Week Commencing 22nd 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!
If last week was all about a FAST crisis then this week is far more sedentary. It’s not that the news is any less significant, but it doesn’t appear to be quite as acute. That will present itself as ‘good news’ but in fact there is a spanner in that sparing in that we tend to sit up and take notice of the train leaving the rails but largely ignore the rather more boring items about the state of the track. The latter is the root cause to the former but the behaviour that averts the calamity is taking notice at a root cause level and acting. So, will you read or just relax?
1. SHOCK RULING WITH MASSIVE IMPLICATIONS
In what I fear is an outcome with untold implications, this week saw the striking off of Dr Hadiza Bawa-Garba, after the GMC went back to the High Court to over turn a tribunal ruling that she should be suspended from the GMC for 12 months, rather than being struck off.
Dr Bawa-Garba was convicted of manslaughter over a death of a six-year-old boy who died at Leicester Royal Infirmary in 2011. At the time, Dr Bawa-Garba was a specialist registrar in year six of her postgraduate training (ST6) and had recently returned from maternity leave. This was her first shift in an acute setting and she was the most senior doctor covering the Children’s Assessment Unit (CAU), the emergency department and the ward CAU that day.
What was largely absent from the official narrative was that she was effectively also covering for 2 of her colleagues with no consultant cover, as well as covering 6 wards over 4 floors, taking GP calls, surgical referrals etc., on her first day back from maternity leave, with no induction and a non-operational computer system. By any other description, this was a day of crisis not of her making but one that is increasingly common across all manner of hospitals today. It appears that her willingness to ‘step up’ or ‘stand in’ has been rewarded with a manslaughter charge, a suspension and now striking off, suggesting that she was to blame and the system in which she was placed was not.
This issue has MASSIVE implications, not least of which is concern that reflective writing from her e-portfolio was used in evidence in a crown court case that found her guilty of manslaughter by gross negligence in 2015, a fact that has caused assessors to advise against being so open in reflective portfolios and which quite possibly negates 10+ years of improved openness around safety and errors. What I am most worried about it what is means for doctors working in over-stretched departments.
The implication is that those doctors exhibiting the most commitment in times of crisis also place themselves in the firing line for manslaughter and a loss of their professional livelihood. I don’t think any could be blamed for starting to think “it just isn’t worth it” in a problem that is not of their making. This is an issue that I have warned about for some years now and was the subject of my conclusions last week, before this case re-emerged. What this case does is add a level of validity to that concern that is just unignorable. However, the loss of this discretionary effort could well also be the straw that breaks the camel’s back because that effort is perhaps the only glue in the system still holding together. If it goes, the house of cards comes tumbling. I can’t really put it any more gently.
2. FINANCIAL REALITY STRENGTHENS
It could be argued that the NHS financial reality is exactly the sort of ‘rotting rail track’ that it is so easy to ignore. There’s always a bad news story, always a Trust saying it’s in trouble but THAT’S the point. It’s additive. In the same way that 1 Ebola case doesn’t constitute a catastrophe, there comes a point, a tipping point, where we have so many that it is unrecoverable without major destruction along the way. It’s almost impossible to state that point predictively and far, far easier with hindsight. But I think we are there… at least in the eyes of the DH and NHS England.
NHS Property hasn’t had its budget agreed. That’s now holding up capital works that have effectively been agreed. An example is the redevelopment of Whitby Community Hospital which is on hold due to capital uncertainty. Of course, it is not the only project effectively stalled but the stalling of such projects is actually creative of more downstream problems, as increasing demand becomes increasingly unserviceable. In much the same way that workforce crises take years to recover from at the point of recognition and intervention, capital projects cannot be ‘caught up’ very easily.
We heard this week also that long-troubled Portsmouth Hospitals has redefined its financial forecasts from a £10m surplus to a £37m deficit. This is a double-whammy for the DH, as the surplus allows it to flatten out deficits elsewhere, whereas a deficit here now means covering that £10m elsewhere too. The growing scandal, which raises its head here again, surrounds the accuracy or indeed honesty in forecasting. It is, of course, largely somewhere between a sham and a fantasy, one deliberate and the other delusional.
The basic sequence of fantasy finance involves the following:
- The system/NHSI/DH sets in motion a dangerous set of incentives that ties funding, through STP, to achievement of financial milestones
- It then literally requires trusts to ‘sign up’ to targets called control totals, which collectively add up to what the DH would LIKE the national accounts to show
- Trusts produce forecasts increasingly from the end result backwards, which arguably is not a forecast, such that they make their budget fit the end result, not their forecast a function of demand and costs
This situation results in a fantasy from the start but is dangerous in an extreme. We have to remember that the STP funding, which almost no trust can manage without, is contingent on hitting milestones but the reality doesn’t match up to the forecasting fantasy. So, what is a trust to do?
What they tend to do is move hell and high water to hit their financial targets in the early quarters, securing a proportion of their funding, and then declare a sudden, unexpected variance later in the financial year, frequently accompanied by back end requests for operating funding to keep the lights on. The state of the track is therefore assessed by the number declaring variance, the degree of variance and how early they allow the illusion to cave in. Let’s just say this year, it started early, ramped up fast and the variances, such as this one – a £47m variance declared in quarter 4 – are huge (and which follows Kings, Lewisham and a host of others).
The effect is toxic. Whereas it is very clear to many that the problem has its genesis in the behaviour of the DH and NHSI, who set conditions, incentives and control totals, in joining in that game, trusts place themselves in the firing line and more distastefully, allow the DH and NHSI off scot free. How so?
Well, as an example, they delay setting capital budgets for NHS Property because they know they’ll need the cash when the fantasy becomes reality. Money is used to provide loans to struggling trusts so that they can pay the wages bill and then, when the poop really hits the ventilation system, sometime in quarter 4, they are ‘forced’ to make capital to revenue adjustments to help balance the DH books. And who is in trouble? Well, as illustrated so well by Kings, it’s the trusts that take the blame, for poor financial forecasting and management. The DH holds it head up high and says something to the effect “well, I was going to fund capital projects but you trusts messed that up by not delivering. It’s your fault, not ours!”
The reason why I think we are reaching that tipping point of no return has been explained in previous editions but includes, as a reminder:
- Cancellation of the financial turnaround programme third wave
- Statements by both Jeremy Hunt and Simon Stephens
- Increased ‘chatter’ about a tax levy specifically for healthcare
- The wider remit of JH, to include social care
- The degree of financial imbalance now existing across system parts, including both providers and commissioners
- The almost complete cessation, even though described as temporary, of immediate activity towards Accountable Care Systems, suggestive that we are on the eve of a major system change – the calm before the real storm
We’ll continue to monitor but my advice is to take even more notice of more financial news, not less, just because it is so common it is boring. Think of it as a raised system CRP. It isn’t definitive in its own right but you should get more and more worried the longer it lasts and the higher it gets…
3. CATCHING UP ON FLU
I am going to call this a good news-bad news story. It might actually be good news for us.
This week’s flu report seems to indicate at least a plateau, if not a slight reduction in system onslaught. It remains well above the seasonal norms and far in excess of last year but we may, just may, be approaching a point of improvement. The concerning component is that care home cases remain extremely high and that has implications for both admissions and deaths. We’ll need another week of sustained improvement to start breathing a sigh of relieve though.
In data taken from the weekly flu monitoring reports from Public Health England, ICU/HDU admissions seem to have pulled back slightly into ‘high’ territory, rather than ‘very high’ where they’ve sat since Christmas. What’s not discernible though, given the almost entirely ‘full’ status of ICU across the country is whether this is due to a lowering of true admissions or a sheer lack of available capacity. The former would indicate a turn, the latter might be a risk factor for increased deaths due to system overload. Ultimately, it will be time that gives us that answer, along with a few more situation reports that come hopefully from PHE and not from the wider media (who would find an increased death rate far more interesting.
The US reports this week that their flu season represents the worst outbreak since the 2009 swine flu pandemic. Thirty-seven children have died so far and nearly 12,000 patients have been admitted to hospitals nationwide. It’s possible that cases could surpass 2014-15, when 34 million Americans fell ill, says the US Centers for Disease Control and Prevention (CDC). In that season, 710,000 people were admitted to hospital and 56,000 died. What’s apparent too is that deaths are occurring at a higher than expected rate in children and fit adults but with the continued trend of ‘in individuals not taking the vaccine’. There’s been a huge question over vaccination effectiveness this year and this has led many to ‘not bother’, ignoring the obvious issue that the vaccine influences severity, not just likelihood.
4. MORE WORKFORCE WARNING SHOTS
As if to add even more woe to workforce data that is positively scary, the DH thought this week was a great opportunity to have another go at Agenda for Change staff, which includes those nurses already confirmed as leaving in droves, in a news item I covered last week.
In evidence provided to the pay review body, the DH said that trusts continue to operate ‘virtually automatic’ increments and that this is creating an annual cost pressure of £600m. We already know that the Treasury has indicated it ‘might’ be willing to give a pay rise in exchange for AfC reform, which obviously includes the removal of automatic increments.
It could be argued that this is not really new news and in that I would agree. However, I think the real news is that they should do this at this very point – maximum crisis and on the back of released figures showing we are haemorrhaging nurses. It’s not the news itself so much as the message it is sending. If I was TRYING to increase the exodus, this would seem like the perfect action to take.
So, let’s remind ourselves of what seems to be happening:
- We’re haemorrhaging nurses
- Doctors are getting struck off because of mistakes inevitably caused by system overload and insufficient support
- Many GPs are giving up trying to recruit because the activity is now seen as pointless
- Practices are handing back their keys at ever higher rates
- Nobody is getting a real pay rise
- The demand continues to increase unabated
In that context, the release of this messaging right now would seem at best an amazing leadership failure and at worst, possibly, a deliberate attempt to increase system destabilisation as a means to an as-of-yet unspoken agenda that requires system collapse to bring on stream. But what does that mean for each of you?
5. SOCIAL CARE SALARY CATASTROPHE
And finally, we are approaching a new tipping point in which many social care providers are on the cusp of bankruptcy due to the ruling that night time care has to not only be paid at minimum wage, as opposed to a flat rate £30 night time fee, but it needs to be back dated, costing an estimated £400m that just doesn’t exist in the system. This is on top of the £1.3bn estimated to be essential to stop the imminent collapse of social care.
That individuals are paid appropriately, given the low wages throughout social care, seems to be a sensible decision. To thrust it onto a system at breaking point, without additional support, looks like a decision wildly disconnected from any consideration of its effects. The cascade is likely to be:
- Domino-like collapse of smaller providers
- Disappearance of social care capacity at the time we need much, much more
- Significant deterioration in discharges from acute care
It’s very difficult to see this turning out well as there is a well-known business saying “cash is king” and there just isn’t sufficient cash in the system to cope with a £400m hit. What we have to appreciate is that social care providers are almost all private companies. They do not enjoy the effect crown protection that NHS providers have, so when the cash runs out, so does time – they go into liquidation and it is immediate.
Some Final Thoughts
In terms of guidance, I am going to repeat what I said last week and the week before. It is vital to ensure you don’t become a casualty out of blind commitment or a sense of hopelessness around alternative options. However, this week the guidance must be considered in the context that a committed, previously high-flying doctor has become a permanent casualty in large part out of that commitment and continuing to do her best. That commitment has to be balanced by protection. This week suggestions it isn’t there and that should leave lots of doctors very, very worried.
Ultimately, 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. As I have said before, 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, well-being and now manslaughter and struck off 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. It’s definitely preferable than a clear message that no matter what the pressure and lack of support, you shoulder the risk personally. That can only make medicine less attractive and thus the likelihood of resolution even more absent. Of course, it doesn’t make the decisions any easier and that much I do appreciate. So, be safe and perhaps now watch your back too.