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Critical News (Published 5th February 2018)

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Week Commencing 29th 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

So, it’s only just February and we have seen multiple degrees of crises in many different ways but this week it’s personal and by that, I mean much of the news has very personal implications, along with some far-reaching ones for both professions and system. However, it is also worth saying that it is a week of both good news and less good news depending on where you sit and for how long. That’s a condition that it seems the Government wants to use, both in contractual terms and quite possibly to address big funding questions.

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1. THE CONSULTANT CONTRACT

Undoubtedly the week’s most significant news was the provision of evidence to the DDRB supporting changes to the consultant contract. To say that it contains contentious issues is a wild understatement and it comes at a time of what could only be described as maximum disgruntlement amongst front line NHS staff coping with the pressures of a winter that some call unprecedented and others call expected but under-resourced. I will be releasing a special report on this item, given the significance but some key points need sharing in the spirit of our Critical News bulletin.

The evidence sets out some principles the Department of Health are adopting, including:

  • Negotiations are being had on a cost neutral basis i.e. no new money
  • In common with public sector pay in general, rises are to be tied to productivity improvements

The core implications of these are that for anyone to receive an enhancement to pay, someone, somewhere has to lose, either in pay or pension, or both. The DHSC states that no doctor will see a reduction in BASE pay as a result of this reform, which tells us much about how they are going to create a pay rise without a funding rise, especially when considered alongside other proposals. These include:

  • Scrapping Clinical Excellence Awards, in favour of a new, local scheme that makes short term awards
  • Awards to no longer be pensionable

Whereas the CEA system is anything but perfect, we cannot ignore that more than 25% of consultants have them. What’s more, although many will argue that the allocation isn’t always fair and objective, it can’t be ignored that those with them have been granted them for going above and beyond, or for achieving great things. It also disproportionally affects more senior consultants. A consultant on 9 CEA awards can look forward to this bit of the proposals taking a third of their pay and, given the pensionable, final salary impact, a third off their expected retirement income.

Given the 75% who don’t have CEAs, the Government appears to be banking on creating this change through division of the profession. The main thrust of the proposals is to rob from the salary rich to give to the salary poor i.e. utilise the savings from CEAs and possibly pensions (unconfirmed) to raise the basic rate of consultant pay and the speed (in theory, given the non-guaranteed nature of performance-related increments) with which you attain higher bands. Given the balance of haves versus have nots, it is likely to be carried but the impact on senior doctors could well be to precipitate a large-scale revolt and an increase in retirement or emigration. That skills drain may well prove catastrophic.

There are many other implications of the consultant contract proposals and I intend to have a full breakdown with interpretation and implications in the next few days.

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2. MORE MONEY, WITH STRINGS

The DHSC has announced the release of a further £540m in the 2018/19 financial year. This adds to the £1.6bn already announced in the budget, although the combined amount falls far short of the £4bn that Mr Stephens said was a minimum. So, is Simon Stephens winning his head on battle over funding by effectively holding the DHSC to ransom?

Well, the £540m comes with strings… quite tight ones. The primary targets for the extra funding are:

  • 9% growth in outpatient attendances for England as a whole
  • 6% growth in elective admissions
  • Significantly increased spending on mental health by CCGs

What I can’t reconcile is just how these levels of activity increase can be contained to a rise that is worth less than a half percent of NHSE’s budget. Furthermore, the DHSC is explicit – the provider sector must return to financial balance in 2018/19. Combined with activity increases, this looks very much more like financial fantasy football than careful planning, especially when we consider the following:

  • This year, the provider overspend is currently forecast to be £623m (over and above £1.8bn of STP funding)
  • CCG overspend is expected to top £500m too

This means that despite no spare capacity, a haemorrhaging of nurses, cancellations now rife, significant overspends in all quarters and more, the now £2.14bn has to negate the combined overspend approaching £1.14bn AND deliver all that additional activity AND increase provision of local mental health services, all on the ‘spare’ £1bn left. And that’s before inflation!

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3. IS DOWNING TOOLS THE RECOMMENDATION?

In a follow-on from the Hadiza Bawa-Garba reporting last week, the GMC has issued a letter to all doctors expanding the understanding around its own decisions and confirming that e-portfolio data was not used in the hearings. Its guidance centres around the responsibility that doctors are under to raise concerns about risk, safety and overload, suggesting that it is then the responsibility of clinical and trust leaders to ensure a safety.

I am sure that the clarification is gratefully received but does it address the true issue of personal vulnerability is an overwhelmed system? Moreover, the ‘calmly raise concerns’ mantra doesn’t adequately consider the context in which this care episode occurred. Whereas levels of staffing and demand have trends, this episode was more of an acute crisis i.e. sudden. Dr Bawa-Garba returned after maternity leave to a first day back melee. It would be easy to speculate that she never had time to calmly step back and consider the wider circumstances. What’s more, had she raised concerns, what was she supposed to do, right there and then, given any response takes time to enact and patients were right there with emergency needs?

This momentary difficulty was emphasised in a letter to The Guardian by the GP, Dr Antonia Moore;

Was Dr Bawa-Garba anxious about returning to work after maternity leave? Was she hoping to be reintroduced to work with necessary support in place? When she realised the consultant wasn’t on site, colleagues absent, IT down, did she consider saying “this isn’t safe so I’m going home”?

What would I do? I am working in a system that isn’t safe: no longer a balance of risk but a balance of least harm. I believe that if I refuse to work, patients will come to more harm because there is no one else to step in. But when I’m up in front of the GMC because of a mistake I’ve made, that will be no defence.

My concern is that state of ‘hopelessness’ will result in many more doctors ‘downing tools’ because they do not feel adequately protected and an increase of individuals feeling that they can no longer practice safely in the NHS environment at all. Far from criticising the GMC, ironically, they may well have protected far more doctors than they think by helping to create a groundswell of working (or not) to rule and exodus. I have long suggested that doctors are working at extremes of personal vulnerability, risking not just professional lives but also marriages, health and more. This case continues to validate that belief and the GMC announcement this week only emphasises it more. However, in being safe, undoubtedly the right approach, we cannot ignore that it precipitates a crisis impact – care not delivered – in a crisis that the PM, treasury, DHSC & NHSI still staunchly deny is there at all.

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4. AMAZON HEALTHCARE

Although far from fruition and ever further from here, this last week saw the surprising and intriguing announcement that Amazon is entering the healthcare arena, backed by JP Morgan and Berkshire Hathaway (the investment firm still led by the amazing and insightful Warren Buffett).

Amazon’s stated aim is to provide non-profit healthcare for its own army of workers, now topping 500,000, and is undoubtedly driven by difficulty in providing adequate healthcare at an affordable level, especially for lower paid staff. However, the immediate impact of the announcement was to wipe billions of the collective share pricing of US healthcare conglomerates, essentially because of Amazon’s propensity to disrupt existing industries.

I am personally intrigued by this because it is one of the scenarios proposed by Clayton Christensen, in his seminal work The Innovator’s Prescription: A Disruptive Solution for Health Care released in 2009, in which he predicts that the escalating cost of healthcare provision will stimulate new entrants seeking to disrupt traditional arrangements. It was always going to happen in the US first but if the model works, why stop there? What’s more, if anyone can marry technology and healthcare into a workable model, it’s a tech giant with a history of disruptive innovation in both technology use and the business models in which that sits.

Future concerns will surround the concept of a profit-making, publicly quoted company innovating in healthcare and potentially displacing providers. Whereas I doubt to many tears will be shed in the US over the most likely losers – traditional insurers – providers won’ t be beyond disruption either and that’s where such a move will raise red flags in somewhere like the UK. Given early experiences with Circle Health and mainstream hospital care, where the system itself seemed to work against their existence regardless of the innovations they sought to bring, it is only likely to show promise for the UK if the system itself demonstrates better readiness and acceptance.

Although that seems far from certain, the combination of this type of disruption and the NHS changes we are perhaps on the cusp of, could well herald a new approach to public healthcare delivered by private organisations. I can’t quite bring myself to believe that an organisation as disruptive and entrepreneurial as Amazon, backed by such business-focused enterprises as JP Morgan and Berkshire Hathaway, isn’t going to take a successful non-profit internal adventure into healthcare and turn it into a profit-making, highly disruptive external strategy. Definitely a space to watch…

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5. PROPOSAL TO HOLD A REFERENDUM ON FUNDING

And finally, this last week saw former deputy chair of the Conservative Party, Robert Halfon, suggest the introduction of a 10-year revolving referendum on funding of healthcare, including how much funding should be raised above inflation. Whilst still living with the aftermath of our more recent referendum, many will consider such a proposal needs far more consideration before enactment. However, the very proposal tells us a number of things, not least of which is that the treasury probably still has no real idea how to overcome the political trap that is to either allow the single most important political football to puncture and go flat on its watch versus lead a funding model or amount change that is likely to get them voted out anyway.

Regardless of the risks of asking a population with emotions and a very variable level of understanding around the complexity of issues a rather binary-type question, the suggestion carries much political promise. By asking the question of how much we should spend – £X, £Y or £Z, you have to also address the issues that £X can only support a limited system versus £Z something closer to now. Consequently, the population votes and the politicians are literally ‘forced’ to adopt the population’s wishes, as we have seen with Brexit, regardless of emerging consequences. A referendum is absolute in it findings. Brexit, for instance saw just arguably 2% of the population go ‘leave’ instead of ‘remain’, producing a 52% to 48% finding. From that point on, the clear political message is “the population has spoken…”

Far from revisiting Brexit, I want to raise the issue of such a close vote to ‘anything’. If you conducted a clinical trial for a new medication that showed a 52% chance of benefit, outweighed by a 48% chance of harm, good luck with getting that through the regulators, especially if there was any degree of confidence interval. That’s the binary nature of a referendum though. So, let’s consider this as a funding decision-making mechanism.

Firstly, a referendum would require universal voting rights. Given our increasingly aged and retired population who are unlikely to have to pay more, you could expect strong support for greater funding through a taxation-based mechanism. However, given that the taxation burden falls to the working population, and predominantly the middle and upper taxation groups, you might expect strong opposition too, from payers who are not currently users. If the question proposed was that it would cost more for the majority, given years of austerity and a rather hypocritical tendency in the UK to demand more just as long as ‘I’ don’t have to pay, the likelihood is a no vote.

A ‘yes’ vote increases taxes and a ‘no’ vote limits service provision, presumably increasingly around full cover for emergency and acute needs with decreasing cover for elective care. An intelligent Government would take the opportunity to propose how you may maximise care within a given funding envelop and if you were really cynical, you could envisage a discussion that centred on a new hybrid system that created an insurance-based system for elective care, paid by those with ‘means’ and provided as a ‘social security’ measure for the elderly and poor. Essentially, you could pretty much rig the outcome to support your policy intentions…

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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.

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