Sunday, December 23, 2012

Improving the NHS next year

Let's hope for better measurement of NHS performance in the New Year than MRSA bacteraemia, number of C. difficile infections, access to treatment times less than 18 weeks and mixed sex breaches. In fact let's hope NHS health care improves even if we can't measure it!

Sunday, November 18, 2012

The price of NHS reorganisation in redundancy payments

Story in the The Telegraph highlights how much is being paid out in redundancy in NHS reorganisation. I had previously suggested (see post) that Sir Neil McKay might have made a good NHS chief executive.

Saturday, November 17, 2012

Father of family medicine obituary

BMJ obituary for Ian McWhinney, who understood the importance of patient-centred medicine and the place of George Engel in this. He suggested that a paradigm shift in medicine would lead to the biopsychosocial model supplanting the anomalies of the biomedical model (eg. see my article).

Friday, November 16, 2012

What are the odds for a no-ball from a bowler’s third ball off his third full over on the second day?

Maybe I gave too much praise to the News of the World in a previous post. Extract in the Daily Mail from new book says that placing spot bets on no-balls is rare. Still, players obviously have been controlled by fixers and there is a question about the results of some matches.

Friday, November 09, 2012

Inefficient to make me redundant

BMJ news story refers to article that finds that less experienced doctors incur more treatment costs. So maybe it's better to keep experienced consultant psychiatrists, like me, when making cuts to meet the Nicholson challenge (see EDP24 news story).

Saturday, November 03, 2012

Payment by results not panacea for problems of NHS

As I've indicated previously (see post), I find it difficult to understand why NHS Foundation Trusts (FTs) are in favour of payment by results (PbR). After all, the motivation for such a system is to encourage other providers into the NHS market. If an NHS FT has an almost monopoly, what does it gain by having competitors come into the market?

A report from the Kings Fund reviews the experience of PbR. It concludes that the current system as applied is not fit for purpose. PbR does not transmit much, if any, pressure to be more efficient. For example, it does not provide an incentive to reduce admission to hospital.

As, again, I've mentioned in a previous post, as far as mental health services are concerned, there has been a delay in implementing PbR. The motivation to introduce PbR in mental health is often said to be because mental health is losing out compared to the rest of medicine by not having PbR. The Kings Fund report puts such a claim in perspective. Any implementation of PbR in mental health should be postponed further until the issues raised by the Kings Fund report are taken on board.

Tuesday, October 23, 2012

Why do child sex abuse cases get dropped for "lack of evidence"

Times article takes the right tack about Panorama programme on Jimmy Savile, about the chance missed for him to face justice when he was alive. The BBC Newsnight editor seems to have decided not to broadcast their programme because initially he thought the case had been dropped because Savile was too old, but in fact it was because there was said not to be sufficient evidence to prosecute. There is an issue about how commonly the CPS drop such abuse cases that Panorama did not pursue in its programme, instead implying more about the pressure the BBC was under not to create a clash with its Savile tribute programmes. Ed Miliband was right to call for an independent inquiry (see video) which could deal with the wider societal issues.

Saturday, October 13, 2012

Barriers to expressing concern in the NHS

Editorial in the BMJ about barriers to whistleblowing in the NHS. It talks about the bullying culture that existed in the NHS (on which I've commented previously several times, eg. see Why do staff report high levels of bullying in the NHS? and Who's bullying whom in the NHS?) at the time of the events that led to the inquiries into the Mid Staffordshire Foundation Trust (again, eg. see previous posts Poor quality of care should not have triggered Mid-Staffs inquiryHealthcare Commission ends its time with "appalling" report and Bayoneting the wounded after the battle is over.)

Actually, the way in which 'whistleblowing' is being used here is probably wider than disclosures under the Public Interest Disclosure Act 1998 (PIDA). What is being talked about is having an open culture in the NHS about performance management. The problems in the past were created by Trust Boards having to self-report to the Strategic Health Authority (SHA). The temptation was for executive directors to say that things were going very well, and non-executives (NEDs) were not well enough in touch with services to know whether this was really the case and endorsed what they were told. Foundation Trusts introduced governors (which included staff governors, who probably were more in touch with what was going on in the Trust, and also governors took over the appointment of NEDs) but it has taken time for governors to realise what their role is. This has now been made transparent in the Health and Social Care Act 2012. And anyway, SHAs are in the process of being abolished.

So, I think the culture has genuinely moved on and changed. And, this makes me bold enough to talk about what happened to me when I was a 'whistleblower' in this wider sense. But the fact that I have not done so until now shows that 'whistleblowing' has been a genuine problem.

My concern was, and still is, about inquiries into homicide by psychiatric patients (eg. see my book chapter and my BMJ letter). Mine is not a maverick position, as evidenced by a letter to The Times with multiple signatories saying that such inquires can become destructive. The problem is that deflecting obloquy becomes an over-riding factor at the expense of professional consequences for staff. I think this is what happened with my NHS Trust's internal inquiry into the care and treatment of Richard King (2005).

The Trust had made efforts to 'beef up' its inquiry, making the case that this meant an independent inquiry from the SHA was not required. This was despite Department of Health guidance that an independent inquiry should be commissioned by the SHA when a homicide has been committed by a person who is under the care of specialist mental health services. I had reason to believe that the SHA had accepted the Trust argument but from my point of view the Trust report was of poor quality. The report was written to maintain public confidence in mental health services by identifying mistakes and errors of judgement. I discussed my concerns with colleagues and formally raised the matter in the Medical Advisory Committee, where I obtained some support. I produced a written critique of the Trust panel report but was refused permission to discuss my concerns with the Chair of the panel that produced the report.

I was unhappy with the Trust action plan, because of the injustices in it, and spoke informally about it to the Trust chair, who said the action plan could not be changed. I therefore made it clear that my understanding of my professional responsibility meant that I would go to the SHA.  I met and subsequently corresponded by e-mail with the Head of Clinical Quality at the SHA. E-mail correspondence followed with the medical director and chief executive, which led to me again emailing the SHA to say that I was unable to take the matter forward with the Trust.

I then received an answer to my critique from the medical director, who had been a member of the panel that produced the report,  to which I responded. Just before this a formal investigation had been initiated into me on another matter. This investigation led to me being told I had to face a disciplinary panel, which never happened after I involved the National Clinical Assessment Service (NCAS).

An independent SHA inquiry report was eventually produced, which I welcomed. I had seen the Trust report as part of a blame culture in the Trust. The independent report was helpful in its recommendations for developing services in the locality and Trust. It made clear that its recommendations may have appeared to replicate the rather imprecise recommendations and exhortations of the first inquiry, but they did not. I think members of the Trust Board found it difficult to hear this message.

I can't say for certain that the timing of the disciplinary matter was related to my raising concerns about the inquiry report. What I can say is that it made it more difficult for me to keep on top of the process of following through on my concerns. There are issues about homicide inquiries by psychiatric patients that need to be discussed openly. I can now speak from my own experience about getting caught up in one (even though it wasn't even my patient).

Sunday, October 07, 2012

Overtreatment harms patients

Recent BMJ article about unnecessary care, together with a video from the website. My book chapter "Clinician bias in diagnosis and treatment" from a few years ago. Would be nice to think there might be an overtreatment movement in medicine.

Monday, August 20, 2012

No easy rapprochment with Pietersen?

Article by Mike Brearley in the Observer thoughtfully discusses the Pietersen situation. Not sure exactly what he's done but it doesn't look like there'll be a quick resolution, which is unfortunate. Brearley had already pointed out before the last Ashes that Pietersen needs his confidence boosting (see previous post)

South Africa deserve to take over from England as number one test team (see previous post). Enjoyed seeing two days of the match at Lords.

Tuesday, July 24, 2012

NHS block contracts for mental health continue for forseeable future

As I predicted (see previous post), payment by results will not be introduced into mental health services next April 2013. The department of health has confirmed to the Health Service Journal that next year was only ever seen as the earliest possible date and the roll-out will be delayed beyond 2014. HSJ blames the lack of reliability of clustering data, but the system also depends on pricing packages of care, and I haven't seen any attempts to do this - unless it's happening with AQP pilots for IAPT (again, see another previous post). It's up to Monitor and the NHS Commissioning Board to determine the future of mental health contracts.

Friday, May 18, 2012

Wednesday, May 16, 2012

British railways still in Lowestoft

Peter Aldous, Waveney MP, has raised the issue in parliament of the development of Lowestoft station, where I travel to work from Norwich (see full text of debate). It's about time Lowestoft caught up with denationalisation of the railways in its signage. British Rail (the trading name of British Railways from 1965) stopped operating in 1997.

Saturday, May 05, 2012

Death of theologians

The death of Eric James (see obituary), biographer of John Robinson (see book review), my director of religious studies when I was at Trinity College, Cambridge, has prompted me to find out what has happened to other theologians who affected me. I find that Alaister Kee also died last year (see obituary notice).

I was influenced by death of God theology. Strange looking back the extent to which people were willing to go to hang on to religion.

Saturday, April 07, 2012

What are the advantages of payment by results in NHS?

A press release from Monitor quotes its Director of Strategy as saying that "Improving the pricing of NHS services is essential to help commissioners make better decisions for their patients, and to ensure that hospitals and other providers of care are fairly reimbursed." It's sometimes difficult to understand what the motivation is for extending payment by results (PbR) in the NHS, when it's not clear that the cost is worth it (see previous post). After all, the report that this quote is taken from has been published to introduce a system for varying the national price if the costs of providing a service are too high or the revenues generated  too low. Some services are too essential to fail.

PbR in mental health services will be introduced in shadow form from this April. If the system works (which must be in doubt) and there are few advantages, it'll be interesting to see what Clinical Commissioning Groups do next year. Despite all the hype, it might actually make sense to continue block contracts. And I'm not saying this because I don't think that mental health services can be provided more cheaply (see another previous post). And, I'm happy for PbR to be experimented with at the edges of block contracts (see another previous post). This will be happening this year with psychological therapies in primary care in some parts of the country, but not in Norfolk and Suffolk where I work.

Sunday, February 26, 2012

Reimbursing NHS-funded care

Monitor has published a report by PwC suggesting in its press release that "New pricing analysis highlights opportunities to improve patient care". The report suggests that what it calls incentives driven by pricing reimbursement are being undermined in the current implementation of Payment by Results (PbR). 

£28 billion out of a total secondary care budget of £66 billion is now contracted through PbR. What the report found is that the non-tariff  income is actually more volatile year on year. This is probably because non-tariff income is being used to smooth out any variations caused by PbR.

Actually this is not necessarily a bad thing. It means that trusts and PCTs minimise the risk of financial difficulties. As Alan Maynard says in his column on Health Policy Insight:-
Scrutiny of local budget bargaining usually shows that annual horse-trading about funding consists of negotiation about the level of investment for the year (de facto a global budget) with agreements that if the hospital stays within this budget and activity level, any misdemeanours on CQUIN and other regulations will be overlooked as far as applying financial penalties are concerned. 
It is this type of budget horse-trading which predominates but is rarely discussed outside tension-filled rooms when annual funding levels are fixed. It is the system that the clinical commissioning groups [CCGs] will inherit: a nice learning curve for the keen but rather naïve GPs whose survival will depend on their ability to play these well-established PCT-Trust games!
If the NHS is really going to be a clinician driven system, actually CCGs may even see an advantage in returning to block contracts. Commissioning support costs may be prohibitive and this money could be invested in services. Again as Alan Maynard says:-
So is it time to abandon PbR, revert to global budgets and use the savings to invest in sensible and simple management of cost, activity and outcome outliers and improving the mean performance of each? 
Reducing outliers and improving average activity, cost and outcomes is essential if The Nicholson Challenge is to be achieved. Squeezing PbR tariffs seems a crude and expensive method of achieving such efficiency gains.
If the Health and Social Care Bill gets through the House of Lords (see Ed Miliband writing in Sunday Mirror), I think it will be much more difficult for CCGs to use block contracts as they might wish because of the emphasis on competition by Monitor. But it would be a sensible way forward and, anyway, PbR can be developed at the edges of a block contract system through the introduction of any qualified provider arrangements (see previous post).

Saturday, January 28, 2012

More on lack of fairness in medical discipline

Julian de Haviland makes a good point in BMJ letter about the lack of independence in medical disciplinary matters. Managerial power may be misused though medical disciplinary procedures (see previous post).