressures by increasing funding. Expecting Trusts to carry on as they are with no additional resource is neither fair to patients, nor realistic.

This is not complicated; for NHS trusts to hit the government’s targets, they must be properly resourced to do so. And the Government, by failing to do this, is letting every single one of us who relies on the NHS down.

Meanwhile, in City Hall, the Mayor of London is currently consulting on his statutory Health Inequalities Strategy. We know that there is huge variation in health standards across London, and we will be pressing him to look at these figures closely, to ensure all Londoners have access to excellent quality care.

While what we and the Mayor can do in our capacity here at City Hall remains limited; and responsibility for resources and supporting the NHS still falls on the shoulders of the government, we are able to impact a vast array of areas which impact Londoners’ health.

You can contribute to the Mayor’s strategy consultation as either an organisation or an individual here, and I would encourage as many of you as possible to do so.

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Landmark study exposes NHS privatisation risks

Outsourcing of hospital support services (like cleaning, catering, and laundry) is extremely contentious. Private corporations undercut traditional in-house operations, making profits by driving down wages and conditions of service. This is obviously attractive to cash-strapped hospitals.

But does it matter for patients?

Does cheaper mean worse, or can the private sector square the circle by providing better service for less? So far, the authorities in Scotland, Wales and Northern Ireland have been unconvinced. They have insisted that the existing in-house services be retained, ensuring that cleaners are part of the ward team, with a shared commitment to patient care, rather than casual, low paid, and often transient extras. In marked contrast, the NHS in England believes that outsourced services can provide value for money.

So far, the jury has been out. Now, we have solid evidence that should make the NHS in England reassess its position.

Back in 1983, cleaning services were among the first parts of NHS to be outsourced to private contractors. The Conservative Manifesto that year justified the outsourcing, saying it would “make the maximum possible savings by putting services like laundry, catering and hospital cleaning out to competitive tender. We are tightening up, too, on management costs, and getting much firmer control of staff numbers”.

It soon became clear that there were problems. There were numerous reports that contractors seeking to save money, for example by employing fewer staff, with poorer working conditions and hence motivation, were achieving lower levels of cleanliness than the in-house NHS staff they replaced. Yet these fears among frontline workers who could see what was happening were dismissed. The Business Services Association, a lobby group representing outsourcing companies, claimed to widespread incredulity that “There is no evidence to suggest that outsourcing cleaning services causes increased rates of infection” ).

So what does the evidence show?

Do NHS Trusts employing private cleaning services experienced more cases of MRSA, a ‘superbug’ that can cause life-threatening infection which has been previously linked to poor cleanliness? We brought together a number of data sources that, surprisingly, had not previously been combined to ask the question. We had data on 126 NHS trusts during the period 2010-2014.

We found clear evidence that Trusts which outsourced their cleaning services reported significantly more MRSA cases. Yet that was not all. Fewer patients in these hospitals reported that levels of cleanliness were excellent and staff reported fewer handwashing stations.

The one way in which outsourcing achieved its intended goal was cost. Cleaning in these hospitals was about £236 less per bed each year. Of course, that does not account for the excess human and economic costs of infections, and we were only able to measure one type, those due to MRSA. It would be surprising if what we found was limited to one type of bacteria.

Why are these findings important? Privatisation of NHS services is now high on the political agenda, as the impact of cuts to health and social care bite. Outsourcing corporations are eyeing the opportunities and the current government in Westminster is sympathetic to their wishes. Their sympathymight be influenced by prospects of following their predecessors to work for these corporations.

Former Prime Minister David Cameron argued for outsourcing in 2011.“It shouldn’t matter if providers are from the state, private or voluntary sector as long as they offer a great service” and “It’s about ending the old big government, top-down way of running public services and bringing in a Big Society approach; releasing the grip of state control and putting power in people’s hands,” Cameron wrote in the Open Public Services White Paper.

Unfortunately, we have shown that, as far as cleaning services are concerned, it does matter who does it. When the money is tight, as it is in the NHS, it can be very attractive to seek the cheapest option in the short term, even if this is at a cost to patients and, ultimately, to the NHS. When these full costs are taken into account, contracting out may prove to be a false economy.

Notes:

The paper, Outsourcing cleaning services increases MRSA incidence: Evidence from 126 English Acute Trusts, by MARTIN MCKEE, VERONICA TOFFOLUTTI, AARON REEVES, and DAVID STUCKLER is to be published in the journal, Social Science and Medicine. It can be viewed here.

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  We’d All Be Dead

Another Secretary of State pushes determinedly, blindly on with NHS reforms, deluded in the notion that they alone can solve the great mystery of health.

NHS waggon with wheels falling off

My message is: no matter how well intentioned, your policy making is doomed to fail, as others have failed before you. May I humbly suggest another solution?

The NHS is now into its 30th year of perpetual reform (perhaps we should hold an anniversary party?). Yet it is still in need of reform. At what point do the politicians wake up and conclude that, in the way they go about it, it is irreformable?

Our ‘heroes’ in government – it happens to be Conservative but could have been Coalition, New Labour, or Jeremy Corbyn – drive determinedly on with their reforms, confident they will succeed this time because it fits with their ideology, or it washes whiter, or it comes gift-wrapped from a captive think tank, or because ‘we are better than our predecessors’.

The New Scientist examined the neuroscience of these sort of political beliefs:
“All told, the uncomfortable conclusion is that some if not all of our fundamental beliefs about the world are based not on facts and reason – or even misinformation – but on gut feelings that arise from our evolved psychology, basic biology and culture. The results of this are plain to see: political deadlock, religious strife, evidence-free policy-making and a bottomless pit of mumbo jumbo.”

Political decision-making is fallible. Politicians can come up with any policy they like because the system allows them to. The only effective check on flawed policy is the House of Lords. But this only applies to legislation, and then is rarely used and can be circumvented. Public pressure may tell occasionally – from a media campaign to a riot. Equally occasionally, an independent rigorous report may emerge years after a policy’s initiation concluding on its ineffectiveness, and it is changed.

But the vast majority of decisions are either taken in private without recourse or are whipped through by the majority party.

And what will it cost – everyone not just the exchequer, including travel to receding A & E departments?

The NHS is one of Labour’s great post-war achievements – a massive improvement and, for a time, the envy of the unprejudiced world. Now Labour is unable to countenance the prospect of a new NHS, no matter how tired or lame the old model is.

The Conservatives have too often wanted to remove this large lump of the state. Consequently they are not trusted with a change of model. Indeed Prime Minister Margaret Thatcher had to reassure Britons in 1982 with the promise that the NHS is “safe in our hands.” But true Conservatives would be much happier if the NHS disappeared altogether: it has been a success deeply embarrassing to their beliefs. With the consequence that Labour defends this ailing institution even more fervently.

The two big parties lock horns over its reform but never join hands to consider its successor. So we are stuck with an institution that will never catch up with better functioning models despite how hard anyone tries.

The electoral system pits these jaded heavyweights against each other – neither having come to terms with the modern world – and they wrestle: pulling the NHS this way and that, removing bits, gluing some back on, replacing parts with prosthetics – or contractors as they are termed, using starvation as an appetite-suppressant, smothering it with procedures and managers, and of course, dipping into those sometime quack cure-alls of marketisation and privatization.

Trapped by their history, the parties are stuck in their ideological backwaters, unable to look to best practice overseas or to reconceive a health service for the 21st century.

The NHS is now experiencing exactly the same underfunding that occurred in the 90s as Thatcher’s world concluded. Gordon Brown arrived and restored the funding to functioning levels….. but went too far, such that by the end of his term money was pouring in only to be appropriated by top management for, um, eh, top management. Excess austerity became the new normal once more and the patient is skinned again.

In a two party state without the stabilising influence of other parties always in the canoe of state, each party in power makes the mistake of assuming that their beliefs will endure for the foreseeable future.

In reality, these are practiced for a limited period, only to be declared false gods by their successors. Small state, big state. Hard on welfare, soft on welfare. Private sector good, public sector bad. Public expenditure good, public expenditure bad.

As citizens and consumers we benefit or suffer from the cumulative output of these regimes, the aggregate, not the separate parts. The moving average of successive governments’ results comes at a high cost in wasted taxes and blighted lives. First past the post voting in which a single party gets absolute power for five years to force its prejudices on the majority is no way to produce a great health service.

All that time, effort, and money being consumed in argument and ‘reform’ which could have been used on medicine.

Let’s take the previous major round of reforms started in 2012 by the then Health Secretary of State. This attempt received a scathing appraisal summed up in this article:

“Perhaps the pithiest verdict on the reforms came from Dame Julie Moore, head of University Hospitals Birmingham: “They cut it from 118 quangos to 234, and they reduced the levels of bureaucracy above me from three to 24.”

The article’s conclusions are spot on:

“It was, from top to bottom, a case study in how not to reform the public services: develop your plan in secret; devote no attention whatsoever to making a public case for it (or explaining its purpose and rationale); remove any shred of internal logic by accepting a series of compromises that go against the original spirit of the legislation; squander vast amounts of capital pushing the resulting botch job through; and then fire the guy responsible, even though for all his mistakes he may just be the only person who understands the reforms enough to make them work.

The lesson we seem to be taking is that you can’t trust any politician to make any reforms to the NHS whatsoever.”

The fallacy of politics.

To state the blindingly obvious, we all need and want an excellent national health service, but its existing form cannot provide this. Wonky politics has produced a model which no matter how many attempts at tinkering with/battering it into submission won’t produce the required results. The villain here is our system of government. In terms of organisational theory a quarter of a century of making limited progress, despite repetitive and costly restructuring, demonstrates that the problem is the model of organisation, not the internal structure; and that it is time for a new one.

Public services around the world remind me rather of manufacturing industries before the Japanese got involved. They established ‘best practice’ to such an extent that, today, if your manufacturing is not world class you won’t be in business. As companies like Sony and Toyota started to export in the 80s, the rest of the world first felt the competitive squeeze, then cried foul, then explained away their success as the product of a foreign culture. Then the unprejudiced went to look and learn. What I term global ‘learning engines’ became established through management gurus, journals, professional associations, consultants, business schools etc. Most industries now have these means to acquire, disseminate and apply knowledge and best practice.

They exist already in medical practice. The protocol for treating a particular cancer is the same in Rio, Rotherham, and Riyadh.

But best practice acquisition is not practiced in public service organisation. It’s high time it was. Not so far away from our island isolation, are health models worth considering: ones designed for all, and not the high cost lottery of the US. Look at France as an eye opener. In its 2000 assessment of national systems, the World Health Organization found that France provided “close to best overall health care” in the world. Worth a look?

Or, the 2010 OECD report notes:

“Australia, Iceland, Japan, Korea and Switzerland perform best in transforming spending into health outcomes……….. There is no one-size-fits-all approach to reforming health care systems……..Adopt best practices from the many different health care systems that exist and tailor them to suit actual circumstances.”
Ah, good point.

In various ways these are all national health services, just not the NHS as conceived here.

The question then arises as to how we might get from today’s NHS to tomorrow’s, especially given all the past party political machinations and failure, and how distrustful we are of change.

Canada provides a model for considering, deciding on, and introducing such a major change to such a sensitive service. Its programme of extensive public engagement and deliberation on four potential health service models around 2000, involved all manner of accessing people: It started with an independently assembled fact and information base (without a spun statistic in sight, oh how sensible). The facilitator of that programme concluded a consensus emerged as much based on values as on hard data. He reported this to government, which accepted and implemented it.

The Canadian government’s current stated purpose on health is to ‘hear what Canadians are thinking on a particular issue. The input obtained during these consultations helps form policies and legislation that reflect the concerns of Canadians.’ On something as important as health, Canada has been trying to make adversarial politics redundant as a decision making process. Could we, should we, dare to do the same in this country?

We live with the consequences of fallible policy making littered around us. Reforms based on the good ideas or whims of another delusional Secretary of State have not and will not work. Only consensual politics will end the political deadlock on NHS – and this means looking to best practice. Grown up politics rather than ideological zigzag. Now, there’s a thought.

I’ll be applying my knowledge of how government really works in future blogs. Follow me at edstraw.com for more on the detrimental nature of zigzag policies.

First  published on Slugger O’Toole

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Big data is one of the most prominent buzzwords in the technology landscape today. Knowing what and potentially why customers think and act the way they do is a critical component of asuccessful enterprise, regardless of thesize of a company or the niche audience they serve. But data is not only valuable in the business of offering products to the masses – it is a necessary part of service industries as well, including healthcare systems.

Recently, technology-based customer feedback innovator, HappyorNot, conducted a survey of patient satisfaction levels from more than 6 million patients spanning 25 countries. Scores were assigned based on data gathered from the patients directly, representing a percentage of satisfaction for each country. Sweden ranked highest with a 92.37% satisfaction rate, followed by the US at fourth (89.33%) and the UK rounding out the top ten (81.60%).

While it is interesting to see the results of survey responses in this capacity, the power of insightful data in the realm of patient care satisfaction reaches far beyond a single report.

Electronic patient survey

The Role of Patient Experience Surveys

HappyorNot offers a simple, self-contained method to acquire feedback directly from patients – an innovative solution for a fairly complex need within healthcare systems. Through a single, easy to use terminal within the doctor’s office or facility, the company gives patients the opportunity to share feedback on care received. Four smileys ranging from happy to unhappy sit just below an on-screen question posed by the facility. Patients push the corresponding button that best aligns with their experience, and the data is then transmitted to a cloud-based reporting service. In the blink of an eye, healthcare providers have valuable data on how they are performing, for each and every patient.

The data gathered from the survey provided some insight into how patients feel about their care experience, including specific questions focused in the following areas:

  • Practitioner professionalism – did the patient feel as though needs were met during the visit

  • Operational performance – did the patient wait too long to be seen

  • Department-specific performance – was the care provided in a specific department satisfactory

  • Overall satisfaction – did the patient feel that the total experience was positive

Having data on these metrics is a crucial aspect of understanding not only patient experiences but also adherence to overarching healthcare standards. Analyzing data from patient care surveys allows systems and facilities to understand how prevention and treatment processes are working in real-time, as well as work toward higher level clinical outcomes and patient safety. Improving these factors leads to less health care utilization, lessening the financial blow to both patients and providers brought about by low-level care.

Having data on patient experiences within healthcare systems is gaining traction among providers and consumers alike for these reasons. The ability to publicly share information in an effort to assist patientsin making decisions regarding providers and facilities is a necessary step toward the overall improvement of healthcare systems across the board. While the smiley terminals offer a simple solution for gathering patient care data, there is cause to believe that permanent, computerized feedback stations that collect more in-depth data from patients could improve the quality of care to an even greater extent.

Limitations of Current Patient Data Collection Methods

Two main sources of data exist for healthcare system performance: the Care Quality Commission (CQC) and the Health and Social Care Information Centre. First, the CQC, acting as the independent regulator of health and social care in England, requires each healthcare provider to register with the organisation and meet a number of legal requirements prior to providing care. Once registered, services offered by each provider are monitored through the use of data derived from patient survey information, in-house inspections, and national data sources. To help patients make the most informed decisions on provider choice, the CQC publishes periodic reports which offer insight as to how well a provider is performing. Unfortunately, the CQC has a substantial lag between receiving data and making it public, and not all providers are inspected and subsequently rated in a timely manner.

In addition to the CQC, the Health and Social Care Information Centre is a national provider of information, data and IT systems for both health and social care. Each quarter, the organisation gathers data on complaints relating to NHS Hospital and Community Health Services – a clear indication of the quality of patient care within NHS itself. The quarterly report from the Health and Social Care Information Centre is made available to the public with information on the total number of complaints for the period, the number of new complaints, and the number of resolved and unresolved complaints. The purpose of the data is to maintain a level of transparency between patients and providers, but given that not all providers respond or have adequate methods to capture complaints in-house, the information only lends a partial hand in promoting patient care quality.

Looking Ahead

The overall satisfaction of patients is becoming a profoundly necessary measure of the performance of various healthcare systems. The HappyorNot smiley terminals use simple data to develop meaningful insight into the quality of care in a number of healthcare facilities, but more can be done. A representative from the UK-based team of medical solicitors, Patient Claim Line, feels strongly that computerized patient feedback stations like smiley terminals are a step in the right direction; however, an understanding of how the patient data is to be used in affecting quality patient care is a necessary rung in the data ladder.

In order for patients to receive the highest quality care, healthcare systems must not only be willing to listen to concerns but also capable of gathering that data in an accurate, safe way. Further, healthcare systems and the companies that support them have to understand that patient experiences are not a single layer deep. Complaints about treatment, facilities, safety and other critical aspects of care can be highly complex, creating the need for technology able to collect and share advanced data. The combination of big data and healthcare is a promising path for providers and most importantly, the patients who rely on and deserve the highest level of care.

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Don Berwick, a North American fan of the NHS and critic of the wasteful US healthcare system, urges us to create ‘Era 3’ of modern medicine ( Berwick D Era 3 for Medicine & Health Care JAMA 2016;315(13): 1329-1330).

Era 1 was the period of noble, beneficent, self-regulating professionalism that powered the NHS assembled by Labour in 1948. In the compromises needed to launch the new health service, the political class conceded to the professions the authority to judge the quality of their own work.

Era 2 began when the variations in the quality of care; the injustices and indignities inflicted on people because of class, gender and race; the profiteering and the sheer waste of Era 1, became inescapable. Era 2 introduced accountability, scrutiny, measurement, incentives and market mechanisms. As Berwick puts it, “The mechanism of Era 2 is the manipulation of contingencies: rewards, punishments and pay for performance”. Labour contributed to the consolidation of Era 2 during the Blair/Brown governments but the Era’s origin is in the late 1980s with purchaser-provider split, imposition of contracting, the promotion of evidence based medicine and the industrialisation of the NHS.

Era 2 has promoted discomfort, defensiveness, and feelings of anger, of being misunderstood and of being over-controlled. Managers and the Department of Health in turn become suspicious, feel resisted and can become either aggressive (the culture of bullying) or helpless while their political superiors invest more and more in “ravenous inspection and control”.

The conflict between the competing and incompatible drivers of Era 1 and Era 2 diverts attention and resources away from improving and redesigning care. The question for policy makers is how can the conflict be resolved productively, and how can Era 3 be synthesised? What would a modern care system look like?

Berwick has some suggestions, but before considering them we should consider two characteristics of our situation.

Firstly, those most publically defending the NHS are mainly defending Era 1. They want to return to a time before the mechanisms of Era 2 emerged in the NHS. They are deeply conservative in attitude and emotionally are prone to shroud-waving when any change is proposed. Catastrophe is never far away, and conspiracies abound. They are reductionist and tend to have a narrow focus on ‘privatisation’ rather than a broad view of Era 2’s mechanisms. Far from being a solution to the conflict between Era 1 and Era 2, they are part of the problem.

Second, the funding of the NHS is so constrained that its normal functioning cannot be guaranteed. The apparent £22 million budget shortfall in England by 2020 is too big to be corrected by increased productivity, new ways of working, pay restraint and reductions in expenditure on medication. The government’s expectation that squeezing the budget will stimulate higher productivity and creativity in work organisation is not shared by most of those running or working in the NHS.

This is not to say that change is impossible, and some will indeed occur. Nevertheless it seems clear that the financial targets will not be reached. Failure to meet targets is more likely to increase the bullying that is so widespread in the NHS than to reduce it. Continuing reluctance to fund adequately the parts of the care system outside the NHS will just make everything even worse.

Moving from the current underfunded and unstable care system to Era 3 will require solutions around funding and accountability but based on a different approach.

Berwick has nine suggestions for helping Era 3 into being:

  1. Stop excessive measurement
  2. Abandon complex incentives
  3. Decrease the focus on finance (once the quality of care is optimal, costs will fall into place)
  4. Reduce professional prerogative
  5. Recommit to improvement science
  6. Embrace transparency
  7. Protect civility
  8. Really listen (especially to the poor, the disadvantaged and the excluded)
  9. Reject greed (it erodes trust)

How can these ideas work for the NHS? Berwick’s experience is based on US medicine, where the problems are starker than in the UK. But the other side of that coin is that the NHS has many people in it who want to make these kinds of changes. Could Labour come to their aid? How do the suggestions fit with the Labour vision of Whole Person Care?

Berwick’s Era 3 is driven by the escalating costs of US health care and the terrible waste of money in their fragmented and consumerist system. What Berwick wants is a single payer system, but we have that already and our funding problem is shortage not over-expenditure. Increasing the funding of the NHS to allow normal function to be restored will be necessary, but how will Berwick’s other aims be reached?

Stopping excessive measurement and abandoning complex incentives within a light-touch management approach would be welcomed, partly because these changes might foster professional prerogative and favour vested interests by reducing scrutiny and inspection. Would central funding and a better definition of what the care system has to do, combined with decisions by elected local government on how it is to be done, be sufficient to check professional prerogative?

Would our Era 3 system form around a structured response to societal changes like population ageing and rising consumerism? Will it depend on full engagement of citizens if the NHS is to be sustained, as argued by Wanless in 2002?  Can we resist consumerism but favour personalisation? 

Would Era 3 see the end of the primary/secondary care division? Would it see an end to commissioning as we know it? And would the emergence of local care systems (perhaps based on Sustainability and Transformation Plans) streamline care for reasons of outcome not cost?  Would the Treasury be accepting of the realisation that this might slow the growth in NHS costs but not save money, as such?

The Coalition government started by insisting on policy based on patient outcomes, but soon had that idea lobbied out of them. Were they onto something important, like a counter to medicalisation and a force for evidence-based policy?  Perhaps policy cannot be based solely on patient outcomes because we cannot measure the totality of them – but things like the National Service Frameworks which were based on evidence were a good thing, even if that thought re-connects us to Era 2 although admittedly the softer end of the spectrum of Era 2 policy initiatives.

Civility really does need protection. We know that “policies” can be brilliant on paper but do not necessarily get implemented, and that working relationships can be more significant than structures or laws.  How would better relationships be stimulated?

Staff satisfaction correlates with patient satisfaction, so investment in staff well-being and genuine staff engagement really do matter. But probably the majority of Trusts are poor in their treatment of their staff – the junior doctors’ fears about being exploited are well-grounded – and whistleblowing provokes clear threats to the whistler’s career. Care staff are trapped in a system of zero hours contracts and 15 minute visits with little or no training or development. Will more pay and better conditions be enough to raise morale and satisfaction?

Rolling out best practice after proper benchmarking and a detailed independent evaluation (an Era 2 approach) does not appear to work. What will? What should be measured and what local variability is tolerable; who decides?

Inertia is deep-rooted in the functioning of the NHS. The rationalisation of paediatric cardiac surgery urged in 2001 has yet to happen, whilst discharge planning and alternatives to A&E have been worked on for decades yet remain problematic. Recommitting to improvement science sounds like it belongs here, but in practice what will it mean? Should we try to solve the discharge-from-hospital problem by preferentially funding the growth of 24/7 ‘hospital at home’ services rather than traditional hospitals? What happens when evidence throws up the “wrong” and deeply unpopular answer?

Claims have been made about the transparency within the NHS and much data appears to be available, even to private companies. Yet anyone trying to get information out of the NHS (usually through FoI) experiences obstruction – often based on spurious claims of commercial confidentiality – or is simply ignored. Who owns the data? Who kite-marks its value? How are parts of the care system outside the public sector brought into a transparency framework?

Sadly few if any other specialities followed the example of transparency by the cardiac surgeons (after Bristol) and put outcome and mortality data freely into the public domain. What will overcome professional reticence; the Royal Colleges?

As for really listening, the NHS is especially bad at this. Can it really move to shared decision making? Can it accept the view that patients and communities are assets not a nuisance? Can it embrace engagement and consultation in genuine processes?

Finally, rejecting greed, will anyone dare disagree?

These and other questions need credible answers if the voters are to commit to significant additional funding to support a modern care system. Can Labour find the answers and use them to introduce Era 3 with the same zeal and determination that brought in Era 1?

Steve Iliffe & Richard Bourne 

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I had a nasty experience a couple of weeks ago. I was booted out of the Royal College of Nursing congress in Glasgow while distributing flyers promoting my Parliamentary Petition calling for a whistleblower hotline for NHS staff. The nurses were interested- my flyers went like hotcakes- but after 30 minutes I was told to leave by RCN Scotland officials insisting the call for a hotline conflicted with RCN policy

Whistleblower nurse Danni Gray, from Stoke-on-Trent Hospital, was incredulous that I was ordered to leave. Danni had come a cropper herself when she blew the whistle (her story is featured in the May edition of the “Nursing Standard”, Volume 30). (The picture shows her and I outside the SECC after ejection.)

Peter Gregson and Danny Gray

The RCN is not the only staff association that fears having whistleblowing discussed by its members: UNISON, UNITE, RCN & BMA have all refused to allow their Scottish members to discuss the petition, which calls upon the Scottish Government to establish an independent national whistleblower hotline for NHS staff to replace the current helpline, widely derided as useless.

Because health workers in Scotland are being blocked from debating whistleblowing, I have launched a second petition to support the campaign- a petition for a Petition and is addressed to the aforementioned unions’ leaders.

The reasons unions don’t like my proposals are made clear in this petition: they give priority to relationships with NHS executive management over members well being. I aim to use public pressure to get the healthcare unions to reverse their stand and allow staff to discuss whistleblowing improvements at branch meetings.

I am calling upon the Scottish Parliament to replace the impotent National Alert Line with an effective hotline with investigatory teeth. When staff contact the current helpline, they are referred back to their trade union or manager – which more often than not has led to either nothing happening or, worse, the whistleblower being victimised. Staff surveys found only 57 per cent of staff thought it was safe to speak up and challenge the way things were done if they had concerns about quality, negligence or wrongdoing.

The new proposal would differ in that it would independently investigate reports about mismanagement and malpractice. It would explore perceived negligence or ill treatment of a patient by a member of staff. And bullying too: the 2015 NHS Scotland staff survey revealed 15% of staff are bullied by bosses or colleagues.

The Petition is shortly to go before MSPs and union support is crucial to parliamentary approval. Please help me make Scotland’s health service safer.

Sign the petition.

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