Is the Royal College of Physicians really a trade union?

The Royal College of Physicians has published its census results.  And it makes intriguing reading.  But for the full extent of intrigue you have to read between the lines, as well as the lines itself.

It is interesting that the press release makes for really morbid reading.  There is not one bit of good news in it.

I was close to topping myself, and going and buying all my consultants a round of baby-cham (not in that order, you understand, as that would be ridiculous).  But before I did so (either of those things, in the appropriate order), I thought I would actually read the report, and come to my own conclusion.

Here are the three things that struck me:

1. The feminisation of medicine is striking (chart C13b on page 27)
2. Clinicians do not feel that the overall quality of care has changed much over the last 3 years (chart 32d on page 65)
3. Clinicians enjoy their job - over 80% of them enjoy their job always or often (chart 33a on page 66)

Now, you would not have found any of those messages in the press release - which was all about gloom, and more gloom.

Why is that?

The only conclusion I can come to is that the RCP is trying to make a political point.  As justification, your honour, I pray leave to submit the following exhibits as evidence:

• The focus on the NHS.  Why would this not be a general survey of how all their members work across potential employers - including NHS, private hospital groups, academic institutions, other commercial institutions.  This is not so much a census of consultants and registrars, as much as it is a data gathering exercise on the experience of members with one particular employer.
• Within the NHS focus, focus on the contracted vs actual hours worked.  I am intrigued that BUPA insurance has kept its private reimbursement limits for consultants fixed for a substantial length of time.  But this gets at nothing like that - all about the NHS and programmed activities.  I spend my life telling managers not to focus on PAs.  Doctors are professionals, and they focus on patients - not on filling a hourly timesheet according to their PAs.  But the RCP seems to be wanting to focus on this.
• Question choice.  So everybody knows that by introducing EWTD one would have expected continuity and training to suffer - that is the logic.  The reason you would do it is because doctors are more alert and fresher to do care for patients when they are actually working.  But it is training and continuity that the survey focuses on (charts C28a, b and c); not on the alertness etc.  And indeed, if one wanted to get to the bottom of this issue, one would also come at it differently - what are the total hours worked by consultants including their other commitments (private, academic, etc).  It is only by looking at this that you can fully evaluate the ETWD.
• Reporting style.  I have also shown the negativeness of the reporting.  But on each question, the glass is always half empty.  For example, in the real world the compliance of a policy with law is always greater than the compliance of working practice with policy.  Only in the perfect world is this not true.  So to report that "29.6% of departments do not work EWTD compliant rotas in practice – despite 94.7% being compliant on paper" without context or comparison is to scare the horses.

So, my advice to consultants is to cancel either your BMA or Royal College subscriptions - as they effectively seem to be doing the same thing.

Response to story about Barts

I have had unprecedented traffic on my story about the resignation at Barts and the London.  Usually, the traffic peaks in the 24 hours after publication.  This time, however, it is still going strong 60 hours afterwards.  And I was also alerted by a concerned colleague that Peter, the CEO, was onto me.

I thought that I would give an insight into why I wrote the story.  After all, my time in the NHS may well be limited.  I can picture it.  A full Trust-wide meeting, and Militant Manager is asked to stand up.  "We know who you are.  We have tracked the IP footprints."  There are only two ways it can go.  There could be a Spartacus moment (thereafter renamed the Militant Manager moment); or I am lead away whimpering like a 6-year old girl.  So given my time with you is limited, I thought I would say something about why I wrote the piece.

It was primarily about balance and scrutiny in the media.  I get irritated by lazy stories - as you can read on this blog entry.  That is how I felt about the resignation story as reported in the press.  My feeling was that people had rushed to the most convenient headline - NHS cuts:

• The Independent: Inquiry launched after leading surgeon resigns over NHS cuts
• The Guardian: Patients physically harmed by NHS cuts and bad management, says surgeon

The stories lack context.  All of us have seen appalling situations in NHS hospitals - even the best of them.  And things go wrong.  It happens.  To get to the bottom of the situation needs more analysis, and context.  It is not always about cuts.

And that is what I was providing.  As you can see, my biggest issue was the stories did not address the agenda of the person involved.   I published what struck me as the potential agenda.  I could well be wrong.  But it made you think, didn't it?

And the rest (including me) is now history.

Another non-story parading as a story

Militant Manager gets irritated by journalists who print a story with the most convenient headline without looking into the agendas of those involved, the context of the story and an opportunity for someone else to put the converse point of view.

For example, take this article by a journalist I quite like - Martin Beckford - on the rise of dementia patients in hospital.  The headline screams that emergency admissions for dementia has risen 12%.  There are so many things wrong with it.  First, it is an odd use of statistics.  The 12% rise figure is not an annual figure as most of us would assume, but actually the rise over 4 years - so actually the annual rise is 3%.  But the headline is cheap when you take it over 4 years.  Second, what do I compare it to.  How have emergency admissions been rising overall?  What is the rise in other conditions?

The other thing is the article only gives paltry information on the context.  You really have to dig to find out that there was a National Dementia Strategy in 2009.  And in February of this year there was a £2m ad campaign (though that would not have really affected these figures).  And coding has been improving over this time.  So in that context of raising awareness, and greater sensitivity to dementia, 12% over 4 years does not alarm me.

Then, what about the agenda of the people promoting the report.  It is MHP Health Mandate, a PR/ lobbying/ communications (you pick) company and the Alzheimer's Society.  Would you think they would have an agenda>  And if that is the most extreme they can paint the statistics - which when put into context is not really that surprising - then the numbers cannot be that alarming in reality.

The report, however, does not really address these points; and then goes on to quote only people from these bodies.  We know how it works - either these quotes are already on the press release, or the promoters make available well briefed individuals to interview.  It is much more difficult for the journalist to find context, agendas and contrary points of view - so they generally suffer.

While we are on the topic why are press releases written in the third person.  Are they not issued by the organisation themselves; and therefore should they not be in the first person.  Is it to make it easy to reprint without alteration?  I really do not know the answer to this question and would be interested in finding out.

I must say that I am concerned about dementia.  It is an issue that we need to grapple with in its right proportions.  And I am glad there are groups that promote its awareness and impact.

My issue is with those who consume those reports, and re-report it.  They/ we need to put it into context.   If that does not happen, it irritates Militant Manager; and hopefully it will now also irritate you.

Noble resignation or convenient excuse to focus on greener pastures

So a Consultant Trauma and Orthopaedic surgeon resigns from his post, blaming management incompetence
in an email [to colleagues?]: cue headlines about NHS cuts harming care.  I am talking about William David Goodier who is set to leave Barts and the London at the end of this year (according to his email).

On the face of it this is a noble act by a doctor who could not in good faith meet the needs of his parents and sacrificed his cherished NHS position.  So thinks fellow alliterative blogger Ferret Fancier.  And Mr Goodier's email is full of detail about the valiant struggle against infernal odds.  If one reads it with violins playing on the gramophone, one can vividly understand what Dr Wilson must have endured on his struggle to the South Pole in the doomed Tera Nova expedition with Scott.

However, Militant Manager is a very cynical sort.  And when a 50 year-old orthopaedic surgeon leaves his NHS practice, Militant Manager's antennae are up and alert.  For I suspect that this has less to do with idealism and struggle; and more to do with filthy lucre.

I have nothing to offer but circumstantial evidence.

First, let us take Mr Goodier's age - just at the inflection point where there aren't sufficient years of practice to justify additional investment in training and education .  So further experience in the NHS is no longer necessary - and all the skills needed to fleece private patients have already been gained.

Secondly, let us look at his (extensive) private practice:

• London Sportscare - a sports and musculo-skeletal chambers run by BMI London Independent (as part of the subsidised support many private hospitals offer to their practising doctors).  Under this guise, he has two weekly clinics, and a weekly operating list.
• London Limb Reconstruction - another chambers, this time run by HCA's hospitals, and based mainly at the Princess Grace.   In this case, Mr Goodier can only do patients on an ad-hoc basis (presumably because his NHS practice timetable does not allow him to make more persistent commitments)
• Medico Legal practice - providing personal injury and medical negligence reports for both plaintiffs and defendants

 Third, let us look once again at that resignation letter.  It is a bit of a rant.  But certain clues can be gleaned:

• Flexible working request.  The letter suggests that he made this last year.  Aaaahhhh, right.  Now, let me see.  Would that allow the aforementioned Mr Goodier to be able to make a stronger commitment to Princess Grace?  Conveniently so!
• The "Non" Issue.  So one of the precipitating issues was the lack of movement in appointing the "second pelvic surgeon." But this post was approved and appointed well within a year.  Most of us (admittedly those of us older than 7) would see that as a pretty reasonable (if not rapid) time frame in the NHS - especially if we had been exposed to the NHS for 30 years, 15 as consultant.
• Demand/ capacity issues.  Mr Goodier writes "Unfortunately, there has been a relentless increase in the workload . . ."  Yes, David.  That is right.  That is one of the underlying problems in the NHS.  And 1m others are putting up with, and rejoicing in it.  But I agree with you David, the NHS would be far better if we did not have patients (wait, let me read that again).
• "Are we there yet?"  Mr Goodier complains that a further 2 consultants have not been finalised.  But wait - it is being worked on right?  And you have clinical leaders in Michael Walsh and Constantio Pitzalis also supporting this right?  And you are older than 7 right?  So can you recognise that it will take time, but we will get there.
• Lack of organisation.  Mr Goodier is unhappy with the organisation of theatres, beds, etc etc.  Is that also not your problem Mr Goodier?  As a consultant there for 15 years, do you not share both the blame, and the responsibility to put it right.  Or are you going to take your ball and go home?  Wait, I forgot that I was using a child under 7 as the metaphor: "Are you going to throw your toys out of the pram?"
• Unprofessionalism.  When somebody does not have the skills to lead a solution, or the emotional intelligence to identify and follow an appropriate leader, they resign; and when doing so, they send a long diatribe that damages the organisation, their colleagues and themselves.

I think this is pretty strong circumstantial evidence.  Overall, my conclusion is that Mr Goodier is not so much driven by ideals as much as by money.

There is nothing wrong in moving to earn more money.  But I do object to somebody who does not have the maturity to distinguish what is a noble struggle, and what is blatant unprofessionalism.  I just wish he had had the decency to thank his NHS colleagues for the years of training and support, and wished them luck in dealing with the challenging needs of inner-city East London.  Mr Goodier, however, lacks such class.

NHS Spitting Images No. 2

Academic & Manager Professor Richard Smith

Absent minded scientist Dr Emmett Lathrop Brown

Is it just me, or is Professor Richard Smith (former editor of the BMJ) a spitting image of  Doc Brown (from Back to the Future)?

You decide.  Please look at the two, and you figure out who the mad inventor is.

Militant Manager's prescription for Public Sector Pensions

Readers of this blog (all the millions) will know of my general opinion on the recent dissatisfaction with the government's proposed changes to public sector pensions.  If you don't, then perhaps you should have a look at my earlier blog post.

I am, however, not merely a reactionary.  I am one of those people who spends time doing thought experiments.  And being a middling NHS manager, my thought experiments are on things like "What is the best form of public sector pensions?"

Intrinsically, I do agree with the idea of defined benefit pensions.  But the key question is: if that is so, what are reasonable rates of accrual?

To start with, I can tell you what is unreasonable.  Take the recent Daily Telegraph report by Laura Donnelly and James Clayton: this showed NHS managers with astronomical pension pots (in the same order as Fred Goodwin - with whom many share knighthoods).

So, I am very unconvinced that pension levels should be so critically driven by salaries - at the top end.  Take a senior employee on £240,000 salary and very close to retirement (do some consultant bodies support particular eminent doctors to become Medical Director shortly before retirement so that their final salaries can be boosted?).  Now each year of employment at that level will boost his annual pension by £4,000.  £4,000 inflation-linked, central government backed pension increase would be worth (easily) £100,000.  So the pension is equivalent to an additional £100,000 income to the employee.

Thinking of this another way - the whole point of high salaries is that if high pensions are important to you as a person, you have the means via the salary of buying such a high pension via your own means.  The in-employment reward should be transparent and shown in the salary (and a 40% supplement to your salary - as a £100,000 pension pot contribution would be - should not be a footnote.  If these people are worth £340,000, let us say it and publish it.  [Take it from me, they are not worth it].

That is where it breaks down the most - at the high end.

So my prescription is that there is a cap on pension contributions from the employer.  Either this is an annual pension contribution cap (e.g., £12,000) or the salary level on which defined benefits are calculated are capped (say at £48,000).  Under the first scenario, the employer could only contribute up to £12,000 per employee per year (whatever the other rules are), and the accruals would have to worked from there.  The second scenario applies say where each year's accrual is fixed with your salary up to a maximum.  Thus if an employee accrues at the rate of 1/60th of salary; if the salary is above the maximum (say £240,000), then the accrual is fixed with reference to the maximum of £48,000 - so the employee only accrues £800 rather than £4,000 as the defined annual benefit on retirement.

This would make public sector pensions more affordable.  And I commend it to the House.

Just why is this man the NHS Chief Executive?

Can somebody explain how a man with such little vision and ability as David Nicholson is the NHS' Chief Executive?

Let me give you two recent examples:

• His review of Innovation.  This has produced the proposal that Trusts should comply with national procurement guidance or explain ("comply or explain").  Am I mad, or is this the antithesis of innovation?  Perhaps the official language of the NHS has been changed to newsspeak. 
  
  Perhaps he would like to explain NPfIT, PFIs and other centralised procurement schemes, before he opines on the merits of centralised bureaucracies.  Talking about taking accountability for decisions, when is he going to take responsibility for the mega-folly that was NPfIT for which he was SRO?  Perhaps he can do that before he begins to lecture others.
  
  Nicholson went onto indicate that in principle Foundation Trusts should be brought to follow the same rule, but “Organisational independence [currently] seems to trump value in a big way.”  Isn't that the point of a FT - that it is not run by a bureaucrat based at Richmond House?  More on that below.
• His separation from reality.  In another recent intervention (at the Mid-Staffs inquiry), he proposed that DoH should retain the possibility of de-authorising FTs.  This is contrary to the general shift of policy for 25 years; and is his job not to implement an elected government's policy?  And what is the benefit of de-authorisation?  That it comes under SHA control?  So let us take London: perhaps he can explain to us why SHA control of BHR, Whipps, West Middx, St George's, South London, St Helier and Newham has produced such great results.  Beyond going against government policy, what is his evidence?

All I can conclude is that this man is a bureaucrat with no driving vision; or that his priorities are on other things if he cannot find a coherent vision for how the NHS should function.

The point of Academic Health Science Centres

I have finally figured out the point of Academic Health Science Centres.  It is to create more jobs for the boys (and, more rarely, girls).

As I have commented before, the NHS goes through cycles of structural change.  During these structural changes the top jobs tend to vary according to the point in the cycle.  In the current point, where organisations are being merged, senior jobs clearly drop.

So what does a bureaucracy do when its jobs are threatened?  Find alternative locations to house its own.  And these are the Academic Health Science Centres.

As we know these AHSCs do very little, but they all seem to have a full board and senior leadership team.  For instance, Cambridge has 4 executive, and 12 non-executive members.  Manchester has a lot too - though it is a bit confusing as to what they do.

Now, once you have a board who does very little, and has done very little, what is the next step?  Order a review to help understand what you should do with this pretty organisation which does jack.  And all the better if the review is done by another member of the great and the good, with consulting support by articulate, intelligent, dim-wits.  So Imperial has appointed Ara Darzi; and King's - William McKee; UCL has appointed Edward Lavelle

Militant Manager's view is that if after so little time of such a heralded process, you have to do a review about where to go, the whole enterprise is of questionable value.

But I am not sure about that; I wonder if Lord Turner is available to do a review of that conclusion?

NHS Spitting Images



Television personality and former nurse Jo Brand



CQC Chief Executive Cynthia Bower
















Is it just me, or is CQC Chief Executive a spitting image of Jo Brand?

You decide.  Please look at the two, and you figure out who the comedienne is.

Does competition improve quality in the NHS?

A debate has recently been re-ignited by Zack Cooper and colleagues' article in The Economic Journal on whether hospital competition improves clinical quality.  Cooper et al find that "hospital competition can lead to improvements in hospital quality."

Such a finding immediately attracts attention.  If true it would vindicate the policy of choice and competition, and as such receives warm welcome in some areas.  In others, it is lambasted.  For example, Allyson Pollock, professor of public health research and policy at Queen Mary, University of London, claims many faults in the research.

As an aside, Militant Manager cannot understand how Ms Pollock is a professor of anything.  There is no disinterested detachment that you would expect from an academic: her website, her writings and her approach are all about confirming her beliefs, rather than challenging them in the face of evidence.  The references she gives for her claims (on the lack of link between competition and quality, and on the limitations of data and methodology) are so generic, it begs whether she has really gripped the detail.

Back on topic, MM also has some qualifications on Cooper et al's findings.  MM did not have access to their latest peer-reviewed publication; and so had to do with reading their working paper.  They essentially find that hospitals who in more competitive markets have better mortality figures for heart-attack emergencies.  MM's issue is whether this may be because more local hospitals allows the ambulance to route heart attacks to the better heart-attack centre (as happens in London?).  So this finding would not be because there is competition, but because there are a number of local hospitals, and ambulances are routed.  Perhaps Cooper et al may have addressed this in the EJ article; but MM would appreciate a better understanding of this.

Nevertheless, what MM found convincing was Cooper et al's review of the literature on the impact of competition on quality in the US (section 3.1).  What they document is a number of consistent studies that show that in a regime of fixed prices, increased competition results in increased quality.  This is exactly the situation in the NHS.

That is the most powerful finding for MM; and one that many should pay attention to in designing or criticising reforms.

Maternity's flaw is not midwives or quality, but economics

Maternity care is much in the news.  Many of MM's readers would have followed the BBC Panorama report on London's maternity care.  The programme concludes that 17 deaths could have been "avoided" in London in 2009.   Yet, this is not new.  There have been stories about the difficulties faced in and by maternity departments for a long time.  The question is why so much attention and is it deserved?  Is there something underlying that is at work and needs fixing, or can it not be avoided?

It could be because of a number of unavoidable reasons.  It could be related to the primordial nature of maternity.  It is when a new life emerges into the world; where our urge to procreate bears fruit.  The attention could be a result of the scale of loss when obstetrics goes wrong.  After all, nobody is “ill.”  And both mother and baby are relatively young.  If these were the reasons why maternity gets so much attention, then there is not much you can do to avoid it.

But MM thinks there is an avoidable problem that underlies these issues.  It is not easily seen, but lies there and manifests itself in poor staffing ratios; lack of doctors on the ward; high rates of vacancy and agency; poor infrastructure and so on.  All of these issues then give rise to problems and incidents.  This fundamental problem is economics; money; lucre - whatever you term it.  Maternity care does not pay for itself in the NHS. 

That may be a bald statement to make, but can be backed up by a detailed review of the economics of maternity.  Militant Manager has built an economic model of a maternity department to illustrate this economic problem (available on request).  At 4,000 births, the model concludes a Trustwill lose c. £2.8m pa, and £3.7m at 6,000 births.

The model was built using publicly available staffing and productivity guidelines.  Many of these are from the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).

Some of you may be thinking that the sums do not work because MM has taken the guidelines from those with a vested interest.  The Royal Colleges are hardly going to suggest meagre staffing.

MM would, however, disagree that this is a fundamental problem – partly because some of the numbers makes broad sense; and partly because the producers also have interests which moderate the financial call.  For example, the RCOG guidelines suggest that units with 4,000 births should have a consultant on the labour ward for at least 40 hours per week and those with 6,000 should have one for 60 hours.  This is ludicrous.  Firstly, it shows an attempt at reflecting the economics, and moderating the call for the number of consultants by paying attention to activity.  If such an attempt was made, then they should have gone the whole and way, and modelled it out.  They would then have realised the parlous state of maternity finances. 

Secondly, and more importantly, each birth is a birth. Should the RCOG not focus on the care given to each birth, and treat it equally?  Why should some babies have a better chance of obstetrician cover?  It is a bit like when a job applicant answers the question “why should we hire you?” with an answer that talks about what they can get out of the job, and how they will enjoy it.  To be frank, that is not very relevant to the company doing the hiring.  The question is how will the company benefit - and in this case, the baby.

Lastly, and most importantly, how can a clinical (not managerial, efficiency or productivity) standard be any different from either zero or 168 hours cover a week?  Births do not follow time patterns, so if a clinically safe birth can happen without an obstetrician on the labour ward, then it is safe that all births happen that way.  Conversely, if a clinically safe birth cannot happen without an obstetrician on the ward, then no births should happen without that.  There is no space for a fudge. 

MM believes that the issue is that people like the RCOG try and solve the fundamental problem of economics in other ways.   The economics does not support great consultant cover; but rather than recognise this fundamental fact, these bodies try and nudge up standards a little at a time, and put the pressure on Trusts to solve it.  Other attempts act in a similar way: for example, the CQC’s publication "Towards Better Births" which aimed to show the distribution of maternity provision, and nudge up standards.  And another is the BBC's Panorama survey.

Fundamentally, however, the issue is that the economics do not add up.  No private provider is working hard to become an elective or AQP provider of maternity care - they are for orthopaedics and other areas.  No Foundation Trust is building spanking new maternity wings - they are building Cancer Centres.  Lots of Trusts are rationing care, and closing their list to non-local geographies.  The numbers do not work.

When the economics do not add up, Trusts do not invest in staff and resources to give good care.  As all good economists know, economics drives our behaviour - even when we do not realise it.  Trusts do not mean to do it; but they do it subconsciously.  The end result is that care suffers, and we get headlines.

The best solution would be to drive up tariffs. 

Why NHS Direct is sitting on one nail

Militant Manager is always puzzled by some things in the National Health Service.  Why do GPs vote for less private sector involvement when they are private contractors themselves?  Why do NHS Trusts work so hard to abide by the EU Working Time Directive, yet allow their consultants to moonlight in the private sector without any restriction on working hours?  Why are there so many bodies who bring out (at times conflicting, and contradictory) guidelines, and rules?  Why would a Secretary of State believe that the optimal method of arriving at the best size of commissioning bodies is by imposing arbitrary management cost allowances?  How can those organisations that rely on concentrated, block contracts ever be judged suitably independent to satisfy the requirements of Foundation Trust status?

It is this last question that I wish to address today.  And it brought into stark relief by NHS Direct which has announced its intention to seek FT status.

Militant Manager knows buy-out and venture capital types (some of them have washed up in Monitor).  Buy-out and venture capital types are good for three things: one is running a good LBO model on Excel (which is not very useful in any other walk of life); two is sitting on boards looking empathetic, but continuously wondering how they are going to explain this to their limited partners and colleagues; and the third is to glean a vague sense of what factors could bring a company down suddenly.

And it is this last thing that is useful in this instance.  One of the things that gets them more excited than a good LBO model, and a board meeting going off plan, is a business with a concentrated customer base.  They know that this will make independence and sustainability difficult.  And given these private equity types have only three useful things to say to the world, we should pay attention to at least one of them.

A business that depends on a very concentrated customer base - and in NHS Direct's case, almost entirely on one customer - is not a business (let alone a self-sustaining one).  It is a hobby like a vintage motorbicycle - entertaining for the owner/ client, but first to be jettisoned in harder times.  Or it is a project - like measuring lichen on Derbyshire hills to understand whether they grow in the sun or shade; whether they grow near roads or near forests.  At the very best, it is an outsourced contract from that key client.  It is most certainly not a client.

The sharper amongst you will be wondering why this does not apply to other project companies like Serco or Capita.  But there is a difference.  Serco and Capita have a large number of contracts; which are not co-terminous and are spread across sectors, clients and geographies.  It is a bit like nails.  If you sit on one nail, it is quite painful and lethal.  But if you sit on a thousand nails, then it is uncomfortable, but not lethal.  Nick Chapman is sitting on one nail.  Tom Riall is sitting on a 1,000.  Whose arse would you rather be?

The even more sharper amongst you will now be wondering why this argument does not apply to Mental Health Trusts, and/ or Community Trusts.  And MM would argue that it does.  But it is a question of degree and judgement.  The four axes to judge on are:

1. The concentration of payors, and their correlation with each other.  NHS Direct has one customer now, but even when 111 is implemented and it gets 10 customers, the customers will be looking to it for the same niche. A niche borne of national initiative.  So if one cancels a contract, it is likely to be because of a change in policy which is replicated elsewhere - so the customers decisions in this regard are very correlated.
2. The avoidability of the fundamental need.  Schizophrenia is not going to go away.  But the need for 111 may well do so.  So Mental Health Trusts are more sustainable than NHS Direct.
3. The distribution of decision making.  Mental Health Trusts get referrals from 100-200 GPs from each PCT - which evidences distributed decision making.  And the PCT commissioning decision is borne of a long history with a number of related parties involved, including social services, police and PCTs.  NHS Direct gets commissioned by some pointy-headed person in the East of England.
4. The independence of price.  In acute care, PbR and tariff are not set by customer and provider.  They are set independently of both, and are a "datum".  This enhances independence.

So when judging the sustainability of organisations, one has to look at these four axes.  So what do I conclude from this:

• NHS Direct is at the extreme of suitability for FT status, and is basically not suitable. Hopefully somebody will listen to me this time.  Not like last time, when nobody listened to me when I said that Europe was not a sustainable single currency area.
• Many Mental Health Trusts and Community Trusts also fail this fundamental test.   Forget about Ambulance Trusts.
• Monitor should start to realise this.  At the moment, Monitor just judges whether the organisation is well controlled and managed at the time of authorisation - but it is possible to manage a hobby or a project well.  The question is whether it is sustainable, and Monitor's assessment (like investment bank risk models in 2007) does not really take into account the full range of eventualities.
• With the concentration of commissioning, acute Trusts are also becoming less sustainable.

The truth, however, is that it is hard for all parties to consider this reality.  They would rather whistle while they sit on a nail.

Why the unions should stop moaning about pensions

Public sector pensions are very much in the news.  The government is seeking to revise future entitlements on the basis of John Hutton's report.  Some unions are mobilising against these reforms.   Others continue to negotiate.

Militant Manager is very interested in the arguments put forward by the unions.  The views can be easily gleaned.  For example,  Mark Serwotka, General Secretary of the Public and Commercial Services Union, has commented in the Guardian.  And Jon Restell, Chief Executive of Managers in Partnership, a start-up union set up by Unison and the FDA (formerly the First Division Association - representing the senior civil service), has commented in the HSJ.

The arguments seem confused.  I am not talking about John Restell's "six reasons" managers should look at hard reality - which are in fact just one reason: "these reforms are a reduction in entitlements."

I am talking about the central issues that they put forward: pensions are affordable, and public sector pensioners are not fat-cats.  The first argument is arguable - and I have not seen a definitive analysis on this.  The second is a fallacy.

Affordability

First, the question of affordability.  Both Mark Serwotka and Jonn Restell make much of the Hutton Report's (the one on public sector pensions - not the white wash on WMD in Iraq) analysis of the projected benefits to be paid as a percentage of GDP.  This chart reproduced from pg 23 of Lord Hutton's report is so central to this point that I reproduce it below, and can be retrieved here.

I am not yet sure what to draw from this chart.  The key idea conclusion that the unions have drawn is that public sector pensions will absorb a smaller proportion of GDP, and is therefore affordable.  I must admit that the government has handled this argument badly.  For me, however, the issue of affordability is not so clear cut.

I need more information than just this to draw any conclusions.  First, I want to know what proportion of the population these pensions are supporting.  If they are supporting a rapidly reducing share of the population, yet the proportion of GDP is not falling as fast, I may still draw the conclusion that it is unaffordable.  

On this question, the data is indicative that the number of people supported by public pensions is falling. I could only find data going to 1992 (on the inpenetrable ONS website) for data on the proportion of the workforce employed in the public sector (this is a useful indicator as given 40 year working lives, this would predict the proportion of new public sector pensioners in 20 years time). Their feature on Public Sector Employment, 2006 shows that in 1992, 23.1% of the employment was in the public sector.  Whereas, the same report says that the figure in 2006 was 20.2%.  So public sector workforce proportion has fallen from 23.1% to 20.2%, a drop of c. 15%.

This drop of 15% in public sector employment proportion does not seem to be replicated in a commensurate drop in the load on GDP identified above.  You only get that sort of drop if you link the 1992 workforce figure with the high load on GDP seen in the 2010-2020 decade above.  This may be legitimate if the 1992 workforce figure was also a peak; but if it was not, then you are not comparing apples with apples. In short, I am not convinced on this, and would need somebody from a statistics programme like More or Less to have a look. 

I also want to look at other data.  For example, what proportion of pensions as a whole (including private and state pensions) are public pensions forecast to take up into the future?  And what proportion of government expenditure is it due to absorb.  These would also point to the affordability - indicating what proportion of the country's desire to spend on pensions or public expenditure, public pensions absorbs.

Fat cats

The second argument marshalled by the unions is just plain incomplete at best, and wrong at worst.  Both leaders make much of the fact that the average public sector pension is very low: Mark Serwotka quotes that average pension "is just £4,200 a year"; Jon Restell states “the ‘gold-plated’ pensions of the public sector are a myth (median women’s NHS pension is about £3,500 a year).”

You do not have to be a genius to see the careful wording, and selectivity, in those quotes.  There is no mention of the years contributed for that sort of pension.  We need those facts to put it in context.  If that is 40 years, then public pensions are indeed not gold plated.  But if the years of contribution are 2, then we are at the other extreme.

The other issue is that we are not talking about the individual here.  We are talking about the average pension.  So if the individual has changed jobs and gone onto another public pension scheme, or indeed a private pension scheme then they may be getting more than one pension.

But the main issue is that the argument is plain wrong in composition.  The government has already stated that those on the lowest pay will not get affected.  If we are meant to draw the inference that reducing entitlements, will affect these small pensioners – that is the very guarantee that the government has already given will not happen.  To hark on is to show that you are not listening.

How to really look at it

So how should we really look at this?  My view is that we should look at it in the context of occupational pension schemes – which is what public sector pensions are.  In this context, there are two key issues: first, what has been happening to occupational schemes as a whole; and secondly, what has been happening to the employer’s own finances.

In terms of occupational schemes, there has been a secular trend in reducing pension entitlements, and shifting towards defined contribution schemes.  This can be seen from the IFS’ Green Budget 2011 report.  A chart from that report is reproduced below, which shows private defined benefit schemes dropping dramatically.  In this context, public schemes are bucking the trend.  

So there is no surprise in public sector pensions feeling the pinch.  All occupational schemes have.

The second part is that a generosity of an occupational scheme is related to the success of the employer, and the employer's own finances.  If we have not seen it already, the government's finances are in a mess: we were running a structural deficit even before the fracture in the markets since 2008.  So, employees of the public sector should expect a smaller pension, rather than jump up and down.

NHS Medical Director seems to have stopped taking his prescription drugs

At least, that is the best reason I can find for the stream of inane and ridiculous comments that Sir Bruce Keogh made at the launch of the Government's campaign to publish data.  As reported in the Telegraph, here are some of his comments [with Militant Manager's commentary in square brackets]:

1. He could envisage an NHS that was "available 24-7". [Isn't the NHS already 24-7, with NHS Direct and A&E?  Maybe he was talking about the date 24/7, coming as it does at the beginning of the school holidays.  Those days are always quite hard to staff.]
2. High-speed broadband could allow people to consult international experts or to take advantage of out-of-hours care provided by overseas doctors in another time zone. [Rather than copper wires allowing foreign doctors to provide out-of-hours GP services from another town zone.]
3. Such technology would lessen the need for a "geographical connection" between GPs and their patients, while it would also enable doctors to conduct what he called "virtual ward rounds". [He is much mistaken.  It is the advent of reviews, listening exercises, quangos, and other pass-times that have allowed GPs such as Steve Field, Charles Alessi, Clare Gerada etc to lessen their geographical connection with their patients; and I know of lots of consultants who already do virtual ward rounds - or is it ghost ward rounds?]
4. He said the NHS had to adapt because “young people won’t put up with having to travel to a doctor and wait 20 minutes when they can just use the web to talk directly to a doctor”. [What!  20 minute wait?????? From the same processes that calls all morning day surgeries in first thing in the morning - so that some wait 3 hours!  Aaagh, if only a 20 minute wait was the norm].
5. Sir Bruce acknowledged that the NHS had yet to lay out a “national vision” for digital access, but he said that it would happen in the future. [Just what we need.  Another grand IT vision.  OOOhhhh, let me volunteer for that one]

The similarities between car design and NHS structures

Car companies have a sophisticated strategy for their cars over time.  Their initial authority is over a particular segment.  But over time, they want to play in different segments.  And they do this by slowly invading that space with a model that consumers are familiar with, and taking their authority and consumers with them.  At the same time, they introduce a different model to fill a space customers already trust the marque with.

This can be seen clearly with Volkswagen's hatchback strategy.  So today's Volkswagen Golf (which is in its 6th iteration, i.e. Mk6) is 50% larger than the original Golf Mk1 introduced in 1975.  It is in effect an offering for an entirely different customer segment.

But on average cars do not get bigger.  And that is because as one model migrates away from its entry configuration, the marque introduces a new model to fill the space it leaves behind.  In Volkswagen's case, as its first family hatchback (the Golf) grew in size, it first introduced the Polo and, as that also grew in parallel with the Golf, it introduced the Lupo/ Fox.

The size changes of Volkswagen's hatchbacks since 1975 can be seen in the chart below.  Size in this instance is calculated as the floor area of the car (length x width) in square metres.

Plus ca change, plus c'est la meme chose.  Even though each model gets bigger, the overall market still looks similar.  So you can see that Volkswagen had an offering in the size range of 5.5 to 6.0 sqm from 1975 to today.  And ever since the early 1980s, it has had a model in the size range of 6.0 to 7.0 sqm.  So though things look like they are changing, they are not.  My child has illustrated this paradox with a drawing of her own.  It is meant to show that each column and each row has a car of each size (small, medium and large) even though it all looks different (at least that is what it is meant to show; please cut her some slack, she is only in the 4-6 bracket).

What does this have to do with the NHS.  The similarities are uncanny.  The thing that changes here are the commissioning bodies.  As a proxy for size, Militant Manager has used the number of bodies that cover England.  So if 5 bodies of a certain level cover England, they would cover a much larger population each than if 50 bodies did the same job.

The similarities between the NHS and car design can be shown by the size changes of NHS commissioning bodies since 1990 - as illustrated in the chart below.

This shows that new bodies are introduced at a small size; and over time they grow in size with each restructure.  Over time bodies grow and die; but new ones are introduced.  So 500 PCGs have now made way for 50 PCT Clusters; 100+ Health Authorities will make way for 4 SHA Clusters by 2012.

It's deja vu all over again.  Despite these changes, nothing really changes.  So as you can see there has always been a body at the 300-500 size level since 1997.  And there has also been a regional structure between the Department of Health and this 300-500 level. 

These are incontrovertible facts; but each generation of politicians and officials think they can do something new.  And like those amongst our organisations who feel there is a technical fix to everything; there are those that think there are structural fixes to everything.

I fear that this may all be caused by the management consultants.  Who has not heard of the consultancy who gets called into a decentralised firm, and insists it should be centralised; and goes into a centralised firm, and calls for decentralisation?  This also sounds like the product of a series of structural reviews by consultants - who understand the problems with current situations; but cannot optimise overall; and cannot place their solutions in greater historic context.

But there isn't a structural fix for everything.  Somebody has already thought of it 20 years ago; and we are all tired of structural fixes.  After a series of these changes, we are exactly where we started.  And a lot of effort, time and money has gone into navel gazing.  The NHS structure is not a consumer problem like car design.

So what are the other lessons for the NHS:

1.  NHS structures change too quickly.  If car companies take 6-7 years to introduce a new model because it takes that long for consumers to adapt and factories to settle down and then be retooled; why would you think that organisational structures (which require much greater familiarity and comfort) can be turned on its head every 3-5 years (as seems to be the current average in the NHS).

2.  The NHS introduces too many names.  After any restructure, there is no need to call it different.  So District Health Authorities need not have been called Health Authorities and then Strategic Health Authorities.  The NHS could have built 20 years of brand equity in the simple, all-season name of "Health Authority."  In fact, while we are on the topic of ridiculous arguments, the NHS' names are too boring.  Why cannot SHAs be called the "Kalahari" or "Focus."  We should be more imaginative.

3.  There is no beauty in symmetry.  So though Volkswagen cover the small family segment via three equally spaced hatchbacks, other marques do it differently.  And there is no "Department for Cars" that mandates a symmetrical approach in every company.  Similarly, the NHS should be able to develop its structures differently in different areas.

Why consultants need more natural predators

Without natural predators, growth in consultant numbers is uncontrolled.  This is the conclusion you reach when you look at the training numbers of doctors through an "ecological" prism: where doctors are the fertile mothers, and registrars in training are the juveniles who will grow to become future doctors.

Replacement fertility measures "the total fertility rate at which newborn girls would have an average of exactly one daughter over their lifetimes" who would go onto have further children. In more familiar terms, women have just enough babies to replace themselves.  It is a bit sexist to define this in terms of women alone, but as 50% female, Militant Manager does not mind.

In a stable ecology, replacement fertility is determined by a number of factors.  First is annual survival rates - the chance that you may die each year (predators, lack of food, disease etc).  Second is the age at maturation (the age at which a female can have children).  The lower the rates of survival each year, and the greater the age at maturation, the greater the replacement fertility.  And this equilibrium is stable because if numbers increased, then survival rates would drop as the population became easier to hunt, or they exhausted their food supplies.  A picture of a cow with an element of its replacement fertility is included for completeness below.

  

On this basis the replacement fertility for hospital consultants is 1 - i.e. consultants only need to have one registrar in their career.  And given 30 years of consultancy (which may increase if retirement is pushed back), and 6 years of training, the stable ratio of consultants to juveniles is 5 (this is 30 years of fertility in the consultant, divided by 6 years of maturation in the registrar).  The child bearing years are so long, the maturation age is so early, and the survivorship is so good, that in a stable population there would be 5 consultants per registrar.

And what ratio do we have today?  We have 5 times what we need, as illustrated in this spreadsheet, and summarised in the table below. 

Of course, the model needs to be adjusted for the more complicated reality.  People retire early, or change career.  There are some who go part-time (often the case for women); and others who go "private" entirely or in part.  There are even some who go to the dark side and become managers.

But these complexities only change things at the margin.  The replacement fertility ratio in humans is higher than the theoretical 2 (the theoretical figure).  This replacement fertility ratio ranges from 2.1 to 3.4 depending on country.  And similarly - though Militant Manager has not seen such an analysis - the stable ratio of consultants to registrars may be around 3 to 5:1.

Yet, we have a ratio of 1:1.  My spreadsheet is based on numbers published by the Information Centre.  This shows how the numbers have deteriorated over the last few years.  One can also see that vacancies for consultants are at negligible levels - the levels at which changes in recruitment practices in Trust will affect the numbers.

The more astute amongst the readers will be pointing out that I have not considered the growth that would be required.  That is by design.  The reality is that in a stable advanced economy, one cannot increase the workforce engaged in a sector without also saying in the same breath that that sector will also account for an increased share of GDP.  The UK already spends 8-9% of GDP on healthcare, and I do not see a groundswell to increase this further.  In fact, national policy is to reduce the share of GDP healthcare absorbs by keeping public spending on it constant as GDP grows.  So there are no grounds to independently plan for rapid growth in doctor numbers.

So what does this all mean.  I have four main thoughts:

1.  NHS Workforce leads should be sacked.  Not only have they allowed this to arise, they are asking the wrong questions.  Militant Manager has searched for years for strategic analysis of training numbers - what numbers do we need; and what drives the replacement ratio.

2.  There is going to be a lot of pain for trainees.  There was - not so long ago - a role for "senior registrars."  They were effectively registrars who had all the requirements for consultancy, but had to do "their time" waiting for a job to come up.  It was not unusual to be in such a stage for 5 years.  Those days are coming back.  And the 5 years will be used to erode, demoralise and reduce the registrar base.  Many will leave the profession, and lots of others will seek other ways to burnish their CVs to distinguish themselves in an the increasingly competitive process of becoming a consultant.

3.  We need a better plan.  Juniors now do a lot of activity in hospitals; and many rotas require them.  So in some respects there is a requirement for this number of registrar level doctors.  But we do not need those numbers "training" and aspiring to consultancy - an aspiration we cannot meet.  That will require a reduction in training throughput, and a change in the stable workforce mix in hospitals - away from "training" posts.  This is a task that will have to be picked up by the new HR directors who replace the sacked ones.

4.  We need more natural predators for consultants. Ideas include taking consultants and leaving them in the serengeti; encouraging more to go camping in Siberia; and introducing diving in the shark infested waters of South Africa as a training requirement.  

Readers will have better ideas, and I would welcome those.