The NHS under pressure

nhs-2 A Facebook friend of mine, Martin Rathfelder, emailed the following case on behalf of his socialist healthcare group:

In its damning report last month, the King’s Fund health think tank criticised the government’s NHS reforms as “damaging and distracting” for introducing even more markets to the NHS, for making it too complex to govern properly and lacking effective leadership.

The man behind these reforms, former health secretary Andrew Lansley, dismissed the report, saying that the King’s Fund should have focused on “whether patient care has been improved”.

We agree: quality of patient care is the most important measure of the success of government health policy. So let’s examine the evidence.

1. A & E waiting times – WORSE

The government has a set a target of no more than 5% of patients waiting over 4 hours in A & E for treatment, referral or discharge.Yet in the period October – December 2014, 414,000 patients waited more than 4 hours for – an increase of 47% on the previous quarter and the worst performance in over a decade. 42,000 patients waited on trolleys for more than 4 hours, a 134% increase on the previous year. And the number of Foundation Trust hospitals missing the 4 hour target has doubled to 66 since the summer of last year.

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2. Treatment waiting times – WORSE

The total number of patients on the waiting list for treatment has increased from around 2.5m in May 2010 to over 3.2m at the end of last year.

The number of patients waiting longer than 18 weeks for treatment at Foundation Trusts has increased by 30 per cent in just over a year. That’s an increase from 87,000 in September 2013 to 113,000 in December 2014.

In fact, 12.5% of all patients have to wait more than 18 weeks– the highest level since the target was introduced in 2008

3. Cancer care waiting times – WORSE

The government has a target of 85% of patients receiving treatment within 62 days of referral from their GP.

The proportion of cancer patients receiving treatment within the 62 day target has fallen from 86.7 per cent in April 2010 to 83.5 per cent in October 2014, with the target missed now for three consecutive quarters. The number of Foundation Trusts missing the target has almost doubled to 31 since the summer of last year.

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4. Delayed transfers of care – WORSE

Delayed transfers of care are where patients still occupy a hospital bed, but are ready to return home or transfer to another form of care. This clogs up the entire medical service, and means that patients might not get the kind of care they need.

The number of delayed discharges from hospital increased sharply to more than 5,000 per day in November 2014, an increase of almost 20% since the previous January. This reflects a longer-term increase dating back to April 2011

5. Adult social care – WORSE

Following cuts over around 12% to care budgets across local authorities in England, there has been a 25% reduction in the numbers of people receiving care through community services, nursing or residential homes, leaving more old people reliant on NHS services.

The government failing patients

These are five key ways that patient care is on the decline. But there are others too. The number of cancelled operations is up by a third between November and January, compared to the same time in the previous year. Ambulance response times are rapidly deteriorating with all three national standards for response times missed in quarter 3 2014/15, largely because of increased handover times at over-stretched A&E departments.

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What is causing this failure of patient care?

Clearly the toxic mix of restructuring, complexity, confusion and lack of system leadership referred to by the King’s Fund report is taking its toll. The view from the front line is that services are deteriorating. Over a third of NHS trust finance directors feel that care in their local area has worsened over the past year, a view shared by a similar proportion of CCGs. But the fundamental problem is the massive financial squeeze by the government, at a time of rising demand.We have discussed previously how the finances are in parlous state due to flat-lining government spending on the NHS. More recent evidence shows that 60 out of the 83 acute Foundation Trusts are currently in deficit, over three-quarters of NHS Trust Finance Directors are not confident of achieving financial balance in 2015/16 and over a quarter of CCGs are not confident that they can stick to budget without compromising care quality or access over the next 12 months.

This is leading to staff shortages and capacity constraints, particularly a lack of beds. Monitor, the English NHS regulator, reports that “constrained bed capacity” is contributing to increased A&E waiting times, that 45 per cent of Foundation Trusts cite “inadequate capacity” as a factor behind missed cancer treatment targets and that with staff vacancies for qualified ambulance staff ranging between 10% and 24% has had a “significant impact on performance”.

NHS-1There is a very clear message coming through. No matter what David Cameron might argue, the NHS has been starved of investment with a direct impact on patient care.

John Appleby, Chief Economist at the King’s Fund sums it up thus:

“Services are stretched to the limit. With financial problems also endemic among hospitals, and staff morale a significant cause for concern. The situation is now critical”

Full article with graphs:

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My reply ran thus:

Hi Martin

I very much agree about the impact of government reforms, though in truth ALL governments would be well advised to introduce a moratorium on change and pressures in order to allow the professionals to do their job effectively, and also to cut the rigid straightjacket of distorting national performance targets and enable a more flexible local systems to be negotiated to reflect the needs of each demographic community. 

The email you sent did not mention the four key factors that are influencing NHS ability to provide a good service:

  1. Far from being able to cut managerial or admin staff, additional resource is required to cope with pressure and constant change from government intiatives. In particular, the internal market between commissioners and providers has led to a huge growth of senior staff to manage contracts, finances and management of breaches and penalties.
  2. Pressure to cut budgets and hit financial targets, resulting in short cuts on clinical pathways and inabiity to process patients effectively, loss of flexible capacity, posts not being filled etc.
  3. Huge skill shortages impacting the ability of Trusts to provide services and placing increasing reliance on locum, bank and agency staff to fill gaps.  This is not necessarily a financial constraint, there are simply not the experienced skilled staff at all levels available, so commitments to employ are meaningless without the necessary infrastructure and flexible contracts to support the training of more specialists.  This has not been helped by down-banding key staff through Agenda for Change – for example, regrading of paramedics to Band 5 has resulted in a national shortage (c2,000 below establishment) and an attrition rate that cannot be filled; current staff are working double shifts without breaks and are leaving for the sake of their own health.  This is a self-fulfilling prophecy caused by government incompetence.
  4. Sheer volume of patient demand, particularly in A&E, for ambulatory care and social care.  Most A&E departments are operating consistently at 50+% above their planned capacity, and are doubly stretched given intiatives to cut elective backlogs meaning the loss of additional capacity, beds, theatre slots etc.

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Martin then invited me to expand on my arguments to add to his blog, but first I need to add further background about the relationship between the NHS and government, and its impact on continuity of service.

Suppose for a moment that an NHS Trust were a private sector organisation, and Martin’s manifesto would be intrinsically opposed to privatisation of NHS Trusts (ie. putting services in the hands of private operators.)  Ignore for a moment the fact that there is not a Trust in this country that does not outsource some patient services, and instead regard this as a hypothetical argument that Trust X is an independent private body owned by shareholders.

Naturally it would have to meet regulation on patient safety and a whole raft more legislation, but as a private operator it would have complete responsibility for devising and implementing its own strategy, managed by the board and answerable to shareholders, most of whom take a sensible long-term view about its strategy and their returns.  Clients would want to be satisfying it was doing a good job and offered good value for money, but they would have no influence over the day-to-day running of the organisation.

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Now step back to reality and realise that the primary shareholder for an NHS Trust is government.  I’m certainly not against public ownership of universal healthcare – quite the reverse, I’ve worked in the industry for many years and am passionate about its health and welfare, am a user of NHS services and will defend it to the death against anyone arguing in favour of an insurance-based system.

However, I do think government is an irrational stakeholder, and unlike Martin I would not benchmark solely against the changes implemented since 2010, when the current government came to power.  If you took 1997 as the starting point, I think there were at least 28 major changes to NHS strategy implemented by government, up to 2011 when the Health and Social Care Act came into force, plus countless minor changes.

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Some might be desirable and useful, though very many were and are utterly irrational changes, causing irreparable harm and distracting the boards and management of NHS Trusts from the job of developing and planning effectively.  No small wonder that the effect has been that most are constantly fire-fighting and with a planning horizon barely six months into the future, when they should be able to plan ahead at operational level for the next financial year at least, and strategically to develop

Granted that change is indeed a fact of life and it would be unreasonable in the complex world of healthcare for things to stand still for very long, but governments are inherently unstable organisations with a focus no further ahead than the following election.  The goal of all governments is to make a mark, to do something, to put a stamp on matters, leave a legacy.

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In the case of the current government, that stamp was carefully secreted away, not mentioned in party manifestos, yet wheeled out as a white paper very soon after the 2010 election.  Labour suggests the Conservative party has a plan “which dare not speak its name” to privatise large chunks of the NHS in the event they win the coming election, which would not surprise me.

At one time the NHS was, if not a well-oiled machine then certainly an organisation with common goals that worked through the spirit of collaboration.  Nowadays the market philosophy engenders a spirit of Them and Us, whereby each Trust remains secretive and operates as a black box, giving as little away as possible.  Where once co-operation in the common good was the overriding philosophy, now each body regards the other with suspicion, plays political games and is defensive in the extreme – just ready for privatisation, you might think.

Labour doubtlessly has its own plans to instigate further change in the way the service is managed and run, the headlines of which include recruiting thousands more doctors and nurses (no detail about how this would be achieved, given the vast yawning skills gap), but nothing on the other reforms that are without doubt being worked on behind the scenes.

For example, PFI must have seemed a godsend from the government perspective.  It allowed dilapidated old hospitals to be demolished and replaced by shiny, modern palaces to healthcare, thanks to private companies funding developments but not adding a penny to national debt.  Sounds great?  On the contrary, PFI deals (which began in 1992 and continued over successive governments, Tory and Labour) have been an unmitigated disaster for very many NHS bodies, since the revenue cost of funding the deals crippled the finances of the Trusts.

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Bear in mind that at current tariffs, all Acute Trusts have loss-making services that must be provided to meet commitments, but generally had enough services in surplus to break even with reasonable comfort suddenly found themselves with huge deficits they could not fund.  This parlous financial state was exacerbated by the new rules of the 2011 Act, which required commissioners to include private tenders not linked to national tariffs for services, thus rendering existing hospitals uncompetitive for no fault of their own.  They often found themselves competing against neighbouring Trusts in games of chicken.

Block contracts for a range of services were replaced by PbR – payment by results.  You’d rightly think these were not in the interests of hospitals, but because of the loss of income they had little choice but to take funding from every patient possible, even if the extra demand was beyond their capacity, in a futile attempt to increase revenues.  In practice, huge increases in demand that could not be turned away spelled operational disaster as waiting lists grew and targets were blown apart.  All because of a succession of government policies taken over many years.

Do yo remember when ALL we had to worry about was the patients?

Notable that the only private provider running an NHS Trust withdrew from its contract, probably because it could not simultaneously meet targets and produce a profit  for their shareholders.  If they can’t, what hope does anybody else have to enable Trusts to succeed within the current legislative framework?

There are many reasons why Trusts cannot possibly succeed in hitting financial targets, one being that they are constrained in what they can pay their staff and the contracts they can offer.  For example, consultants and surgeons are not permitted to work flexibly, paid on a piece rate basis, nor to be incentivised to stay with bonus schemes.

Were it not for the rigid straightjacket which prevents NHS organisations competing like-for-like with the private sector, Trusts may well be as effective and efficient as any.  Why?  Because the people who run these services at all levels know their business intimately and can make the right decisions for the good of patients.  As it is, Trusts are often forced to pay more attention to costs than the well-being of their patients, which to their way of thinking is a total anathema.

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It doesn’t end there, of course.  “Target culture” is a double-edged sword that can be used wisely to promote higher standards, but have many issues.  Take RTT (Referral To Treatment, also known as “18 weeks”), which is widely credited with having brought down waiting times for major procedures such as hip replacements from years to a notional ceiling of 18 weeks from initial GP referral, though a first Outpatient Appointment, all diagnostic tests and preparation, follow-up appointments, a DTA (“decision to treat”) and finally surgery (“admitted pathway”) or other forms of treatment (“non-admitted pathway.”)

You can see why such measures would be popular with politicians, since they appear to indicate progress towards goals, enabling the Westminster contingent to bask in the reflected glory of hard-working clinicians and nurses.  There is no doubt that some elective pathways have improved enormously, as they would have done regardless thanks to non-invasive surgical techniques that reduce recovery time, but easier to credit the measurement regime for incentivising improvement.

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But there are major problems with a statistical measurement, chief among which is that it distorts the provision of services to ‘one size fits all.’  Fact is that most of the national standards employed take no account of differing demographics and local priorities; they take no account of the fact that some specialties (especially but not uniquely Trauma & Orthopaedics) will always be longer than others (eg. dermatology cases.)  Inevitably some will always perform far better than 18 weeks, while others will always struggle, even without increased demand.  Targets as absolutes  – and as a performance expert this is a topic I know inside out.

On occasions I’ve lectured on the subject of healthcare performance management, and when I do I quote a little story which runs thus:

In the days of the Soviet Union, there was a little tractor factory in Siberia.  The manager of the plant was a a good man, well-respected and hard-working, much loved by his workers and who took a pride in making a contribution to the fatherland.

One day he was called into the office of the local party chief, who greeted him with a bear hug, sat him down.  They poured the vodkas and drank a toast: “Za vashe zdorovie!”  Then the party chief looked glum.

“What’s wrong, Boris Nikolayevich?”

“Our orders have come from Moscow, Alexei Mikhailovich. Your target for tractor production is doubled.”

“But that’s impossible.  We can’t produce twice as many tractors.  We’re already at full speed and I can’t find more skilled staff, let alone train them.”

Boris shrugged and poured two more shots of vodka.  “We must do what we can or the factory will be closed down, and who knows – we might both end up being executed for our pains.  Cheers!”

So the tractor factory manager went back to his desk and started working hard on how to improve production.  He made several organisational changes, speeded up the production line, shouted at his suppliers to work harder, exhorted his staff to put in extra hours.

And then, as if by a miracle, the last day of the year arrives and the production target has been hit.  There are wild celebrations across the town.  The manager is carried shoulder-high and cheered down the streets by the townspeople and his employees.

And Boris greets him with another bear-hug, pours the vodkas and drinks to his health.

“Just one thing,” he says, “you told me last year that the target was impossible, yet you broke all records and met the target.  How did you do it?”

“Ah, easy!” cries Alexei, “we produced the volume of tractors… but they will all break down in the first six weeks.”

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The thing is that no matter when you cut costs and time, quality of service will decline.  Yes, you can become more efficient, to a point, but when the topic is best clinical practice there are limitations.  Add to the mix demand in volumes of patients being referred and even the best Trusts in the country will find a backlog building and performance suffering. Not difficult to see how this culture led to the Mid-Staffs debacle, with corners being cut and standards dropping.

So what’s the answer from the commissioning system?  Financial penalties for failing to hit targets, whereupon failure becomes a self-fulfilling prophecy!  Bear in mind some of the Trusts in question are probably in a deficit to the tune of  £50-100m, so another £1-2m added to the pot certainly is not going to incentivise any Trust to improve, only to increase levels of paranoia at the cost of patient care.

So, given failure of national targets by practically every Trust in the country the government has had no choice but to provide extra funding for A&E and to address the elective backlog – but even then demanded detailed information to demonstrate they were getting bang per buck.  Make no mistake about it, thanks to governments money now rules above patient care in today’s NHS.

But the twist in the tale is this:  once you have implemented targets and then take off the brakes, what happens?  Standards decline rapidly since there is no longer a straightjacket of enforced targets to retail the priority, as the current government found with RTT.  Fact is that Trusts have now, like Pavlov’s dogs, been trained to respond according to the targets rather than focusing attention on what needs to be done most urgently in their own demographic to improve healthcare for the local population.  Target culture is a distraction from what really counts.

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I grant you this:  if you were designing the service from scratch, you would not do it how the service has evolved, but thanks to generations of politicians leaving their sticky paws over it, we are where we are.

Why then would I be among the first people to defend the NHS?  Simple: for all its faults, which are generally not of its own making, the NHS is the envy of the world, excepting possibly the very rich and right-wing components of US politics.  They would say the NHS represents “Socialised” healthcare, meant as an insult.  Not so:  the NHS provides democratic healthcare, a universal service provision free at the point of delivery, regardless of wealth and status.

Many millions receive brilliant care, day in, day out – and as has been pointed out by many commentators, do so at vastly lower a proportion of GCP than that taken up by healthcare in the USA.  This it does through the dedication of many thousands of staff, a large proportion of them vastly underpaid.  In short, this is an institution worth saving as a legacy for the British people, but if it is to be saved it must be saved first from politicians of all hues.

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I doubt if Labour would abolish the Health and Social Care Act, since one essential rule of politics and organisational development is that you can never, ever turn back the clock to some rosy-tinted era – and even if you could, you would be hard-pressed to choose a date as starting point for the next phase of NHS development.

For example, could you abolish the artificial market mechanism?  Only if you had something better with which to replace it – and given the inherent complexity of the system that seems highly unlikely.  Parties are all for trashing their rivals but rarely have a better solution to offer.

Were it my choice I would simplify the layers of bureaucracy, enable a tariff system that reflected costs fairly – which may be different depending on where you are – and allow Trusts to manage flexibly and recruit the skills they need without let or hindrance.  I’d renegotiate consultant contracts and job plans with the condition that they had far more flexible time built in to allow for peaks and troughs.

In fact, it’s not difficult to envisage how things could be better, but rather than government feeling it has to regulate further, a moratorium on government tinkering and a loosening of the financial whip could be replaced with a duty of care on all Trusts to provide quality healthcare to meet the needs of its population base, and provide value for money – but in that order.

Trust the professionals to do their job without interference, since, unlike banking prior to the 2008 financial crisis, there are already many layers of regulation and scrutiny already in place within healthcare.

My message to ministers is this:  allow the NHS to return to its former glory by nurturing and respecting this fine institution, not punishing it and fragmenting it further, and certainly not by instilling within it market dogma or any other form of government-induced madness.

 

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