Former NHS Nurse and manager now contemplating the NHS from outside

Archive for the ‘News and Current Affairs (general)’ Category

Why are more people going to A&E?

That seems to be the question which is currently challenging health politicians and the media. Of course it is not a new question for those working in healthcare, since it is perfectly possible to track each and every attendance and episode of care that takes place. Even before I stopped being a commissioner at the end of 2011, senior managers were scratching their heads about the increase in ‘unplanned care’ and trying various methods of ‘managing activity’.

There is no doubt that attendance in emergency / unplanned care has increased, but why? The analysis we are given doesn’t tell us about when people attend, but in trying to answer the question, they point to changes in GP out of hours services. That suggests that there are no problems with the availability of GP services ‘in hours’. However, when a new Urgent Care Centre was opened in this County, it was discovered that faced with the chance to attend and be seen immediately rather than wait for an appointment at some of the less well run GP practices, people chose the former. It wasn’t all about out of hours services at all.

The lack of ownership by GPs in out of hours care is also blamed, but many out of hours services are literally owned by GPs as well as provided by them (it just isn’t obvious since they are contracted out). Of course, if you contact these services you are unlikely to see your own GP, therefore you might as well go to an urgent care facility. When you get there though, you might find yourself triaged into a GP service, where the same doctors providing out of hours care are also based. Funny how that isn’t mentioned.

Patients and their individual needs, are quite rightly being recognised as central to health provision. But with that recognition comes the realisation that people will use those services in the way that feels right for them. That might mean accessing emergency care for things that they perceive as needing attention now, even if those providing the care don’t think that is what is needed. If you feel you need to see a health professional and you know you have to plan to need it to attend your own GP surgery what will you do? Probably access a place you know is always ready to take you.

Then there are the telephone advice services – first NHS Direct and now 111. In deciding to change the focus of these services, a decision was made to completely dismantle the former in order to start up the latter. As NHS Direct ran down, then more people were referred to A&E. Everyone knows that assessment and triage of the patient are the most important parts of deciding what is wrong with someone, who is best placed to help them and what should be done. The more experienced the person doing this is (on the phone or in person), then the more effectively that problem will be dealt with. It stands to reason then that if you get rid of qualified staff before the new system is in place you are asking for problems.

Finally something that no one has mentioned. Children are some of the biggest users of emergency care. They become ill quickly, in an unplanned way. Parents rightly worry that they need attention right now and take them to A&E. We know that the birth rate has been rising steeply, we know school places are under massive pressure. I wonder if some of the increase in attendance relates to the increased number of under 5’s?

Like most issues in healthcare, this is complex. I doubt there is no easy answer nor a single cause. The propensity of politicians to blame in turn the previous government or GPs is simplistic and plainly wrong!

Is this the best way to cut the deficit?

No one doubts the need for deficit reduction. If I think about the difficult decisions I had to make 5 years ago or so, when I realised that my personal debts meant that my monthly payments to creditors practically outstripped my income. Something had to give, and that something was my credit cards and loans. The experience was painful, and sacrifices were needed. But today I have just a small amount of remaining debt (other than the mortgage and every month I have money to spend. Christmas, which used to be a time to dread has come and gone and I owe no more today than I did last month.

The nation’s debt is thankfully much greater than anything I could conceive personally, but the principles are the same. The causes of this are well written about, but in my opinion not worthy of mention since it can’t help us now. The Government takes an interesting approach to trying to balance the books. Reducing the size of the public sector I can understand; it hurts me to say but a lot of jobs were created and money was wasted. You need to be careful about the ways in which you cut services and with them jobs, it creates uncertainty and fear and leads to risk aversion. More jobs are lost and less created because of this. If jobs and services don’t spring up elsewhere then some of those people become unemployed or else take lower paid, lower status jobs. This in turn means that those who might have taken those jobs are shifted further down the pile. The most vulnerable in society suffer most from this approach.

In turn the Government has taken a look at the growing benefits bill and decided that this can and must be reduced. dependency on the state needs to be reduced (even as someone who believes in the welfare state) I can hardly argue with this desire. But by starting with the most vulnerable in society this Government risks the label so often given to the Tories of the past. It feels nasty to target benefits to disabled children and those with cancer. Especially in a week when Cameron has said that he would like to see the 50% tax rate for those earning £100k to be abolished even though it is bringing plenty of tax revenue into the exchequer.

Tonight the House of Lords has shown it’s worth and voted for changes to the Welfare bill associated with these elements of cuts. It is a shame that they haven’t shown the same approach with the Health and Social Care Bill!

A bit of a mess?

It seems that the Health and Social Care Bill, the legislation designed to cut bureaucracy and fix an NHS that is not quite broken is in trouble. For months now, health unions, professional bodies and respected ‘Think Tanks‘ have described deep flaws within the proposed legislation. To us, despite the length of the numerous papers produced so far, firstly as white papers, consultations and discussions and now as a Bill, it has produced many more questions than answers. How will specialist services be commissioned and managed? How can we be sure that GPs will be willing and able to commission all of the services needed? How can we prevent GPs being part of businesses that are set up to provide services and then giving them huge profits? How can we be sure there will be sufficient levels of accountability? Will there be enough money / people / resources in the system to actually do the work? Will patients really get more say in their care? Do people really want choice or do they actually want a well-functioning local hospital which they can access? Can we be sure this isn’t the thin edge of the privatisation wedge?

It turns out there really are more questions than answers and apparently the bill is to be delayed while more of the answers are explored.

Meanwhile people within the much maligned PCTs are leaving. Last week we had 3 retirement lunches in one particular meeting room, two on one day.  2 colleagues within my own team have found new jobs and will be gone by summer, a third has an interview at the end of next week. We all check the job adverts weekly or even more regularly. The GPs that are currently sorting themselves into consortia are beginning to worry that even if they have the management budget to pay people there may be insufficient useful people around to employ within the new system (that is if they actually employ them since it is now rumoured that there will be some kind of commissioning hub).

I might be a PCT employee but I am not daft. Greater GP engagement and accountability in commissioning would be welcome. Less of a head count in the PCT was desirable and probably necessary. Perhaps public health might be better placed in local authority. But it actually didn’t need to be as nasty as this.

What next? Maybe little will change? Maybe progress will slow? The damage is already done though. We have been tarred as useless managers who do little for the actual patient. When actually I believe we have the potential to do much that is good. We wait and we will see!

Too Little, Too Late!

Contrary to what the government might like us to believe, and also contrary to what the Department of Health might think General Practitioners are not the only doctors working and living in England.

This quote from the DH follows the exceptional meeting of the British Medical Association (BMA) today:

We are disappointed the BMA has decided to take this step, including now opposing elements of the Bill they previously supported, rather than work constructively with us to improve services for patients. The BMA’s own survey shows their position is not representative of many of their members, who are keen to be involved in our proposals. The reality is over 5,000 GP practices, covering two-thirds of the country, have already signed up and have started to implement plans to give patients better care.

I have a few things to say about the comment – firstly, when was it the job of the DH to comment about policy that isn’t actually law yet? Secondly it suggests that all doctors are GPs and that the BMA leadership has had the support of their membership in agreeing to the policy change. My understanding (and I am sure someone will correct me if I am wrong) is that it is because the rank and file membership of the BMA did not actually agree with the stance of the leadership that today’s meeting was held.

But of course the Bill has been published and it is progressing through parliament. No doubt this and other criticism might lead to a few tweaks of the finer details (plus a few more major changes) but essentially the GPs of England are to be the commissioners of health services and no extraordinary BMA meeting will change that.

It is my belief that even if Andrew Lansley was to be told that this policy would result in half the doctors in England resigning and a catastrophic deterioration in health outcomes he would not change his mind and alter the Bill significantly. Bloody mindedness prevails and we are on a collision course for people to line their pockets, for people to set up their own little businesses and for the dismantling of the NHS as we know it.

What is clear is that none of the health unions in this country can make a blind bit of difference to this mess at this stage; the titanic is already approaching the iceberg and those on board can only hope for a safe trip in the lifeboat to shore!

Pay more, work longer, end up with less

What a cheery week this is turning out to be.

Gadaffi is busy overseeing the murder of his own people, politicians across the world are busy scratching their heads and wondering what to do without seeming about to create another Iraq. Meanwhile we find that petrol is now £6 per gallon (remember that measurement?) food prices rise by the week. Soon enough we will all need banker style bonuses to make ends meet.

Fat chance. This is 2011 in the UK. This is the year (or perhaps decade) to bash the public sector worker. We are apparently all lazy people on massive salaries who push a pen (or certainly sit at a desk) all day inventing rules for rules sake. Not only to we turn up late, leave early, have too much holiday, perhaps get paid overtime and some other unnecessary benefits but at the end of it all we can live it up on a grand gold plated pension for 40 years or something.

I joined the NHS pension scheme when I was 18. Every month since then I have paid 6% of my salary into this pension. I have no idea what 30 years of paying into the scheme equates to. What I do know is that for some time I have known that we are all on borrowed time. The final salary must go, the early retirement must go and we must all work longer.

Strangely enough even in 1980 we were being taught about a demographic time bomb. We were told that as the baby boom generation aged then the population of the country would age. As time went on and diseases were cured, or better managed with an ever ending stream of new and ever more expensive drugs we were told that that time bomb was ticking so loudly you could hear it a mile away.

Even as the private sector abandoned their final salary pensions (many of them ones that the employees didn’t even have to pay into) we failed to recognise that one day that would be us.

I was never going to be able to retire at 55, but 60 seemed reasonable. Now who knows? No one in my family lives to a  particularly old age, though both my parents are alive (aged 73). My lifestyle is reasonably healthy so perhaps I will live long. I pay £250 per month in pension, this is more than my hubby can afford to pay into his private scheme so I am in effect paying for 2 of us. He does a manual job and at 52 is already weary.

On retirement we won’t have a mortgage but could still be financially supporting our son since it gets harder and harder for young people to afford to buy property etc. We would however like to be able to go on holiday and enjoy ourselves while we can.

You have to fear that in the next 20 years the norm will be for no retirement and a philosophy of work till you drop!

Time to confront the lies being peddled

This letter appears in today’s Guardian:

Feel free to ask me to justify that Nottingham city council pays our chief executive £160,000. She voluntarily took a £20,000-a-year pay cut when she took up the job three years ago. Ask any council leader to justify what their chief executive is paid, but please stop comparing them to the prime minister. The prime minister, in addition to his £142,000 salary, enjoys free housing, free transport and a range of other living-cost benefits. Then there’s his pension. Now that he’s been in office for more than just three months, he’s entitled to half his salary, index-linked, every year for the rest of his life. It’s all part of the package, even though, like Gordon Brown before him, David Cameron has decided to turn it down. Of course, he can afford that kind of grand gesture, since, like 17 of the 22 others in his cabinet, he’s already a millionaire.

Cllr Jon Collins

Leader, Nottingham city council

I’d like to see an estimation of the real salary of the Prime Minister because the anger and hatred being demonstrated by the government on this matter is getting out of hand!

What is this big society?

When you work in the public sector as I do, you cannot help but come across some amazing people. I don’t mean those people who work as nurses, doctors, therapists, social workers even managers and who as many do carry on working after others have gone home, who go that extra mile. No I mean people who, on top of their usual lives actually do things for others because they want to, not because it is their job, but because of a sense that they can and should do more for others. Around us there are people who help out in schools, hospitals, charity shops, take people places, visit the elderly and disabled or who sit on committees and make a difference to the way those with jobs view the people they are there to support.

In my current job I come across many people who work hard but who aren’t paid for that work. Some do so knowing that they are already financially secure, that they have already had their careers or that they want to give something back for an experience or event that changed them. Generally these people do this work because they want to, not because anyone has told them it might be a good idea.

The voluntary sector doesn’t actually come for free. Charities need organising, charity shops pay rent, and those organisations which appear to function through good will actually needs people to recruit the volunteers, train them, galvanise them and maybe pay expenses. They need to check people working (even free of charge) with the vulnerable have suitable training and support. Voluntary organisations need premises to operate out of and they need to be able to provide services for others. None of this is free.

Good will is a valuable comodity, and people who expect others to provide services using it do well to remember that. Good will doesn’t come completely free, there is a cost. The big society is made up of good will, but if you think it is something you can have in lou of something that should be paid for then you are mistaken.

David Cameron would do well to remember that!


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