The Rolf Harris dirty songbook

Now Rolf Harris has reminded us of Jake the Peg, let's not forget our amusement at the version of his Two Little Boys on "I'm Sorry I'll Read That Again" (see lyrics).

He looks weird, sounds weird and is weird

Why does me saying this about Farage not have as much effect as The Mail saying it about Miliband?

Science and the pharmaceutical industry

Fears about reduction of pharmaceutical R&D funding drive Lord Sainsbury, Chancellor of the University of Cambridge, to argue for blocking Pfizer's potential takeover of AstraZeneca (see Guardian article). He doesn't mention in the article that AstraZeneca had selected Cambridge Biomedical Campus as its new UK-based global research and development centre and corporate headquarters (see press release), which I guess may not happen, at least in the same way, if the takeover goes ahead.

What gets lost in this conflict of interest is whether R&D really leads to therapeutic advances (see Light & Lexchin, 2012). For example, most (80%) of the increase in drug expenditure in British Columbia between 1996 and 2003 was explained by the use of new, patented drug products that did not offer substantial improvements on less expensive alternatives available before 1990 (Morgan et al, 2005). 

Most new drugs are not superior on clinical measures and increase healthcare cost pressures. Medicine has always exploited the placebo effect. Pharmaceutical marketing is not always scientific (Applbaum, 2006). We may need less medicine not more (eg. see previous post).

What can I listen to on car radio?

Just had to listen to Gold via iPad app to make sure it was still there (but without presenters) as could only get Smooth on car radio today - see why. Why change my habit?

Reduce drugs we give people in NHS

The Guardian gives over its front page to an interview with the retiring NHS chief executive, who in my opinion should have resigned in 2009 (see previous post). He argues for an extra change fund to switch hospital to community based care. There is clearly scope for this to happen, but it does need a properly based philosophy of care to underpin it. Actually, what we need as a society is less medicine not more (see another previous post). This means doing what he says we should not do, which is reduce the drugs we give to people.

And there's nothing wrong with serious A&E cases being centralised in major emergency centres, but that's a relatively minor issue compared to providing effective alternatives to admission to hospital. And one of the biggest mistakes would be to dismantle the primary care system we have in this country, which is envied by others, even if it has lost its way a bit with countless NHS managerial reforms. And of course we do still need acute hospitals.

Update on previous post

Even the NHS is supported by the drug companies

Why is Janssen supporting the 2014 Mental Health Network Annual Conference? The Mental Health Network was established by the NHS Confederation, the membership body for all organisations that commission and provide NHS services, to "provide a distinct voice for mental health and learning disability service providers". It is supposed to speak on behalf of the whole NHS, so I'd have thought it didn't need pharmaceutical company money to do that.

The cost of the Guardian

I've been moaning about the Guardian costing £1.60. Today I was charged £1.20 when scanned in the shop even though the paper still has £1.60 on the front!

Blog resistance

Hey, now I know why I blog! See Howard Caygill's Digital Resistance. Blogging "... plays a significant role in delegitimising domination by making it available for scrutiny and comment from a variety of perspectives, potentially contesting the tendency towards monopolization of information, wealth, power and ultimately violence essential to legal rational or even total domination".

The "spectre" of Savile

CockRoache has been found not guilty. Reinforces the case for a public inquiry (see previous post).

Kev, stop tweeting!

Whatever the hurt pride, I can't see that Kevin Pietersen tweeting "I'm shocked and saddened by reports in the media today concerning my future with England ... " has helped his case. Even with Michael Vaughan's support (see Telegraph article), his difference with Andy Flower is something that needs to be sorted out in private, not in the media (which includes Twitter) following the Mail's report. I'm sure Pietersen doesn't mean to bring the England team into disrepute but there's nothing to be gained by 'fanning the flames' in public.

As I said in a previous post, resolving difficulties with Pietersen has not been easy. After all, it was Alastair Cook that facilitated Pietersen's reintegration after the last fiasco. As I pointed out in my tweet, Shane Warne took full advantage of this before the Ashes, encouraging the sledging on the field. As England fall further down the rankings from their peak in 2011 (see previous post), it's important that Pietersen is not made a scapegoat. But the England team is more important than his ego. He shouldn't need to state his desire to help regain the Ashes for England. It should go without saying.

Lack of political leadership on child protection

Ed Balls continues to say he knows better than the Court of Appeal in the case of Sharon Shoesmith (see BBC report). I'm not sure if the bad taste in my mouth about this is worse than his about her payout. Thank goodness Tim Loughton got sacked as Children's minister before his outburst on the Today programme this morning about the same payout (again, see BBC report).

Loughton seems to be just point scoring against Balls, saying that Balls made a botched job of sacking Shoesmith. However, it's fairly clear that the Court was saying more than that Balls merely made a procedural mistake (see previous post).

What we need is for politicians to give a clear lead about the way forward for child protection. At least the chief inspector for Ofsted has said that good child care directors shouldn't be made scapegoats (see Times article). Michael Gove has been reported to be "furious" about the agreement with Haringay council, but this may just be about the confidentiality agreement.

We do need an open discussion about this issue, and the resignation or sacking of Ed Balls should be pursued by Ed Miliband (see another previous post). This would also allow Labour to rebuild its economic credibility and clear out the past poisonous role Balls had in Gordon Brown's inner circle.

Letter to Private Eye

Better value for health care

In July this year, NHS England issued a call to action to debate the issues about the future of the NHS. Monitor's paper about closing the NHS funding gap is in part a response to this debate.

Monitor correctly highlights that staff will have to work "differently and smarter". However, in general its response seems to me to be much of the same eg. reducing waste and a belief that community care is cheaper than hospital care.

There is some emphasis on self-management of long term conditions, but not enough in general about the potential financial savings of more patient-centred care. There is no mention of reducing over diagnosis and over treatment (see previous post). Monitor is going to have to get a bit more imaginative if it is going to sustain flat funding for the NHS.

Lord's will be pleased

Which was the more "ruthless" option? At least England carrying on to a 556 lead (see scorecard), rather than enforcing the follow-on, has guaranteed a fourth if not fifth day for Lord's finances. Still, nice to see another hundred from Joe Root (see previous post).

Maiden test century for Joe Root on home ground

It was worth making the long journey from Norwich to Headingley yesterday. Interesting museum at the ground showing history of Yorkshire County Cricket Club. See video made for 150th anniversary.

British freestyle wrestling's villain dies

Mick McManus has died aged 93 (see Telegraph obituary). What has happened to Kendo Nagasaki, Jackie Pallo, Les Kellett, Adrian Street, Johnny Kwango etc and Kent Walton? I used to watch them on the telly with the old English working class, the Queen and Harold Wilson.

Disciplining Margaret Thatcher

Times article about the authorised biography of Margaret Thatcher by Charles Moore picks up (as does the Guardian) on the memo written by the then head of her policy unit, Sir John Hoskyns, which accused her of bullying her weaker colleagues. Sir John went on, "To survive you have an absolute duty to change the way you operate." The Falklands war followed and the rest is history. I don't think most people knew at the time that the sending of the task force would end in war but winning in the Falklands changed people's attitude to the prime minister.

AN Wilson (see Mail article) argues that Thatcher was not in the true sense a bully because she "reserved her fire for those who - if they had any spunk - were in a position to fight back". I'm not so sure. Her unwanted and unreasonable conduct itself determines whether it is regarded as bullying. I'm not advocating the bullying application of bullying policy (see previous post). She may well have believed that she alone rescued Britain from its post-1945 years of semi-socialist decline, but not everyone benefits from capitalism (see previous post). To analyse any situation from the perspective of the objective and reasonable person is never straightforward as personal experience and judgments will inevitably taint perception. However, she failed to create an environment in which people have the right to be treated with consideration, dignity and respect.

What was unique in severity and duration in case of Mid Staffs?

The government initial response to the Francis report has been published. I still worry that Mid Staffs has been unfairly singled out (see previous post). I'm also not convinced that the new Chief Inspector of Hospitals can provide a "single version of the truth", if there is such a thing, in his or her so-called balanced assessment of hospitals. These matters are always open to interpretation. How this will be helped by inspectors "looking the [Trust] board in the eye" I'm not sure.

Nor am I clear what embedding "a zero tolerance of avoidable harm" in the DNA of the NHS means (see previous post). Harm may appear avoidable in retrospect but not necessarily so before it happens.

It's also good to reduce "paperwork, box ticking and duplicatory regulation and information burdens" but why by at least a third and how will we know whether that target has been met (aren't we supposed to be moving away from targets)?

Can zero harm be a reality in NHS?

Press release from the NHS Commissioning Board confirms that "Professor Donald Berwick is being brought to the NHS to chair a National Advisory Group on the Safety of Patients in England" (see terms of reference and members). David Cameron has asked Berwick "to make zero harm a reality in our NHS". At least he's appreciated that the Francis report needs to be put in the context of patient safety research (see previous post).

Berwick talks well (eg. see video on BBC website). He recognises that most healthcare staff intend well and I too want the NHS to be the safest in the world. But it's misleading to expect no errors in healthcare (see another previous post) and Berwick might need to refine at least his language. Being a doctor is not the same as being an airline pilot.

Berwick must be glad to have left the vitriol of US healthcare politics behind him (see Who is Don Berwick?) It's difficult to relate to some of the emotive language used there (see previous post). But UK healthcare politics too can be based on misunderstandings (see previous post). Hopefully, Berwick and his group can help take the Francis report forward in a sensible way.

Too late to call for David Nicholson to resign

The Mail is keeping up its campaign to get David Nicholson, NHS Chief Executive, to resign (eg. see article) . If he was going to resign he should have done so in 2009 (see previous post). The previous government had already started to change the top-down approach (see previous post). This has got lost in the current government's wasteful reorganisation (eg. see previous post) but David Nicholson has been a steadying influence in the upheaval. That's why David Cameron can't let him go at present.

What Nicholson should be asked to state is where he stands on his claim on Mid-Staffs that “While this was an awful case, it was highly unusual that such poor quality care and patient complaints could go undetected in the NHS for so long and we will make sure this will never happen again.” This was wrong and he should be made to say so. Perhaps the government response to Francis report will say this.

Creating a patient-centred culture in medicine

She may not like me saying if she thinks I am not taking her seriously, but Part One of Julie Bailey's book From ward to Whitehall should be required reading for training health professionals. Part Two is about the politics that followed her mother's death up to the publication of the Healthcare Commission's report (see previous post). I'm not convinced that Robert Francis' recent report has yet answered how to "stop the suffering" in the NHS (see previous post), which has been the motivation for her campaign.

Francis makes no attempt, as far as I can see, to set his findings in the context of the literature about patient safety. A crucial document in this is To err is human, which recognised the common nature of iatrogenic damage. Patient safety has been framed as an explicit public concern since.

The problem is that protocols designed to reduce errors have actually made patient safety worse (see previous post). These factors meant that what was happening on the wards in Mid-Staffs was not appreciated. The Cure the NHS campaign was started because Julie Bailey had a poor response to her complaint. It was so bad (not that I'm blaming the matron who responded and the Director of Nursing that reinforced the response, because they were caught up in this manageralism) that, as far as I know, she has not yet had a proper answer. There clearly has been a culture of investigation at Mid-Staffs since but it sounds as though it has been destructive. According to the BMJ of 42 doctors referred to the GMC only four will face a hearing.

Francis, again as far as I can see, did not pick up on the evidence he was given about the Healthcare Commission "going out with a bang" in the report on Mid-Staffs (see previous post). This doesn't mean that I don't take the evidence from Cure the NHS seriously. It's just that the managerialism introduced by the Healthcare Commission did nothing to support health professionals in exercising their responsibilities in providing care (see previous post). Medicine still needs to become more patient-centred as Francis says. Hopefully the government's response to his report might help to take this forward.

Scapegoating Mid-Staffs

I may have missed something because it's four volumes, but I'm not totally happy about Robert Francis's Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. He wrote in his press statement:

There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. They had to endure filthy conditions in their wards. There were incidents of callous treatment by ward staff. Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care. Patients were discharged without proper regard for their welfare.

Although as far as I know he did not state this, he has done nothing to prevent press claims that the report has exposed "catastrophic standards of care at the trust, leading to at least 1,200 needless deaths" (see Telegraph story). The Trust had a high Hospitalised Standardised Mortality Ratio (HSMR) at the time (there were hospitals with higher rates - see previous post and my post at the time of the publication of the Healthcare Commission report), but in fact Francis makes clear that:

... it is not possible to conclude, without more information than the HSMR alone, that a high outlier is attributable to poor care. Nor is it possible to say that any specific number or proportion of deaths was from an avoidable cause. Nothing to the contrary has been suggested.

To reiterate:

Whether a subdivided or overall SMR is reviewed, it is always important to keep in mind that a high rate of “unexpected” deaths cannot be translated into a number of “avoidable” deaths, any more than a low rate of such deaths means that all is well.

So, the media shouldn't be making such claims about avoidable deaths. And, although the apparent improvement in HSMR rates at mid-Staffs may have been due to "manipulative coding" in Brian Jarman's words, this just reinforces the relative nature of the measure of HSMR and the need for caution in interpreting the data.

My main concern is that despite Francis' attempt to avoid scapegoating of individuals by emphasising institutional failure, he has scapegoated the hospital himself. As he says:

It will no doubt be said that episodes similar to those described ...  could be found during the period looked at in many trusts.

My problem is that he calls this a "complacent attitude". I don't think I'm being complacent by pointing this out. One of my first ever posts on this blog was taking Ian Kennedy to task for bragging that the Healthcare Commission had improved care in the NHS when I knew this was not the case. By saying this attitude is complacent, Francis has avoided dealing with the issue.

As an example, an article in the BMJ this week highlights that problems in the provision of appropriate nutrition and hydration have been reported in the medical literature for nearly 4 decades. As I indicated in a previous post, the BMJ authors note that the Health Ombudsman found a "lack of access to fresh drinking water and inadequate help with eating in half of cases during her investigations into care of older people".

Basic care needs to be taken seriously not only within hospitals but also in care homes and the community. Health care is not an easy job. Mid-Staffs is not the only place where there needs to be improvement in this respect.

Improving university education

Reading Ian Parker's resignation statement from MMU has made me think about the effects of the target culture on universities. MMU has a change agenda based on a corporate strategy that sets 14 key performance indicators. In the current competitive market with other universities, there must be  a question about whether these are achievable. For example, by the law of averages, half of the universities will score above average on student satisfaction and half will score below.

I'm sure Ian has been defending academic values. The Council for the Defence of British Universities (CDBU) has been set up because misguided policies are undermining universities. Target cultures arise from not being able to easily measure a broad social good like "health" or "education". This blog has commented several times on the problems this created in the NHS (eg. see Why do staff report high levels of bullying in the NHS? Note that Ian says he has been bullied and this should be taken seriously.). The boxes were being ticked by NHS Trust Boards in their reports to the Strategic Health Authority but in fact a poor culture of care had become endemic. In a culture that could punish people for failure to meet targets, managers and staff in general are likely to behave dysfunctionally.

It's perfectly reasonable for Ian to defend his students but this has cost his job. Hopefully university education can be improved beyond increasing the number of 3 and 4 star staff submitted to the REF (Research Excellence Framework). As CDBU says, universities should be "places where students can develop their capacities to the full, where research and scholarship are pursued at the highest level, and where intellectual activity can be freely conducted without regard to its immediate economic benefit".

Need for reappraisal of notion of errors in healthcare

Very good article by Sonja Jerak-Zuiderent argues that patient safety needs to be conceptualised in terms of 'living with uncertainty' rather than errors in healthcare. Errors do not necessarily detract from safety and to ensure safety it is important to allow for the possibility that errors will occur. Practitioners live with uncertainty and a margin of error will always occur in their practice. This is not being complacent about iatrogenic damage and harm which is a major concern.

It is problematic to assume that safety will follow from protocols designed to reduce errors. In fact, safe practice requires an openness to change and the need for new responses. Creatively understanding what safety means in a specific instance can even require disregarding established protocols or guidelines. Assuming that safety will follow from protocols loses the benefit of living and acting in the real world. Mistakes need to be valued as a core element of life itself. Living with uncertainty does not mean that anything goes or that one is complacent about errors and is a safer mode of clinical practice.

Sir Jimmy Savile groomed an entire nation

Excellent article in The Telegraph by a freelance journalist who has covered child protection issues, realising that she'd been "hoodwinked" [her word] by Savile on the set of 'Jim’ll Fix It’. She was dumbfounded by his hand licking and crude patter. I suppose from his point of view, however unconsciously, he dealt well with his physical repulsiveness. Quite an achievement to be "not far off being England’s very own Mother Teresa". Paedophiles may not be "everywhere" but they are widespread, and they may not be "impossible" but they are difficult to detect.  As I've said in a previous post, the government needs an independent inquiry to look at these wider societal issues.

HRH is a post-modernist?!

JRSM article by Prince Charles talks about his integrated approach to medicine and health. Includes too much of the spiritual and complementary for my liking but at least he quotes George Engel (eg. see previous post). And HRH knows that his is a wider definition of integration than is commonly used, so hopefully he won't undermine such an approach. However, he seems to have been taken in by psychoneuroimmunology and stress causing shortened teleomeres. The overenthusiastic  optimism of Paracelsus doesn't justify HRH's promotion of the irrationalism of alternative medicine.

Improving the NHS next year

Let's hope for better measurement of NHS performance in the New Year than MRSA bacteraemia, number of C. difficile infections, access to treatment times less than 18 weeks and mixed sex breaches. In fact let's hope NHS health care improves even if we can't measure it!

The price of NHS reorganisation in redundancy payments

Story in the The Telegraph highlights how much is being paid out in redundancy in NHS reorganisation. I had previously suggested (see post) that Sir Neil McKay might have made a good NHS chief executive.

Father of family medicine obituary

BMJ obituary for Ian McWhinney, who understood the importance of patient-centred medicine and the place of George Engel in this. He suggested that a paradigm shift in medicine would lead to the biopsychosocial model supplanting the anomalies of the biomedical model (eg. see my article).

What are the odds for a no-ball from a bowler’s third ball off his third full over on the second day?

Maybe I gave too much praise to the News of the World in a previous post. Extract in the Daily Mail from new book says that placing spot bets on no-balls is rare. Still, players obviously have been controlled by fixers and there is a question about the results of some matches.

Inefficient to make me redundant

BMJ news story refers to article that finds that less experienced doctors incur more treatment costs. So maybe it's better to keep experienced consultant psychiatrists, like me, when making cuts to meet the Nicholson challenge (see EDP24 news story).

Payment by results not panacea for problems of NHS

As I've indicated previously (see post), I find it difficult to understand why NHS Foundation Trusts (FTs) are in favour of payment by results (PbR). After all, the motivation for such a system is to encourage other providers into the NHS market. If an NHS FT has an almost monopoly, what does it gain by having competitors come into the market?

A report from the Kings Fund reviews the experience of PbR. It concludes that the current system as applied is not fit for purpose. PbR does not transmit much, if any, pressure to be more efficient. For example, it does not provide an incentive to reduce admission to hospital.

As, again, I've mentioned in a previous post, as far as mental health services are concerned, there has been a delay in implementing PbR. The motivation to introduce PbR in mental health is often said to be because mental health is losing out compared to the rest of medicine by not having PbR. The Kings Fund report puts such a claim in perspective. Any implementation of PbR in mental health should be postponed further until the issues raised by the Kings Fund report are taken on board.

Why do child sex abuse cases get dropped for "lack of evidence"

Times article takes the right tack about Panorama programme on Jimmy Savile, about the chance missed for him to face justice when he was alive. The BBC Newsnight editor seems to have decided not to broadcast their programme because initially he thought the case had been dropped because Savile was too old, but in fact it was because there was said not to be sufficient evidence to prosecute. There is an issue about how commonly the CPS drop such abuse cases that Panorama did not pursue in its programme, instead implying more about the pressure the BBC was under not to create a clash with its Savile tribute programmes. Ed Miliband was right to call for an independent inquiry (see video) which could deal with the wider societal issues.

Barriers to expressing concern in the NHS

Editorial in the BMJ about barriers to whistleblowing in the NHS. It talks about the bullying culture that existed in the NHS (on which I've commented previously several times, eg. see Why do staff report high levels of bullying in the NHS? and Who's bullying whom in the NHS?) at the time of the events that led to the inquiries into the Mid Staffordshire Foundation Trust (again, eg. see previous posts Poor quality of care should not have triggered Mid-Staffs inquiry, Healthcare Commission ends its time with "appalling" report and Bayoneting the wounded after the battle is over.)

Actually, the way in which 'whistleblowing' is being used here is probably wider than disclosures under the Public Interest Disclosure Act 1998 (PIDA). What is being talked about is having an open culture in the NHS about performance management. The problems in the past were created by Trust Boards having to self-report to the Strategic Health Authority (SHA). The temptation was for executive directors to say that things were going very well, and non-executives (NEDs) were not well enough in touch with services to know whether this was really the case and endorsed what they were told. Foundation Trusts introduced governors (which included staff governors, who probably were more in touch with what was going on in the Trust, and also governors took over the appointment of NEDs) but it has taken time for governors to realise what their role is. This has now been made transparent in the Health and Social Care Act 2012. And anyway, SHAs are in the process of being abolished.

So, I think the culture has genuinely moved on and changed. And, this makes me bold enough to talk about what happened to me when I was a 'whistleblower' in this wider sense. But the fact that I have not done so until now shows that 'whistleblowing' has been a genuine problem.

My concern was, and still is, about inquiries into homicide by psychiatric patients (eg. see my book chapter and my BMJ letter). Mine is not a maverick position, as evidenced by a letter to The Times with multiple signatories saying that such inquires can become destructive. The problem is that deflecting obloquy becomes an over-riding factor at the expense of professional consequences for staff. I think this is what happened with my NHS Trust's internal inquiry into the care and treatment of Richard King (2005).

The Trust had made efforts to 'beef up' its inquiry, making the case that this meant an independent inquiry from the SHA was not required. This was despite Department of Health guidance that an independent inquiry should be commissioned by the SHA when a homicide has been committed by a person who is under the care of specialist mental health services. I had reason to believe that the SHA had accepted the Trust argument but from my point of view the Trust report was of poor quality. The report was written to maintain public confidence in mental health services by identifying mistakes and errors of judgement. I discussed my concerns with colleagues and formally raised the matter in the Medical Advisory Committee, where I obtained some support. I produced a written critique of the Trust panel report but was refused permission to discuss my concerns with the Chair of the panel that produced the report.

I was unhappy with the Trust action plan, because of the injustices in it, and spoke informally about it to the Trust chair, who said the action plan could not be changed. I therefore made it clear that my understanding of my professional responsibility meant that I would go to the SHA.  I met and subsequently corresponded by e-mail with the Head of Clinical Quality at the SHA. E-mail correspondence followed with the medical director and chief executive, which led to me again emailing the SHA to say that I was unable to take the matter forward with the Trust.

I then received an answer to my critique from the medical director, who had been a member of the panel that produced the report,  to which I responded. Just before this a formal investigation had been initiated into me on another matter. This investigation led to me being told I had to face a disciplinary panel, which never happened after I involved the National Clinical Assessment Service (NCAS).

An independent SHA inquiry report was eventually produced, which I welcomed. I had seen the Trust report as part of a blame culture in the Trust. The independent report was helpful in its recommendations for developing services in the locality and Trust. It made clear that its recommendations may have appeared to replicate the rather imprecise recommendations and exhortations of the first inquiry, but they did not. I think members of the Trust Board found it difficult to hear this message.

I can't say for certain that the timing of the disciplinary matter was related to my raising concerns about the inquiry report. What I can say is that it made it more difficult for me to keep on top of the process of following through on my concerns. There are issues about homicide inquiries by psychiatric patients that need to be discussed openly. I can now speak from my own experience about getting caught up in one (even though it wasn't even my patient).

Overtreatment harms patients

Recent BMJ article about unnecessary care, together with a video from the website. My book chapter "Clinician bias in diagnosis and treatment" from a few years ago. Would be nice to think there might be an overtreatment movement in medicine.

No easy rapprochment with Pietersen?

Article by Mike Brearley in the Observer thoughtfully discusses the Pietersen situation. Not sure exactly what he's done but it doesn't look like there'll be a quick resolution, which is unfortunate. Brearley had already pointed out before the last Ashes that Pietersen needs his confidence boosting (see previous post). 

South Africa deserve to take over from England as number one test team (see previous post). Enjoyed seeing two days of the match at Lords.

Proud to be British

Queen and Bond unite for London 2012 
A 12-part guide to the UK in 212 words each
Acquital of Paul Chambers 
For openers, London puts on a smashing show
Opening ceremony a jolly good show?

NHS block contracts for mental health continue for forseeable future

As I predicted (see previous post), payment by results will not be introduced into mental health services next April 2013. The department of health has confirmed to the Health Service Journal that next year was only ever seen as the earliest possible date and the roll-out will be delayed beyond 2014. HSJ blames the lack of reliability of clustering data, but the system also depends on pricing packages of care, and I haven't seen any attempts to do this - unless it's happening with AQP pilots for IAPT (again, see another previous post). It's up to Monitor and the NHS Commissioning Board to determine the future of mental health contracts.

David Southall's ordeal

BMJ article summarises David Southall's story, which I have mentioned before (see previous post).

British railways still in Lowestoft

Peter Aldous, Waveney MP, has raised the issue in parliament of the development of Lowestoft station, where I travel to work from Norwich (see full text of debate). It's about time Lowestoft caught up with denationalisation of the railways in its signage. British Rail (the trading name of British Railways from 1965) stopped operating in 1997.

Death of theologians

The death of Eric James (see obituary), biographer of John Robinson (see book review), my director of religious studies when I was at Trinity College, Cambridge, has prompted me to find out what has happened to other theologians who affected me. I find that Alaister Kee also died last year (see obituary notice).

I was influenced by death of God theology. Strange looking back the extent to which people were willing to go to hang on to religion.

What are the advantages of payment by results in NHS?

A press release from Monitor quotes its Director of Strategy as saying that "Improving the pricing of NHS services is essential to help commissioners make better decisions for their patients, and to ensure that hospitals and other providers of care are fairly reimbursed." It's sometimes difficult to understand what the motivation is for extending payment by results (PbR) in the NHS, when it's not clear that the cost is worth it (see previous post). After all, the report that this quote is taken from has been published to introduce a system for varying the national price if the costs of providing a service are too high or the revenues generated  too low. Some services are too essential to fail.

PbR in mental health services will be introduced in shadow form from this April. If the system works (which must be in doubt) and there are few advantages, it'll be interesting to see what Clinical Commissioning Groups do next year. Despite all the hype, it might actually make sense to continue block contracts. And I'm not saying this because I don't think that mental health services can be provided more cheaply (see another previous post). And, I'm happy for PbR to be experimented with at the edges of block contracts (see another previous post). This will be happening this year with psychological therapies in primary care in some parts of the country, but not in Norfolk and Suffolk where I work.

Reimbursing NHS-funded care

Monitor has published a report by PwC suggesting in its press release that "New pricing analysis highlights opportunities to improve patient care". The report suggests that what it calls incentives driven by pricing reimbursement are being undermined in the current implementation of Payment by Results (PbR). 

£28 billion out of a total secondary care budget of £66 billion is now contracted through PbR. What the report found is that the non-tariff  income is actually more volatile year on year. This is probably because non-tariff income is being used to smooth out any variations caused by PbR.

Actually this is not necessarily a bad thing. It means that trusts and PCTs minimise the risk of financial difficulties. As Alan Maynard says in his column on Health Policy Insight:-

Scrutiny of local budget bargaining usually shows that annual horse-trading about funding consists of negotiation about the level of investment for the year (de facto a global budget) with agreements that if the hospital stays within this budget and activity level, any misdemeanours on CQUIN and other regulations will be overlooked as far as applying financial penalties are concerned. 

It is this type of budget horse-trading which predominates but is rarely discussed outside tension-filled rooms when annual funding levels are fixed. It is the system that the clinical commissioning groups [CCGs] will inherit: a nice learning curve for the keen but rather naïve GPs whose survival will depend on their ability to play these well-established PCT-Trust games!

If the NHS is really going to be a clinician driven system, actually CCGs may even see an advantage in returning to block contracts. Commissioning support costs may be prohibitive and this money could be invested in services. Again as Alan Maynard says:-

So is it time to abandon PbR, revert to global budgets and use the savings to invest in sensible and simple management of cost, activity and outcome outliers and improving the mean performance of each? 

Reducing outliers and improving average activity, cost and outcomes is essential if The Nicholson Challenge is to be achieved. Squeezing PbR tariffs seems a crude and expensive method of achieving such efficiency gains.

If the Health and Social Care Bill gets through the House of Lords (see Ed Miliband writing in Sunday Mirror), I think it will be much more difficult for CCGs to use block contracts as they might wish because of the emphasis on competition by Monitor. But it would be a sensible way forward and, anyway, PbR can be developed at the edges of a block contract system through the introduction of any qualified provider arrangements (see previous post).

More on lack of fairness in medical discipline

Julian de Haviland makes a good point in BMJ letter about the lack of independence in medical disciplinary matters. Managerial power may be misused though medical disciplinary procedures (see previous post).