When is a deficit not a deficit?

Being retired I don’t often meet Health Service managers, but merely snipe at them from the sidelines.  However I met some the other day and sniped face to face about the impossibility of squaring good clinical services with “good” financial management.  I pursued my usual line of “If every acute Trust is in deficit then it’s not the Trusts that are wrong, but the system.”

Well. I was put right on that.  The Trusts you had to worry about, they said, were the Trusts who could not explain their deficits.  In some cases these had sort of appeared out of the blue, and the managers found it most puzzling, but from outside you could see it coming so they had a problem.  “We have a £40m deficit” they said “but it’s not a problem because we know exactly why”.

Oh boy.

I thought that perhaps if I were to go to my bank and say “I have an overdraft of £10,000 but it’s not a problem because I know exactly why” then, adopting this principle, the bank would say “well, that’s all right then”.  Somehow I don’t think that’s very likely.  A deficit is a deficit.  It may be nice to know why it’s there but if it cannot be sorted (or written off) then I for one think that it is a problem.

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?

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.

Don’t let wool be pulled over your eyes

…or maybe not.

Our Trust decided it was going to have another round of back-office cuts to try and meet its deficit, so it set off by telling all the over-65 staff that they were to have their contracts terminated (there was a bit of a rush with this, as the law was to be changed to forbid this, to be enacted some 6 months later). We lost a senior orthopaedic surgeon, some of whose patients were so angry they followed him into the private sector, but we also lost two of our valued and hard-working clinic receptionists, who had spent the last 15 years or so manning the desk for the rheumatology and orthopaedic clinics.

I was sad at the manner of their exit, but returned the following week to discover that the reception desk was empty, and that my patients (many quite disabled) had to walk 60 yards round to main outpatients, queue for ages and then return to the rheumatology waiting area. It transpired that the reception staff had been cut by four. Two desks had been abandoned, and the remaining staff were tearing their hair out trying to cope with the large numbers of patients, who at peak times would be queueing almost 50 yards down the main hospital corridor.

I complained to our Medical Director who, Pilate-like, washed his hands of the matter. Well – I suppose the hand-washing set a good example on the C.Diff. front. After several other complaints directed at those to whom he had directed me I finally got an answer – which was that the restructuring had only lost one full-time equivalent post, and implying that the reception manager was falling down on the job. Having seen her, in tears, trying to cope a week before, I was not impressed so summoned her to ask if the figures were true.

She told me they were. However, they included two receptionists based at the cottage hospital, and one member of the pre-admission team, who could hardly be classed as main hospital receptionists either because they worked somewhere else or because they did another job entirely. None of them had previously been in the reception staff budget.

It got worse. My secretary was suddenly phoned by an anxious senior manager, telling her that she now had to collect a huge pile of outpatient outcome forms (the ones in colour), book the follow-up appointments and code the details. Otherwise, she was told, the hospital would lose oodles of money because it couldn’t claim for the work done. Guess who normally did this work. The receptionists they had just disposed of.

It is very sad when managers not only try to delude others, but appear to delude themselves. If you are faced with an improbable scenario, or offered some rumour, check it out and get the facts. Preferably in print. Then you can screw the bastards back.

Look after the pennies…

In our hospital it became apparent that we were missing out on income because we were not coding properly. I have no objection to chasing money if it is a consequence of better (or more ordered) practice. But things can get out of control.

In 2009 it was finally agreed that procedures done in NHS outpatients could be charged for. It was also decided that it was necessary to devise a new outcome form to take account of the 18 week target for completion of treatment. So a new form was devised on which all the new relevant information could be entered.

Now with targets there are certain subgroups of outcomes. A repeat follow-up patient need not be counted, so they require a box. There are several outcomes that “stopped the clock” – for example direct admission, first appointment default, discharge – and there are others that left the clock running or start a new one.

The new form appeared.

It was printed in colour.

Each of the clock groups was in a different colour which bore no relation to the goodness of the outcome – thus a stopped clock (which we didn’t have to worry about) was in red. The colour was in large blocks.

Now I know a bit about colour printing as I do some at home. It is quite expensive. So I thought “Why the hell are we printing these forms in colour? The colours mean nothing. They are expensive. The outcome sheets are discarded once the information has gone onto the computer, so if we are seeing 200,000 outpatients a year we are throwing away an awful lot of money.”

I have no idea how many outpatients were seen across our three hospitals, because  no statistics were provided, but if every one of my colleagues sees what I see then my figure is probably an underestimate.

So I wrote to a manager asking why the forms had been printed in colour. I was not given a direct answer, only told that it wasn’t that expensive (4p per sheer) and would easily be covered by the extra income that the forms would facilitate.

The cost of a black and white sheet might be at most 0.3p. So we were wasting over £5600 in unnecessary costs, but it doesn’t matter as we would get it back…

Actually, to be fair, someone did see sense, and the forms were changed to black and white – a good two years after I made a fuss.

The only way to beat a target is to cheat

If we rheumatologists want to increase our new:follow-up ratio we can

  • Count DEXA scans for osteoporosis as new referrals and not as tests
  • Pull all the simple stuff under the rheumatology label (eg all the back pain patients who go straight to our physio service – after all, we supervise it)
  • Book requests for earlier appointments as new patients (after all, it’s a new letter!)
  • Abandon the “SOS” (“give us a ring in 6 weeks if it’s not better and we’ll see you again”) system which patients love and is highly effective – and get the GP to re-refer
  • Discharge everyone and ask the GPs to refer them back – which they will have to do

If we want to meet 18-week targets we can

  •  List patients awaiting tests as “watchful waiting” (which stops the 18 week clock) rather than “awaiting tests” (which doesn’t)

I am aware of many who play such games. It’s sad that we waste our time inventing ingenious ways of beating the system instead of relaxing at home, doing research or writing letters to “The Times”.

Drugs, and why (not) to prescribe them

I don’t intend to embark on a discussion of overprescription and the use of dangerous drugs in an inappropriate way (although I did read a piece that incensed me, about why patients with RA should not receive methotrexate because we rheumatologists dish it out with gay abandon). Rather I want to discuss why some drugs are denied to patients by non-clinicians (or non-specialists) because of financial considerations alone.

In my long experience of dealing with applications to use drugs – and these are always for highly specialist things that almost always cost lots of money – I have encountered managers and clinicians who fall into two groups. There are those who take a pragmatic, and to my mind sensible approach, which is that if a clinician submits a detailed application there must be a good reason, and thus errs on the side of agreeing. There are also those who are jobsworths, and shelter behind detailed guidelines to find any excuse to avoid allowing use of something expensive while not always having any reasonable clinical argument to back up their decision.

Certolizumab is a case in point. It is a biologic therapy – a tumour necrosis factor antibody used in the management of severe rheumatoid arthritis. Because it is one of a family of TNF antagonists it has been treated as identical to the others available (infliximab, adalimumab and etanercept). A deal done by the manufacturers offered a free 3 month trial of certolizumab; as a result, some GP managers and therapeutics committee members decided that it should be the first choice TNF antagonist because of the cost saving (also it was presumed that TNF failure at 3 months was the end of the line for that particular treatment).

However this decision failed to account for several factors.

  1. The mechanism of action of the TNF antagonists is not physiologically identical, and there is therefore no reason to believe they should produce identical clinical effects. Antagonists ending in “ab” are antibodies against TNF but the human immune system can and does produce antibodies against them. Those ending in “cept” are fake TNF which blocks the receptor sites on cells.
  2. There are differences in side-effects (not fully detailed, but it appears that the “ab’s” have more serious respiratory side-effects than the “cepts”)
  3. It is never clear whether new “me-too” drugs will have exactly the same profile as the old ones, either in efficacy or side-effects
  4. It’s all very well comparing two drugs each against placebo and inferring they have similar efficacy, but without a head-to-head trial the verdict remains not proven, as the Scottish courts would have

So one must conclude that the evidence on which a decision to use certolizumab first, even though there is much less clinical experience of it, was not clinical evidence. Cost is the prime mover.

Another example is the use of Infliximab in Behçets disease – an uncommon but disabling condition characterised by nasty skin lesions (including involvement of the mucous membranes of the mouth and genital area) and an arthritis. I had one such patient whose disease responded dramatically to Methotrexate, but she developed serious side-effects. So we had to terminate the treatment and she had a major relapse.

She had already received all the standard starting therapy, so we were at a dead end. I was not going to use thalidomide, for which there was trial evidence of benefit, because of her age and the possibility of her becoming pregnant. There were two case reports of dramatic benefit from Infliximab given as a short course.

I applied through the local vetting committee for permission to proceed. It refused on the grounds that there were no clinical trials and that anecdotal evidence was not good enough. I could however use thalidomide…

So I was faced with a patient in serious trouble, but forbidden to use a safe drug and offered the ridiculous option of a seriously dangerous one that was, it seemed to me, mad to consider in a young lady. I fear I lost my temper as well as the battle. The patient moved away, having lost her job because of her disease, so I don’t know what happened to her. However in the intervening three years – guess what? Following up on the anecdotes a trial was done. It confirmed benefit. For the want of a nail…

At the end of 2012, some four years after this shameful episode, I learned at a rheumatology meeting some of the details of a new scheme to develop specialist centres for Behçet’s patients. All you now have to do to get authorisation for infliximab (which unsurprisingly has now been shown all over the place to work like magic) is discuss the case with one of the centre specialists and they will rubber-stamp it. There’s nothing worse than being ahead of one’s time.

And there was a third shameful jobsworth episode. A patient of mine with ankylosing spondylitis had, off her own bat, got herself funding for residential rehabilitation at the Royal National Hospital for Rheumatic Diseases in Bath. While there she had been entered into a trial of TNF blockade, and had been on treatment for three years. At this time the biologic drugs had not been approved by NICE for use in AS, so when the trial came to an end I applied for individual funding from her Primary Care Trust. This was refused. She was devastated as she saw that her condition would slide inexorably backwards. The refusal seemed to me to be both uncharitable and stupid. I knew that NICE had already issued draft approval and it was only a matter of time before full approval was confirmed. After that the PCT was legally obliged to cough up. But it stuck to its jobsworth principles, claiming that draft approval wasn’t good enough. Having had considerable experience of NICE decisions I knew that the only ones that got disputed were those that NICE had turned down. For the sake of a few weeks, maybe months, the PCT was prepared to make my patient suffer.

However she did not take this lying down. Instead she went to the regional television news, made her case, got the media firmly on her side (I added a bit of gravitas), caused a major public fuss and got her treatment. I still find it hard to understand the inflexibility of the PCT in the circumstances, but it all caused her, and me, considerable annoyance and inconvenience.