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Job planning needs to improve to deliver more

By Mike Broad - 5th July 2010 11:15 am

Radiology, pathology and anaesthetics should be more productive considering the “high number” of doctors working in those specialties, an Audit Commission report claims.

The report, called Making the most of NHS frontline staff, urges trusts to take a more disciplined and transparent approach to the consultant contract. It says the number of SPAs assigned each week to consultants ranges from 1 to 2.6, and some consultants are working 15 PAs - equivalent to a 64-hour week.

“The essential problem is the quality of consultant job planning, which often lacks rigour or alignment with service objectives,” it says.

The study, which is based on benchmarking work carried out at more than 50 trusts, suggests there is potential to make significant savings by making better use of doctors and nurses. Hospital doctors, it claims, account for 13% of the acute hospital budget.

It finds that the numbers and grade mix of doctors often does not seem to be the result of careful planning of service and training needs. The average number of trainees supervised per consultant in general surgery varies from less than one to more than six in the hospitals it looked at with no obvious rationale.

Furthermore, the cost of locum doctors in trusts varies from 3% to 20% of medical spending. It says: “Clearly there are concerns abou the quality and continuity of care delivered when such extensive use is made of temporary doctors. In some cases, high spend is focused on particular departments.”

It also highlights the variance in admission rates per doctor. It varies by an “inexplicable” factor of more than two, from 129 per doctor each year to 329. The number of first outpatient appointments per doctor varies from 108 to 380 each year.

In nursing, it finds a wide variation in the cost per occupied bed, the number of nurses per bed and the use of temporary nursing. There’s also an unexplained variation in grade mix. The size of wards is the most significant factor in nursing costs per bed.

The report concludes: “The number of hospital admissions has continued to rise year on year. However, there will be greater emphasis in the future on treating people earlier and closer to home so, in theory, reducing the demand for hospital care. This will put further pressure on staffing, making knowledge of the workforce and strategies for efficient management even more important.”

Read the full report.

Tags: Consultant contract, Funding, Productivity
Posted in Hospital Dr News | 2 Comments »

Services are already being cut, survey reveals

By Mike Broad - 28th June 2010 8:18 am

The economic downturn is already having a significant and haphazard impact on NHS services, despite government reassurances that frontline services will be protected.

A BMA survey of its local negotiating committees reveals widespread plans for redundancies, recruitment freezes and service cutbacks.

Nearly three quarters of the 92 LNC chairs who responded said clinical services or infrastructure developments were being postponed for financial reasons. Two in five said that access to treatments or therapies were being limited.

Nearly two thirds of respondents said that there was a freeze on recruitment, with the overwhelming majority saying it covered clinical posts.

A quarter said there were redundancies planned in their trusts.

While the government has guaranteed growth in spending, in real terms, on the NHS, it’s also under pressure to make efficiencies of up to £20bn over the next four years.

Dr Hamish Meldrum, chair of BMA council, said: “There may be areas where there is a genuine need to examine ways of working and services being offered to ensure they are delivered in the most cost-effective manner. But all too often we see blanket bans, indiscriminate cost-cutting and decisions seemingly taken for political and financial expediency rather than because of good clinical evidence.

“Patients, local populations and health professionals should be actively involved in decision-making processes involving change and there should be genuine devolution of decision –making to the local level. We urge the government and NHS organisations to focus on those areas where they can truly eliminate waste.”

Nearly half of responding LNCs were being consulted on cost and efficiency savings. The amount of savings being sought averaged 6%.

Meldrum added that the survey’s findings, which were launched at the start of the BMA’s Annual Representatives Meeting, also suggested that consultants’ SPAs are being squeezed.

Tags: Cuts, Funding
Posted in Hospital Dr News | No Comments »

Support for higher taxes on unhealthy lifestyles

The Independent - 16th June 2010 6:49 pm

More than a third of people believe higher taxes on alcohol, cigarettes and unhealthy food would be the most effective way of cutting NHS spending, a survey finds.

If the money spent on healthcare has to be reduced while maintaining the same quality of care, 35% of people think higher taxes should be the answer.

Almost one in five (19%) support moving more treatments from hospitals into the community and people’s homes, while just 11% think NHS staff numbers should be cut.

Almost one in eight (12%) said there should be a bigger role for private companies in providing NHS care, but just 8% were in favour of closing some district hospitals in favour of super-centres specialising in disease areas.

The latest poll of 3,000 members of the public was commissioned by Philips Electronics for its forthcoming report, Philips Health & Well-being Index.

Are we prepared to pay for revalidation?

By Tom Goodfellow - 3rd May 2010 9:26 am

All the political parties have told us that, despite the approaching financial crisis (the tax that dare not speak its name), frontline NHS services will be protected. So that’s all right then! At least the lads and lassies running the excellent medical services for our gallant troops in Afghanistan can sleep easy in their bunks knowing that they will not need to hold car boot sales in order to buy a few sticky plasters.

Meanwhile, at home, the paranoia runs high. I was stopped in the corridor yesterday by a colleague who hissed: “It’s true! Charlie got it straight from his mates in the SHA last Friday; they are considering cutting doctors pay by 30%.” So, here is my contribution to the NHS funding debate.

At the HCSA Council meeting last week we were considering our response to the latest GMC consultation document on revalidation. I also spent some time reviewing the draft report by the NHS Revalidation Support Team on enhanced appraisal.

It is a worthy document and although “the role of the appraiser is already highly skilled” (phew!) the enhanced appraisers will need to have “integrity, commitment, personal effectiveness, self-awareness”, and the ability to be “fair, unbiased, impartial, objective, supportive, understanding, empathic and honest, acknowledging preconceptions and able to adapt behaviour appropriately”. They will also need an extensive “knowledge and skills framework” (how I detest such jargon) in order to “serve the multiple purposes of detecting unsafe practice etc.” to support revalidation. Wow! I am thinking sainthood here!

Now I am no mathematician. At my school if you could do long division you were directed towards engineering and the physical sciences. If you were dyslexic for numbers (like me) you did biological sciences and became a doctor. (There was little in between, other than the arty farty types who did English and became teachers).

However I have done some crude calculations on the likely costs of enhanced appraisal for 37,000 consultants on the back of a fag packet and this is what I have come up with. It is based on the training requirements and costs of about 5,000 appraisers doing approximately eight appraisals per year, estimated PA time for both the training and the actual appraisal of the consultants (about 2 PAs each per appraisal). I will not bore you with the sums, but the total is not far short of £50m per year. Work it out yourself if you do not believe me.

Of course it could be argued that the funding of the PAs is already in the NHS budget so the only new money would be for training. However the enhanced appraisal will be taking consultants away from other NHS work to a far greater degree than the current rather ad hoc system squeezed in over a lunch break, so this will prove a genuine “cost” to the NHS.

I rather suspect some CEOs, desperate to slash costs in the coming storm, may start to question the evidence base for all this.

Tags: Funding, Revalidation
Posted in Tom Goodfellow | 2 Comments »

Funding review which threatened jobs on hold

By Francesca Robinson - 14th April 2010 1:28 pm

A controversial shake up in the way clinical training is funded in England has been postponed for at least a year.

The Department of Health had proposed to introduce a new system this month which would have redistributed some funding away from medical training posts.

A review has recommended that the current Multi Professional Education and Training levy (MPET) should be replaced with a tariff based system where the funding follows the student or the trainee.

It proposed cutting the money paid to trusts for the provision of undergraduate medical education. It also recommended that the funding for the salaries of junior doctors should be reallocated so that only the education and training element of posts is reimbursed and not the service contribution.

Under the new system trusts would no longer receive 100% funding from the DoH for the salaries of foundation doctors and the proportion of funding for specialist training posts would also be cut. Savings from these changes were intended to free up money for training nurses, midwives and other healthcare professionals.

Following concerns raised during the consultation the DoH has now agreed to proceed more cautiously.

The BMA had warned that the proposed changes were being introduced too quickly and that the funding cutbacks could result in trusts shedding medical academic posts.

The DoH has now announced that no changes will be made this year. Instead placement rates and a range of options for funding postgraduate medical salaries will be piloted by strategic health authorities. The aim is to test the impact any changes will have on individual trusts.

A spokeswoman said more detail on the pilots would be published after the election.

Gill Bellord, director for core membership services at NHS Employers, said: “NHS Employers want a system that fairly recognises the overall costs of training and provides sufficient quality training to meet future healthcare needs. We will look forward to seeing what the pilots reveal.”

NHS Employers is in favour of scrapping the model of 100% salary support for all trainees because it says it would effectively make trainees supernumerary.

It argues that trainees are employees of trusts and provide a variable level of service contribution and that funding for their posts should reflect what trainees actually do. This would make funding of their posts consistent with payment by results funding.

Dr Tom Dolphin, junior doctors’ committee vice chair, said: “How commissioners of medical education choose to distribute their discretionary funding for posts should be on the basis of the quality of the training available. It’s almost always a good idea to pilot something before deciding whether to implement it fully and any pilots have to be run in a transparent way that makes it clear how the funding flows and why.

“Unintended consequences of reform have the potential to disrupt service provision if funding changes are too abrupt, and at the undergraduate level care must be taken to avoid damaging academic medical departments. The Department of Health is aware of these risks already.”

Tags: Funding, MPET, Training
Posted in Hospital Dr News | 1 Comment »

Let’s get our hands on non doms’ surplus cash

By Katherine Teale - 22nd March 2010 9:55 am

We had another ‘talking-to’ by our chief executive this week. This was to brief us (again) on the dire financial situation.

In fact, however dire we thought it was, it’s worse. Much worse. Now it’s up to us to disseminate this information to everyone in our ‘patch’ whilst simultaneously maintaining good morale, and, while we’re at it, coming up with some bright ideas of how to get us out of this mess.

What about calling in some management consultants, I hear you ask? For some reason, this idea didn’t find favour with our finance director, who looks like a man having sleepless nights.

My idea to solve our financial crisis is as follows - with everything going on, you may have missed the fact that Lord Ashcroft of Belize has apparently been spared ‘tens of millions’ of pounds worth of income tax by his non dom status. Am I the only person to see this obvious solution? Simply getting the Tory Party chairman to pay a bit of income tax would fund the hospital for several years to come.

We can also while away long hours in theatre speculating about what on earth Lord Ashcroft does for a living to owe so much tax - does he in fact actually own Belize? Or, indeed, most of Central America?

Meanwhile, I note with resignation that while we are being told to consider whether replacing theatre staff is really necessary, the governance department is still recruiting to vacancies. At least I’ll be able to reassure staff that, should they have time to fill in any critical incident forms, there won’t be a shortage of people to carry out a detailed root cause analysis and risk assessment, and produce a 10 point action plan telling us what we’ve been doing wrong.

The other department whose members don’t need to worry about receiving a P45 anytime soon is the quality improvement department. Yes, we have a whole department of people entirely devoted to improving the quality of everything, but they appear to do this in secret - none of the front line staff I’ve asked knew of their existence, which shows you just how essential they are.

The only reason I know about them is because they keep pinching my staff - they have policy of ‘seconding’ people from front-line areas and sitting them in front of a computer for six months while their erstwhile colleagues have to manage without them, thus greatly improving patient care.

The staff feel not unreasonably aggrieved that while those bankers, ably aided and abetted by the government, got the public finances into this mess, we now seem to be the ones left to sort out the problem - as usual the poor old taxpayer and patients will be the ones to suffer. With an election looming, the public sector has been shielded from the affects of the recession so far but after the election that is going to change.

“What about all the talk of ring-fencing NHS funding?” asks our lead nurse. Good question. The only things ring fenced at the moment seem to be City bonuses and Tory peers’ bank balances.

Tags: Funding
Posted in Katherine Teale | 2 Comments »

Hospitals need to ‘axe thousands of more beds’

BBC Health - 17th March 2010 8:17 am

Nearly 30,000 hospital beds in England should be axed to save money and improve care, a think tank says.

Reform says the NHS’s focus should move away from hospital treatment as more people suffer from conditions, such as diabetes, which can be treated at home.

It says a quarter of beds could be axed to fund more personalised treatment.

The government said local health chiefs could decide, while the BMA said cuts made for purely financial reasons would be “immoral”.

The hospital bed count has been falling for decades, but Reforms’s call represents a more rapid programme than has been seen in recent years.

There were just under 300,000 beds in 1987, but by last year that had fallen to 160,000 as advances in treatment have meant patients do not need to spend as long in hospital.

However, the majority of the closures happened during the 1990s and the think tank believes politicians now need to be brave about pushing ahead with reform - even if that led to some hospitals being closed or downgraded.

NHS cash crisis prompts first wave of cuts

The Guardian - 2nd March 2010 9:25 pm

More than a third of NHS primary healthcare trusts, which fund hospitals in England, are running deficits that have led to a cutback in surgical operations and seen calls to close casualty departments, according to a joint study by The Guardian and the think tank Civitas.

The analysis, which used figures from the public board meetings of 100 trusts, shows the health service overspend this year is more than £130m. The Department of Health has warned trusts they cannot enter the new financial year in the red and health authorities which do not cut costs face repaying cash from next year’s budget or being subjected to central control.

The funding gap has already had an impact on patients, with GPs in Hertfordshire being told to get “approval” for a list of procedures including hysterectomies, removal of “skin lumps and bumps” and tooth extraction. Managers have advised the family doctors that in many cases “it is usually better to wait to see if symptoms resolve themselves”.

Although the government has said the health budget would not be cut, analysts say that even with “zero real growth” the NHS will face a shortfall of £20bn by 2013 - a gap that will grow to £38bn by 2016.

James Gubb, head of health policy at Civitas, said the tide of red ink was “of huge concern” given the tight budgets the NHS will be facing very soon.

NHS cuts of 400 pounds per person in England

By Mike Broad - 15th February 2010 12:28 pm

The NHS in England will make cuts of £400 per head of population over the next four years, claim health campaigners Health Emergency.

Seven of the ten strategic health authorities (SHAs) in England have mapped out cuts totaling £15bn over that period.

The remaining three SHAs (North East, Yorkshire and Humber and East of England) have yet to reveal the scale of their planned cuts. However, estimates based on their current share of NHS spending suggest that they would bring the total to around £20bn.

By far the biggest cuts (averaging £673 per head of population) will fall on London, with West Midlands facing the next biggest at £450 per head. Most other regions are looking at cuts of between £290 and £400 per head. The smallest cuts appear to be in the East Midlands (£187 per head).

Staff numbers will bear the brunt of the cut backs, claims Health Emergency. NHS North West, NHS South East Coast and NHS Yorkshire and Humberside are seeking to reduce staffing by 10%, in line with last summer’s controversial McKinsey report.

Detailed plans in North East London spell out the need to cut nursing costs by a third, spending on doctors by 40% and other overhead costs by over 30%. And University Hospitals of Leicester Trust is already planning to axe 700 jobs to cut spending by £58m in the next year (£5m per month). Similar policies will soon be emerging across the country, campaigners claim.

NHS London is setting the pace on cutting back, where there are plans to slash spending by over £5bn. This will also be achieved by axing up to a third of hospital beds, a wholesale switch of A&E and outpatient treatment away from hospitals to health centres and polyclinics, cuts of a third in the length of patient consultation times with GPs, and cuts of up to two thirds in spending on primary care and community services.

The NHS chief executive Sir David Nicholson set a challenge in 2009 for authorities to make savings of between £15bn and £20bn between 2011 and 2014.

Health Emergency information director Dr John Lister said: “Thousands of health workers’ jobs could be axed in every region. But it’s clear that patients and the public are being deliberately kept in the dark as these plans for unacceptable cuts are hatched up behind closed doors.

“Obviously these cuts are driven first and foremost not by NHS or public sector failure, but by the deficit caused by the banking crisis. But instead of cutting wasteful spending on management consultants, profiteering private providers and pointless NHS bureaucracy, these cuts are biting in to the bone of basic frontline services. Health bosses everywhere must be told this will not be accepted.”

Tags: Cuts, Funding
Posted in Hospital Dr News | No Comments »

FTN paper on cutting consultant’s terms & conditions

By Mike Broad - 10th February 2010 1:15 pm

This is the full text of the Foundation Trust Network (FTN) document leaked to Unison and then run originally in The Guardian:

1. Introduction

In July 2009 FTN undertook a survey of members to examine their priorities for reform of the agenda for change programme. In light of the QIPP programme and the economic realities facing the NHS over the next several years, with a number of member organisations we re-visited the topic of workforce flexibilities as a key part of foundation trust strategies for managing risk and service reconfigurations.

There is now widespread recognition that:

• Cash will reduce in service (15-20 billion) with no third year commitment from treasury to even flat cash - so the situation could get worse than currently predicted.

• Non-pay costs are rising faster than general inflation and NI contributions at around £500m.

• The commissioning aim will be to take 30-40% activity out of secondary sector.

• There is no allowance in tariff for pay - so real reduction in funding pay bill that will not be made up by using natural wastage.

• Even using full natural wastage only produces 2.9% but will not give the shape of workforce and skill mix required to sustain patient services in new configurations.

• Redundancies are likely to be needed with the best case option being local voluntary agreements.

2. Changes Foundation Trust Employers Wish DH to Pursue

Below is the list of changes foundation trusts want to see to workforce conditions in order to sustain patient services together with an indication of the key priorities (Red Line - note that Hospital Dr has italicised these instead):

• Reform to the need to seek Treasury approval for voluntary redundancy schemes

• Negotiate redundancy payments in 12ths to ensure that the duty to mitigate losses can be implemented if employment achieved quickly in another NHS body. This would create an incentive to move quickly.

• Reduce the number of pay points on A4C Bands (Red Line).

• Change Schedule k so that staff members are not able to opt back in to Agenda for Change having accepted local arrangements.

• Freeze increments on incremental pay progression for 2/3 years. Then change increments to two points - one for learners one for experienced staff (Red line).

• Agency staff - refresh the guidance and PASA agreements to drive down unreasonable costs of agency staff. Recognise that some agency (1%) will be needed. DH to review immigration requirements as these have had considerable impact on availability of quality, medical locums.

• Sick pay - 6 months full/6 months half pay unlikely to be able to negotiate change. So, local robust sick management needed. However, change sick pay so that plain rates are paid for sick pay (Red Line).

• Either abolish or extend the time (7am to 10pm) for plain rate payment on basis that many staff chose to work nights (Red line).

• End permanent injury allowance and potentially temporary injury allowance.

• Make clear NHS will not be able to offer employment to every trainee – national review of commissions.

• Tackle regulatory demands for continual expansion of statutory training: plus DH to create more e-learning products.

• Stop clinical excellence awards (Red line).

• New consultants - reduce SPAs for newly appointed consultants to enable them to develop clinical skills - suggested 9/1 (Red Line).

• Existing Consultants - reduce SPAs from 2.5 to 1.5 or 1 (if possible).

• Pensionable items - review all including London rating and CEAs.

• Stop recruitment & retention premium for all staff.

• Cap pensions for higher earners (over £100k: easier to do as part of a whole public sector review of pensions) and look at removal of other pensionable items such as London weighting and CEAs.

3. Agreed Foundation Trust Network Position on Guarantees

In our working group there was some discussion of how FTN should respond on behalf of the foundation trust community to any request for guarantees on jobs. The Group believed that the flexibilities outlined above were now a requirement for managing the fiscal realities but that even with these it would not be possible to give job guarantees. In reality, many of the factors that will determine the shape of future health and social care services are not under the control of providers but will be determined by commissioning decisions around pathways and competition in service provision.

The statement below was approved:

“Foundation Trusts do not believe that, in the economic climate and given the system and reconfiguration challenges they are facing, it will be possible to offer any guarantees that compulsory redundancies will not be required. However, all Foundation Trusts will want to fulfil their responsibilities as good employers in supporting staff to find suitable alternative employment in partnership with the local health economy as a whole.”

FTN January 2010

Tags: CEAs, Funding, Pensions, SPAs
Posted in Features | No Comments »