Government needs better medical advice

This week’s (24th October 2015) BMJ carries a news piece about Secretary of State for Health Jeremy Hunt’s misuse of weekend mortality data.  The editor, Fiona Godlee, has written to Mr Hunt criticising his continuing statements that excess deaths at weekends were the result of poor staffing.  Several months ago the GP and columnist Margaret McCartney pointed out that although the figures showed an increased mortality there was no proof that this was related to staffing issues, and Godlee has now stated “What it [the quoted study] does not do is apportion any cause for that excess, nor does it take a view on what proportion of those deaths might be avoidable”.

The government’s rather weak defence is to shelter behind a spokesman who said that “clinical experts have said this is likely to be a consequence of variable staffing levels”

Likely?  Maybe.  Certainly? No.  Hunt implied the problem was a medical one.  Presumably he was not briefed that medical staff require access to investigations which require non-medical staff, such as radiographers and laboratory workers.  He has also not been told, I assume, that shift working results in things getting missed at handovers, and lack of clinical continuity is not a result of low staffing levels but of limited working hours that require the imposition of shifts.  And it is often lack of continuity that results in serious problems.  If you assess a patient regularly over several days you will spot subtle changes.  If that same patient is supervised by four, five or more doctors all the subtleties will be overlooked.  Noes are often brief; I recall getting out of a nasty medicolegal case when the complainant’s GP notes had a throwaway remark that they were going scuba diving in Fiji – something that was quite incompatible with the pain, distress and functional limitation she was claiming.  But sadly it appears that even at the very pinnacle of medical expertise, in government or in ivory towers, folk jump to unwarranted conclusions.  Dare I? Yes!  The case of misrepresentation of statin benefits is another example of a failure to assess literature properly.

My advice to Mr Hunt is to get better advice than he has at present, preferably from more than one source and certainly from people without vested interests or conflicts of interest.  The risk of a foot-in-mouth situation will be significantly mitigated, and many doctors will feel less threatened (largely as efforts to blame them for everything will diminish).

And that brings me to something else the government needs – a psychologist.  Not for themselves necessarily, but so that they understand that bullying imposition of targets, financial plans and contract changes are softened.  It’s hardly surprising that trainee doctors have reacted vigorously to Mr Hunt’s attempted imposition of a contract that will cut their pay and worsen their conditions, not least when his response to their complaints has been opinionated and boorish.  Could he not have foreseen there would be a spat?  Is it really in his, or the government’s interest to alienate doctors? It’s bad enough that changes to pension calculations will result in today’s trainee doctors getting a pension that’s roughly half what people of my generation are getting. And having to work longer to get it.

So come on Mr Hunt.  Nice works better than nasty.  And as I have said before, how can you increase staffing levels when there’s no money to pay for them all?

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Fixing the rotten NHS

I have been saying for years that the NHS is a “failed state”.  Reaction has ranged from agreement (among enlightened medics) through disinterest (among unenlightened medics) to dismay (among the public) and outright opposition (from politicians).  However its current position is increasingly recognised as unsustainable – or as I would prefer to be honest, bankrupt.  We have the absurd situation where the so-called commissioners of services, or CCGs for short, are so cash-strapped that they are trying to persuade GPs to ration prescriptions and referrals to secondary care.  On the other side the acute Trusts, or providers, are also “in deficit”.  They have tried over several years to apply temporary fixes.  They reduce spending by cutting staff; as a result, they fall foul of the monitoring body, the Care Quality Commission, which castigates them for inadequate staff numbers.  But they are equally castigated for overspending, whereupon the managers are put in the stocks, pelted with (figurative) rotten tomatoes by the public, and forced to resign if indeed they have not fallen on their swords already.  Meanwhile the government decides to harass the staff by forcing them into seven-day working, failing to assess or perhaps even realise that the costs of this are unsustainable.  It has already caused enough trouble by insisting on obedience to the European Working Time Directive.  As a result hospitals have been forced to employ more staff to cover shifts (simple maths – if you reduce individual hours worked by 20% you need 20% more staff to allow the same total hours).  Revenue costs have soared thanks to the building of new hospitals at unaffordable mortgage rates with almost endless repayment terms; this is known as PFI but is actually NHSSPM, or NHS Sub-Prime Mortgage Madness.

It is a miracle that up to now individual experience of the NHS has held up.  There are notable and well-publicised exceptions, often due, entirely predictably, to a lack of staffing and overstretching and stress of what staff there are.  But when over 80% of acute Trusts predict a year-end deficit, and the total deficit is predicated at £2bn per month it is time to say enough is enough.  We have spent almost the entire life of the NHS trying to fix it, and have failed.  It is time to stop papering over cracks – to stop funding shortfalls by budget transfers from capital to revenue, to stop secret bail-outs, to stop mergers that don’t work.    A business model where both the customer and the supplier are equally bust is unimaginable.  A model in which bankrupt people can continue to muddle on is mad. It is time to accept that the NHS is not a business but a service. And we must take a deep breath and start again.

This is not a time for political posturing either.  The NHS has been held up by the Labour Party as one of its crowning achievements.  Apart from the fact that it doesn’t currently work it is time for that Party to concede that it did not invent the NHS.  The principles were set down before the Second World War in a report commissioned by the British Medical Association and refined to an action plan by a civil servant during the war.  Only the accident of history that led to a Labour government in 1945 resulted in the NHS’s introduction under a Labour administration; had Churchill retained power, the Conservatives would have introduced it.  So that makes it all the more sensible that we forget who actually did what, and abandon the clearly sinking ship rather than bleat on about how wonderful it is, what a symbol of social equality it is etc etc.  Find me a single reorganisation of the NHS that has achieved its objectives (and there have been many reorganisations and objectives).  I cannot.  The fires in Rome have burned sometimes brightly and sometimes not, but fiddling has not put them out.

We cannot go on like this.

I have spent a professional lifetime scrutinising plans to save the NHS.  I have one overriding principle which seems essential to me, but appears to be overlooked by most.  It is this.  The first thing you do when someone comes up with a plan is to find one single thing that will scuttle it.  In science this is called the null hypothesis.  I remain amazed how many planners, many from medical backgrounds who have spent time doing research, do not do this.  As a result I have spent a parallel professional lifetime crying in the wilderness, pointing out why something will not work, watching while people implement the something and finally saying “I told you that wouldn’t work” when it doesn’t.  This was the fate of Cassandra, the prophetess of Greek mythology who always told the truth but to whom a curse was applied – that no-one would believe her.  Then there is a second non-scientific approach to change.  If you are trialling a new drug you do small pilot studies first – you do not launch the thing to the public in one fell swoop.  But there have been innumerable NHS initiatives that have been forced on services across the board.  So, when they fail, the whole organisation is affected rather than a small and remediable part.  Lastly there is what I call the panic plan.  Things are failing; organisers know that they will be held to (unreasonable) account and implement short-term “solutions” that don’t last and may make things worse.  Or they blame the doctors for being spendthrift, self-centred, lazy and greedy.  Which certainly makes things worse, because it antagonises the very people you need on side.

People have trumpeted the “need” to have good social service backup to keep people out of hospital, and have espoused the gospel of “Care in the Community”.  Sadly, however, many of these disciples have not analysed the costs of these alternatives.  Dispersed care is inefficient.  Peripatetic staff generate travel costs and more are needed to traipse about.  So while it may all be nice, it may not cost any less.  I am not going to state it costs more; I don’t know.  But common sense suggests it will.  So let’s not do it – at least until a pilot shows that money can really be saved.

Now I have been criticised when in Cassandra mode for being negative.   Why, people ask, when you think you can see clearly what is wrong, do you only tell people what is wrong and not put forward proposals of your own to put it right?

There are two answers.

  1. If no-one has come up with a way to put it right so far, what makes you think that my “solutions” will be any better than anyone else’s?
  2. While my negativity is evidence-based, my positive suggestions are not (because they haven’t been tried yet, or thought of yet, or if they have someone sensible has applied my null hypothesis rule and proved to their satisfaction, and sometimes mine, that my proposal won’t work).

But perhaps that isn’t a good enough reason not to try.  So I shall.

Back to the beginning.  We want these services.  We have this amount of money (forget commissioning and providing – all the money comes to both from government so any so-called deficit is an overall inadequacy of funding).  So what can we spend on what?

This is the so-called zero-based budgeting system.  We set out what we wish to provide and then calculate how much it will cost.  What we want includes GP services, acute hospital care, cold surgery, cancer treatment, mental health provision and all the other subgroups.  That provision requires facilities such as GP surgeries and hospitals and staff to run them.  We know (roughly) what the demand is, so can estimate throughput.  So we can calculate the costs of it.

So far so good.  If government allocates that amount of money then all is well.  If government can explain to the people that large parts of the money are not actually for healthcare (but for things such as staff pension costs) so much the better.  But suppose the money is not enough to do across the country what the country wants?

Four options.  The first is to increase the allocation so it is enough.  The second is to look for real and sustainable savings.  The third is to decide not to provide some of the things everybody wants – at least for nothing. The fourth is to generate income from non-NHS business.

No government will ever offer a bottomless purse, so we can rule out option 1.  On to option 2.  Real and sustainable savings are not achieved by cutting down on the one variable in NHS spending – the staff.  Buildings have fixed costs, but staff revenue represents 75% of the spend, so offers the “best” way to make savings, but cutting staff leads to mistakes and omissions, so you fall foul of the CQC as we have already seen so that plan falls down.  Real savings are made by cutting unnecessary drug prescriptions, by streamlining supplies, by abandoning high-cost vanity projects and by renegotiating debt.  All of these are possible; the last has already been implemented here and there; certainly no future PFI projects should be sanctioned – ever.  All you are doing is shifting the borrowing off one balance sheet to another, hidden one, usually at an interest rate that exceeds the rate at which the government could borrow for itself.  Some of the others could work but require a re-evaluation of the cost-benefit ratio.  For example, statin prescriptions are an enormous drain on resources for a small (indeed uncertain) gain in health.  Many patients are being given them for conditions they don’t have and may never get.  So abandon them!  Stop prescribing unnecessary antibiotics as well.  Others may think of others.

Actually, don’t forget commissioning and providing.  Abolish them.  All the system does is generate huge transactional costs at no benefit to any patient.  And while we are about it get rid of all the targets that require staff to spend vast tracts of their working week ticking boxes.

Option 3 has several possibilities. Again, some have already been taken up; varicose vein surgery is no longer offered on the NHS.  Others are controversial; expending huge sums on cancer drugs in cancers with poor prognoses; bariatric surgery for the obese (self-inflicted problem); not treating smokers with cardiac surgery unless they give up; abandoning arthroscopic surgery on knees; privatising sports injury services (also self-inflicted); cosmetic surgery; intensive care admissions for the seriously ill elderly; charges for outpatient appointments and A&E attendances; charges for inpatient hospital meals.  The list could go on but I imagine that some of these suggestions will have raised hackles already.  But, folk will say, what if it was you?  So what if it is?  If it came to it I would be happy with all of the above; I would also wish to be euthanased if I developed severe dementia, particularly if I became disinhibited and aggressive.

But – just because some of these discussions would be difficult does not mean we should not have them. Have you forgotten?  The NHS is bust!

Option 4 comes up against politicians (again).  Money is short, staff are stretched, so why even consider spending money on non-NHS sidelines, or what in NHS jargon is “non-core business”?  Quite simply, because some of them may be profitable and provide funds to plough back into patient care.  Look, for example, at redundant hospital buildings.  With closures and mergers there are lots about.  They are largely brownfield sites.  They get sold off.  Services such as power and drainage are already in.  The sites are developed, and developers make a giant profit.  So why not become the developer?  Or why not lease the site for a reasonable revenue income?  It has been done, but selling land is akin to selling the family silver; you might make a small gain but, in my experience, it is rapidly fed to the deficit.

Of course many will say (or whine) that doing some of these things will reduce quality.  Maybe.  I am sorry if it does, but if we cannot meet the quality standards we set ourselves – and currently the majority of NHS organisations cannot – then we need to re-examine the standards.  For what is the point of endlessly striving to achieve the impossible?

I could predict that the political response to this will be to say that some organisations do meet the standards, and if they can then so should every other.  But if you analyse why they meet them you find that most are very well funded.  If 20% are well-funded and 80% are not… you might as well say that it’s a disgrace that 80% are below average.  Come again?  That’s a statistical nonsense.  Think about it.

I remain uncertain that anyone is prepared to grasp the nettle and embark on a root and branch NHS demolition and resurrection (sorry – I had to get one more cliché in).  But if you are, phone me.