"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Monday, 22 July 2013

Rotten Egg Hunt

I've already written about how I think Jeremy Hunt visiting hospitals is a gimmick, and I've politely suggested how he can do some actual good, rather use his time as a minister for self-promotion. Now the Guardian Professional (which, I have to stress, is not the society pages, it is a separate part of their website that appears to be used for puff pieces for PR companies) have an article which describes jeremy Hunt as a "good egg". In response I added this comment:
22 July 2013 10:42am
This hagiography is embarrassing: it made me cringe. Are you talking about the same Hunt as me?
"As a long-term NHS customer, he does seem to think like a patient." 
Well, that shows the problem immediately none of us are customers of the NHS. I am a long-term patient, I have had type 1 diabetes for 40 years and I have used the service regularly. I can tell you terrible stories of the NHS during the Thatcher/Major years. I can also tell you how immensely the NHS improved in the early years of this century. I can tell you as a real long term condition patient what the NHS is like. Lansley's reforms are tearing the NHS apart and hapless, clueless Hunt is unaware, and does not care.
Hunt's visits to hospitals are a gimmick. You are wrong: every minister has done them. They like their picture to be taken with smiling patients: Hunt is no different to any of the other Health secretaries.
If he really wanted to know what the NHS is like, he would attend all the patient meetings, like I do (do you? I have never seen any evidence that you do). Hunt should go to his local GP's Patient Participation Group - and if his GP does not have one, he should start it. He should go to his CCG Patient Reference Group, he should attend the FT governors meetings of the FTs in his area. These are all patient-run groups. It is in these meetings that he will know about the pressures in the NHS, about poor care that patients get. And more importantly, he will be able to find out what patients want.
You're obsessed with urgent care and returning it to GPs? Good. Now tell me how Hunt has improved this? Earlier this year a co-op of GPs in Hackney tried to tender to take over the OOH service that was being delivered badly by Harmoni. They were told that they could not be commissioned because there had not been a full competitive tender. Hunt was the secretary of state that brought in the Section 75 regulations on procurement, and he is the man who is stopping GPs from taking over OOH services.
I attend my local CCG commissioning meetings, for a year patients have been improving quality in our local services. Last week we were told that money is so tight that all commissioning has to be on cost alone, and that as patients we will soon be consulted on rationing treatments. Hunt did that. Twice during the meeting the Drs there stopped us and said that what we were suggesting would contravene Section 75 regulations: patients could not commission the services they wanted. Hunt did that.
"He gets down to the nitty gritty of prescribing the exact amount of medication for a diabetic patient." 
Huh? Was Hunt legally responsible? If that patient had been given the wrong dose, would he have been prosecuted? What a silly, obsequious statement to make.
You want to know about diabetes? I will tell you. Diabetes treatment is in a shambles, there are not enough Diabetic Specialist Nurses (you know, those people who give continuity of care?). At my GP there has been no GP with a specialist interest in diabetes since the previous one retired 5 years ago. The DSN told me at the beginning of the year that because of cuts in staff I would be seen once a year not twice as I have been throughout the last decade.
Then there is the issue that in this month's Balance magazine (Diabetes UK's magazine) I read that the needles I use are being withdrawn. I asked my pharmacist about this and she told me that it was because the needles are not popular and hence the drug company was not selling enough of them: the withdrawn is because of profit. Yet for clinical reasons I need these needles. Why isn't Hunt standing up to the drug company and saying to them "bugger your profits, we want patient choice, so you should provide the full range of needles or you'll not be allowed to sell any"?
The same thing happened to me a decade ago over my insulin. I had three month notice (via Balance, the weasly drug companies couldn't even be bothered to contact me) that the drug that was keeping me alive was being withdrawn. Why? Because the drug company wanted me to use their alternative which cost three times more (and which I had used, and it made me ill). Where was the NHS then? Why didn't the NHS protect my supply of insulin, and use its huge might to force the drug company to continue to supply the insulin I need? Hunt is not aware of this: he does not care, the debacle over my needles shows that he does not care. Incidentally, the drug company withdrew the insulin for humans, but (even though it is human insulin) it is available for treating diabetic dogs.
"I have anecdotal evidence from my contemporaries, that this happens."
Err, anecdote is not evidence.
Sorry, but this is a terrible article and the only excuse I can give the Guardian for printing it is that this is the Guardian Professional where contributors pay to publish puff pieces.
OK so I was ranting, but I think I was justified. Then four hours later there was a reply to my comment:
Gladiatrix > richardblogger 22 July 2013 3:11pm 
You don't actually know if Jeremy Hunt does attend the types of meetings which you have suggested. For all you know he may well do. 
I am sorry about the problems with the withdrawal of the needles which you use but see no evidence that you have actually raised this with your MP, with the select committee or with the SoS himself although you are blaming him for it. Given the nature of his role there is every chance that Jeremy Hunt hasn't been told about this, in which case you should bring it to his attention. 
The s.75 regulations were Andrew Lansley's idea not Jeremy Hunt's. 
Again, with regard to your preferred type of insulin if Jeremy Hunt doesn't know about this, because he wasn't responsible for the health system at the time it is unreasonable to blame him for it. The person who should have stopped it was either the then SoS or the CE of the NHS. Did you contact either of them?
I read this two hours later. I typed a reply, but by the time I posted it comments had closed and my reply was rejected.

The Guardian had closed comments after only eight hours. Why? Why were comments only enabled for such a short time? Anyway, here is my reply to Gladiatrix:
And you don't actually know if Hunt is doing anything useful when he visits hospitals. I contend he isn't. He does not have the training, and since he's not an employee then I doubt if he's actually covered by negligence insurance. He's a spare part, and worse, if Dave called Hunt on his mobile phone, Hunt would be back in London at a shot: no employee (nor volunteer) can do that. I could easily find out if he has ever attended a patient meeting as a patient, do you want to put money on his attendance?
As to the needles, it has just been sprung on me this month and I am told they will be withdrawn within three months. (Think about it FFS, this is what keeps me alive it is serious.) Contacting my MP (who is a junior minister) will be pointless. I know this because I've contacted him before, about the so-called "listening exercise". As a patient I was not invited to any of them in my area (I suspect that no patients were, I've asked around and no patients were aware of them). I wrote to my MP asking if he could help me get to one and he delayed and then replied after the exercise had finished to say that they had finished! Now you may think that is conspiracy - preventing an outspoken and informed patient from attending a so-called "listening" meeting - but I put it down to incompetence and contempt for the electorate: this government really doesn't care about the population. 
Why doesn't Hunt know about how patients have no choice about the medical devices they use? According to the article writer (and presumably also, you) he knows exactly what is best for patients. Well I think he doesn't care. OK, so here's another diabetic rant, something Hunt is doing nothing about. There are 4 or 5 manufacturers of insulin, all delivered through an insulin pen. However, the "cartridges" are all different: you cannot use a competing insulin in another company's pen. I take a large dose and only one pen will deliver that dose (ahem, that pen is likely to be withdrawn too, so another rant is due when that happens) so it means that I can only use one insulin. Where's the choice? If Hunt really knew patients' concerns he would be campaigning right now to get the drug manufacturers to standardise on insulin cartridges. There is no reason that they shouldn't standardise. Why isn't he? It's because he is a amateur, he's just a rent-a-suit minister, one day Culture Secretary, the next, Health Secretary, and the day after, back on the back-benches as a hapless nobody. He has no passion for the NHS and no ability as a patient activist.
"The s.75 regulations were Andrew Lansley's idea not Jeremy Hunt's."
Rubbish. The regulations (not the section) were published, and then changed, in April this year. Hunt became the Secretary of State in September 2012. They are Hunt's regulations. (Of course, if you want to be pedantic the actual regulations are signed by Lord Howe, but Hunt is the boss.) Are you seriously saying that Hunt is a puppet delivering what the Leader of the House tells him to? Hmm that would agree with what I'm saying about Hunt being an amateur, temporary, pointless minister.
Anyway, its lovely to see that you are blaming me for the failure of the system. The system can be improved by putting patients in control - and getting rid of the straitjacket of the procurement regulations would be a start - but all you want to do is blame patients. 
I have tousled with "Dick Vinegar" before, I find that he is opinionated without providing much evidence behind those opinions (hence my comment about "anecdotes" above).

I encounter his undying belief that technology will solve everything throughout the NHS. However, when I hear it from an NHS manager I can at least excuse them that they know nothing and are echoing what they have been told to say. This is not the case with "Dick Vinegar" who appears to have the ear of politicians. (I wonder if he has written any code? I tend to find that the people who believe that technology will solve everything - for example Tim Kelsey - have never written any code themselves.)

Dick Vinegar

This is the nom de plume of Richard Sarson who says he is a member of the "Parliamentary IT Committee". Richard Sarson was the Editor of the PITCOM website from 1995. PITCOM was disbanded at the end of the last Parliament and was replaced with the Parliamentary and ICT Forum (PICTFOR) in 2011. I cannot find any trace of Richard Sarson on the PICTFOR website.

Thursday, 11 July 2013

Patient in Chief

One of the principal aims of the Health and Social Care Act 2012 was to remove the responsibility from the Secretary of State for the provision of NHS services. Lansley's "great idea" was that NHS England (the country's largest ever Quango) runs the NHS and once a year the Secretary of State hands them a list of instructions ("the mandate") for them to fulfil in the following year. However, few believe that is could be possible, certainly not in the short term. In the Fifth Report on Commissioning, Stephen Dorrell, the Chair of the Health select Committee said:
Voters will, however, rightly continue to regard the Secretary of State as accountable for the development of the NHS—there can and should be no doubt that ultimate responsibility rests with him. The Government must therefore put in place structures which enable the Secretary of State to respond to this political reality.
Inspite of the warnings that it is not possible for the Secretary of State to abrogate responsibility for the NHS, Jeremy Hunt and his lieutenants have tried hard to make it a reality. (For example, recently Anna Soubry, the Minister of State with nominal responsibility for cancer care, refused to answer questions from MPs telling them they have to ask NHS England and not her.)

Hunt has clearly decided to appoint himself the "patient-in-chief". However, in Hunt's rarified environment of Westminster politicians, hacks and wonks, his idea of a "patient-in-chief" is to spend all his time complaining about the NHS rather than taking actions to improve it. It's as if Hunt has become the personification of a Daily Mail article: the NHS is no longer his responsibility, it's someone else's problem.

It has always been a responsibility of Secretary of States to be seen in the NHS, mostly visiting hospitals for pictures alongside smiling patients. During the passage of the Health and Social Care Act the Labour Party needed to get publicity and to get the Press (who appeared to have had some kind of D-notice imposed on them about anything to do with healthcare) to report something about the party and their NHS policy. Labour came up with a idea where their health spokespeople would "shadow" people working in the NHS: GPs, consultants, nurses, porters. These gave valuable photo opportunities, and allowed Labour politicians to talk to the Press about their experiences. It was a bit of a gimmick, but one that was desperately needed considering the Press refused to report anything about NHS policy.

Hunt, a man who has never been known to have an original idea, has co-opted this policy. In April it was announced that the Secretary of State would
deliver care "in some capacity" and would be carrying out cleaning and portering duties while observing clinical care given to patients.
at Watford General Hospital's emergency department. This, we were told, was "part of a back to the floor experience". However, it was just PR. While Labour could be excused the PR gimmick because they were starved the access to the Press, Hunt does not need to do this.

Cleaning and portering duties on one occasion does not make Hunt realise what it is like to be a cleaner or porter. Hunt has a ministerial phone and it was understood that if the PM phoned him (even for legitimate reasons - like say a national crisis) then Hunt would immediately return to London. An NHS worker cannot do this, none are expendable, if they leave unexpectedly patient care is affected; Hunt knew that he was in addition to the staff needed so if he left unexpectedly the care would be just the same. Hunt was not earning an NHS wage, and after his shift did not have to go back to the bills and debts of a porter's wage. Even the aim to "observe clinical care" was phoney: it is inconceivable that the trust would not have put on a special effort during the day that the Secretary of State was visiting. It is also inconsistent. Hunt is modelling himself as the "patient-in-chief" so what does he do? He pretends to be an NHS worker!

Hunt should stop these "work experience" pantomimes. They serve no useful purpose: he neither experiences how it is to do the job, nor what it is like to be a patient. Moreover, they appear phoney and hence are counter-productive.

If he is serious about being the "patient-in-chief" then Hunt has to become a patient and see the NHS like we do. I am not suggesting that he becomes ill (I would never wish that upon anyone) but there are more effective ways to see how the NHS performs than by pretending he is a porter. When Andrew Adonis became transport minister in 2009 he prepare himself by travelling on every mainline railway, this way he could experience the rail system like a passenger and learn about where improvements should be made. Hunt should learn from this: he can be a patient without being ill.

What he needs to do is become a patient activist. To justify its uncalled-for reforms the government made a big announcement that the NHS would work by the principle of "no decision about me without me". The Lansley reforms added new structures to do this in addition to the existing patient participation opportunities. This is how Hunt can experience the NHS from the patient's perspective.
  1. He should attend the Foundation Trust governors' meeting of his local trust. This is not a huge obligation from him, they have to be held four times a year and are usually half day meetings. At the governors' meeting he can hear about the concerns from patient representatives about the quality and patient experience at the trust. He will also see the effect of cuts in tariff and the increasing numbers of fines have on the smooth running of the trust.
  2. He should attend local Healthwatch public meetings. These are not statutory and the policies of Healthwatch vary across the country, but Hunt should attempt to attend as many as he can for his local organisation. Healthwatch should know where the local problems are. If he attends his FT meetings then he can put Healthwatch concerns in perspective with the challenges that the FT has to overcome. This should allow Hunt to adjust his policies to improve the NHS in general. If his local Healthwatch are not reporting local issues then this is a failure and he should change his policies to enable them.
  3. He should attend his local CCG's patient reference group. These vary across the country, but every CCG had to have some form of patient involvement in commissioning as part of authorisation. Hunt should attend his local group regularly - possibly once a month or every other month. This will allow him to see from the CCG's perspective the difficulty they have in providing services when faced with NHS cuts. He will also see how the relationships between GP commissioners and NHS providers are developing and see the effect of procurement law on the delivery of services.
  4. He should attend his local GP's patient reference group. Again, this is not a huge obligation: an hour or so every other month. This will allow him to see the concerns of GPs and their patients. 
  5. If he has some extra time (perhaps by cancelling some of his dancing lessons) he should attend his local Health and Wellbeing Board (every other month, 2 or 3 hours) so that he can determine for himself whether the board is effective.
The important point is that he does not do these things once. At a minimum he should do these things for at least a year. Since these meetings will be attended mostly by patients (or in some cases, run by patients) he would be able to see what actual patient concerns are (hint: in my experience as a "patient activist" no one has ever mentioned immigrant's use of the NHS, it is not a patient concern).

Hunt: stop the work experience and become a patient activist.