Chairman's speech to the Conference of Senior Hospital Medical Staff 2005 - Dr Paul Miller
8 June 2005
Colleagues, this has been a year of real progress for consultants and CCSC; of new approaches and changes by us, which are already showing success; but sadly, of risks to standards of patient care, caused by ill-considered NHS policy, driven through despite growing evidence of real dangers for patients.
Contract
At last, we have had a good contract year. Not delayed negotiations, not tense ballots, not widespread implementation failure. In this last 12 months we have achieved, we have delivered steady progress on contract implementation in all 4 nations, though with continuing problems particularly in Wales and Northern Ireland. I must also commend colleagues in Scotland for their defence of their contract from ridiculous parliamentary criticism. Most consultants are now on the new contract and seeing the benefits they have long deserved, with better pay and guaranteed time for the supporting work needed for high quality patient care. I can say with confidence that most consultants now find that their new contract is better for them. And most consultants I meet now appreciate the hard work of so many people in achieving this for them.
The contract has also delivered reducing hours of work for consultants for the first time ever. When I became chairman, I wanted to see the end of the long hours culture for consultants. As a junior doctor, I routinely did weeks of over 100 hours with on call. It was accepted and even considered necessary. Yet no-one would go back to that now. Very recently, consultants actually worked weeks of over 60 or more hours, before on-call took them over 100 hours. It was not good for us or safe for patients. The culture which expected that is now all but gone. We, and patients, should delight in its passing.
It is now quite common for new posts to have one or two half days off each week, to keep to 10 PAs. At last, our contract is delivering what consultants have long asked for. We now need the DDRB to do their job properly and accept that our pay scales are set too low.
Pensions
We have done much work this year with the BMA pension department about the NHS pensions consultation. We have provided a great amount of information about the consultation options. We have surveyed consultants, we know what they think; they are incandescent at threats to their pensions. We have ensured that the views of consultants are well included in the BMA response. The whole issue is now to be subject to new negotiations. However, if this turns out to have been a cynical, meaningless pre-election promise with no substance, I have no doubt that consultants and other NHS staff will be so sickened as to leave in large numbers. We took NHS employment on the promise of these pensions. The DDRB has repeatedly kept our salary down because of how good it believed our pensions to be. It is therefore unacceptable to slash pensions especially for individuals who have made irrevocable lifetime financial plans based upon the current scheme. I have no doubt that any such forced changes to NHS pensions will lead to calls for industrial action.
Next, changes. We listened to our membership, and next year, CCSC will remove 12 observer seats to make way for more representatives elected by consultants. This has to be right. But even more, look at the changes to this conference. We are now inviting a representative from each Medical Staff Committee or LNC, and have the best attended, most representative consultant conference ever. These changes must not be the end of improved communication and representation. With a passion, we want to represent you to the best of our ability. But we need your help. Get your colleagues involved. Democracy is not a spectator sport.
Patient care
I want to use the majority of my time to confront, in detail, the most serious issues threatening patient care and the NHS. This is not just an English issue. There are clear examples of leakage of these policies into Scotland. And I have heard very senior officials refer scornfully to Wales as the 'control group' for the English experiment, so it is likely to come to you too.
Certainly, I give the Government huge credit for funding rises unprecedented in the history of the NHS. I do not doubt their commitment to, and belief in, the importance of healthcare for the population. I also am impressed at their apparent commitment to what Sir Humphrey would undoubtedly have called 'very brave policies, Minister' - and I want now to consider why these policies are so dangerous for patients and politicians, though possibly not for doctors. Our goals as consultants are entirely aligned with those of patients, not least because earning more in a new system is poor reward for knowing that you and your family risk lower standards of healthcare. We are all patients at some time.
For over two and a half years, I and others in the BMA have been analysing the interactions of the policies of plurality of providers, Payment by Results and patient choice. We reached conclusions in January 2003 which others are only reaching now. Let me emphasise that we have always supported increased NHS capacity to reduce waiting times for patients. And we have always supported patient choice. We protested when this was diminished in the early nineties. But we believe it has to be more, and more realistic, than Halifax or Hull for your hip, Nottingham or Nuneaton for your knee, Canterbury or Cheltenham for your cataract. For a start, patients want to be confident that wherever they choose, they will attend a hospital with low MRSA rates and will get to see a properly trained and appointed consultant. A consultant with adequate time to devote to them, working in a system which does not managerially drive them towards second best care for the sake of cost or targets. And they want a system which values the importance of training future doctors for their own old age and for their children; a system which upholds research to develop better treatments. Consultants want all of these things too, but they are under threat as never before. So even though treatment centres could increase consultant pay, consultants are far more concerned about the effects on clinical standards.
Now, many of you will be aware of a vigorous, even passionate, debate within CCSC about how to express our concerns about the effects of these policies upon patient care. For two and a half years we have tried very hard to influence, persuade and convince those in power that there are some problems with these policies which will harm the interests of patients. We have been listened to and we were clearly many months ahead of others in our understanding. But it is hard to ignore the feeling that we were also being ignored at times because our messages, though polite, were not always comfortable. Fortunately, the rest of the NHS and many other bodies are now endorsing what we have been saying. Some say that we should be louder in public about these problems. I support the suggestion that we should expose and explain rather than oppose and complain. But I also note what other great figures have said. Albert Schweitzer said 'Example is not the main thing in influencing people. It is the only thing.' Martin Luther King said 'The time is always right to do what is right.' So, here and now, let us try once again to influence by examples of the damage to the NHS and patients.
Examples
We warned that the system being created was a hugely unfair playing field between 'old' NHS providers and 'new' providers. The new providers will be paid more per case than the NHS while necessarily “cherry picking” the easiest and cheapest cases. They would have no responsibilities for teaching or research. They would not have the cost of follow up or complications. Their out-of-hours emergency cover was questionable and we were less than convinced about the clinical quality of some of the doctors likely to be employed. We warned that the inevitable result would be destabilisation of the NHS and closure of NHS units-not because they were clinically poor, but simply because the rules were unfair. Colleagues, we were right on all counts. Indeed, the results have probably gone further & faster & dafter than even we imagined.
Southampton
To reach the mandatory level of non-NHS elective surgery in Southampton, much elective orthopaedics was transferred from the NHS to the independent sector Treatment Centre (ISTC). Nothing to do with the choices of patients, everything to do with following political orders. Consequently, Southampton had to plan the inevitable ward closure and staff redundancies. Unsurprisingly, it now seems that some are unsuitable and too complex for the ISTC. But the NHS unit is no longer available, so they are in limbo, allegedly being sent all over the place and do not even appear on any published waiting list.
Now, we have repeatedly been told by Secretaries of State that they will not force patients to go to hospitals they don’t want to choose. Yet this is doing precisely that, forcing patients to go anywhere but the Southampton unit they might have chosen.
Cherry picking
It has been said that ISTCs will not cherry pick the easiest, cheapest patients. Anyone who says this either does not know what they are talking about or is deliberately misleading you. The detailed costing and contracting that this would require are currently far beyond the abilities of the NHS. And Treatment Centres simply do not have the resources such as out of hours staff and ITU beds to do the more difficult cases. It would be unsafe for them not to cherry pick.
Training
The NHS bears all the responsibility and associated costs for training medical students, junior doctors and all other NHS staff, within their lower tariff, while the ISTCs have no such costs. We have been pointing out this unfairness for over two years. A very senior Government health advisor recently suggested that ISTCs may have to be paid extra to train. This will only increases the funding unfairness. But more than this, the transfer of most of the easiest operations out of the NHS is now increasingly being shown to be damaging the training of future surgeons. What a scandalously short sighted approach!
Research
Very similar arguments exist for the costs of research upon the NHS, which ISTCs do not bear. Further, the transfer of all these easier cases is seriously biasing the case mix for research in the NHS.
Follow up
There is no clear plan for the arrangements or costs for longer term follow up or complications from ISTCs, just an expectation that the local NHS will do it, usually without resources.
Quality of care
We now have in the public domain the story of an ISTC medical director who is reported to have resigned over concerns about the quality of care, with serious questions about out of hours cover, continuity of care and multiple surgeons flying in for short periods of work before returning home.
Alliance Medical
We have Alliance Medical contracted to provide over 600,000 MRI scans for the NHS, yet condemned in a scathing internal NHS report as being 'mobilised with no governance structures' such that the NHS could not log concerns, and which goes on to describe
- Suboptimal care for patients.
- Reduction in credibility in the service provider and therefore of willingness of NHS sites to co-operate with Alliance Medical.
- Underuse of the contract and therefore financial loss.
Reports were taking over 6 weeks to arrive from overseas, were difficult to understand, and only 55% or the minimum contract was actually delivered.
And on top of this, it now seems they are not even accountable to the Healthcare Commission, for very questionable reasons.
Funds are having to be directed into these private mobile scanner units in hospital car parks, while those same hospitals cannot afford to run their own scanner.
This is not value for money, and it is not what is best for patients. Just imagine how much the NHS could have achieved if these enormous amounts of money had been directed at mainstream NHS clinical services. Because while we all applaud the improvements in health and healthcare, and reduced waits for patients, let’s remember that these are achieved by the NHS and the contribution of ISTCs is tiny, and expensive. Last year, despite all the political praise heaped on ISTCs, the NHS still delivered 96% of cataract operations and, of course, 100% of the care for patients in Accident & Emergency, obstetrics, cancer, mental health, paediatrics etc. The NHS, not ISTCs. And I must take the opportunity here to correct one of the most misleading statements of the last year; that the cataract centres do 8 times as many operations in a day as the NHS. This is simply not true. The figures do not say that, and the NHS units do far more besides than only cataracts.
So, are we against any changes? No. Consultants are the change leaders, modernisers, innovators of patient care in the NHS. If we had slavishly followed every fashionable breeze in the NHS in the last fifteen years, we would have been for opt-out hospitals; for the purchaser provider split; for fundholding; for the market; then against the market; against fundholding; then once again for the market; for practice based commissioning. Many other similar lists exist, look at district and regional health authority arrangements.
What we are consistently for over the years is high quality services for patients. These are rarely helped by yet another wave of reorganisation. Indeed, these usually harm patient services by consuming huge amounts of money and attention.
We are concerned about clinical failings in the cataract caravan scheme and in other ophthalmic treatment centres and especially with overseas clinical teams. We are aware that these have come to the attention of the Colleges and of the NPSA and others. The results of investigations into these matters, which we understand have lead to harm to patients, including blindness in some cases, are awaited with interest. We understand that the Clinical Governance Support Unit may now be considering concerns flagged up. We are aware that the Healthcare Commission are still investigating adverse events with overseas clinical teams in ophthalmology from as long ago as 2002!! This is a source of frustration to the profession and must be a concern for patients and relatives. We welcome the efforts of the Colleges and NPSA and others to try to bring the lessons from, and memories of, these events to the attention of the Service. We remain concerned about poor quality and uncertain clinical governance arrangements in these novel Independent Sector schemes. Individuals might wish to reflect on whether they would wish their relatives operated on in a caravan by “ a specialist” from another hemisphere on a short working holiday in the UK or whether they would prefer the safety and security of visiting a local consultant, properly appointed by an Advisory Appointments Committee, who will be available locally for any post-operative care needed in premises equipped to deal with complications in a facility underpinned by proper clinical audit of clinical outcomes and not just reports of patient experience bases on smiley faces as is used in the mobile units. Certainly, as things stand, I would not accept an MRI scan or elective surgery from these Independent Sector Treatment Centres.
Last month I attended a memorial lecture for Patrick Okura, a leader in mental health services in the USA. One quote of his was, “It’s not how smart you are or how knowledgeable you are-you have to depend upon other people to help you. In that way you are able to succeed.” And I thought that was a very apt lesson for where we are now. We are offering to Government our vast collective knowledge and experience to help make changes and improvements to health that will really benefit patients.
Because for all its faults, and accepting that all organisations can learn to be better, the problems I have been seeing with patient services in Treatment Centres make me truly believe that the NHS is not only worth protecting and cherishing, it is the most important and valuable piece of social capital in our country.
Improvements
So for starters, here are 10 easy, quick, cheap changes which would transform the experience of many NHS patients.
- Twenty years of increasing managerialism have failed. An excessive emphasis on targets has failed. Even large amounts of money have failed to achieve as much as it should. What is needed now is a much greater emphasis on clinical leadership and management of services. From the highest level, the message must go out to engage with consultants and work with us locally and nationally to harness our ideas to develop and improve services.
- Invest more in support staff and much more in training for medical managers and service leaders.
- Make such jobs more attractive so consultants actively want to take on these roles.
- Listen to constructive criticism, don’t just dismiss it. Rubbishing concerns and being endlessly upbeat in the face of problems is not a substitute for a workable policy with clinical engagement. For example, Choose and Book began as a simple plan to enable electronic referrals, but is now supposed to deliver a complex clinic booking system. It is simply unworkable, because there was no adequate clinical input.
- Stop treating the ISTCs so much more favourably than the NHS, at least let us all compete on a level playing field. Better still, move away from competing and integrate the ISTCs back into the NHS to allow coordinated, planned patient care.
- Drop the perverse additionality rules so that consultants who want to do more work, or innovate, can do so after fulfilling their NHS contract.
- Let’s see what we can do with the NHS IT system to make it clinically useful. Use it to deliver good quality data systems to produce meaningful information for patients, information endorsed by engaged consultants, which can also inform consultant appraisals. There are already good examples of this, and it needs to spread.
- I heard Mr Blair expressing concern about health in Africa. Well, stop the NHS poaching doctors and nurses from developing African countries and start recruiting ethically.
- Ban smoking in confined public places.
- And, in an NHS which has more money than ever before, stop charging patients through the nose to have TVs in their room that they cannot switch off.
While most of these changes will not cost much, it will be necessary to continue real increases in NHS funding beyond the 2008 budget. Medicine advances, and as a nation we must use increasing national wealth to invest in improving our national health.
In closing, why do these policies probably not threaten us as much as they do patients? Because patients still rate NHS doctors as the most trusted of all professions. They know that when they are sick, they can count on us. Just last month I had the privilege of listening to Lorraine Bracco, the actress who plays Dr Melfi in The Sopranos, talking about her experience as a patient. Her wonderful account of the impact on her life of the care she received from her doctors was truly uplifting. Politicians talk of “patient choice”. We must never let them forget that across the world and throughout the years,
We are the patients' choice!