Was the recently dismissed Royal Surrey Hospital employee connected to the board?

Not many of my readers would have heard about the dismissal of the Associate Director of Informatics from Royal Surrey Hospital for "breaching the Trust's standards of business conduct policy and our standing financial instructions."

"Police investigate fraud . . . " shouted the HSJ. Some others picked up the story as well - such as E-Health Insider (who are they?).

But not all the relevant details seem to have been picked up. There was the intriguing coincidence of surnames between the dismissed Mr Lewis and the Trust's Deputy Chief Executive, Dr Sue Lewis.

Is Peter Lewis the Deputy CEO' Sue Lewis' husband?

As Lewis is a common surname, MM decided to use her manicured fingers to dial a friend from a long time ago (you do not ask a lady any question that would give insight into her age or her weight; let us just say that it was >10 years ago).

This friend works at a nearby hospital, who was able to confirm that her information was that the two were indeed husband and wife.

I wonder which is the more awkward environment: the dinner table at the Lewis household, or the board table at the Trust?

Do missed appointments cost money?

There has been a rash of stories about missed appointments costing vast amounts of money:

• The BBC quoted Epsom and St Helier who estimated that missed appointments cost the Trust £5.6m
• The Sunday Express quoted a figure of £800m lost for the whole of the NHS

The question is: do they cost so much money?

Let us look at how these figures are arrived at.  They are arrived at by multiplying the number of missed appointments (DNAs in the jargon - Did Not Attend) by a notional cost of the missed appointment. And the notional cost in these two articles are c. £120 per appointment.

There are two weaknesses to this methodology.  First, the analysis assumes that a missed appointment means that the whole infrastructure of out-patient care (nurses, receptionists, test facilities, and doctors) are just kept waiting looking at their watch, and wasted.  Second, the analysis assumes that the cost of this is the same as PCTs are charged for each appointment (which is roughly £120 when averaged between new attendance and follow-up tariffs).

The first is a ridiculous assumption.  I know of very few clinics that work on the assumed basis.  In reality, most clinics are overbooked, assuming some DNAs.  Moreover, outpatient clinics are very poorly analysed and planned according to some ancient template.  As a result, patients are allotted times that may bear little relation to reality.  How many times have you gone to see a outpatient waiting area that is rammed full?  How often have you as a patient waited for far too long to see a clinician.  The basic point here is that in reality DNAs are a small wrinkle in our imperfect outpatient demand and capacity management; and only a small fraction of the allotted time is actually wasted if any.

The second assumption is just wrong.  It shows a misunderstanding of cost and price.  If you break a pram in John Lewis, the cost to John Lewis (assuming they do not charge it to you) is not the full price of the pram - but the cost to them (what they will pay to have it replaced).  Similarly the price of outpatient consultations is not the same as their cost.  And the marginal cash cost of a consultation will be much lower than the £120 charged to PCTs.

So these losses are just paper losses.

In reality, DNAs impose large costs when clinics are analysed and managed very well.  But hospitals who manage that will also be managing their DNAs to the minimum unavoidable level.  These bald and high-level estimates are just idiotic, and we could do without them.

Worst 10 Trusts for Management of Access Targets - Disproportionately FTs

It is a well-known secret that targets based on clock-stops promotes inappropriate behaviour.  They motivate Trusts to focus on ensuring that most of the people starting definitive treatment are within 18 weeks, rather than treating patients in referral order (after allowing for clinical urgency).  It is a subtle, but important distinction; and Trusts can get stuck in the trap of managing clock-stops - not their total patient base.

This post names and shames the worst of these Trusts.  And it finds that Foundation Trusts are actually poorer at governing access targets.  So much for the ability of FTs to improve performance and governance.

This inappropriate management does not necessarily happen by strategy.  It can happen by by the natural dynamics of actions in a Trust, without active thought to it.  For example, how many Trusts have breach lists - patients who will breach if not treated imminently?  And how many service managers run around trying to get these patients on a proximate operating list?  The effect of this is not to treat patients in order of referral; but to focus on those patients who are about to breach 18 weeks.  The effect of this is to treat people within 18 weeks disproportionately.

It also happens because of the culture within the system to achieve 18 weeks.  To take this out of context, it is a bit like the treatment of Iraqi prisoners.  The Western Forces had no active strategy to degrade prisoners at Abu Ghraib; but the overall culture and philosophy of the western forces was to demonise and dehumanise the opposition.  In addition, there were subliminal signals from leaders that international humanitarian law was over-zealous.  That slowly results in (to coin a phrase) "institutional torture".  Similary, the culture, targets and performance management within Trusts is on 18 weeks.  Senior management do not focus on the length of the longest waiters (and still waiting), but on the 18 week target - which focuses on those being treated in the month.  The result is "institutional neglect" of long-waiters.

This culture also results in many concrete actions to intensify the problem.  In any management meeting, more time is spent on those specialities and services whose performance is at the threshold - who have marginally breached or a marginal change will lead them to breach.  Central resources, such as analytics, IT, transformation (what is that, by the way?), strategy and - critically - investment, get disproportionately devoted to these areas.  The end result is that those areas with much greater difficulties (e.g., orthopaedics) get ghettoed into the "too difficult" box, and resources are spent negotiating different profiles with commissioners for those.  The overall result is that patients get treated out of referral order (without clinical justification).

So if that is the problem, how do you identify the worst offenders.  This can be done by looking at the discrepancy between the time people being treated have waited, versus the length of time waited by those not being treated.  In general, if you are managing by referral order (disregarding clinical urgency), people being treated should have waited longer than those waiting for treatment.  So if we look at the statistics on referral published by DoH, the percentage of patients treated within 18 weeks should be far lower than the percentage of untreated people within 18 weeks.  So if we are exactly meeting the existing "clock-stop" targets, on average at least 92.5% of all patients (admitted and non-admitted) would have waited less than 18 weeks (this assumes that there are equal admitted and non-admitted pathways - a simplifying assumption).  Therefore, much more than 92.5% of patients waiting for treatment should have waited less than 18 weeks.  But if we find that only 87.5% of patients not yet treated have waited less than 18 weeks, then I conclude that there has been inappropriate management going on.  And I define a new score - which I have called the MM Obstacle Score of -5% (which is 92.5%-87.5%).  In fact, any negative score, and slightly positive scores probably indicates that Trusts are mismanaging access targets.

[I realise that urgency does change this significantly.  I will return to incorporating this factor on a future date. For now, I realise that this is a simplified picture.]

And now to the list of the worst 10 performers.  This is presented at the top of the blog, with their MM Obstacle Scores based on November 2011 statistics.

8 of the worst 10 are actually FTs.  And they are meant to be the ones with a proven ability to govern themselves better.  In fact, if one considers the 180 Trusts who had admissions of more than 5 patients in November 2011, 60% of the worst performers were FTs, whereas only 51% of the best performers were FTs.  FTs are systematically poorer performers than other Trusts in this measure.  And they are meant to be better at self- governance!

Blog Post Updated on Monday 23rd January 2012, 16:00, to include bring out the fact that Foundation Trusts were disproportionately poorer performers.

Full Text of Clare Gerada's letter to Members

You may have read about the letter that Royal College of GPs Chair - Clare Gerada - sent to her membership.  For example, the Guardian titled their piece: NHS reform bill 'threatens its long term survival.'  The Telegraph titles their piece on the letter NHS reforms must be stopped for 'patient safety'.

From this coverage, you may think that this was a rabble rousing letter.  In fact, it is much more "on the fence" affair seeking membership views.  In effect it is a cover letter for a survey.  The full text of the letter is produced below.

Of course, there are ifs and buts.  For example, the wording of the letter is very leading.  And the full results of the survey will not be published; and Clare can mine the data for her agenda.

However, the coverage is excessive, and may further induce strident views from GPs in their response.  All self-fulfilling . . .

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Here is the full text of the letter

Survey on the Health & Social Care Bill

Message from Dr Clare Gerada, RCGP Chair 21 December 2011

Dear RCGP Member,

As you know, the Health and Social Care Bill is in the final stages of its passage through Parliament and this will be the last opportunity for the College to seek your views. This short survey is designed to test out member opinion on recent developments in relation to the Bill and how the College should respond. I feel it is important to share this with all our members in the UK, not only to keep you up to date with the issues, but to gather as many of your views as possible as we prepare to take important decisions for both the College and the future of the NHS.

We have reached a critical moment in the College’s work to take forward our profession’s concerns about the Heath and Social Care Bill. When we look back in years to come, I want there to be no misunderstanding of the position the College has taken or criticism that we did not do enough to inform and engage members or to protect patients and the NHS.

Since September 2010, the College has articulated a consistent position in relation to the Health and Social Care Bill. Although the College has been active in raising GPs’ concerns - submitting a full response to the White Paper consultation last year, engaging with the Future Forum listening exercise over the summer and proposing amendments to the Bill to try and improve it – fundamental concerns remain and the NHS faces an uncertain, potentially very unstable future. We have not to date opposed the Bill outright but have made it very clear (pdf document) that it removes the systems and structures that underpin the NHS in England through:

The removal of the Secretary of State’s legal responsibility for providing a comprehensive health service. Dismantling the system of commissioning responsibility for area based geographically defined populations, replacing it with commissioning based on populations registered with general practices.

The overriding emphasis on competition and any qualified provider, rather than integration and shared working. Introducing new arrangements for postgraduate medical education and training, moving to a system of ‘Local Education and Training Boards’, funded by a levy. This will not be as fair, efficient or effective as the current system and may not safeguard the important role played by deaneries.

As the Bill has progressed through Parliament, further evidence has emerged which has deepened our concerns. The NHS Operating Framework for 2012/13 (pdf document) confirmed that Clinical Commissioning Groups (CCGs) will be asked to function on operating costs of just £25 per head of the population, a substantial reduction on current levels. In the meantime, draft guidance published by the Department of Health (pdf document) has raised concerns that the market for providing ‘commissioning support’ to CCGs will be dominated by a small number of large commercial providers offering end-to-end packages of support, undermining the principle that commissioning should be clinician-led. These developments – combined with the challenge across the NHS in England of finding £20 billion of efficiency savings – are resulting in a greatly altered landscape. If CCGs are given responsibility without power, there is also a risk that public frustration about the need to ‘ration’ health services could unfairly be targeted at GPs.

Repeatedly our surveys and communications with members have revealed that GPs are concerned that the reforms will weaken the effectiveness of the NHS and its long-term survival as a public service covering the whole population. For example, in our most recent snapshot survey of RCGP members in October 2011, 65.3 per cent of respondents expressed disagreement that theGovernment’s reforms would lead to more cost effective delivery of care, and 66.3 per cent disagreed that they would result in better patient care.

From the outset of the Government’s proposed healthcare reforms, we have been clear that:

• We fully support greater clinician involvement in commissioning and planning services for geographically defined area based populations.
• We believe that provider side reforms could deal with many of the issues without the need for repeated organisational change or many of the proposed reforms.
• In particular, we believe improvements could be brought about by models of care such as GP Federations, where practices can pool expertise and resources to deliver broader services to patients close to their homes, working as appropriate with other NHS, third sector and private providers.

Over the longer term, it is also important that we work with politicians and the public to determine what the NHS should be providing, how it should be funded and how, over the next decade we address the big health issues facing our population. It is our view of course that in order to create an NHS that is fit for the future, this must include more GPs spending more time with their patients.

As a profession we must now decide on a way forward which reflects our unique understanding of how these changes will impact on the health system we work in and the patients in our care. Should the College decide to call for the Bill to be withdrawn, there is no guarantee that this will be successful. Nonetheless, it is my view, and that of many others, that stopping the Bill now, placing GPs in the majority on the boards of the PCT Clusters/NCB outposts and focusing on addressing the serious financial crises facing the NHS, is the safest way forward for patients and communities.

It is important to note that as a registered charity the College is, and will always remain, party politically neutral in its stance on the reforms. We have been working with Government Ministers and the Department of Health team to ensure that the voices of GPs and their patients are heard as the implementation of the reforms progresses, and this is something we will continue to do. However, this does not prevent the College taking a professional stance on whether to support or oppose changes that affect us, patients and the NHS so directly.

As doctors, we need to justify our practice by reference to the best available evidence, and the evidence, little that there is, suggests that the changes being introduced through the Bill are not going to bring about the improvements in efficiency, quality or equity the NHS desperately needs.

Your views matter and will help shape this crucial debate. Please take a moment to to complete a short survey on this issue .

Yours sincerely,

Dr Clare Gerada Chair of Council

CPD: confused public health doctors

Militant Manager wanted to self-mutilate again when he read the latest BMJ's editorial.  Penned by Jamie Lopez Bernal and Martin McKee (both of the London School of Hygiene and Tropical Medicine), it is so flimsy and polemical, that I wondered if they had not veered away from the GMC's Duties of a Doctor which include the requirement to "Recognise and work within the limits of [your] competence."

The central tenet of their article is that any potential economic benefit of higher speed limits is likely to be outweighed by the adverse effects on health.

To try and get a handle on the adverse health effects, they postulate (and work hard to exaggerate) these:

• Greater casualties on the road.  They quote a US study which showed a 16.6% increase in deaths when speed limits were increased.  They postulate that this could be due to both greater traffic and greater collision risk.
• Greater emissions
• (Potentially) greater obesity as more people take to the cars, rather than walk.

I must say that I have not laughed so hard since NPfIT was cut off at the knees.

Surely the point of speed limits and travel is not to minimise road casualties.  If that were true, this study suggests that only men between the ages of 25-44 should drive as they are the safest in terms of casualties per 100,000.  Actually, an even better way to minimise traffic casualties is to shoot babies at birth in the delivery suite - that would reduce road casualties by 100% in due course.

And surely no sensible person is going to really think that increased speed limits would have an impact on obesity!  Where is the evidence?.

Of course, they acknowledge that there may be some benefits.  The only one they mention of course is widely positioned as "economic benefits."  The two particular areas of economic benefit that they note are freight transport (the benefits to which they dismiss contemptuously saying that HGVs would continue to have a 60 mph speed limit); and small vehicles transport - where they do not see any impact on journey times (as most small vehicle transport happens during the busiest times, they claim, when there will not be an impact from higher speed llimits).

Doctors who - after 6 and more years of training - cannot master public health, cannot be expected to understand the basic tenets of economics. MM would like to point out that economic benefits of higher speed limits accrue to consumers as well as producers.  These include leisure travellers, sunday drivers and everybody else.  Economic benefits are the sum of consumer and producer surpluses (not just the latter as these authors seem to believe).

And even the benefits to producers cannot be quantified by theoretical argument.  It is an empirical question.  That these proposals have resulted in such voluminous coverage, and as they would have the impacts on casualties that the authors believe show that we may expect higher speed limits to alter behavoiur and travel times.  And therefore the economic benefits are likely to be substantial - and need to be shown empirically.

That is the central point that is missed by these authors.  That you need empirical evidence both for the benefits as well as the costs.  You cannot conclude an argument purely by juxtaposing an estimate of one of the costs (casualties) with a flimsy theoretical dismissal of the benefits, coupled with shroud waving over obesity.

Only if they have such evidence can they write "In the light of this evidence, it is difficult to see the proposal to raise the speed limit as anything other than a populist gimmick . . ."  Without it, this is just a rhetorical device.

And once these benefits have been shown, the choice should not be left to some paternalist, confused public health doctors; but voters.

Lastly, I cannot rest without pointing out that "extending coach and bus lanes on motorways during busy periods or subsidising rail fares" are not really alternatives.  They require more money.  They are alternatives in the same way that Buckingham Palace is an alternative to a terraced house in Tottenham.  Clearly the former is a place where Militant Manager would be comfortable; but it is only the latter that she can afford.

Overall, I cannot see how the BMJ can take itself seriously when it publishes such drivel.

Most popular Militant Manager posts in 2011

These were the most read stories in 2011, with the number of unique people reading them during that year.  Please note that the number of unique readings are an underestimate of true readers (the majority of viewers go directly to the main Militant Manager blog page - militantmanager.blogspot.com - and cannot be attributed to any one article without detailed analysis.  And as we know NHS Managers are not capable of doing any analysis).


1.  Noble resignation or convenient excuse to focus on greener pastures 279 views
This readership is surprisingly large given the article was only posted on 13 December, and so only had 3 weeks in 2011.


2. Why consultants need more natural predators 270 views
Another post that focused mainly on issues related to doctors.  Interestingly, when I started the blog, my view was that it would be more read by managers.  But it seems that the blog is far more read by doctors . . .


3.  More Del boys will become GPs  124 views
Another issue focused on doctors, and looking at the subtle effect of the health reforms on the composition of GPs.  I must point out that I neither support nor condemn these effects - I am just pointing them out.


4.  The similarities between car design and NHS structures  111 views
The most popular article focused on management issues.  I thought this article deserved greater readership, but it was not to be.  Maybe it will develop a cult following.


5.  The point of Academic Health Science Centres 97 views
On the whole, my more tongue-in-cheek articles (on Clare Gerada, on Bruce Keogh, on Cynthia Bower, David Nicholson, and Richard Smith) did not rouse great interest.  This was the exception.  Probably because Academic Health Science Centres, like Secure Facilities, do not have a point.