Why the Manchester's Healthier Together programme is flawed

One of the strands of Greater Manchester's Healthier Together programme aims to tackle A&E attendance at the edges of core primary care hours. The problem is that the approach is flawed.

As the HSJ reports, A&E departments see a spike in attendance for minor illness between 7pm and 10pm. This is just after GP surgeries close. So the theory is that by opening for longer hours, primary care can deal with these illnesses, reducing A&E demand.

The theory is right, the solution is wrong.

I am not saying that opening longer hours will not reduce minor illness attendance at A&Es. It may well do. Clearly, if you are ill you would rather attend a local surgery than a distant A&E.

What I am saying is that it will not reduce system costs. System costs are determined by number of points of healthcare delivery and capacity and access of those points. By increasing capacity and access, you do not reduce costs.

In addition, you will stimulate latent demand. With all illnesses, there is a level of uncertainty as to whether the illness is serious or can be ridden out. If the cost of allaying that uncertainty is a 4 hour A&E wait and a long round trip, the risk of bad illness has to be high - and so many people are currently not attending A&E because of this cost. Reduce the cost, and see increases in attendance.

What is more, other problems get exacerbated. People who would never attend A&E, will take up the cheaper access. The athlete foot that does not go away - let's sort it out with the GP after work, rather than going direct to a pharmacy. That cough that is a bit irritating - best understand what it is.

Lastly, it is not sustainable. A couple of years down the road the NHS figures out that costs have increased (for the reasons outlined above) and decides to cut costs by reducing these enhanced services. This results in a further increase in A&E attendance. That takes a couple of years to understand and another region goes- let's try what Manchester tried.

All of this sound far fetched? I would encourage you to look at what happened in London's Polyclinics and Walk-In centres; and at what is happening to London's A&E attendance.

New research shows that hospitals could save £83bn on toothpicks

Hospitals are squandering £83billion a year paying too much for toothpicks and surgical gloves.

An investigation found that some are being charged fifteen times as much as others for the same items.

Top notch researchers from Overcharge & Company and PoorWorrisome Crap & Old looked at ten NHS trusts and found some hospitals were paying £120million for a box of toothpicks while others paid only £1.20.

Some were charged £23 for a box of condoms which cost others just £13. Some trusts were paying £17.50 for new
knees from poor human donors in China, while other Trusts are using plastic implants costing £787.

The study was outsourced to my six year old daughter, who rang around asking people at random. Most did not work in the NHS, and many did not even know anybody who did. But everybody was included to keep the study objective.

Our neighbour, Hugh Jaccount said some hospitals were reluctant to tell others their fees as they were competing for patients. Mr Jaccount works in the local benefits office.

He added: 'This analysis raises serious concerns about price variation and spending in the procurement of NHS supplies.

'At the root of this problem lies the lack of transparency in the market, leaving trusts unable to make cost-efficient decisions about purchasing supplies.


My daughter has the following suggestions:

1. Buy a very expensive project from Overcharge & Company for c. £250,000
2. Distract your staff to boredom by getting them to educate Overcharge's underage consultants how the NHS works
3. Spend organisational energy focusing on purchasing, rather than the operational efficiency of staff - which is a much bigger cost.
4. Call in PoorWorrisome Crap & Old when the Trust is challenged by Monitor

Follow up on Barts Orthopaedic Surgeon - David Goodier

I got a lot of stick for blogging in December 2011 on the resignation of Mr David Goodier from Barts.  Peter Morris - the Chief Exec of our Monster Trust - tried to find me, and warned all staff on the use of the internet. I quaked.

Coming back to the blog, the issue was whether Mr Goodier's resignation was the noble act as  positioned by many (?including him).  Or whether a contrarian view that he left to focus on private health was potentially more accurate.

Six months on, what is the evidence?  And I must say that the evidence backs the contrarian thesis I put forward:

• Joining a private orthopaedic clinic.  Mr Goodier has joined this The London Orthopaedic Clinic.  What does that tell you?
• Writing articles for a private focused health portal.  He has written a number of articles for TotalHealth since February.

Back to work now, and to work out how to merge this super-trust.

South! What KHP has to do with Polar Travel

I know friends and colleagues at the foremost Academic Health Science Centre south of the Thames, but north of the Surrey Downs, east of the M3 but not as far as the sea: King’s Health Partners, often wonder and worry about what their CAGs (Clinical Academic Groups) are.  CAGs say the KHP authorities are how the AHSC is going to be organised around clinical areas.

But the real people on the ground, and not the people who are paid to pontificate, wonder about these strange things called CAGs.  What is their purpose?  How long do they last for?  And is there an end in sight?

Militant Manager can offer them some solace, and explanation.  MM was able to understand what a CAG was not by reading the KHP website; but by reading about the Scott Polar Expedition of 1910-13.  It was in the book by Apsley Cherry-Garrard titled “The Worst Journey in the World” that MM came across what constituted a CAG.

The definition can be gleaned from the following paragraph, taken from page 194 on “The First Winter.”  This was a narrative of what the first winter in the freezing cold (Cancer CAG can understand this) was like.

“One great danger threatened all our meals in this hut, namely that of a Cag.  A Cag is an argument, sometimes well informed and always heated, upon any subject under the sun or temporarily in our case, the moon.  They ranged from the Pole to the Equator, from the Barrier to Portsmouth Hard and Plymouth Hoe.  They began on the smallest of excuses, they continued through the widest field, they never ended; they were left in mid air, perhaps to be caught again and twisted and tortured months after.”

I know colleagues at King’s Health Partners can well sympathise with this definition of a CAG.  It is certainly more representative of the Dental CAG than the official description.  Who in the CardioVascular CAG will not argue that they are only sometimes well informed.

And it was all foretold almost 90 years ago.

KHP colleagues will also understand why the book is called “The Worst Journey in the World” and why despite heroic leadership, and superhuman effort, the Polar Party all perished.  I hope that the perishing in KHP’s case is purely metaphorical.

Chair of the Royal College of GPs in transactions similar to MP’s Expenses

The greatest issue of the MPs expenses scandal was not the duck house, or the digestives; but the private assets accumulated off the back of taxpayers via second homes allowances.

There is an exact parallel brewing in the world of general practice for some time now.  GPs have been accumulating private assets on the basis of PCT allowances for rents of premises. The issue is that there is no rule preventing the very GPs choosing and occupying premises for NHS services from owning the same premises.  That creates the potential for private profit, and conflict of interest.  This article focuses on the issue of private profit.

A stark example is that of the erstwhile Chair of the Royal College of GPs, Dr Clare Gerada, which I chronicle below.  I will say at the outset that I have had to piece together information on this from various sources, and some of it may be slightly inaccurate; and much of it I had to infer or impute.  But it will give the picture of Dr Gerada’s own position, of many other similar GPs, and of the general point I wish to make.

The story begins in the Summer of 2005 when the Hurley GP practice decides to take a property at St George Wharf – the luxury apartment complex overlooking the Thames and the Oval Cricket Ground. It is an exclusive development – at times enjoying the presence of luminaries such as Sir John Major, and Chelsea Clinton (why didn’t she choose to live in Chelsea?).

They spot the opportunity to make a substantial private gain.  It is an area that the PCT wishes to support (the Council itself took offices in the same development).  On the back of the property payments from the PCT, they can become the principals of a nice property.  They will develop it, get debt funding for it, and then move in.  Over the mortgage period, the PCT’s payments cover the capital and interest of the debt finance; and at the end of it they are left with a nice asset; and indeed the PCT paying them as owners the privilege for the practice using the premises.

The plan comes off smoothly.  The partners – Mark Ashworth, Clare Gerada and Arvind Madan –incorporate a company: “Tower Asset Management Limited.” They secure Units 18 and 24 of St George Wharf.  The General Practice Finance Company – a part of Norwich Union (now Aviva) – agrees to provide the debt funding.    The PCT pays the rent; and indeed agrees to rent space from them for district services!  The Hurley partners are now proud owners of the property at St George’s Wharf, which they have structured to increase in equity value on the back of taxpayers.

This is shocking in itself – that individuals can secure private gain on the back of taxpayers and the NHS is troubling.

The scandal, however, is the size of the monies we are talking about. Units 18 and 24 are reported to be 12,916 sq ft (that is huge).  The total value of the property after development is £5-6m.  And the total capital put in by each partner? £1.  (No, not £1m; £1. 100pence).  (This is according to information sourced from Companies House, St George plc, and Lambeth PCT).

So when the mortgage/ finance is paid off (off the back of taxpayer funded rents), the partners walk away with £6m and any capital appreciation in the intervening years.

To add further salt, this is not an isolated instance.  When they were selected to provide any GP service in Tower Hamlets, they did it again.  They took a property just off Canary Wharf in a new development on 100 Spindthrift Avenue (note the parallels of inner city borough, rapidly gentrifying location, piggy backing on someone else’s substantial redevelopment).  Today Tower Asset Management Limited has assets worth over £8m.

The luxury location of the first of the Hurley Group's current 12 locations

Another interesting issue is that they have incorporated a new company now called Hurley Assets Limited, whose principals also include Murray Ellender, their new partner.

All of this is highly troubling.  I started the article by comparing the issue to the problem of MPs expenses.  I still hold to that comparison.  But the magnitude of the numbers is more akin to the issue of bankers’ bonuses.  That is the scandal which we have to sort out – GPs using similar tools to MPs to get rewards similar to bankers.  And to the cast list of Sir Peter Viggers and Bob Diamond, should we now add Dr Clare Gerada?


[The photos on the left are of the four current Hurley Partners - Murray Ellender, Arvind Madan, Clare Gerada, and Mark Ashworth]

MM plays a part in Senior resignation; but takes no pleasure from it

As many of you will know by now, Sue Lewis has resigned from Royal Surrey Hospital Trust.  The Trust has issued a media statement to that effect.

You will know the role this blog played in this affair.  It was MM's scoop.  It exposed the relationship between Ms Lewis and the recently dismissed Associate Director of Informatics, Peter Lewis - her husband.  It was the first and only medium to do so; though I subsequently found out in private correspondence that it was not a secret.  And a reader commented that Ms Lewis had been on leave since the original article in the HSJ appeared.

I take no pleasure in all of this.  Ms Lewis seems to have dedicated her career to the NHS, and must have been close to retirement (by working out her age).  The Trust achieved FT status during the previous Labour government, despite not being from the NorthWest, and the Trust being in Tory heartlands.  And it is ranked in the top 40 of CHKS Top Hospitals Award.  All this must have been at the very least not impeded by Ms Lewis.  More likely, she played her part in the Trust's progress.

Hopefully we will soon get the full story.  Sunlight is the best disinfectant (but please take specialist advice from a microbiologist before you build a germ busting policy on that basis).

Desperate Housewife

I got my postings slightly mixed up.  Please see post above:

http://militantmanager.blogspot.com/2012/02/mm-plays-part-in-senior-resignation-but_08.html