Week Commencing 8th January 2018
5 Insights You Need to Know
Welcome to the NHS WEEK THAT WAS, a Monday synopsis of the most important things that happened last week, with a degree of interpretation. No waffle, no minor news – just the significant stuff to ensure you are current. Enjoy!
So, it’s true to say that our first news of 2018 isn’t exactly bland. In fact, we wouldn’t be out of place saying “directly from the war zone”. There are some enormously significant pieces of news this last week and we’ll do our level best to inform and interpret in an unbiased manner but without falling into the trap of downplaying the significance. Not sure ‘enjoy’ is the rightful intro… so we’ll go with self-edify!
1. CRISIS GOES FROM RISK TO REALITY
The writing has been on the wall in the run up to true winter and it has proved to be an accurate assessment of a risk now firmly most trust’s reality. NHSE and NHSI claimed that the NHS was more prepared for this winter than any other but that has not proved to be remotely sufficient for the onslaught that many trusts are now facing, which we can see in the alerts, A&E figures and in the raft of communications coming out of professionals and professional bodies.
In the last week we have seen the following unfold:
- Letter from senior physicians informing the PM that people are dying prematurely in corridors
- A&E performance for December dipped to 85% and only 73% for type 1 units (equalling worst figures on record)
- One type 1 unit managing just 40%, with 75 waits of over 12 hours
- Exponentially increasing flu cases (with the worst still to come it seems)
- Senior managers discussing that staff on literally ‘on their knees’ trying to hold it together
I am guessing for many that this is not news so much as confirmation of what you are experiencing on the ground, daily. I also suspect that the isolated items of news, although completely consistent, are only the tip of the iceberg, supported by the release of more individual trust data this morning from North Bristol, showing 122 breaches of the 12-hour target in December and type 1 performance of 70.3%, its lowest ever. The most worrying aspect of this is that the conclusion of crisis is predominantly based on December and yet January is proving tougher still.
It is perhaps galling then that on the Andrew Marr show, when challenged about ambulances waiting hours to get into emergency departments and the reported death of an 83-year old who waited more than an hour for an ambulance despite having acute chest pains, Theresa May claimed there was no crisis and that “nothing’s perfect”. As Andrew pointed out, had he waited as people were now, he wouldn’t be here doing the interview, given his own stroke in 2013.
In the spirit of interpretation and guidance that these news bulletins strive to achieve, I think it is important to remember the following:
- It is going to get worse before it gets better (flu is only just really starting to bite and the system is over full already)
- There will be deaths that would have been preventable had this crisis been taken far more seriously at the top but now almost certainly are not
- There are limits as to what you can do without adding yourself to the casualty list
- In a crisis not of your making, you have to consider the degree to which you are willing to put yourself at risk (a bar that might be higher IF there was more immediate light at the end of the tunnel and in which a burnt-out doctor or nurse only adds to the crisis)
- Consider your own personal role and contribution in the crisis – know what to do!
I think that the two most important pieces of a advice are that it is the response by individuals and leaders that determines whether a crisis heads for recovery or towards disaster, requiring everybody to know just what to do, and that the commonest reason for progression from crisis to disaster comes from under-appreciating the pace and scale of a crisis until it is too late, requiring all to know just how to assess their true state.
2. WHEN THE MOST SIGNIFICANT NEWS IS NO CHANGE
This last week saw a fairly significant re-shuffle of the cabinet, with ‘almost’ all commentators convinced that Jeremy Hunt would be ‘redeployed’ somewhere else. As some will know already, I took the opposite view, which proved to be correct.
Jeremy Hunt not only got to stay but gained a wider remit to include Social Care, making him Secretary of State for Health AND Social Care, in what many are ‘now’ saying makes sense and in which I am again taking an opposing view. Why?
Well, firstly, across his tenure so far, we have seen the NHS descend into the crisis we have mentioned above, not helped by his very own handling of the junior doctor’s negotiations, the outcome of which he sees as a sensible model for Agenda for Change negotiations, affecting nurses, allied staff and most back office functions. When many suggest that this is the treasury, not him, I would point out that regardless of this being true or otherwise, whether it is ineptitude, hidden agenda or just being ineffectual, his remaining in post is unlikely then to result in a significant positive change. Why now?
However, my third element of reasoning is based on the very reason many think the new remit is a good idea. Surely, the merger of health and social care can only help solve some of the flow and integration challenges we see? Surely, the merger of health and social care budgets can allow sensible approaches to funding a pathway that spans both? All true in principle but in reality, there remains a finite amount of money that isn’t remotely sufficient for either. Unless that can be addressed the primary effect of formal ties in this area will be the flow of money from the acute end of the system to the social care end, justified on the basis that helping that end will benefit the other. Again, this is also true in principle (despite almost every ‘scheme’ predicated on reducing admissions failing to actually address admissions) but it fails to deal with the reality that the NHS, especially the acute sector, is already on its financial knees, now, today, at this moment, and thus any flow of money away from this, however ultimately beneficial, has the potential to collapse the acute sector in the short term (assuming it doesn’t anyway). Consequently, it only gets my vote as a good idea IF new money is found and as the season of miracles has just passed, this seems unlikely.
So, why did I call the re-shuffle the way I did, when almost everybody else saw it differently? My personal belief, based on observations over 15 years, is that Mr Hunt is in post to do what will ultimately be one of the least palatable, most controversial and politically riskiest manoeuvres of recent times – to lead a fundamental change to the premise and basis of the NHS, including its funding model, what is included and how it runs. I cannot possibly convey, in a simple news brief, the evidence-base and extent of signals that underpins that position, but my current best guess includes the following:
- Separation of emergency and elective, in terms of what is ‘traditional’ NHS and what becomes ‘new system’
- The growth of insurance to cover elective care, with some social support for those that can’t afford it (but with an ever-higher set of bars to be eligible, just as has happened in social care)
- Accountable care organisations effectively becoming a stepping stone to the above but also facilitating the entry of larger corporate bodies of the nature found in the US system
In effect, we are talking about a far firmer end to ‘universal and free’ in favour of a system that isn’t necessarily cheaper (the UK system being one of the most financially efficient systems on the planet) but is more affordable at the Government-level, even if not for the general population. At a political level, the alternative is an increase proportion of GDP devoted to healthcare, which in turn means less for other areas of spend, against a backdrop of Brexit and its increased short to medium term economic effects. Even if this were palatable, it ignores the reality that there is very little headroom to increase personal taxation.
So, Jeremy stays. He stays because the job he is there to do is not yet done. He is, for the most part, the architect of that plan. Eventually, when the corner is turned, he will be ‘sacrificed’ to alleviate political pressure and population discourse, at which point, his reward will come from whatever part of the new system he steps into when stepping out of healthcare. In my humble opinion…
3. RETIREMENTS & RESIGNATIONS
If there seems to be a trend at the top of NHS organisations, it is that senior people are retiring or departing. After a comparative quiet spell in this regard, recent times seem to have brought a raft of resignations and retirements. The question is whether these are individual New Year’s resolutions or individuals seeing or knowing something that is only now truly unfolding.
That many are retirements, rather than taking up new challenges is potentially significant, in that although many of these leaders have many years of service under their belt, with no ‘retirement age’ obligation, a decision to retire rather than move starts to feel like ‘enough is enough’. At a behavioural level, we would normally expect retirements to occur at distinct age points e.g. 60 or 65, or, when the potential direction of an organisation looks almost certainly downwards. If retirement on a ‘high’ (or at least not a low) is the underlying reason, then it does add to a picture of increasing instability. Regardless, the loss of experience is a risk to stability in its own right.
Recently, the following are of note:
- Helen Shields of Isle of Wight CCG chief (retirement)
- Dame Jackie Daniel, University Hospitals of Morecambe Bay Foundation Trust (to pursue other interests)
- Bridget Fletcher of Airedale NHS Foundation Trust (retirement)
- Sir David Behan, Chairman, CQC (stepping down to allow someone else to lead the next phase)
Watching this space will be important to see if a strong but prominent trickle turns into a stream.
4. GOVERNANCE OVERSIGHT AT THE OVERSEERS
One departure that has raised many eyebrows is that of David Allison, now ex-CEO of Wirral Teaching University Hospitals Foundation Trust. That departure was announced in December but was immediately followed up with stories of bullying, governance issues and more.
The announcement was that he would leave the Trust with immediate effect to take up a secondment with NHSI, after which, he would be redeployed somewhere closer to home. Although this sounds like situation normal for the NHS, it emerged that NHSI had been informed of concerns but had still offered him a secondment.
In an ongoing piece of excellent investigative journalism from Health Service Journal, it became clear that the trust’s director of finance, chief operating officer, interim director of nursing and medical director had previously raised serious concerns to the trust Chairman about Mr Allison and then, when no action was taken, a collection of directors blew the whistle to NHS Improvement citing both governance and cultural issues surrounding both Mr Allison and the chairman.
It turned out that Mr Allison had also taken up a position of special advisor with firm Draper and Dash, a software house focused on data and analytics, without informing anybody but then using his position to broker discussions and introductions. But… this is all ‘history’ albeit fairly recently, so why the feature in the news brief?
This last week, NHSI have announced a full investigation into the governance issues, as well as cancelling his secondment. Draper and Dash have also removed his offer of position, wriggling under the excuse that they expect their directors to follow all of the normal requirements for disclosure. But still, why is this significant news?
The primary issue at hand is that NHSI are investigating a potential scandal in which they are implicated, having sought to redeploy him and offered him a secondment in the meantime. They did this, in appears, having had very significant concerns already raised with them. My question – just who oversees governance failings when those that oversee governance failings are subject to suspicion that their own governance has been less than robust? It reminds me of the accusations of protectionism that surround Sir David Nicholson, when it emerged he had effectively been a pivotal figure overseeing perhaps one of the worst governance failings we have ever seen. It does seem like some things just don’t change.
5. DRAPER & DASH DISH UP A DAPPER NEW DIRECTOR
And finally, given we mentioned Draper & Dash in the previous article, probably a company very few have heard of, we thought it of note to announce the appointment of a new non-executive, in the form of a certain Jim Mackey. To be clear, there is no suggestion that this is in anyway suspicious or without proper declarations, but it remains noteworthy given his tenure as CEO, until recently, of NHSI and now as NED in the very Draper and Dash that David Allison was appointed to, not to mention both being ‘North Easters’, where David Allison was being redeployed to after his secondment.
We’re going to leave the news and interpretation right there though as this is a story unfolding but in which Mr Mackey may only be involved purely circumstantially, though the triumvirate link of Draper and Dash, NHSI and the North East, none of which, I would point out, is it either unethical or immoral to have on your CV!
Some Final Thoughts
I believe I started by suggesting that the emerging news at the start of 2018 was at the very least not boring. If this transpired in the first proper week back, I can only watch the NHS space with a degree of trepidation. I know this is a time of year when many are considering their options and those options are, of course, influenced by how they interpret their current circumstances.
I would urge caution. It’s just a week, however eventful that week may be. The direction of travel is more important than the precise circumstances in the moment. That direction is shaping up now and although it looks far from rosy, we need a little more time to determine the responses from leaders and the effect of those responses.
In the meantime, it is vital to ensure you don’t become a casualty out of blind commitment or a sense of hopelessness around alternative options. The secret to security is steady-handed, authentic, unemotional interpretation of the circumstances and their implications, something that I will continue to contribute to as best I can. Be safe.