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Critical News (Published 22nd January 2018)

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Week Commencing 15th 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!

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QUICK PERSPECTIVE

In breaking news, a good news story ‘almost’ made the fold this week in the form of breakthroughs in providing a single universal blood test for many cancers, work progressing by Johns Hopkins University. However, its inclusion in the top 5 would have meant dropping one of the following cluster of less good news, the absence of any one of which have resulted in the synopsis departing from its core aim of ensuring you know the MOST IMPORTANT things that transpired in the previous week. So sadly, not many glad tidings. Sorry!

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1. CRISIS CARRIES ON

The flow of crisis news abated somewhat this last week but it is clear that the crisis has not, as the fall out starts to emerge.

In a continuing spat between Public Health England and CCGs, the start of which was PHE/NHSE purchasing the cheaper trivalent vaccine instead of the more advised quadrivalent form in a season predicted to be tough and in which the less-covered B strain of influenza is particularly prevalent, a number of CCGs are choosing to defy PHE guidance on using Tamiflu.  Their justification is that there is a highly questionable return on investment, but there is an underlying suggestion that the guidance reinforced by PHE this week in a letter to all CCGs is a panic, cover-your-rear reaction out of realisation that they have perhaps contributed to a gargantuan crisis this winter by being penny rich and now pound poor.

Besides this almost side observation, the two more central items of note are the unfolding financial calamity at the hands of the winter crisis, along with an indicator of its true extent or depth in some regions. Starting with the latter, the Greater Nottingham health economy declared a major incident due to overwhelming demand and an absence of beds resulting in extremely limited flow and discharge from hospitals. The disruption to ‘business continuity’ is resulting in them taking extraordinary measures to restore safety and flow. Another way of considering this is that a true crisis response is kicking in and thus a consequential financial hit too, as 75 extra community beds are commissioned in a rush, with 45 more to urgently follow. It is very clear that this is not a situation they have the monopoly on but everybody else seems to be currently too overwhelmed to write it up!

On cue, NHS Providers, representing most NHS trusts, indicated to NHSI that their members are experiencing a very significant financial hit at the hands of 55,000 cancelled elective procedures, as well as extra costs associated with coming with demand. They have called on NHSI to relax its rules around use of agency staff and do more to assist providers, who are clearly not going to meet their control targets. This call for more emergency measures comes on the back of their call to Government to increase NHS funding to £153 billion by 2022/3, a sum the Office for Budget Responsibility said was needed, given projected increased demand for services.

So, to summarise, we sit in the midst of quite possibly the worst NHS crisis in most people’s working memory, with a £33 billion gulf between actual funding and true demand cost, with a DH and a PM saying “what crisis?” and the Treasury saying “what spare cash?”. It feels very much like the prediction in ‘Our NHS is Crashing’ is coming home to roost and this may well just be the point at which it lands. In reality, with the mutterings coming from Jeremy Hunt, his reappointment to a wider remit role and warning sounds from various committees, we are almost certainly seeing the pinnacle of what I described as intentional decline and thus the start of a new system. The steps to that system may well also involve a new tax or ‘levy’ but given the population’s current rebellious attitude to austerity, this itself might just be part of the process of justifying an alternative funding model, based perhaps… on Jeremy’s book!

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2. TURNAROUND PROGRAMME GETS TURNED OVER

In a move this week that many have cheered and, not entirely surprisingly, I see differently, NHSI cancelled the next wave of its financial turnaround programme that sees consultancies parachuted in to Trusts departing from their control totals. The cheer comes from the brigade (a large one) that believes, not unreasonably, that these consultancies do not add much value. However, it’s the message, not the move, that has me concerned.

Only months ago, NHSI was shouting out how much of a difference this programme was making to the Trusts taking it up. Even a few Trusts lined up to say that they had found it helpful. So, it raises a question of why then cancel it? The following spring to mind:

  • The benefits were overstated, and thus it wasn’t value for money
  • Even if the benefits are valid, we can’t afford the cost
  • NHSI might be stock-piling its own savings to cover its rear at year end
  • We’re about to see a sea-change that makes the programme irrelevant and thus improper to be spending money on

I don’t like the implications of any of these. The first would mark a travesty in openness but more sadly a loss of hope because the programme could not produce a benefit. The second suggests we are in such a dark place financially that we can’t even afford things that apparently improve that financial position. It is entirely possible that NHSI are avoiding anything that constitutes a spend in preparation for saving its own rear end as the winter crisis turns into a financial calamity. That this would be the utmost in penny rich, pound poor should come as no comfort to anybody, assuming the programme was working (and if not, return to point 1 where all hope is lost).

The last suggestion represents a hypothesis that we are on the cusp of a system change, in which spending on consultancy for programmes that will never see the light of day or get abandoned part way through, ceases because their futility or redundancy is already known by those commissioning the programme. Whereas this would seem like a very reaching conclusion, it would have to be taken together with a renewed renewal of Jeremy Hunt, his wider remit to include social care, a new longer term appointment at the helm of NHSI and the apparent disintegration of the relationship between NHSE and the DH, along with the suggestion that NHSE may well get ‘merged’ with NHSI. Major changes are afoot and the very fact that they aren’t explicit gives us clues to their magnitude, controversy and, ironically, immediacy.

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3. HAEMORRHAGING HEALTHCARE PROFESSIONALS

In another apparent miscommunication, it seems we don’t in fact have a plan to fix nursing numbers, in a workforce crisis that took a massive turn for the worse this week.

In figures provided to the BBC by NHS Digital, nurses leaving the NHS has risen 20% since 2012/13, peaking last year at 33,000, representing one in 10 now leaving the NHS in England each year. Besides leaving providers even more bereft of this essential workforce, it also means there are now more leavers than joiners, rather destroying the argument that a.) we have a plan and b.) there are more nurses than ever. Nurse leaders said it was a “dangerous and downward spiral”, but despite the figures, NHS bosses said the problem was being tackled.

The wider implications of this are both obvious and less appreciated. At a time of rising demand, everybody gets that fewer nurses undermines any chance of really coping with it. However, in my mind, the bigger issues surround what it means and what it will do. Fundamentally, it means that the NHS is not improving its retention of nurses and thus existing nurses, with experience, are reaching the point of having ‘had enough’ at a greater rate than ever. We have to be clear, this is NOT a 10% jobs turnover, in which nurses move to other Trusts. This is LEAVERS i.e. retiring nurses, emigrating nurses and nurses that presumably see other professions as far more palatable and perhaps lucrative.

In terms of the impact, it pitches into a tighter downward spiral in which the very existence of the problem worsens the problem in almost every regard. Unfolding, it might look like this:

  • The leavers rate signals that nursing is no longer palatable
  • We lose senior nurses with huge experience and backfill them with junior ones, more slowly
  • We further lose both capacity (net numbers) and capability (net experience)
  • The existing, experienced workforce, even more overwhelmed, reaches ‘had enough’ point too
  • The spiral accelerates…

The relaxing of nursing numbers in training by cancelling the bursary is a simplistic approach to restoring nursing numbers because at very best it replaces senior with junior but fundamentally fails to address the problem that nurses are seeing nursing as no longer palatable. The removal of the bursary will hardly add to the attractiveness of the profession, given the headline suggests “gain £50,000 of student debt so you can work in an unpalatable profession with an overwhelming load where the existing nurses are leaving at a rate of 10% per annum!”

My major concern is that figures like these support my hypothesis of a point of no return i.e. we reach a point where the problem is in charge and we can’t remotely afford the solution. The impact has a knock-on effect on doctors and we might just have to get used to the idea that there is no good outcome and thus disaster mitigation becomes the name of the game. That’s the sugar-coated version, by the way.

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4. AMBULANCE SERVICE NOT TO THE RESCUE

Arguably simple a part of the wider winter crisis, this week saw a whistle-blower attribute 40+ deaths or harms to ambulance performance failures in East of England, including 19 due to delays. Sadly, this will come as no surprise, but it remains a highly significant news item, not least for the families of patients who were let down.

The significance arises when seen alongside what we already know. To ensure that is crystal clear, it includes:

  • Patients dying in corridors, unnecessarily
  • 12-hour waits escalating at an alarming rate, considered blow out in some places
  • Ambulances waiting 5+ hours to even drop their patients off
  • Staff on their knees
  • Health economy-wide major incidents being declared

The message is very, very clear, this is a system at implosion point. In crisis terms, this is the point at which a crisis has clear potential to turn into a disaster and is the point at which it is critical the situation is treated as such or the attitude itself becomes part of the problem. The problem the NHS faces is that the leaders who carry the most weight of conclusion remain firmly of the view that this is not a crisis, we are well-prepared, and all is going according to the new winter plan.

The reality that this news item illustrates is completely different. There are bodies. The rate of news on ‘bodies’ is accelerating and there is a danger of repeating the UK-equivalent of the Ebola crisis, which only turned a corner when there was sufficient acceptance of the likelihood of it becoming a disaster and thus a sufficiently crisis-appropriate response. It is possible that the crisis feeds into the hand of a Government considering a system change but that’s no consolation to patients or staff. It is imperative that everybody knows what to do to limit bodies and it isn’t just ‘work harder’, which will likely add staff bodies to the patients ones – much akin to killing off the pilot in a plane in trouble… then what?

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5. CARILLION CAREERS OFF THE RAILS

And finally, I am sure it will have escaped nobody that Carillion, the huge provider of construction, PFI, hospital facilities management and more went into liquidation this week, following previous multiple profit warnings and failed attempts to renegotiate overwhelming debts.

The functional news is that it calls into question many existing contracts and partially-built projects and we will have to wait and see how that is handled. A number of hospitals have already announced they are commencing contingency measures.

The more scandalous aspect of this collapse is the continued awarding of projects to Carillion after it announced profit warnings and concern was raised over its stability. The existence of a ‘gravy train’ is challenged by very few, save for those very much a part of it. However, it seems that a gravy train might be attractive to some but it sits in a gravy boat that eventually just sinks, at tax payers expense and at a time in the NHS that couldn’t be worse.

To add a commentary to the calamity, I have long warned that part of the problem is that NHS suppliers get squeezed to the point of non-viability, a situation made worse by extending payment times too. Eventually these suppliers break and the cost of sorting out the chaos is invariably far more than paying a decent contract price in the first place. The suggestion is that Carillion was more gravy train darling than a casualty of this issue. However, this issue will have undoubtedly have contributed to the demise, as well as being fundamental to the lack of possible rescue – if there’s no money in the contracts, who will want the Carillion remnants? If the NHS wants its work completed… it’s going to pay dearly.

We will continue to report and analyse as we know more.

 

Some Final Thoughts

The second news synopsis at the start of 2018 has not allayed any fears arising out of the first. Whereas the early news was about coping with the operation side of the crisis, we are now seeing the financial component kick in and the workforce component, long suspected despite ministerial reassurances, confirmed. We hear talk of talking ‘up’ the NHS. I am not a fan, in much the same way, despite appearances in this news report, that I am no fan of talking down either. Realism is the required approach. However, when the realistic position is genuinely a crisis on the point of a disaster, that realism is going to look awfully bleak.

In terms of guidance, I am going to repeat what I said last week. 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. There comes a point where everyone has to consider their circumstances realistically. It’s not a failure. Failure is to allow somebody else’s failure to acknowledge or address the reality to become your own personal crisis at a health, marriage or well-being level. We are losing precious professionals at an alarming rate. Burnt out ones don’t help, and it might just be better to have people ‘do what they can within sensible limits’ but remain than burn themselves out and go. That doesn’t make the decision any easier and that much I do appreciate. So, be safe.

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