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.
Nationally the NHS has come in for some dreadful headlines in recent weeks. Indeed it’s quite hard to keep up with the flow of reports and statistics – both official and unofficial.
Late on Monday evening (October 17) the Guardian’s main online headline ran: “Revealed: how NHS cuts are really affecting the young, old and infirm – Services slashed affect patients on frontline such as pregnant women and elderly despite assurances they would be protected.”
Leaving aside the headlines about the passage through Parliament of the coalition government’s Health and Social Care Bill and the dire warnings from some of its critics and from health professionals, we can dig through the data behind the headlines to run a quick health check on some of our local health care provision.
Waiting for treatment
August’s figures for the time taken from referral to treatment showed a rise in the number of patients waiting longer than the all-important recommended maximum ‘waiting time’. Across England there was a forty-eight per cent rise in patients waiting more than eighteen weeks to be treated in hospital: “Sharp rise in NHS patients waiting more than 18 weeks for care”.
Nationally the average waiting time for those completing referral to treatment in August was 8.1 weeks for those admitted to hospital and 4.1 weeks for those who did not need to be admitted to hospital.
For NHS Wiltshire patients admitted to hospital, the average (median) waiting time from referral to treatment was 10.9 weeks – only eight PCTs recorded longer waiting times. But the percentage of NHS Wiltshire patients admitted to hospital and treated within the eighteen week target was a respectable 93.5 per cent against the national average of 90.4 per cent.
For those not admitted the average (median) waiting time was 4.8 weeks with 97.7 per cent completing referral to treatment within the eighteen week ceiling.
For Great Western Hospital the average (median) waiting time between referral and treatment for patients admitted to hospital was above the national average at 12.7 weeks. Yet the average (median) waiting time from referral to treatment for those not needing hospital admission was 3.6 weeks – well below the national average.
And 98.1 per cent of non-admissions were treated within the eighteen week limit – against the national average of 97.3 per cent.
Care of the elderly by hospitals
Some of the most alarming and outraged headlines concerned the Care Quality Commission’s (CQC) report on the care of the elderly in hospitals. Based on unannounced inspections in April this year, this looked at two elements of that care - patient dignity and nutrition. The report did not look into the elderly’s medical treatment.
The headlines were damning: “Treatment of the elderly is a national disgrace” (The Independent.) Under the headline “Our nurses must go back to basics”, the Mirror’s veteran columnist, Paul Routledge, said: “Making nursing a graduate profession has been a medical success and a caring disaster.”
The Great Western Hospital was among those criticised in the report – but not as harshly as were some hospitals. For the full story and GWH’s response, read Marlborough News Online here.
While the CQC’s national report was very worrying indeed, there was also worrying news about the capability of the CQC to monitor care properly. While the coalition government has cut the CQC’s budget by about one third, its remit has been widened to include GP’s premises and it currently has about two hundred staff vacancies.
The wait for diagnostic tests
August’s monthly data from the Department of Health showed a growing number of people in England were not getting one of the fifteen key tests - like scans and gastroscopies – within the NHS’s recommended six week waiting time: “Patients waiting too long for NHS scans”.
NHS Wiltshire scored well in this data even though August’s figures are liable to reflect appointments postponed because of holidays and specialists on leave. Out of a total of 4,427 tests in the fifteen categories, nineteen were performed beyond the six week wait and three were beyond thirteen weeks. Some of those may have been based on rogue data recorded by the first time use of new software.
To take one of the more common diagnostic tests as an example: out of 1,633 non-obstetric ultra sound tests commissioned by NHS Wiltshire, 1,233 were completed within four weeks and none ran over the six week waiting time.
The NHS’s budget
On October 7, NHS managers called on the government to be more honest about the financial challenges facing the NHS in England. They fear that the public will hear the government’s claim to have increased spending in real terms and not understand when cuts have to be made.
The Primary Care Trusts are facing cuts to their staff, huge savings and the intricacies of the government’s developing and changing restructuring plans.
When in April a Marlborough News Online writer challenged Devizes MP Claire Perry’s upbeat press release – “Claire Perry welcomes £19 million extra for NHS in Wiltshire” – the Conservative Research Department did finally agree that the increase over inflation was “marginal”.
In fact it was 0.1 per cent. To call the 0.1 per cent an increase at all increase was optimistic based as it was on an inflation figure of 2.9 per cent with a 3 per cent funding increase. That was what the promised ‘real terms’ increase meant.
Even with pay freezes and job losses, the NHS has to cope with the steep increases in fuel and energy costs and other inflationary pressures. At the same time, NHS Wiltshire has to meet its share of the national target of £20billion in savings and to pay off the debt inherited from its predecessor care trusts.
And lurking in the background is the Health Secretary’s forthcoming ruling on the changed emphasis of the government’s competition rules that may wipe out much more than that ‘marginal’ increase in Wiltshire NHS’s 2011-2012 budget.
Just imagine it’s October 2012 and your left foot is really painful – as in keeping you awake at night. In October 2011 it was your right foot that hurt and your doctor sent you to the local NHS hospital for treatment at its podiatry clinic (for foot health - more than chiropody.)
By October next year, your doctor might well offer you a choice for treatment for your left foot – by your local NHS hospital, by a charity, by a social enterprise group or by a commercial company. Podiatry was one of the services the government wanted put in the fast lane to provide competition to the NHS and choice for the patient by October 2012.
When Health Secretary Andrew Lansley first launched the policy he called it “Any Willing Provider”. It’s now somewhat more reassuringly called “Any Qualified Provider”. We are not re-entering the era of snake-oil salesmen. But we are entering unknown territory.
The timescale is tight. NHS Wiltshire were told late in July that they had to complete consultation by the end of September on the government’s list of eight possible services. So on September 12 they held a Stakeholders’ Assembly - gathering about sixty-five local professionals, councillors, representatives of charities and patient groups and some of the doctors involved in the new commissioning groups to help select the first three or more services.
After much discussion three services came to the top of the list: treatment of neck and back pain (physiotherapy plus), direct access diagnosis (blood tests and more) and memory clinics (for those in the earlier stages of conditions such as alzheimer’s.) As it turned out, podiatry was one of the services least favoured to be part of the first round of setting up competitive providers – so your left foot’s safe with the NHS till well after October 2012.
Two other services – developmental disorders (ADHD and autistic spectrum conditions) and lymphodaema (swelling caused by lymph problems) – may come into the frame once more work has been done on how they could fit with related treatments and how to specify their work.
There are, of course, a great many hoops for any potential rival provider to go through. Are they a credible outfit – with financial stability, appropriate legal status and so on? Will they improve the service to patients? Can they find the right staff? Can they respond to referrals from GPs fast enough? What about training?
One thing is certain: there will be no protection for any kind of provider - government policy focuses primarily on effecting choice. This is a “very explicit political judgment on how to improve the NHS.”
All this will most likely bring added headaches for GPs and their colleagues in the new commissioning groups which will take over the budgets from the primary care trusts. First it will make control of the budgets much more difficult – even precarious. Secondly it may often face GPs with conflicts of interest.
Will they advise patients which treatment to choose when that choice may well affect the commissioning group’s bottom line? We may well see the rise of “patient advisers” attached to surgeries to help patients choose.
Those advisers and the complexity of overseeing and checking the new providers, tracking fragmented sources of cost and keeping clear of the clutches of competition umpires, will all involve a host of backroom jobs – or, as the government likes to call them, bureaucrats. And this at a time when most of the savings from the coalition’s radical NHS restructuring are supposed to come from ‘cutting bureaucracy’.
And no one can foresee precisely how the new commissioning groups will be able to make these services a satisfactory part of continuing and integrated treatment of their patients.
GPs and commissioning groups will be open to scrutiny and public shaming by the competition tsars that want to give non-NHS providers every chance to succeed. This is already happening with the choice of providers for elective surgery (such as hip replacements) – see Marlborough News Online’s earlier story.
There’s evidence already that social enterprises and charities will not get any favours in this process – in fact the risks in size and sustainability they bring to the NHS may doom them.
The social enterprise, not-for-profit group Central Surrey Healthcare (CSH) has been running community health for a large area of Surrey since 2006. Last year David Cameron presented them with the first ever Big Society award – a recognition that CSH’s 770 entrepreneurial nurses, therapists and other community staff have been providing quality care for less money. Even the Cabinet Office said CSH are delivering substantial improvements in quality and efficiency.
But when CSH bid for a new £500milion contract to spread their work to more of Surrey’s patients, Surrey primary care trust decided to hand the contract to Assura Medical Limited (75% owned by Virgin.) It seems the main reason was that CSH could not raise enough money for the necessary surety bond.
Has this decision put money before quality of service? CSH’s own contract comes up for tender in the next twelve months. The fear is the coalition government’s rules will favour another bid from a private, capital-rich company and dish the social enterprise workers.
And bearing in mind the experience of the health workers of Surrey, will charities and social enterprises in Wiltshire be successful when they make smaller scale bids for services under the ‘Any Qualified Provider’ label?