NHS News and Comments by Mr R Lilley

Don't know what to say...

The young woman stood, sentinel, eyes fixed on the wafer-thin man in the bed.

The crisp white sheets stretched across his chest.  He hadn't moved since the nurse tucked them in.

All night the woman had watched as death's door inched open.  The only privacy, a curtain between them and the ceaseless clatter of a busy hospital ward.

As the the dawn crept across the frosted glass of the window, the old man breathed his last.  In a fleeting moment, he was gone.  

The woman's tears splashed onto the linen.  She was lost in her thoughts.  Memories of her dear Dad; a cocktail of holidays, uni, birthdays, regrets... 

Suddenly the curtain swished open; 'Everything all right... cup of tea?'

It took a while for the interloper to capture the scene, a moment to realise.  Like the man, the moment was gone.

The man had died in the care of our NHS.  Well beyond his three-score-and-ten.  

A tribute to his tenacity and loyalty to the years he had cared for a wife with dementia.  

Doctor's appointments, hospital transport, tests, waiting for results, nursing homes stinking of urine, untrained staff, muddles at the pharmacy, weekend emergencies.  Telling their story time and time again... each time to another stranger.  Getting a wheelchair, handing back walking frames.  Carers late and unreliable...

A whole system that, at times, seemed designed to keep people out of the system.  Make it incomprehensible, difficult.  You have to be determined to be an NHS customer.

Three months earlier, the man had buried his wife.  Now he was going where he wanted to be... with her, once again.

I heard this story from his loyal daughter.  A single mum with a responsible job.  A manager in the NHS.  

Over a Costa she took me through her story.  She was diligent, careful not to trash the NHS... but horrified at what she had seen and her parents had endured.

All of this was in the back of my mind when I tried to track down my neighbour.  I generally keep an eye on her but I'm on the road this week.

As I left for the train station I popped in to find her distressed; a painful foot... difficult to walk.  

Already she struggles with a walking frame. 

She didn't want to go to hospital.  

I left but called, to check with her at 6pm.  The carer had arrived, the leg was swelling... an ambulance called.

I discovered the next morning, 14hrs later, the ambulance was still to arrive.  

Ambulance control had called to check on her through the night.  Cautioned by their advice; she had not eaten nor drunk anything for all that time.  Somehow she managed, unable to reach the toilet...

As I write this, I still don't know what will happen.

Two stories of the work of our NHS. 

I don't know what to say...

-oOo-

Up-date:   

My neighbour has a broken ankle and is recovering in the community hospital. 

The ambulance service tell me they get to Tier 1 calls but the numbers mean they don't get to Tier 2/3 anything like as quick as they want to.  They are forced, by staffing and resource issues, into making priority decisions that none of us would want to make. 

The NHS manager cremated her dad and scattered his ashes along with his wife, in their garden.  

I still don't know what to say...

Have a good weekend.   

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Take the hurt out...

I've had my first invitation to speak at a 'Ten Year View' conference.  I've said 'yes'...   I've no idea what I'll say!

We know, big change is coming.  We know the NHS environment is going to get tricky... we'll need to be pretty clever to figure out how we move forward.

I'm guessing 'change' will be ambitious.  The kind most of the NHS is unprepared for and might resist.  Vested interests and ignorance... the twin enemies of change.

Three key areas; primary care is collapsing, community care has to be beefed up to keep more folk out of secondary care and outpatients... the last relic of a sixties health system.

The role of the smart manager is to start thinking about how we prepare our colleagues for what happens next.

What happens next?  I can guess!

Primary care?  By common agreement, shortage of staff and demand tells us change is needed but everything I've seen suggested is resisted.  GPs are throwing in the towel.  There is no point throwing more money at it. It's likely to implode. And, there's a +40% drop in community nurses.  Everything outside hospital is falling apart.

We have no workforce plan but I'm pretty sure the workforce will have to look different.  That means trained differently and re-skilled.  We need to start learning that coaching beats teaching.  I can see no value in HEE, they've had their chance.  We need a new agency.

We've no digital strategy but I know the management of patients by the use of technology is inevitable.  The whole sector needs a clear out.

We know outpatients is both a money-sink and an income generator.  A whole new approach needed.  Who has a plan?  Doctors buying stuff from doctors doesn't work... they just 

keep buying the same stuff.

We could start with some basic rules about change;

  • Respect the past and take the best of into the future.
  • Change is simple when we think we are in charge, so include people.

If you want to make real, radical, smack-em-in-the-eye, change, there are four things you need to think about.

A narrative; spell out what are you trying to change and why.  Create a compelling case for change.  What is it?  Saying; 'there's no more money' and 'do more, cheaper' is not what I have in mind.

Be honest about what you don't know;  be frank, ask the people doing the job.  Ask them what to do faster, cheaper, safer.  Share their good stuff and avoid reinventing the wheel. 

Make it personal; planners may want change... but... the people doing the change will want to know; 'What's in it for me?  If I'm going to change the way I work, how does it make my life easier?'

Respect complexity; there are 70k ways for the human body to fail, 13k organ systems, 6k drugs and 4k surgical procedures.  No one knows everything but ... nuts and bolts are as valuable as ideas.  Boring things save lives and money.  In the scramble for change, don't forget the detail. 

People only see their bit.  You come to work and do your bit as well as you know how but you won't see the bigger picture.  How will you know there is a better way, better outcomes in another country, another county, another place just up the street?

Or, you may be the best and no one knows how good you are!   

That's why data is vital, transparency crucial and sharing ideas the only game in town   

...and, if we are to change to a data-future it can't be weaponised, used to attack, list and grade people and places.  Data is a fulcrum point and keeps us safe.

I'd guess, most people come to work, do their bit best they can, go home, come back and do it all again the next day.  They have family, kids, shopping, holidays, birthdays, stuff to do and bills to pay.  The big picture is something they don't see but they are expert at their bit.

When people realise how vital their bit is and want to improve it, they own it and we might get the NHS marching in step and that is the big step change... if everyone hears the same tune.  Can you hear it?

What's the simple compelling change message?

We are getting older and sicker and we need to get cleverer and more innovative.

That's a start.

We are working in analogue and the world is digital.  We must open our minds to a safer, quicker, more efficient future.

That works.

Make sure your bit is as good as it gets and share it.

Yup, I'll buy that.

The way we've done stuff, the way we've learned, the way we've been paid, the way we feel comfortable may have to change.

That hurts...

It's the clever manager who makes a plan and takes the hurt out of change.

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Don't come out too badly...

Why should a company that provides the software to run GP records be interested in my attitude to privatising the NHS?

Using their Patient Access platform, EMIS have emailed patients, with a 79 question survey.  Three hundred thousand people are being asked if they'd like to pay ten quid a month to jump the queue at the GPs. 

Patient Access is an add-on to practice software that allows you access to your records, repeat prescriptions and making appointments... if the practice approve.

Why do EMIS want to know about my views on the NHS?  Once they have accumulated the information, what do they intend to do with it?

I can envisage they could segment some of it because, in order to register with Patient Access you have to supply your date of birth and address.  

And, of course they would probably be able to correlate that with the number of GP appointments you have, the drugs you take and even, what's wrong with you.

A cornucopia for political parties, researchers, advertising and IT companies and insurers.  Data, the new oil.

300,000 people is a chunk of opinion.  The work has been funded by Patient Platform Ltd, which operates Patient Access as part of the EMIS Group.  

I'm not sure I knew, or anyone else for that matter, that my email address could be hawked around the EMIS group?  

Aren't there rules about the use of data?  I thought data could only be used for the purpose for which it is collected?  

Why are they collecting my data?  No one does anything for nothing.  How are they going to make money out of me? 

According to the GP trade magazine Pulse, who broke the story, Jason Keane, chief executive of Patient Platform Limited, which runs Patient Access, said: 

'This survey is part of ongoing work by Patient Access to understand more about our users and their attitudes to healthcare, to enable us to better serve them.'

I'm not sure how EMIS can 'serve me better'.  Or does Jason mean how GPs can serve us better... like getting us to stump-up a tenner for ten minutes of their valuable time... one of the questions in the survey.

I'm pretty certain EMIS wouldn't be daft enough to break any data protection rules... they'd be crazy.  But I do think this gets data protection a bad name.  

Moreover, in these sensitive times about the use of data; might give EMIS a bad name and more important, the GP practices who use EMIS, a bad name?

I wonder if any of the LMC's knew about this?  I wonder how many GP practices knew access to data and patient attitude surveys was part of what they bought into?  Perhaps the GPs are being paid?

For me, this raises a lot of issues...  

I think it's ill-judged, skirts the edge of what might be acceptable, threatens reputation damage, raises questions that must be answered, deflects EMIS from their mission of the safe and confidential custody of our information and I think it looks exploitative and sharp.

Apart from that EMIS don't come out too badly. 

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Respect them...

Who runs the NHS?

There's a joke; 

'... the Martians decide to copy our NHS.  They landed on Gappelter Common, Bromsgrove, for some fact finding.  

'Take us to the leader of the NHS,' they demand of a startled, passing, community nurse.

Confused, she couldn't decide where;  NHSE, NHSI, CQC, NHSD, DH+?  Fed-up with waiting for an answer they flew off and joined Bupa.'

No one knows who runs the NHS.  One thing is for sure it isn't NHSI.  

York Teaching FT are about to start one of those VAT-fiddle companies, transferring hospital staff into it, with no choice.  This wheeze has caused all sorts of rows.  NHSI stepped in and called a halt.  Or at least, a moratorium.  York are waving a metaphorical two fingers at NHSI and are going ahead, anyway.

There is not a lot NHSI can do without changing the regulations.  FTs are semi-detached organisations, free to do as they please. 

The FT brand is pretty-well dead.  As far as the public are concerned; a hospital is a hospital.  But, FTs do have some operational freedoms.

What is the attraction of setting up companies to manage back office functions?

Trusts spout some hocus-pocus about the companies are 'free' to take on extra work and make money.  They claim there'll be less bureaucracy, pay rates can be changed and pension contributions abated.  Plus, some health and safety training can be circumvented.

The truth is, most of the freedoms Trusts claim for these schemes can all be achieved without 'off-shoring' their activities. 

The big attraction; the VAT fiddle.  It's complicated.  

Trusts are exempt from VAT.  That means they can't reclaim VAT on things they buy.  It sort-of means Trusts pay 20% more for stuff than commercial comparators.

Shifting services to the VAT-fiddle companies means work still gets done but there are savings because 20% VAT is claimed back.

There's about £2bn at stake.

The Treasury says Trusts have the cost of irrecoverable VAT factored into their funding... 

The Treasury are also pretty clear on tax-fiddles.  Their guidance (Box 2.3) forbids; unusual financial transactions, eg imposing lasting commitments, or using tax avoidance 'unusual schemes' or policies using novel techniques.  That looks pretty clear to me.

The pressures Trusts are under, to conjure savings, makes the attraction of these schemes understandable.

The Treasury could change VAT rules but that might have wider implications I can't think of.

For me, the real concern is the people.  I've had several emails from time-served, NHS folk who do not want to be shipped out of the NHS as part of a tax-fiddle.  

With TUPE, their status is protected.  But, if the organisation was subsequently sold, they may not be.

As hard as some boardrooms may find it, there are a lot of people who work in the NHS, who don't wear a uniform and sit at a desk rather than stand at the bedside, who have just as strong a sense of public service and vocation as any clinician.

Many of them, with education and professional qualifications that could command much higher status and salaries in the private sector... but they don't.

Having a career in the NHS is what they want.  Not a job in a tax-fiddle.

I was privileged to spend a day with the excellent Worcestershire Health and Care NHS Trust.  Lead by the fabulous Sarah Duggan and her insightful Chairman Chris Burdon.

At their awards evening, four members of staff, clinical and non-clinical, gave a personal testimony... why they work in the NHS, their drivers and insights.  They've all had career choices but chose the NHS... for its ethos and role in the life of the nation.

I'm not sure I have experienced more moving moments than I did on that evening.  Soft-centred?  No, real people telling us real stories.

NHS people are special people and special people deserve to be treated specially well.  They are not commodities for tax fiddles.

They are our people, our family and we should respect them.

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Machines, their servants...

Helen Stokes-Lampard, RCGP-Chair, complains her profession is being bullied by technology firms.  Bullied or challenged?

Consider, for a moment, how her profession treats it's customers.

Next to impossible for commuters to get an appointment in reasonable time.  Impossible to see a consultant without their say so.  Impossible to get a prescription without they sign on the dotted line.  They are the gatekeepers and the pullers-up of the moat to health services.

Millions of working, commuting, middle-classes will turn to technology and risk sidelining primary care to an irrelevance. 

Primary care is not working for doctors; they either find being a GP unattractive or can't get out of it fast enough.  Practices are closing.

The DH pledged 5,000 more GPs.  Actually, there are 1,000 fewer.  RCGP's answer; bung Australian GPs +£18k, to come here... for less wages, rain and queues around the block... that'll work.

Whomsoever you may wish to blame for this decline is a pyrrhic argument.  Simply; it has to be dealt with.

The management of appropriate patients with the help of technology is an obvious solution to the pressures of demand and supply.  

Somehow, the RCGP has allowed itself to get sucked into public squabbles and legal battles with Babylon and maybe other technologies, that GPs find disruptive to their prospects.

GPs, not all, but enough, seem to regard Artificial Intelligence as some kind of voodoo.  Arthur C Clarke said; 

'... any sufficiently advanced technology is indistinguishable from magic'.

It's not magic. It's simply machine-learning, fact-accumulating, remembering algorithm, like Siri, Alexa, Tesla, John Paul concierge services and the heart of Amazon's transactional operations.  It detects when there is 'unusual activity' on your credit card... checks to see if it's been pinched.

AI is approved by the FDA in anaesthetics, to keep us safe. 

The evolution of these technologies is inexorable and doctors should be leading it.

The fact that it threatens GP's financial stability is easily resolvable.  Changes to the way practices are paid do not require quantum computing to fix. 

Not for every patient... obvious.  For every ten that it could help creates headroom for GPs to spend time with the twenty it can't.  

These technologies are not taking over family practice but family practice should be taking over AI.

Instead, GP leaders argue over advertising text on the Tube, regulation and the obvious... it is not universally applicable. 

Patient management by technology makes room for managing more complex patients more realistic.

Instead of waging war with the future, the RCGP should be shaping the future.  Contributing to the IEE P7000 global standards initiative might be a start.

The shareholders in the NHS, the public, have made it clear, they want the convenience of remote consultations.  

Stokes-Lampard says; 

'Those with the latest smart phone, those who speak English and live in cities, those who have high speed broadband, are being offered something that others are not...'

Does that mean; because we can't all drive a car there shouldn't be any roads?  The thought that no technology can be introduced until the last person in England can use a smart phone... is ludicrous.

Rather than picking fights with technology companies, better to make them honorary members of the RCGP and manage the future from inside the tent.

Babylon's boss, Ali Parsa claims the 'Cherry-picking' eligibility criteria, the RCGP complain of, was developed by doctors at the host CCG, not him. 

He also claims to be able to offer his organisation's services to all practices for £1 per patient per year.  The RCGP must put that claim to the test.

Pioneers get arrows in their backsides and Babylon are collecting their fair share but there are other services making quiet progress.  Bet the farm... this is going to happen.

The RCGP have a choice to make; lead the changes or be made inappurtenant by them.

Luddites smashed machines, fearful for their employment and the impending irrelevance of their manual skills.  The risk of becoming servants of machines.

GPs face an entirely different challenge.  

Their skills are in dangerous, short supply... for a new future as community physicians, it is they who must make machines their servants.

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Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.