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!

Kindle or actual book?

For Christmas I received a Kindle from hubby, along with a lovely leather cover with light for reading from my son. when these electronic book devices started appearing a couple of years ago I insisted that I would never convert. I love the feel of a real book, I love turning the pages, holding it and also love trawling bookshops for something new.

When I go on holiday though, I have been known to take half a dozen books with me. There have been occasions that I have forgone articles of clothing or shoes for books. I have packed them into my hand luggage and bought more at the airport. This has to be madness if there is an alternative.

When I went on a coach trip to Germany recently I looked over the kindle of my friend Sue and decided that this was a good idea for ease when travelling and subsequently made my request. I have to admit that I quite like my new toy, even if I do feel a bit guilty every time I turn it on that I might be putting printing companies out of work. I love the way you can download a sample of a book and I like the way you can turn the page forwards and backwards so easily. I also like the fact that you can enlarge the text (I know I need to get the optician to review my contacts but until then..)  I am less keen  that I never know quite what page I am on, instead I know what percentage of the book I have read. But I am willing to give the whole thing a go. Today I have downloaded a couple of travel guides for my upcoming trip to the States. I think this is going to be great for checking out things to do and places to go on the go! We shall see.

Caring for people with learning disabilities when they are sick

I am an adult nurse who started their training in 1980. We received education and training across many spheres of nursing practice, but nothing specifically about the specific needs of people with learning disabilities. I worked in a long stay mental health facility for 8 weeks during my training, people with severe mental illness were mixed together with people who had learning disabilities and some people who probably started off with little in the way of an illness of any kind. As general nursing students we were able to offer some more general nursing care, after all everyone develops physical illness. The first time I encountered patients who were learning disabled was when I was a District Nurse. I had little knowledge of their specific needs and learned most about their conditions from their carers (family members and care home staff). What I did know was that I needed to offer care, compassion and time. I needed to give time and to listen and to use my instincts. I didn’t assume someone with a learning disability had no feelings, could not experience pain or that I knew best. My knowledge looking back was woeful, but to the best of my knowledge no one came to serious harm or died because of me.

Over the last decade or more, nurse training in the UK has been split into different areas of care – adult, children, mental health and learning disabilities. In the main nurses remain within their sphere of practice, despite the obvious cross over between disciplines. My own training failed to prepare me to care for many people I have encountered along the way, but there are ample opportunities to learn along the way. There can be compassion and there can be kindness. Yet again today I am ashamed and embarrassed by a report that suggests that nursing care in this country isn’t all it is cracked up to be. But I refuse to believe it has to be like this!

Happy New Year!

So 2012 has arrived. It is good at this point in the year, i.e. at the start to reflect back on the good, bad and ugly of the previous 12 months and to look ahead to the coming months. 2011 was pretty eventful. In June I was interviewed for a job which finally in October I was able to start. In December I was at last allowed to stop doing two jobs at once, just as well as the new one has just got pretty busy. There are lots to do to help support the improvement in services for people with cancer. I just hope that this job can last past the end of my secondment (March 2013); as the year goes on that should become clearer as we await a report on the future of clinical networks which is due in the next few weeks. The great thing about a new job is that it means you have new things to learn, and things have moved on massively in the world of cancer care since I was working clinically so my learning curve has been pretty steep. I actually look forward to going to work each day and that is a pretty good thing.

I am also pleased to report that my dad, who was coincidentally diagnosed with cancer around the time of my interview, has completed chemotherapy and at present seems to be doing well. This is a huge relief as the cancer is secondary and probably cannot be cured. It was great to see him eating and drinking well and buzzing around us all as usual. Fingers crossed that the scan he had a few days ago confirms this.

My son, who is studying in California for a year is home for Christmas. It has been great having him home even if it seems to have doubled the amount of washing and ironing I have to do and has increased the food bills considerably. He goes back on January 15th, but this time we can look forward to seeing him just a month later when hubby and I visit for his 21st birthday.

So I start 2012 hopeful that this might be a reasonable one for me personally. At work we continue to live through the protracted process of the new NHS Bill which is not yet law, but which is causing a fair amount of change for the sake of change. The GP commissioners are flexing their muscles but at the same time discovering that commissioning is not about telling people what to do and expecting it to just be done. From my new position within a clinical network which will be part of the Commissioning Board I am finding all of the PCT related stuff interesting. People are not surprisingly positioning themselves and that is always fun to observe!

New years resolutions? Well probably best not to promise anything but I will try to blog more (but then I have tried that before).

I wish everyone who takes the time to read this blog post a happy and healthy new year. I hope 2012 is full of promise for you too!

At last

After being interviewed for a new job, a secondment, at the end of June, I have finally got started in the role. For the last two weeks, and for probably another two weeks I am in effect doing two jobs. This is an approach I would not recommend but sometimes we have to make sacrifices in order to get what we want from life.

I moved desks, within the same building, on 3rd Oct and since then have combined induction into the world of cancer and palliative care with managing what I can physically do in the world of maternity and acute children’s commissioning. I am really pleased to say that the new team have been really welcoming, my old team gave me a good send off and all of the people within the network that I have met so far have been friendly.

My new job started with a 2 day meeting in London which was great for giving me a grounding on current issues in cancer services and also in working through some issues about how we can best approach the issue of needing to make sure the voice of the patient / user / carer heard in the way services are planned and provided. I think that hopefully there will be lots for me to write about on this topic once I get my brain properly into gear.

As for the old job, there is plenty that I would like to write about how you should not manage people, and about the emotional mechanisms a person may use to cover up their own short comings and make you feel guilty for them. However that may be difficult and what is more I think moving on rather than going on about it might be more healthy!

The Health and Social Care Bill has this week progressed further on its slow and painful journey to some brave new world that is only clear to people like Andrew Lansley. But it is now inevitable that it will soon be law; it pains me to say but the sooner the better now. We cannot continue with all of this uncertainty and what is more the PCTs are busy making the necessary changes to make it happen and it would be a crime to put the brakes on and go into reverse now. My hope is that the review of clinical networks comes out clearly saying that they need to be developed and strengthened and that what is more that my job needs to be made permanent. There is no way on earth that once I say a final goodbye to commissioning that I intend to go back. But I guess they say never say never!!

It’s my 6th anniversary

It is 6 years ago today that I posted my first blog post, boy time flies! I believe I am sitting in the same place, possibly about the same time of day. It is Saturday morning, hubby is putting in some over time (though these days he is on a salary and doesn’t actually get paid for it, he just love it so much!) and I am sitting in bed, laptop on lap. really I have more than enough to get on with. I have house work; who doesn’t but given my recent laziness an urge to blog should not be ignored at the expense of dusting, hoovering and bathroom cleaning!

One of the reasons I am still quite reticent about posting my thoughts is that the kinds of things I would like to say could get me sacked. It would be enough to say that the passage towards my new position has not been facilitated well by my employer. But good news, following my impending holiday (starts next Friday, yipee!) I will at last be able to start the job secured as a secondment in June.The urge to badmouth ones managers is something that you are always wise to suppress especially since I have been hearing stories of people being disciplined and sacked for doing so.

I am part way through a course to become an RCN Steward and the days spent with fellow trainees have been enlightening particularly when it comes to hearing about some of the things that nurses get up to and what is more say online. Whether it is using work computers to run some kind of raunchy dating agency, browse the kind of information they shouldn’t or else posting derisory information on facebook for the world to see apparently people are out there doing it all. What is more, my steward colleagues are kept busy providing them with support and managers are kept busy taking the errant employees down a disciplinary route. I do not intend to have the same thing happen to me!

Of course there is plenty more to write about, or there most certainly will be when I get stuck into working through the world of quality improvements to cancer care. This much I promise.

Blocks to blogging

Since April I haven’t really felt inclined to posting anything to my blog. I have thought frequently about why this might be and I think the answer is that when I feel low, confused about things and generally fed up though not particularly angry I often find I just don’t want to blog. This has been my state of mind since April. As I mentioned in my post the other day, the first thing that took place was the ‘pause’.

Wisely, it seemed at the time, the government who had not thought through their NHS changes, realised their may be fundamental problems in winning the hearts and minds of both those working within healthcare and those using it. The key problem was that they couldn’t adequately articulate how the new NHS would be better than the old one. They couldn’t tell us how the fundamental ethos of the NHS (free at the point of contact for all of those in need) would be retained. Essentially they couldn’t tell us how this wasn’t privatisation by the back door. The whole pause thing was, just as most consultations are, pretty much paying lip service to the doubters. Some changes were announced but it is clear that the Health Secretary is determined to push things through.

Further announcements about structural changes go on unchecked, despite the fact that the Bill is no further forward today than it pretty much was in April. The SHAs have clustered, specialist commissioners are preparing for a rationalisation complete with redundancies; those who remain will be footprints or some such! Yesterday this diagram appeared in the Guardian to demonstrate what the new leaner, less bureaucratic NHS will look like.

While all of this has been going on my own employer has tried to keep us informed and up to date. The truth is that there has been little to keep us up to date with except perhaps the fact that the changes continue. The GP consortia may now be Clinical Commissioning Groups, but that hasn’t changed the level of positioning and posturing being undertaken by senior colleagues. The extent to which everyone worries about what the consortia want is at times paralysing. This makes for a less than cheery working environment.

Time then for a secondment. A trip to the Cancer Network, which you will see from the diagram will be an advisor to the commissioners, and indeed to the provider. It will report to the National Commissioning Board. If things go well, then perhaps this will be a permanent move. What is sure though, is that my mood is lifting and I know I will have the chance to learn and do new things and for me that can only be good.

Its been a long time

Over two months to be precise. Since my last post in April the NHS has paused so that the NHS Health and Social Care Bill can be properly consulted on. Sadly it looks like there will be little significant difference to the way in which health services will be commissioned and provided. Andrew Lansley’s legislation continues its slow and painful process through Parliament and PCT employees not already redundant or moved await their fate. I on the other hand have taken a small step towards safety. In a bit over a month I will start a secondment with our local Cancer Network, I am taking a job with responsibility for improving the quality of cancer services. This is a pretty tall order, but will be an interesting challenge. I hope that this secondment will lead to something permanent once the future of Clinical Networks are secured.

In other news my son will soon be off to California to study at Pitzer College for a year. He is excited and I am excited for him.  It will feel pretty strange though to have him so far away.

The NHS pause, a general feeling of malaise with my current job and some family health troubles have prevented me from feeling inclined to post to my blog. Guess what though? I am now feeling more inclined to write more and I’ll be back soon!

Yipee a short week!

Some weeks the time flies by and suddenly it is Friday. This is a short working week and it seems an eternity since Monday morning. The causes have been both work and the problems of ordinary life that sometimes kick you to remind you not to be complacent. Work wise, the actions of a few people in an NHS Trust and the decisions they made without discussion on Friday last week impacted on my working week big time. This has the effect of meaning that the diary you thought you had at 8.45am on Monday has suddenly changed by 9am. It also means that you cannot be productive in the way you thought you would be. One good effect was that while waiting to go into a meeting with some Directors on Tuesday I did a massive clear up job on my email inbox and that is a really good outcome for the week.

On Tuesday afternoon at around 4.30pm all was calm; I decided to make the most of the good weather and get out of the office, go home and sit in my garden for a while. A chain of events meant that by the time I got home at 11pm, my car was in the garage awaiting repair to work out why it wouldn’t start plus a smashed bumper, and puncture caused by my darling husband forgetting to steer while being towed!

A day off yesterday wasn’t spent taking Matt back to Uni as planned, but on the phone to insurance companies etc. The silver lining was that I managed to cut the grass and finished a book I had been meaning the time to read.

Today being carless means a walk to the station and a train. The good thing is we get to finish at 3pm; time off for hard work and good behaviour. No work for me till Tuesday; lets hope no one decides to do anything today that might affect the potential tranquility next week!

Increased choice? Unsustainable demand?

Politicians of all colours are now very keen to offer us increased choice in healthcare. There is an assumption that if you can choose to ‘buy’ your healthcare from anywhere you like then this will lead to the best becoming better and if a provider is not good enough then they will see that they need to improve or else suffer the consequences.

Choice, or perceptions of the ability to choose have been evident in education for some years. The schools that have been perceived to be ‘good’ are over subscribed, they are staffed by excellent teachers and people move house to be able to send their children to them. In some areas, where people are particularly mobile and affluent this may be the case. In healthcare choice in relation to maternity has been a particularly popular phenomenon with some people. Choice of the place you have your baby, whether this is home, a midwife led unit or obstetrics unit, or whether it is about choosing one hospital provider over another is very important to some people. Exercising choice can be a tricky thing. For one thing you have to know what choices are available, and in maternity you have to understand something of your own level of risk in exercising that choice. Perhaps your pregnancy is medically or socially risky when it comes to making some of those choices, perhaps you don’t have the means to travel 30 miles to a chosen different hospital. Perhaps also the services in your area struggle to attract the right mix of skilled staff, not because they are providing a poor service but because they are geographically situated close to an area where staff can attract higher pay.

If you are pregnant, then one thing is sure you will need some kind of maternity service, and it will be the duty of your local healthcare commissioners to make sure you can access it safely. Those commissioner will be required to make sure that the maternity services offered are safe, adequately staffed and that those staff are appropriately qualified to fulfill their role. Maternity Matters gave us a role in promoting choice and in making sure that those choices were available and that people were assisted in making those choices. When though does choice become a want or a demand? When does choice and the way it is exercised by the few mean that those who are more able to move, more affluent, more able to make choices have a detrimental impact on the many?

As a nurse working in a PCT I am obliged to take part in one of the much maligned prior approval schemes that are popping up all over the place to manage the demand for healthcare. ‘Low priority’ treatments such as removal of  non cancerous skin lesions and varicose vein surgery are judged against a set of criteria set by a panel of doctors and approval is given or not for surgery to take place. What strikes me most about the way in which cases are presented is the extent to which GPs and surgeons struggle to tell patients that their problems don’t quite meet the criteria. Often they will write that the patients ‘wants this surgery performed’, and I am left wondering; yes, but do you think it needs to be performed.

I had the pleasure of setting up a new nurse led service a few years ago for people with rheumatoid arthritis. My job was to manage the day-to-day issues that arose for patients coping with a long-term illness, while taking potentially lethal drugs and still needing to deal with normal life. We set up a great service with a help line, monitoring clinics, home visits etc. What it taught me though was that where you create choice and opportunity you will also create demand and to a certain extent want. The people who shout loudest will often if you are not careful get the biggest share of what is on offer and that may be to the detriment of those who cannot shout and indeed may not even know what to say.

Whoever is in charge, whoever does the work of commissioning or buying healthcare, whoever provides it, there will never be enough of it to go around if someone doesn’t take the responsibility for making sure that decisions aren’t only made because of what is wanted, where it is wanted and whom it is wanted from. That of course is what makes my job interesting if not tricky!

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!

Just make it up as you go along

The NHS and Social Care Bill is currently being examined by the Health Parlimentary Committee. Information coming out from meetings being held at this stage of the process is fascinating. Andrew Lansley, the Health Secretary who dreamed all of this up was yesterday grilled by said committee. The following paragraph is taken from the Guardian online:

“He surprised some MPs when he admitted they were “still thinking through” what would happen should one of the newly empowered GP consortia go bust. Lansley said: “The responsibility lies with the NHS commissioning board. To identify and then intervene – they will have powers to take over responsibility or ask another hospital to take over.B ut he said there was still a debate about what would be the “trigger” for the NHS commissioning board to step in”

And this:

In an overture to those concerned about the reforms, and in a nod to the parliamentary push back from Clegg’s team, Lansley said there would be “opportunities to clarify, if not improve, the bill as it goes through parliament.”

and finally this:

“Lansley insisted that the bill was compatible with EU law and that he was supported by legal advice. But when pressed five times by Labour MP Valerie Vaz to publish the exact legal advice, he appeared to refuse.”

As someone living through this debacle and who will certainly lose the job I have even if I do get myself another.  As someone who may be a patient involved in this mess in the future, I wonder if these people know what they are doing to the health service? What is more don’t they actually think it matters if the potential problems are worked through before the Bill becomes law? Obviously they don’t or else you wouldn’t have the feeling it had been invented at a cocktail party, written down on the back of an envelope and then presented as a fait au complit!

Time to reflect

I am on holiday from work this week. During March each year you will always find that there are lots of people away, generally using up their annual leave before the end of the financial year. Probably as many people absent from their desks as in August, but at this time the weather is generally rubbish and depending on when Easter falls there may or may not be lots of kids around. This year the weather is dry and mild and the kids are still in school since Easter isn’t for another month. A week at home with no one else around is great for both recharging those batteries and as an aid to general reflection.

Two events have sought to aid my thoughtful mood this week. The first was Friday when I received a pension statement as part of the process of consulting with staff to move people between NHS pension schemes. In black and white (with lovely coloured charts) it tells me exactly when I joined the scheme and for how long (  up to 14th Feb) I have been paying in. This is scary for someone who has been making contributions for so long. It tells me how much I could walk away with at 55 (if I was still in a nursing job which I am not) at 60 and at 65, both in terms of a lump sum and as an annual pension. This serves to tell me that if nothing changes to the scheme (which of course it will) then by 60 I will have sufficient in the pot to be able to take a pleasant holiday, pay off any remaining debts and perhaps help out my son, plus I could live frugally for the next how many years (given that hubby has no useful pension of his own to speak of) but if I wait till 65 I will receive only marginally more. I guess seeing the facts laid out in this way serves both to reassure and to cause anxiety. In one way the money is there, but is it enough, and what will future changes mean?

The second event was yesterday when I went into work during my leave to collect my long service award from the chief executive and board. For 30 years of NHS service I received a certificate which someone in the HR office had obviously made. The fact that this part of proceedings had been done so cheaply was in a way reassuring (no money wasted). any lack of professionalism in the certificate was made up for the fact that the executive team turned up for the lunchtime ceremony. They laid on a light lunch and small talk wasn’t too painful since there weren’t too many people present. The £150 in vouchers I received (this comes from the endowment fund incase you worry that I am preventing someone receiving a trip to A&E or something) will probably be put towards a new TV; soon we are going to move into the era of the LED TV though it won’t have any 3 D features I can assure you!

Today I am off to lunch with some of the ‘girls’ I managed in a previous life and then, joy of joys the rest of the week will be all about painting the living room ceiling and walls!

Lies, damned lies and statistics

Politicians love to give us statistics. They love to tell us that the reason that things are so bad is because of the poor performance of their predecessors. apparently the financial deficit is this bad because the previous government spent too much money (this might be true, but doesn’t take account of the banking collapse and subsequent global recession) and apparently the NHS is in the mess it is because faceless bureaucrats waste money and generally don’t make clinicians perform better.

From my point of view though when governments try to justify policy on a complete and deliberate misinterpretation of statistical fact they have gone too far. According to Andrew Lansley and his colleagues one of the key reasons for needing to dismantle the NHS is because of the UK’s poor health outcomes. They say that despite the massive investment in healthcare we are less likely to survive a heart attack or cancer than other European countries. This article in the BMJ suggests that is plain wrong. It also suggests that the government are misrepresenting what the statistics are actually telling us.

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!