This Week’s NHS News

primary_care_training_news

Does the job…

Norfolk and Suffolk FT are having a torrid time.

The Board are struggling with legacy, geography and the local health economy.

The CQC have been frequent visitors… in and around the place for six months or more.  The decline continues.  If that doesn’t tell you something of the fruitlessness of inspection, nothing will.

The CQC can tell us there is a problem, they can report it, they can tell the press, they can stand on the top of a hill with a megaphone and shout about it, but it won’t fix it.

Mental health services are specialised and not everyone’s cup of tea.  Recruiting to them, everywhere, is difficult.

What to do?

First job; get the CQC out of there.  They can do no good and they are doing more damage.

Park the CQC bus in the carpark for six months and it becomes impossible to recruit.

Pressure on the Board will mount, risking management by ‘don’t bring me bad news’ becoming the norm and bullying becoming rife.

We have to call time on the CQC and shout ‘stop’ at the Trust.

Stop for long enough to create the quiet needed to listen carefully to the front-line and the patients.

The Trust needs support.  Proper support.  Not NHSI’s 90’s style grip.  If the Hosptial is to survive it will need patience, pounds and people.

Nothing can change by Whitehall down.  Neither will it change from the Board Room down.

This needs ground-up, root and branch.

We also have to accept the location of Trusts is by happenstance, not isochrone planning.  That means some hosptials, like this one, are always going to run at a deficit.  The NHS is a pubic service, not a chain of frock-shops.

Taking on the leadership of Trusts, like this, is increasingly unattractive.  Soon, only the Kamikaze will do it.

No18’s latest wheeze is to look to McDonald’s to improve NHS leadership.  He’s a bit of a fan.  He wants biz-people to come in and show us how.  Good.

The NHS can learn from everywhere.  Part of the problem is that the NHS has neither the time, nor the money, to become an educating, learning organisation.  More significant is what we learn and from whom.

A big part of leadership is giving good people the time and space to do great things.  Neither the DH, NHSI nor the CQC have any understanding of that.

Pressure for performance usually means performance implodes.

NHS chief executives run organisations with close on a £billion turnover, tens of thousands of staff, with a mind-boggling rage of skills, talents, languages and qualifications.

Countless specialties and the ultimate responsibility for the lives of thousands of patients.

Add to that oppressive and haphazard regulation, made-up quality standards, legal requirements and the fact that the majority of their staff are paid on national rates, over which they have no control.

Don’t forget diminishing resources, demand they cannot refuse nor control, illogical political interference and an IT environment based on Windows XP.

They rarely earn more than £200k and a pension scheme that costs them a packet.

Shall we talk about a counterpart running a FTSE company?

It is likely to be smaller, nowhere near as important or complicated as a hospital and the median pay is £3.93m, plus share options, bonuses, big-bung pensions, company car and first class travel for the individual and the family etc., etc.

What can we learn?  Trust bosses and managers are highly qualified, come to work with a strong sense of vocation and do the best job they can in, sometimes, intolerable circumstance… and are poorly rewarded.

Things that don’t help are raising expectations by pretending £20bn next April is anything more than under historical funding levels.

Strangling social care is log-jamming the system upstream and downstream primary care is on its last legs.

Add to that, IT systems that don’t speak to each other, no digital strategy and no money to deliver one.  Regulators with unreasonable demands and whacky-wheezes by the day…

… it’s a wonder anyone does the job.

Have a good weekend.

————————-

Your purpose…

If you’re interested in politics, these are historic times.  If you’re not… ‘I’m a Celebrity’ is approaching its denouement!

If you’re interested in management, Brexit is a case study in how not to ‘do’ negotiation.  A mélange of circumstances, naivety, inexperience, wrong people.

How a former junior doctor and journeyman politician, Dr Fox ended up negotiating global trade deals, amazes me.

Why we though a former member of the SAS and professional contrary-ist, David Davis could negotiate the most important treaty of our life-time is staggeringly bonkers.

We are now on our third amateur… and paying the price.  How Michel Barnier must be chuckling, over a late-night cognac.  We have no one to match his elan, mastery and experience.

Why we’ve tried to negotiate all this, with the press looking through No10’s letter box, is beyond me.  A sieve leaks less than Whitehall.

Lesson one; confidentiality is key.

We haven’t controlled the time line, an absolute basic and all the negotiations have been ‘over there’ when we know scene-setting is a vital part of influencing outcomes.

Lesson two; master the time-line, control the environment.

Confusion over what constitutes a good exit when the nation is split; half thinking they were lied to and the other half thinking it didn’t matter, is… well… you know…

Lesson three; figure out what you want.

Stop talking about a ‘deal’.  A deal is what card-sharks and secondhand car salesmen do.  Professional negotiators look for an agreement with future partners.

Lesson four; you are what you sound like and you’ll be treated like it.

Just about everything that could be done wrong, has been.  Now we are likely to lose a prime minister, a government and our place on the world stage.

If we are to respect the outcome of the referendum, we have to find a way out.

One of the basic rules of ‘negotiating-to-win’ is, it’s not about winning.  It’s about winning-over.  There’s always something else to negotiate.  To say this is ‘the only deal’ is premature.

Managers, who spend their professional lives negotiating, know this is no time for well-intended amateurs or politicians with a vision… god help us.

If we are to have another go, what would the professionals do;

Lesson five; keep the kettle boiling.

Say to Barnier; there are things we want to talk to you about.  Come to Lancaster House for informal talks to explore the boundaries.  He would be unable to refuse.

Lesson six; confidence building.

If we have any kind of relationship with him, go off the record.  Talk about a strategy for unlocking a more finessed agreement.

Make it clear these are not public conversations, demonstrate a trust in him.  He knows the current ‘deal’ will destroy the UK parliament and he won’t want that.

Lesson seven; share the problem.

Put the cards on the table, say; this arrangement will force an election and put the British Constitution into chaos.

Bad for the markets, the EU, currencies, companies and everyone trading across La Marche. How can we arrive at a conclusion that will help us both?

Lesson eight; make the detail your friend

Provide some additional information, not necessarily new.  Where we are now is based on the information we have now.  Lay it out.  Test the assumptions.

You only need a crack of light to open a new horizon.

Lesson nine; best people get best results.

Change the people.  We don’t have a ‘B Team’, force majeure, it is now the ‘C Team’.  Go to industry, universities get the brightest and best people we can find.

Lesson ten; ask questions.

Change the language from red-line talk to green light (open) questions; ‘how about we did this’, ‘would this work for you…’, ‘what if we did this.’

Use the words ‘you’ and ‘we’.

Lesson eleven; it’s only over when you want it to be.

Barnier needs an agreement. If we say the negotiations are not over… then they are not.  Stop the clock.

All skilled managers know, negotiation is not a policy, it’s a technique.

The key is to remember what you are negotiating for.  The real reason; jobs, livelihoods, peace and the future for our kids.

Lesson twelve; don’t lose sight of your purpose.

————————-

Patients…

There’s nothing clever in saying ‘I told you so’… but I did.

I said it would happen… it has.  Relatives, carers and friends, worried and staff thinking; what’s next.  Patients and clients… a distant consideration.

About ten days ago it emerged that the CQC had written to local authorities and others, warning, care provider, Allied Healthcare was in a financial predicament.

It was a bad move.  They might just as well have moved in the broker’s men.

Predictably, risk-averse Councils moved contracts, relatives and clients panicked and staff looked elsewhere for work…. Xmas is no time to be out of a job.

Allied Healthcare have given contracts away and look all but finished.

Who’s next?  Primecare, the OOH provider, part of Allied have told CCGs they have thrown in the towel.  Just in time for the winter weather.

I’m told to expect another casualty next week.

Causation?  Money and staffing.  Just like the NHS.

For only so long can companies exist on cash-flow.  In the end, they have to make a margin.  They can’t.  There’s not enough money in the system.

I hear, at a recent conference for a lobby group of private sector providers, DiDo promised more ‘partnerships’.  Somebody needs to have a quiet word in her shell-like.

Most of the Trusts she is responsible for can’t balance their books and they don’t have to make a margin or keep share holders happy.  Private companies have no chance to survive with contracts priced at the bone.

The sensible advice; private sector… contract with the NHS or social care and you’ll lose yer shirt.  Don’t do it.

The sensible advice; local government or NHS… double check the financial stability of your contractors.

Are they paying their bills on time, talk to the front-line staff, are they being paid, hassled to squeeze in an extra call. Are people leaving?  Ask for a bank reference.

Despite a life-time in business and a belief in the private sector for its ability to adapt, adopt, be nimble and all the things a bureaucratic lump like the NHS can never be, I have to say the NHS is no place for private companies.

Looking back, I can’t think of one that has come into the NHS and made a decent fist of it.

Serco pulled out of patient facing services.  Carillion collapsed.  Interserve have fallen off a cliff.  One care home a week is closing others are in irrecoverable debt and refinancing fresh air.  AlliedHealthcare… finished off by regulators.  Primecare gone.  Circle paid £5m to get out.

Virgin… they’ve sued us and dumped contracts.  Capita, well, enough said.  PFI deals… don’t mention them.

What to do?  I used to think competition was a good thing.  I still do.  It levers up quality and keeps a handle on costs.  In the NHS… somehow the reverse is true.  It levers down costs and we lose our grip on quality.

Public or private, cost is cost, governed largely by labour costs that are linked to national pay bargaining and a global and national shortage of skills.

Overheads?  Despite the rows about NHS pen-pushers; the UK spends 1.2% of health expenditure on admin compared to an OECD average of 3%.

In an environment run with faxes, pencils and Windows XP… it’s a bargain.  The private sector seldom get near it.

There are four things…

First, no private supplier should be anywhere near an NHS, or social care contract, without posting a performance bond.  That means; if there is grief, we have some cash to help sort it.

Second, if a word from a regulator can send a provider into a tail-spin, we have to change the way we regulate.

The financial stability equation is too subtle a task for the ham-fisted CQC.  The performance unit at the Treasury could do it.  Early warning data submitted as part of the contract terms.  A contract bung is cheaper than a contract failure.

Third, pre-tender checks must properly stress-test providers against diminishing money in the system and realistic pricing.

Projected NHS and social care annual up-lift is well under the historic average.  There will be more failures.

Fourth; private sector… stop thinking you can work on money vapour.

Wise-up, you can’t and it’s no good for your brand and no good for patients.

————————-

Magic…

Let me introduce you to the French Drop.  Members of the Magic Circle, fear not, I won’t give away your secrets.

The French Drop, sleight-of-hand, is a way of taking a coin from one hand, into the other… making it disappear.  You can also make it reappear.  Done well, it’s magic!

Done badly and it’s like listening to No18 on the BBC Today Programme prestidigitating with twenty billion quid… the ‘extra’ to keep the NHS running for the next five years.

It’s an illusion; it amounts to about 2.9% next year and well under the 4% historical average, for subsequent years.

His latest ‘now you see it, now you don’t‘ is shifting £3.5bn into ways and means of keeping people out of hospital.  On the face of it, a good idea.  In the practicality, a horrible waste.

Let’s have a look at how this misdirection is to be performed.  Without any apologies to The Magic Circle!

The trick is based on a version of the French Drop;

… take the money away from secondary care and give it to hybrid, teams of high-end professionals, who will keep people out of hospital and pretend what you’ve taken away is still there, to pay for the same professionals to do the day job.

Good luck with that.

£3.5bn spread over 5 years, across 200-odd, CCGs, working with a system wide shortage of nurses and community staff and social care on it’s knees… do the maths.

As the Nuff’s super-sharp Sally Gainsbury tells us;

“This additional money amounts to annual increases that are broadly in line with the 3.4% overall that the NHSE is getting over the next five years

 …..far from representing a big shift in funding towards out-of-hospital services, this money will simply allow GPs and community services to keep up with demand over the next five years… [and] is not going to lead to a significant change in the way that people experience healthcare.”

A major part of No18’s magic is to make admissions from care homes disappear.  He’s right but this is the wrong way to go about it.

Is it an exaggeration to say; care homes are becoming unfit for purpose?  Nearly half deliver poor quality care.  The original concept of a care home was giving elegant, elderly people a soft landing into a full-board future of tea parties and the White Cliffs of Dover.

Instead, over time, they have become full with very frail people, many with more comorbidities than you can count, increasingly including dementia.

These residents are way beyond ‘care’.  They need nursing for which the establishments are neither prepared for, staffed, nor trained.

Hence, at the first sign of a UTI, the flu, or a virus, they look at their insurance risk and ring 999.

The same is true of domiciliary care, staffed with well intended people, with, often, inadequate training, poor languages and pitiful pay.

All this points to a catastrophic failure of the CQC.  It is they who are responsible for inspecting and regulating this patchwork of services many of which, in their own admission, exist on the brink of failure.

Solution…

  • No care-home provider should be licensed to operate unless they have 24-7 nursing cover, full prescribing skills, an on the spot phlebotomist and expertise in tissue viability, infection control and a geriatrician.
  • No domiciliary provider should be allowed to take our money unless it provides a weekly call from a community matron.
  • All providers should be required to post a performance bond realisable in the event of poor service delivery or failure.

The CQC may tell you they cannot insist on this level of care.  I’m not sure that is right but if it is, their Chair and Board should go, immediately, to ministers and demand to be given the powers, otherwise their existence is futile.

The care home sector may lobby against it and it is at that point we will find out what No18 is made of.

The care sector is on the brink of collapse, over-borrowed, under skilled and in, over their heads.

Bail out their care standards this year and you’ll need more cash to do it next year and escalate year after year.  Inflation will spiral out of control.

To stop this; require care homes to have higher levels of professional staffing to meet tougher registration standards and up-skilling.

The money?  Use the £3.5bn for obligatory training for care providers in advance of a new, rigorous licensing programme.

It’s not magic.

————————-

 Contact Roy – please use this e-address

roy.lilley@nhsmanagers.net

Know something I don’t – email me in confidence.

Leaving the NHS, changing jobs – you don’t have to say goodbye to us! You can update your Email Address from the link you’ll find right at the bottom of the page, and we’ll keep mailing.

GDPR

We don’t sell or give access to your email address to any third parties.

You can unsubscribe at any time.

———-
Disclaimer

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