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Look after yourself


7 February 2013

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Looking at the ‘to do’ list for the NHS over the next few years, I worry that we’re heading for a workaholic meltdown.

The biggest challenge, as ever, is balancing the books. The £3 billion underspend the NHS has just handed back to the treasury does not fill me with confidence.

Rather the reverse – we’ve been too tight on money in the last two years and many patients who desperately needed care have not received it even though the money was allocated for them.

Looking at the ‘to do’ list for the NHS over the next few years, I worry that we’re heading for a workaholic meltdown.

The biggest challenge, as ever, is balancing the books. The £3 billion underspend the NHS has just handed back to the treasury does not fill me with confidence.

Rather the reverse – we’ve been too tight on money in the last two years and many patients who desperately needed care have not received it even though the money was allocated for them.

In the long term, the picture’s looking grim, with the Nuffield Trust now predicting a decade of austerity for the NHS, with a ‘funding gap’ of up to £54 billion by 2021/22. If every patient in the UK stopped smoking, ate and drank sensibly, took 30 minutes of brisk exercise every day, used condoms, stayed mentally well and only bothered the NHS for vaccinations, it might just survive.
So what are clinical commissioners to do? Plenty it seems. The National Commissioning board has just set out its priorities and rules for 2013-14. It’s called ‘Everyone Counts’ (and not to be confused with the REM hit ‘Everybody Hurts’). The NHS CB has decided to ignore the government and not implement a new formula for allocating health funding across England. So although Andrew Lansley promised last year the allocation would be made on the basis of age, to please those old Tory voters perhaps, the NHS CB has stuck to deprivation.

This could either excite you that the board has the power and independence to stick two fingers up to government, or worry you that an unelected super-quango has such power.  Either way, I hope they use their power compassionately and responsibly. Here’s just a sample of what they’ve promised:  CCGs will have their "progress" judged on 35 measures. There will be a  'zero-tolerance' approach to provider performance. Real time patient feedback will be introduced for whole NHS by 2015, and commissioners must act on it. CCGs will however be able to choose their own ‘improvement areas’ for quality payment. Performance of individual surgeons is to be published by next summer, to guide both patients and commissioners. Routine NHS services should be available seven days a week. And all referrals will be paperless by 2015.

I can understand the arguments for these changes, but are they deliverable in such a tight time frame? There seems little point in lighting and heating hospitals all weekend but only offering emergency services, and it’s outrageous that your chance of surviving hospital depends on whether you get sick ‘in hours’ or ‘out of hours.’ According to a Health Service Journal survey, NHS chief execs rate the ‘out of hours’ safety of their hospitals as only 5.9/10. The theory goes that if routine GP and hospital services were available throughout weekends, there would be fewer unnecessary emergency admissions. But the plan requires investment, resources and union backing.

The publication of performance data of individual surgeons was promised after the Bristol Inquiry 12 years ago. The fact that it hasn’t happened yet suggests it’s hard to do in a fair way that doesn’t discriminate against surgeons taking on harder operations and doesn’t hinder surgical training. But heart surgeons have shown it is doable, and commissioning and choice only start to make sense when you have robust outcome data to guide you. Will CCGs have the guts to withdraw services from poorly performing hospitals or individuals? There are bound to be tough legal challenges when this happens.

Even before the Francis report, the coalition has promised that the NHS will be forced to own up to mistakes and apologise to patients. Also promised is a new national database of children at risk,  ‘Ofsted style’ ratings for hospitals and care homes, and all over 75’s to be screened for dementia (without sufficient evidence base). Work is always limitless and time is always limited. The mental health of NHS staff is the biggest elephant in the room, and we don’t want to make it even worse by trying to do too much, too fast, driven by a political timeframe and without evidence that it’ll work. We need to slow down, regroup and look after each other.

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