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.