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.