Jeff James’ resignation last month as Chief Executive of two primary care trusts (PCTs) – Wiltshire and Bath & North East Somerset (BANES) – came as a great shock to his colleagues and friends. He had been with Wiltshire NHS since it was formed in 2006 and was appointed to BANES this year.
As part of the government’s major reorganisation of the NHS, Wiltshire and BANES were ‘clustered’ together to save money and make way for the abolition of PCTs in 2013 when the GP-led Clinical Commissioning Groups (CCGs) and Wiltshire Council take over. During the ‘clustering’ process, the team he had built at NHS Wiltshire saw many redundancies as costs were saved.
Jeff James, who is 58, has worked in the NHS for thirty-one years – sixteen of them as a chief executive. He was ordained priest in the Church of England in 2002.
Why did he resign? Jeff James told Marlborough News Online that he had looked at the balance in his life between work, home and the church, and found it was not the balance he wanted.
Why did he resign now? “Now is as good a time as any. If I didn’t change now, I’d have to wait till 2013. Going now gives someone the chance to see through next year’s business plan and conclude the handover to the CCGs and the local authority.”
Did he resign because of the government’s reorganisation? No, but… “In 2013 the kind of job I’ve really enjoyed doing won’t exist.” The fragmentation of the NHS means that no one will again have the whole canvas of health services to work with. James now has national, regional and local responsibilities and is involved in almost every part of Wiltshire’s health service.
The Wiltshire PCT’s portfolio of responsibilities is being divided between the CCGs (in charge of some local commissioning), the yet-to-be-formed NHS Commissioning Board (in charge of specialist services), Wiltshire Council (public health and, through the new Health and Wellbeing Boards, strategy), Great Western Hospital (community health) and support services (Commissioning Support Services – CSUs, the latest out of the Department of Health’s copious store of acronyms, whose agenda is still be settled and which will ultimately be privatised.)
Jeff James would miss, for example, overseeing NHS Wiltshire’s work running the screening calls for Wiltshire, Swindon and Devon – work in which his team have become expert.
In the Marlborough area, Jeff James is best known as the man who closed Savernake Hospital Minor Injuries Unit (MIU) and Day Hospital very soon after the community hospital had, at great cost, been expanded and renovated. Why were they closed?
James says the decision was not specific to Marlborough and was brought about partly by costs and partly by a change in the model of service – creating a new balance between care at home and care in hospital. During his time at NHS Wiltshire he has pioneered the much admired Neighbourhood Teams bringing care and daily treatment to people in their homes.
James makes the point that consultation on the future of health care across Wiltshire had begun in 2005 - before he and NHS Wiltshire came on the scene. And that was also driven in part by costs. The Kennet and West Wiltshire PCT (K&WW) had run up an over-spend of £44 million by the end of 2005 and were on track to add another £24 million during 2006-2007.
The future of Savernake had been considered by the (then) Wiltshire Health Authority in 2002. Then the issue was handed over to K&WW: “They were very optimistic about the money available, very optimistic about the clinical role of Savernake and not as aware as they might have been about the trends in hospital usage.”
Beds in community hospitals were becoming less busy. More people were going home sooner after surgery. And community nursing and minor treatment in GPs surgeries was becoming the norm: “Gosh! How did anyone reach the conclusion that [upgrading Savernake] was the right thing to do.”
James and NHS Wiltshire’s Chairman, Tony Barron, have been criticised for the way they conducted the judicial review led by Val Compton which alleged the consultation on closing the MIU and Day Hospital was unfair and the decision unreasonable. Why, for instance, did they contest the cap on costs? Each side had to pursue their ‘best interest’ and “The wider consequences in the NHS if we had lost would have set a pattern with serious financial consequences. We had a responsibility to conduct our case pretty vigorously.”
Both James and Barron have been the subject of some pretty fierce personal attacks. During the 2010 general election campaign, the Devizes constituency’s independent conservative candidate pictured them as arrested criminals in American-type police mug-shots. And one campaigner greeted James’ resignation with a tweet: “The end of the road for Jeff James”.
“It’s part of the rough and tumble. When I first started in the NHS there was a committee, in the late 1980s chief execs and chairmen came along and we started to have a much more personal debate. Tony and I decided to make a lot of the running in the public debate – it was a style choice. If you are the person who is the accountable officer you can’t but be held responsible.”
“We don’t live in respectful or deferential times – that’s a good thing. But we can all wish there was a different tenor to the debate. The alternative is that you withdraw from the public. Out of the public exchange you don’t get agreement, but by not doing it anonymously people may come to understand the reasoning.”
The NHS’ future
Jeff James sees some risks in the government’s new design for the NHS. He has made sure that as an organisation NHS Wiltshire has low costs – “mean management to fit austere economic times” – and the costs for the CCG’s will be higher. (Wiltshire NHS costs £21 per head of its population, against an average of £35 for other PCTs in the region and a probable £25 for the CCGs.)
In the government’s Health and Social Care Bill, local authorities get more say in health services, running the new Health and Wellbeing Boards. Might some of them flex their muscles and try to dominate the commissioning process? James admits there may be ‘tensions’. They may know the pain in closing a school: “Imagine how much more exquisite that pain would be if they were allocating health service resources” – closing a ward or a hospital. And at least one person on the Boards will have to face re-election.
In Andrew Lansley’s new order “We’ll have three agendas: the local ‘popular’ agenda, the clinical agenda and the national political agenda – with the local agenda bumping into the national one.”
Jeff James’ future
Once it’s decided when he will leave his posts (he can be held to six months’ notice), Jeff James wants to take some time off. “It’s a bit like deep-sea diving – after the pressure of the last few years, I need to decompress for a time – or I’ll get the bends.”
Then he wants to divide his non-family time about 50-50 between work and the church, and would very much like to do more parish work. Where will that be? “My wife comes from Cornwall and I’m from Wales – so we’ll see!”
Having watched Jeff James in action over the past six months for Marlborough News Online, I’ll bet he very soon gets a call from a university – his experience and analysis will be a great draw for them. The university might be in Wales or it might be nearer to Cornwall.
On Wednesday morning (January 11) the Daily Telegraph’s front page, lead story was headlined: “Hospitals feed patients on 90p a meal, official figures show.” The story was also given wide publicity as one of the morning paper front pages shown on the previous night’s ITV News at Ten.
The newspaper’s report – using figures from Andrew Lansley’s Department of Health – highlighted Wiltshire NHS as spending more on food and drink per patient per day than any other primary care trust. But was the report accurate?
Picking up the headline, the Telegraph said that “the lowest spender was Western Sussex Hospital Trust which was listed as paying £2.57 a day to feed each patient” – presumably that is where their 90p came from – rounded up for headline purposes from 86p. The Telegraph then wrote that “several other trusts spent less than £1 on each meal”.
Quite how that justified using ‘hospitals’ in the plural for the headline is not clear. Nor is it clear why the headline used the present tense when the figures were for 2010-2011 – that’s up to the end of March 2011.
However, there is a major problem with the figures. They were not collected to any standard formula. This means that some of the costs quoted were for ingredients only and others included the costs of buying, storing, cooking and delivering the meals.
The Telegraph did approach Western Sussex hospitals who explained that their figure only covered ingredients. If they had included “the total cost of sourcing, preparing, cooking and serving food and drink” their figure would have been about £8 per patient per day.
That was not enough to get the Telegraph to change their misleading headline.
The Telegraph also assumed that you can simply divide the daily cost by three to get a per meal cost. But breakfasts generally cost considerably less than the main meal of the day and suppers will cost a sum in between that for breakfast and the day’s main meal.
Apart from the figure for West Sussex, another figure caught the eye: Wiltshire NHS was spending £22.31 per day per patient – the highest. This was computed including all the additional costs like cleaning the canteen and providing meals for visitors and the catering staff’s employment costs.
But even this figure has no relevance at all to the present situation. Wiltshire NHS has not provided a single hospital meal since June 2011 when – on government instructions – its community hospitals were handed over to be run by the Great Western Hospitals Foundation Trust. And GWH told Marlborough News Online that the current figure for its community hospitals – including Savernake Hospital – would be closer to £15 per patient per day for ingredients and preparation.
The £22.31 and £15 figures really only emphasise how very expensive it is to run small community hospitals spread across a huge county, when the large acute hospitals can buy ingredients and services in bulk and therefore so much more cheaply.
In the latest assessment of hospital food, GWH was rated as “excellent” and for the record the 2010-2011 figures showed GWH’s daily costs for food and drink per patient at £5.50.
Responding to the report, the director of the GWH department that provides food and drink, Mark Bagnall, said: “We put a lot of effort into providing patients with a choice of high quality, nutritious food and prepare almost 580,000 meals a year at the Great Western Hospital. No one wants to be in hospital in the first place so it is important that patients receive the food they need to recover.”
And he emphasised the differences size made to the cost of meals: “With such a large number of meals being produced we can achieve large economies of scale which means we can produce good food at a lower cost than some smaller organisations and our current average spend per patient per day is around £6.00 - which is broadly in line with many other Trusts of this size.”
The figures, issued through the NHS Information Centre, appeared in an agency story (Press Association or PA) timed at 02.49 am on Wednesday morning (January 11). But the Telegraph headline was shown on television at about 10.25 pm the previous evening. And the Telegraph’s journalist had had time to include extra research and comment.
So it seems likely the figures were leaked to the Telegraph well ahead of the PA story. Both the Telegraph and PA stories included long quotes from the health minister, Simon Burns.
What’s the game?
A clue comes in the Telegraph’s own story: “Government sources said last night that concern about the poor state of nutrition in some hospitals had prompted David Cameron’s warning last week about declining basic standards of care in the NHS.” So this, it appears, was designed to support the prime minister’s campaign.
Or perhaps this was an attempt to deflect attention away from health secretary Andrew Lansley’s problems over the faulty breast implants crisis. This issue has forced him to criticise the private health sector – to which he is about to hand over large parts of the NHS. And also means he has to extend regulation and its attendant bureaucracy.
Alternatively, this could simply be part of the coalition government’s longer term plan to destabilise the NHS and so make it easier to justify its costly reorganisation and the surreptitious moves toward privatisation.
The Department of Health has pointed out that the money hospitals are spending on food has gone up over the past five years. The average per patient per day in 2005-2006 was £6.53 and in 2010-2011 it was £8.58 - which somewhat undermines the Telegraph's headline.
Marlborough News Online is making enquiries to find out why this information was published at this time and in such misleading form.
The health secretary, Andrew Lansley has sent (February 16) an email to the “leaders of all prospective clinical commission groups (CCGs)” reassuring them they’ll be fully in charge of commissioning health services in England once the primary care trusts are abolished in March 2013. This follows criticism from GPs that too many regulators are being put in place to oversee their new commissioning duties and that their freedom to commission will be much reduced.
As Marlborough News Online has reported, some local GPs have voiced this criticism and following our reports a copy of Mr Lansley’s email has been forwarded to us. It seems to reflect the government’s anxiety that they may be losing the argument over their NHS reforms.
The email opens: “I am writing to you to set out the important freedoms you can expect when the Health and Social Care Bill is passed into law and when CCGs take on their full statutory responsibilities. You will no doubt be aware of some of the interest the Bill’s return to the House of Lords is attracting in the media. This is not unusual for high-profile legislation, and I would like to reassure you that the Government remains fully committed to the successful passage of the Health and Social Care Bill.”
Mr Lansley then gives his reassurance to CCG leaders on three main counts:
“1. You will have the freedom, with your new powers and responsibilities, to commission services in ways that meet the best interests of your patients.” He tells the GPs: “It is a fundamental principle of the Bill that you as commissioner, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests.”
This is a remarkable u-turn as from the general election onwards Mr Lansley and the Cooperation and Competition Panel have been telling commissioners when and how to put services in the hands of various kinds of private provider – what this government used to call ‘Any Willing Provider’ and then changed to the softer ‘Any Qualified Provider’.
“2. You will have the freedom to work with whoever you want to in commissioning health services.” This section of Mr Lansley’s email is all about the fears that the CCGs’ support services – such as payroll, record keeping and analysis, HR and financial control, all work previously done within the PCTs – will in future be carried out by large privatised companies which will to all intents and purposes take over the commissioning work.
This refers to the widely voiced criticism that the CCGs, sometimes clubbing together to pay for support services, will merely be reinventing PCTs, just on a slightly smaller scale.
Mr Lansley puts the onus firmly onto the GPs: “Whatever commissioning support arrangements you choose, you will always retain responsibility as a CCG for the commissioning decisions you make – the Bill does not allow these decisions to be made by other bodies.” This, of course, provides cover for other parties to put forward commissioning plans – so long as they are signed off by CCGs.
“3. You will be free from top-down interference.” Mr Lansley tells the GPs leading the CCGs that they “…will have the legal responsibility for the NHS budget entrusted to you from April 2013 onwards, and the legal power to use it in the interests of your patients.”
In fact the CCG leaders will not have responsibility for the NHS budget for England – as a quarter of it or about £20 billion will be kept back and used by the NHS Commissioning Board for, amongst other things, directly commissioning primary care and specialised services – and to create a system to ‘oversee ’ the CCGs.
Mr Lansley also tackles the criticism he’s heard from some CCGs that the clinical senates (which he writes without capital letters) being set up in response to last summer’s re-think on the Bill, will not be able to ‘second-guess the decisions you take.’ He reassures the GPs that these ‘senates’ will only “advise both CCGs and the NHS Commissioning Board on clinical issues at a broad strategic level.”
There are two elements of the coalition government’s policies for the NHS in England that are not mentioned in Mr Lansley’s email.
First, there is no mention of the local authority-based Health and Wellbeing Boards (H&WBs). These are supposed to be responsible for assessing the health needs of their whole area – rather than just the needs of the area covered by each CCG.
The policy in the coalition agreement was to elect people onto the PCTs to give, as the Lib Dems wanted, democratic legitimacy or accountability. When Lansley suddenly decided to abolish PCTs, the Lib Dems needed to find some other way of getting their democratic legitimacy. They chose the H&WBs. But as the Bill’s is written only one elected councillor has to serve on each of these Boards (this may be increased by amendment in the House of Lords.)
However, this appeased the Lib Dems’ demands for democratic input. The precise role of the H&WBs and their place in the new hierarchy of quangos is still not clear. It is well known that some councillors thought the H&WBs would allow them to commission NHS services.
Mr Lansley’s words of support for the CCGs make it quite clear the Boards will do no commissioning. And their omission from Mr Lansley’s email makes it unlikely they will ever be a threat to the ‘freedoms’ promised to GPs and their CCGs.
The other startling omission is that there is no mention at all of Mr Lansley’s mantra for patient power which featured so clearly in the White Paper that preceded the Bill: “No decision about me without me.” In the world of GP power that Mr Lansley portrays in his email, the role of the patient has disappeared.
This is almost certainly because some GPs in the CCGs had begun to see a nasty conflict of interests between what patients would want and what the GPs would want to commission.
In case GPs leading CCGs really were beginning to feel unloved, Mr Lansley has soothing words for them: “Your desire to improve services stands as testament to your dedication as public servants. In return, the Government will hold true our word to give you the powers and freedoms you need to deliver better services for patients.”
As one doctor expressed it to Marlborough News Online, some doctors feel they are being set up to take the blame when the money runs out for the NHS. Will they then be seen as ‘dedicated public servants’? Others believe there will be conflicts of interest with some GPs taking advantage of the reforms to bring more work into their surgeries, so earning themselves more money. Will they then be seen as ‘dedicated public servants’?