Nurses and other expenses

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I had a stressful day on Friday that I’d rater forget about, related to extraneous events that I just can’t deal with at the moment.  I’ve posted a happy picture of me and a  friend swimming last May because it makes me smile.

Luckily, or not, I’ve been diverted by the nurse shortage, which is of course due entirely to events outside the government’s control, and for which their policies and short-termist swingeing cuts cannot possibly be held accountable. Oh, and they’ve been saying, ad nauseum in answer to any number of questions in parliament, just how many ‘extra’ nurses (doctors, paramedics) there are since they started running the show.

Top of Hunt’s list of reasons for the NHS’s staffing problems, is the rising bill associated with fed up staff whose pay and terms and conditions have been eroded significantly since 2010. These staff, many of whom had worked for the NHS for decades, suddenly started to up sticks and display their greed and lack of compassion and vocation by working via private agencies instead of the NHS.

Hunt doesn’t like this. I thought that was how the great god Market was supposed to operate, Jeremy? Otherwise, why are you privatising NHS Professionals? This is the public, in-house staffing agency which makes a profit for the taxpayer. Why, you could even develop it, drive those agency costs down with another nice bit of enforced competition (see Health and Social Care Act for how that works, though it is rather expensive at £5billion a year from the NHS budget just for competitive tendering).  I’m beginning to wonder about Hunt’s brain. Surely blind adherence to dogma and an utter disregard for logic precludes such high office? Hunt is certainly having the kind of effects on the NHS that his tumour namesake continues to exert my own life. The things he’s made me do.

The nurse shortage was highlighted by a newspaper report the other day and it’s a key area of concern not least bearing in mind Hunt’s inexplicable decision to stop nursing degree bursaries and replace them with tuition fees and loans. But the whole story is far more shocking than that.

This report raises a host of relevant issues. The Migration Advisory Committee has recommended that nursing should remain on the shortage occupation list allowing non-EU nationals to be recruited from abroad. It also argues that that the Department of Health (DH) and the NHS failed, with no good reason other than the perceived need to save money, to create enough nurse training places.

It’s estimated that 9.4% of nursing places in England are vacant; and there were 17% cuts to nursing training places under the Coalition government which was a “significant contributing factor” to the current shortage.

The NHS training body Health Education England wanted to commission 3,000 nurse training places in 2016/17. But as a result of “funding constraints” it only commissioned 331 – one tenth of what was needed.

The MAC report concludes:

“It is clear to us that the current shortage of nurses is largely of the health, care and independent sectors’ own making. They did not learn the lessons from the late 1990s/early 2000s when a similar shortage (and reliance on foreign nurses) occurred. Almost all of these issues relate to, and are caused by, a desire to save money. But this is a choice, not a fixed fact. The Government could invest more resources if it wanted to.”

Then a quote from a Department of Health spokesperson:

The Department of Health is “delivering on our plan to train more home-grown nurses”.

What? Could anyone in possession of any of the facts, or indeed a functioning brain, say anything more utterly stupid? It’s no wonder everyone was asleep till the budget woke them up.

Unfortunately, yes, they could. I’m not even going to let you guess who said it:

Hunt in the BMJ: “We’re reforming the funding of nurse training in order to make sure we can afford to train more nurses.”

I suppose he’s referring to his aforementioned plan to replace bursaries for nursing training with loans and tuition fees; bursaries that allow many older people with valuable life experiences to train as nurses, at a time of recruitment crisis and shortages. A policy that will not only actively discourage, but will effectively prevent, many of these people who have families and limited financial resources from training as nurses Hunt has also acknowledged that staff planning has been lacking in the NHS for decades. Yes, it has. So at what point since 2012 when you took over as Secretary of State for Health did you consider actually doing something about it Jeremy?   Bravo Mr Hunt indeed.

And behind all of this of course is Mr Hunt’s big push on safety. Safe staffing involves having enough suitably qualified staff, and the Francis and Berwick reports into the Mid-Staffs failures specifically address this concern and recommends NICE  – an independent body – to undertake the review. Jeremy liked this, because it allowed him to batter nurses over the head with their lack of compassion and vocation, and their silly pretensions at understanding how to manage the complexities of modern medicine, surgery and technical equipment when they’d be far happier floating up and down with lamps and starched hats, porting flannels with which to transfer pathogens onto fevered brows. Except that the actual evidence might result in the need to actually produce real qualified staff rather than imaginary ones and having to pay them to boot, darn it.

Enter NHS England, the body set up to run the NHS after the Secretary of State for Health was absolved of that little responsibility by the Health and Social Care Act (2012), the one that officially made the NHS no more. (You might have missed that too.) They decided, before the Nice report was published to take over responsibility for the research themselves. Now you might wonder about vested interests versus independence, you might wonder about standards of evidence. You might wonder at NHS England’s their lamentable budget and plan to save £22billion more in ‘efficiency’ savings despite the parlous state of NHS trusts’ finances. You might have predicted that the DoH would withold the NICE information under Freedom of Information. But nicely, NICE then decided it was in the public interest to release the information later, and you can see their reasoning here.

There are many examples of government tactics to avoid answering difficult questions; they’ve reached a level where debate is not happening because spin is automatic, it’s reported often without question in the right wing tabloids and broadsheets, misused statistics are stated as fact, significant evidence is buried in favour of cherry picking from often discredited research (the NHS Risk Register has still not been released).

One of the nastier methods involved the Prime Minister’s repeated use of his late son Ivan’s disability as a means of blocking debate on the NHS in parliament because this proved his love for the NHS. The Camerons must have been through hell, and nobody can argue that they didn’t do their very best by Ivan. They didn’t hide him, he was clearly deeply loved. Yet their experiences are always mitigated by wealth, by the ability to set up a converted basement at home to care for their son. Cameron used Ivan as emotional blackmail to get out of answering questions about his intentions for the NHS. The Camerons’ is also not an experience made more harrowing still by the bedroom tax and the government fighting a High Court decision arguing the bedroom tax discriminates against disabled people by challenging some of them in the Supreme Court.

The NHS is an now a collpasing omnishambles, to borrow an ill-fated phrase from an ill-fated leader; one created by government policy over the past fifteen or so years that introduced the internal market (those fundamental conflicts of value systems between the human and the financial again) although Labour at least invested money and our NHS ranked highly among health services in 2012. Since then, the coalition and Tory governments under Cameron have destroyed it. They haven’t asked us what we want, they’ve lied, been caught lying, continued to get away with lying to us and to each other. Many of the staff in the NHS have no idea what the Health and Social Care Act did – which is laid the foundations for privatisation while burying the bodies of pitfalls and costs beneath the foundations of their spin flyover. It’s time for the government to take responsibility and do the job we are paying it to do, while telling us exactly what that is.

Finally, I couldn’t resist adding this piece from Conservative Home in full. I’ll let it speak for itself. At least the author is honest.

The Government’s dispute with the doctors’ union continues to escalate, with junior doctors preparing to hold the first full walkout in the history of the NHS.Writing in the Daily Telegraph, James Kirkup gives the recalcitrant medics a warning from history. He warns that the BMA is repeating the mistakes of the National Union of Mineworkers, over-estimating the nation’s dependency on their members.

That Britain’s economy could survive without British coal was unthinkable, right up until it wasn’t. Kirkup argues that technological progress and competing models of provision mean that our monolithic state healthcare provider may soon find itself similarly outflanked.

But whilst that might be true, it is by no means certain that we have reached this point now. For all that Arthur Scargill’s attempt to topple Margaret Thatcher is the stuff of legend, it shouldn’t eclipse the fact that there were plenty of miners’ strikes before that final confrontation and the miners won most of them, enjoying public sympathy as they did so.

Jeremy Hunt could end up being a modern-day Margaret Thatcher, bringing truculent trades unionists to heel and unleashing modernity on one of the UK’s totemic industries. Or he could be Edward Heath.

As Simon Jenkins points out in today’s Daily Mail, public support for the NHS is currently bulletproof. This makes it incredibly hard to reform: in fact, the public health lobby have convinced many politicians that it is easier to reform the public than to make a serious attempt to reform public services.

“Cost to the NHS” is thus one of the main pillars of modern drives against smoking and obesity. But setting aside any liberal qualms we might have about that, it isn’t clear that this represents a viable long-term solution.

Anybody who the state ‘saves’ from a tobacco or food-related death will still die of something, and the NHS will pay for it. If that person is forced to live a long life then they will likely end up costing the NHS far more than they would had they died younger – the increasing ability for medical science to prolong our senescence is by far the greatest structural challenge the service faces.

Treating expenditure on smoking and obesity-related health problems as money that can be straight-up saved, without accounting for the inevitable transfer of the burden to other parts of the health budget, is therefore extremely disingenuous.

Assuming that we can’t force people do be so healthy that we can afford the NHS, we’re then still confronted with the need to reform it.

It may be that needless deaths caused by industrial action lead to a dramatic sea change in popular attitudes, but as it stands we’re a long way from a place where “wholesale reform via head-on confrontation” seems likely to work, even as a last resort.

Rather, Conservatives should have a long-term, strategic vision for healthcare reform which involves the piecemeal adoption of decentralisation, liberalisation and modernisation in doses the public will tolerate.

Obviously there are a huge number of things this could involve, and Party policymakers should canvass widely for proposals. But when it comes to tackling the outdated and overweening influence of militant unions in the NHS, here are two suggestions.

In his article, Kirkup mentions “the George Washington University study that estimates 85 per cent of a typical doctor’s work can be done perfectly well by a “physician’s assistant” with a fraction of the training or wages.”

If that is the case, perhaps one way to increase staff supplies in the service – without resorting tocontroversial over-dependence on foreign nurses – would be some form of ‘Territorial NHS’, or Health Service Reserve, modelled on its military counterpart.

Volunteers would receive pay, training, and legal rights to take time out of their ‘civilian’ life to work for so many weeks of the year in the NHS. This shouldn’t be impossible: the Armed Forces reserves already offer recruits the opportunity to train in a huge range of technical skills.

A larger, flexible pool of ‘physician’s assistants’ would reduce the NHS’s dependence on full-time professionals. This would not only ease immediate wage and staffing pressures, but make it easier for management to respond to future shifts in demand.

Like any nationalised industry, one of the major problems facing the health service is its need to predict future demand without the aid of psychics. The long training current staff require makes it impossible to rapidly adjust to unexpected demand (without importing labour, that is.)

A ready pool of capable staff, which can be topped up relatively quickly, could thus plug gaps as they arise and make it easier to do that with British personnel.

Given public affection for the NHS, and the esteem in which its staff are held, there’s no reason to think that recruitment would be impossible.

The other way the Government could clip the BMA’s wings would be to diminish their capacity for strike action.

One could approach this task in at least two ways. The blunt-force approach would be to declare doctors, at least, to be one of the essential professions – such as the police and the military – whose members are forbidden to strike. If the junior doctors keep up their current antics this may well become politically possible.

But another way would be to step up the decentralisation of the NHS and make hospital trusts legally-distinct employers.

At a stroke, this would bring the public sector into line with the private by making politically-motivated, industry-wide strikes impossible.

This is because, with sympathy strikes and secondary picketing illegal, trades unions can only call strikes over a specific grievance with an individual employer. In the private sector this has led to conciliatory, service-based unions.

But because all public sectors workers are ultimately employed by the Government, they have been spared the effects of this legislation.

Making hospital trusts independent would not only mean the end of the national strike, it would also yield other benefits. By employing staff on private sector terms such essential and sensible reforms as locally variable and performance-based pay, as well as rational, private-sector pensions, would be as irresistible as they have been in the private economy.

Faced with an incentive to innovate and reduce costs, some trusts may even start to innovate with things like the “production-line” surgical hospitals pioneered by Devi Shetty – channelling the savings into other areas.

It would also mean that in the event of a dispute at any trust, the Government would not be on one side of the table, under political pressure and with the easy out of simply paying up from taxation or borrowing.

One day, the BMA will have their 1984. But it would be complacent to assume that this is it, or that bloody-mindedness alone will bring it about. Conservative strategists owe it to themselves, and to the country, to lay the groundwork properly.

 

PS Henry here describes himself as ‘centre-right’.

 

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The theatre of cancelled ops

The little boy wants to know whether he can go to school yet; his Mum is waiting for her op too. She is clearly unwell and is distracting the boy, smiling at him. I’m sat, gowned up and pressure-socked, fresh from my meeting with the anaesthetist in which we have talked in great detail about how he will manage the vomiting I get post-surgery, and pain relief because I’m allergic to morphine. I feel reassured, and I tell him so. I am hopefully to be in the anaesthetic room for 0830 and the theatre for 9, although there might be a short delay as we wait for a bed.

Ah, the B word.

The time begins to slip by. Patients trickle into the blue bay (ready to go), and a couple of go off for their surgery. Gaggles of green-gowned theatre staff pass in the corridor, carrying notes. Interesting that it’s called theatre; I guess it’s because those surgeons of old used to perform operations in front of an audience. This is also a kind of immersive theatre, those little tableaux, separate yet in it together, wondering what the other is in for. There’s doubtless a dramatic template in our heads. My old ambulance boss, Dougie, once asked a doctor in the ED what was the most difficult part of his job; Holby bloody City was the reply.

So, we talk to our relatives or friends, half watch the BBC news, keep half an eye on each other. From time to time a surgeon or anaesthetist leads another patient off to make their pre-op notes. Nurses and HCAs, smiling and chatty, pop in and out and talk to people, bring pre-op medications. I’ve already had my paracetamol. I’m not worried, just glad to be on the way to knowing what’s what, tempered by the knowledge that in the near future I will know and there will no longer be room for that little miracle I’ve been carefully holding in a little pot in my head with lid screwed firmly down.

The little boy and his Dad say goodbye to the woman just down the row; the man clutches the top of her arm and squeezes for a couple of seconds, pulls her towards his chest. She smiles. The little boy, red school jumper (he loves the badge) and big winter coat, holding hands with Dad and walking away. I tell her how lovely the boy is, and we strike up a conversation. I have to ask her permission to talk about it here, so for now it remains between us.

The woman’s surgeon appears, asks her to come with him. She returns with a nurse who is visibly upset; her all-day surgery has been cancelled because there is no critical care bed. She knew when she saw the surgeon’s face. Her surgery should have taken place now, within a strict time-frame after the end of some other treatment. Now it will be another two weeks at least.

A nurse comes to tell me, at 1100, that there is a bed meeting just starting.  Someone will come and talk to me when the meeting is over. It’s been a slow, Hunt-like dawning, the signs and symptoms accruing into the jolt of knowledge that my operation is in jeopardy despite having been first on the list in theatre 4.

At 1215 a bed manager appears. We go to one of the consultation rooms.

“Good news or bad news?” I ask.

“Bad news, I’m sorry”. He shakes his head.

He is clearly wondering whether I’m going to be angry. I’m floating, having known this was coming, and a lump of something clunks in my chest. We sit, and I ask the bed manager where the problems are.

He is open, apologetic, a kind man.

There is a flood of medical admissions at Derriford, which does not have the spare bed capacity to manage. Social care of course is in crisis also and we are stuck. There are two emergency neurosurgery admissions including a trauma, which of course get the theatre slots based on their clinical need. This isn’t about patient choice, or a truly 24/7 NHS, this is about saving lives. There are a couple of more urgent cases than mine which have gone into another theatre; again, cases whose need is of a higher priority. Mine, and presumably some others in similar need, have been dropped.

“I could let you sit here all day and hope, but in the end there will most likely still be no bed.”

I should receive a phone call on Monday to tell me if there’s any chance of surgery next week; but that again depends on clinical need and the bed situation. I thank the bed manager and tell him that I don’t blame the hospital at all for this. I really don’t. There is one proviso, however – I’m going to blog about my decision to go to the BBC with what happened later, and Derriford hospital really must at some point come out publicly and explain the situation to all of us. How are we to know the real causes of this crisis when everyone is apologising and not telling it like it is?

As with all these issues, the picture is complex and nuanced. Yet here we are, with these poor staff buffering the ire of upset patients as they tell us that we can’t have our expensive surgery and that the surgical teams who want nothing more than to do a fantastic job and who’ve prepared and planned and explained, are now as angry, stressed and upset as we are. We had talked, the woman and I, about trusting our surgeons. I’d made the point that they’re all obsessives, immersed in their art and in their science, in their patients, in the planning and the discussions and the human fears. These aren’t people who are motivated by money.

What has this relentless financial framing of everything done? All the grand political speeches about efficiency and management and patient choice, and unaffordable costs to the taxpayer. We are told endlessly of the legendary effects of competition, enforced tendering (enshrined in the NHS by the Health and Social Care Act 2012), the driving down of costs. You can’t make a silk purse from a sow’s ear.

It’s resulted in a simplistic, self-perpetuating notion of efficiency and target cultures, a hogwash of corporate branding and a grand FUBAR of squandered surgery, buckets of cash effectively chucked down the drain. The waste of today is obscene.

It’s left people in dire need floating away on a tide of political spin and lies, blaming each other while the offshore hedge funds that are often behind ‘investment’ in our public services channel all our money away in order to fulfill their purpose in life – to make a profit, preferably without the annoyance of having to pay any tax. How is that good for patient care? Why this profiteering model and not one of social enterprise? Look to our tangled political culture of donations the vested interests for your answer.

The nurses offer me tea, a sandwich, biscuits. They say that the day case ward over the way is now a proper ward with 12 beds, in an attempt to up the capacity. But they’re operating on the edge, with no leeway, no resilience in the system. They think the hospital should cancel the routine cases for a couple of days, let it all breathe. They are upset, empathising. I go off on a rant. They tell me I’m allowed.

Meanwhile, in parliament, Caroline Lucas had sponsored the NHS Reinstatement Bill, developed over the past couple of years by Professor Allyson Pollock.  With a cross-party group of MPs in support (but no official backing from Labour – why not?), it was being filibustered by Tory MPs. Smug at their cleverness, waffling about deporting foreigners. They don’t like the bill, so they talk it out, all part of parliamentary process in which we cannot interfere; it’s a tradition, a religion even.

This link explains that we now no longer have an NHS. And we don’t. The bill was our chance to get it back.

So a challenge: venture from your grand Gothic theatre and sit here on our lowly stage, you puffed up parliamentary performers, makers of pig noises, and farters in the general direction of democracy. Join us, in the blue bay on Fal Ward, and watch the fear flitting across faces, listen to the conversations, the little jokes, the stories. Then account to me, and to my new friend, for what you are doing to our NHS and our democracy. We are angry. Come and sit with us. Come and look us in the eyes.

Incidentally I have yet to receive a response from Geoffrey Cox QC MP. I’m going to ask to see him in person. I’m going to look him in the eye and hold him accountable.

 

 

Still no beds

I’ve still not heard about my op, and so I call Tony my neuro oncology nurse. He says it’s impossible to say when the surgery will be, as Derriford hospital has had to cancel 90% of its neurosurgery ops this week. I will hear as soon as there’s news, he promises, but it might well be next week now.

Bed-blocking is a key issue, and this is bound with 6 years’ of cuts to social care budgets and the concomitant increased pressures on district general hospitals who have to take up the slack. If there is no care there, and the community hospital beds have been cut repeatedly, managing frail elderly people becomes increasingly a case of shoving them into ‘spare’ beds which exist for acute conditions, surgery and so on. To have 90% of the neurosurgery in a top district center cancelled in a week is pretty devastating.

For my type of diagnosis, NICE guidelines state that I should be referred within two weeks of the diagnosis; this was easily exceeded and I saw my first neurosurgeon within 3 days, specifically because he did not want to leave me hanging around over the weekend without having discussed the plan. He (Mr Titus Berei) then called me personally on the Tuesday morning to tell me he’d spoken to Mr Fewings who is now my consultant. Mr Fewings saw me three days after that. So, nothing but excellence and compassion there. Ditto for the referral from my GP, which was done at 5pm on the evening of my request for an urgent appointment, and the full neurological assessment had been undertaken including all the scans and bloods by 5.30 the following afternoon in the AMU at Derriford.

Now, the guidelines state they have 31 days in which to start treatment, the first part of which is excision of my tumour. Until such time as this can take place, I have no histology, no certainty about what I’m dealing with, and no treatment plan. Imagine hanging there, swinging on gibbet hill, waiting for your neck to snap. Derriford hospital neurosurgery department was ready to smash that target too, were it not for circumstances outside their control, circumstances caused entirely by austerity, government mismanagement of the NHS over the past 6 years and swingeing cuts to social care.

That, bearing in mind my mental state, resulted in a surge of anger. Anger that the real story is not out there. Rage that this government continues to lie and spin and hide evidence and divert the blame onto Trusts for financial mismanagement, stopping bursaries for nurse training, attacking junior doctors over some ridiculous meaningless mandate for a ‘truly 24/7 NHS’ that was predicated on the willful misrepresentation of a report claiming 16% more deaths for those admitted at weekends which even the report’s author countered.

Meanwhile, notice how Jeremy Hunt and Cameron et al take no responsibility, ever, for their briefs. They are paid public servants, yet they are not accountable for their mismanagement of the NHS and other public services, it’s always Labour, or Trusts, or feckless poor people, or doctors, or nurses, or people expecting to be paid fairly for what they do. The (un-mandated read my lips no top down reorganisation of the NHS) Health and Social Care Act 2012 actually removed the responsibility of the Secretary of State for Health to provide free health care for the population. Are you angry? You should be.

Having spoken to Plum this morning, I had posited the idea of contacting my (Tory) MP, and she encouraged that idea strongly. So I dialled Mr Geoffrey Cox QC MP’s surgery in Tavistock and launched into a frighteningly coherent rant through lips which are today especially rubbery, and which I feared would simply degenerate into the tears I have yet to shed (because if I start to cry, I suspect I might not be able to stop).

I have asked several key questions, and made some very specific points about accountability, transparency of government, ideological actions and ignorance of, misrepresentation of or burying of evidence.

I have asked what is going be done to fund social care so that this type of nightmare no longer occurs. And I won’t take the £600k bail outs currently being handed out to Tory-run councils only as an answer to that.

I have asked why we have among the lowest beds per head in Europe.

I have asked how exactly government policy is aiming to deal with the current crisis and who in government is going to take responsibility for it.

I have asked for absolutely no spin or bullshit, nor devolving of blame; I have asked my elected parliamentary representative for straight, open answers on the situation as he sees it and the actions that his government is going to take to address them.

I have pointed out the stupidity of the 24/7 NHS in situations such as this. I didn’t mention the shambolic and pathetic attempts by the Dept of Health advisor the other day to explain in corporate business speak to a committee of MPs exactly how they had failed to cost any of the 24/7 NHS, nor to account for whether or not the £10 billion so-called bail out of the NHS included this money.

I did point out that junior doctors have my support, 100% (the strike next week might potentially affect my surgery too, but I’ll take that), and that this is not about money, it’s about saving the NHS from destruction prior to privatisation.

I warned Mr Cox to be straight, since as a paramedic I know what goes on, I know first-hand the effects of coalition and Tory cuts so he can’t fool me.

I pointed out that anyone can suddenly find themselves in my position – and that’s when you need the NHS.

I mentioned that had we been under an insurance-based system as in the US that I would most likely be sunk now (the least efficient, most expensive, and least equitable system in the world really only seems like a great model with which to replace our incredible, equitable, cost-effective NHS when you’re a politician with personal interests in giant private healthcare and insurance corporations, as numbers of our representatives of all parties are, doesn’t it?)

The NHS, still surviving after years of big investment by Labour, was still a great value system in 2014, but note the plummet to  28th in the world by this year. Now the spiral of crises in funding and beds is hitting terminal velocity; yet it’s not the government’s fault. Regardless of that, if I lived in the US, and if I had managed to get insurance, it would have been massively expensive and studded with exemptions to enable them to avoid paying my bills because of my past medical history.

The advisor I spoke to took the rant with good grace (and rather too many casual ‘okie dokies’ if he is, unlike politicians, subject to a performance review target culture) and is passing the information urgently to Mr Cox, who will be looking at the situation in Derriford, and then I hope addressing some of my policy points and – crucially – the social care crisis.

I’m still feeling rather calm, but it would seem I’m going to really need that shrivelling prayer.

Oh, and I’ve just posted off my DVLA form B1 and driving licence to voluntarily surrender it on medical grounds.