It is bringing it into focus, but the Doctors’ “Strike won’t cure sick NHS” – Mark Britnell in the Sunday Times – Whoever wins the heated battles over junior doctors’ pay and seven-day working, the health service needs a radical overhaul. This is just the start of civil unrest. The Doctors causing problems will be replaced by the patients causing even worse ones. Doctors already under pressure cannot expand their working hours safely, and are already voting with their feet. The unhappiness is due to prolonged undercapacity due to political neglect, lack of decisions or leadership, on the funding and gender bias of medical schools over many years. It cannot be reversed suddenly. Mr Hunt’s complacency and lies are winding up the profession, and that’s without the GP exodus. The Guardian says make or break time..
The confrontation between the government and junior doctors over seven-day working exposes tough issues about the type of NHS we want and what we are prepared to pay for it. With medics voting on whether to strike after weeks of protests that brought thousands on to the streets, the matter is coming to a head. But whoever comes out on top in this stand-off should be careful what they wish for.
For the government, potential success in changing doctors’ pay and conditions is just the start of reforms to weekend and weekday cover which, they claim, could save up to 11,000 lives every year.
Even if doctors in training accept these demands, further negotiations lie ahead with senior staff, followed by large-scale change to clinical services across England. Many emergency services will need to be consolidated to provide better 24/7 care. Ultimately, the model of a local, fully functioning A&E as people commonly perceive it will change for good.
If the British Medical Association’s (BMA’s) junior doctors committee succeeds in scuppering the government’s manifesto commitment to seven-day working, it could well be a Pyrrhic victory.
Studies have shown that patients admitted on a Sunday are 16% more likely to die than those brought in on a Wednesday — a shocking statistic that health professionals have known for some time and which The Sunday Times has been at the forefront of highlighting with its Safe Weekend Care campaign.
A failure of negotiations would maintain what Sir Bruce Keogh, the NHS medical director, has described as “an avoidable weekend effect which if addressed could save lives. This is something that we as clinicians should collectively seek to solve”.
Does the BMA have a constructive alternative? It is mounting a powerful defence of the status quo, but in doing so risks being seen as opposing better services.
Already, evidence is emerging that patients are avoiding hospitals at weekends because they fear the death rates. Either side could win a battle only to lose the war in terms of public sympathy, professional support and taxpayer cash.
The government, encouraged by its election victory and private polling that indicates support for seven-day working, has momentum and reasonable clinical evidence to mount a strong case.
The Academy of Medical Royal Colleges published a report in 2012 that said it was unacceptable that patient outcomes should depend on when they were admitted to hospital. It added that variations of this type were “insupportable”.
The government can also claim that its latest offer has taken into consideration junior doctors’ fears that they might have been on the sharp end of a pay cut. Clinical areas where there is a high unsocial hours element, such as A&E, attract higher payments, and the government has now agreed to protect this pay up to 2019.
For the BMA, however, this is unlikely to be enough. Trust is low on both sides and junior doctors want proper recognition of unsocial hours as “premium time”.
Some have also asked whether the extra costs of improved weekend working might be better spent on problems such as sepsis; a blood infection that kills 37,000 a year.
Looking at the battle over staffing levels and the NHS’s workforce, it is worth comparing the situation with other leading healthcare systems. Between 2004 and 2014 the number of hospital doctors in the UK grew by an impressive 44%, yet we still have far fewer doctors than other comparable countries — 2.8 per 1,000 people compared to Switzerland (4), Sweden (3.9), Germany (3.9) and Australia (3.3). Conversely, Canada (2.1), Singapore (2) and Hong Kong (1.8) have fewer doctors than us but equal or better clinical outcomes in some areas.
Bringing us up to average OECD staffing levels would require spending an extra £5bn a year on 26,500 more doctors and 47,000 nurses. Given the NHS deficit of nearly £1bn in just the first quarter of the financial year, this is not going to be entertained. Indeed, there is no guarantee there will be staff to hire. The World Health Organisation estimates there is a shortage of 7m healthcare workers worldwide and says this will increase to 13m by 2035.
Fortunately, more can be done to balance staff supply and demand. Successive governments have not planned our healthcare workforce needs adequately. Powerful cartels combining royal colleges, universities and post-graduate bodies have mixed with professional demarcations, trade union turf wars and role rigidities that have made workforce planning overly bureaucratic and inflexible. Our medical education is world class but needs to be reshaped to produce doctors who will benefit our NHS and economy.
Many service industries have embraced 24/7 working to meet rising consumer needs. They have done this through the sensible application of technology, a careful assessment of consumer behaviour, the standardisation of business process (think pathways of care instead of narrow specialisms) and support for learning new skills. In this regard, the NHS is still in the early stages of development.
Last year, the NHS national information board suggested that plans to exploit digital technology could save £10bn. This is a bold claim but tech-savvy nations such as Israel and Singapore have already realised that simply employing more staff may not be feasible even if it is desirable.
Globally, health has been sluggishly resistant to productivity gains through the adoption of new technologies. It will need to raise its collective game if we are to care for our growing and ageing populations.
There is evidence that — as in telecommunications and banking — patients themselves can take more control over their care through supportive technology and, in doing so, reduce consumption of healthcare by as much as 21%. Quality and satisfaction rates also improve, providing evidence that none of us likes being sick and dependent if we can help it.
But technology cannot solve all the pressures we face in healthcare. Caring for our carers is crucial, too. I have worked in 60 countries with public and private sector healthcare organisations alike. Many are still getting the basics of staff motivation and management wrong.
In the NHS, staff wages account for around 70% of spending but bureaucratic management and heavy-handed regulation often sap the energy and innovation of our greatest NHS asset — staff.
In my book, In Search of the Perfect Health System, I examine the key features of hospitals across the world that have higher staff satisfaction and productivity, finding that they share similar characteristics: an unswerving focus on providing better patient care; measuring this transparently; holding staff to account for its delivery; giving them more autonomy to get on with it; and supporting them with new skills.
I often ask NHS staff and managers around the country how many have had a meaningful appraisal in the past year — fewer than 30% of hands usually go up. For a caring industry, it cannot be right that staff are left unsupported or unaccountable for the care they deliver.
In America, an estimated 400,000 patients die prematurely each year as a result of preventable harm. The BMA suggested there were 12,000 avoidable deaths per year in Britain compared to 1,700 on our roads. We would not fly if the random quality controls in healthcare were adopted by the aviation industry.
The essential elements of improvement — a devotion to quality, accountability and transparent measurement — were adopted in other industries decades ago and it is time we did the same in health. Of course, safer care is usually cheaper care too.
However, the financial squeeze and looming funding crisis in the NHS will cast a shadow over the doctors’ pay dispute and desire for seven-day working.
NHS England has estimated that seven-day working might cost between 1.5% and 2% of a hospital’s income but has also suggested a funding gap of £30bn, of which £22bn will be met through better efficiency and managed patient demand.
OECD reports show that spending on health across the developed world has slowed since the global financial crisis, and NHS spending has increased by just 0.84% in the past few years, which equates to only a quarter of its long-run average increase.
The NHS can produce efficiencies but we also need to share the proceeds of our growing economy if we are to catch Germany, France and the Netherlands. They all spend at least two percentage points more of their national wealth on health.
Whoever wins the current dispute will also win responsibility for these far more intractable problems. Both sides need to start working together.
Mark Britnell is senior partner for the Global Health Practice at KPMG. His new book, In Search of the Perfect Health System, is published by Palgrave Macmillan
Ask what is not provided. The CCGs (Clinical Commissioning Groups) in the UK Regions would be better named Clinical “Omission” Groups. CCG would become COG, and their purpose would therefore be much clearer to “Joe Public”.