Chief executives have significant doubts their hospitals are as safe at weekends as they are in the week, the latest HSJ/Capsticks survey reveals.

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How confident are you in weekend cover at your trust? 5.9/10

The fourth quarterly acute trust barometer asked chief executives to rate their confidence in weekend cover at their trust from one to 10 (one being the lowest). The national average score was only 5.9.

The news comes after the NHS Commissioning Board announced it was setting up a forum under medical director Sir Bruce Keogh to provide better access to routine services seven days a week.

The overall confidence rating would seem to support the idea that some trusts must merge to support the cost of providing comprehensive medical cover over seven days a week. But the results also show leaders of smaller organisations are more confident their hospitals are as safe at the weekend as during the week.

The average confidence across trusts with a turnover of less than £400m was 6.3, while trusts above that size had an average score of five.

London trusts were more confident than those in other areas, with an average score in the capital of 6.8. The lowest regional score was the NHS North of England strategic health authority cluster where the average was 5.3.

How confident are you that consultants use time for supporting professional activities for the benefit of your trust? 5.1/10

The survey of 55 hospital bosses also found significant doubts about how responsibly top medics were using their time.

The terms of the 2003 contract recommend consultants be allowed to use a quarter of their contracted hours on teaching, clinical audit and other work that is not the direct treatment of patients, known as “supporting professional activities”.

Asked how confident on a scale of one to 10 they were that their consultants were using these 10 hours a week for the “benefit of the trust”, the national average was 5.1.

Consultant terms and conditions have come under the spotlight in recent weeks, with a Department of Health announcement on changes to the standard contract and a University of York study showing consultant clinical activity, as measured by “finished consultant episodes” per month, declining since 1999.

Figures released last week put the consultant pay bill for England at £5.5bn.

Last month the British Medical Association wrote to medical and HR directors at hospital trusts, warning them not to advertise new consultant contracts with less than 10 hours, or 2.5 units of SPA time.

One medical director described the letter as “BMA special pleading for 10 hours do-as-you-please time for consultants”. They added: “SPA can be difficult to quantify and monitor, and many consultants refer to it as ‘time off’.”

Another told HSJ: “We do not believe it is appropriate to pay every consultant 2.5 SPAs which is 10 hours activity a week, every week. We pay all consultants 1.5 SPAs, new and existing, and in this time we expect them to be able to carry out essential admin, teaching and to get themselves revalidated. We pay additional SPAs for agreed extra roles according to a schedule.”

Asked to comment on the survey findings, Tom Kane, deputy chair of the BMA consultants committee, said: “If managers do not feel they are getting value from consultant SPAs, we would urge them to use the consultant job planning process to agree objectives.

“While the work that SPAs allow them to do frequently does save trusts money, many of the benefits extend beyond the finances of the individual trust, for example feeding into national policy initiatives. We would urge trusts not to take the short-term step of cutting SPAs. Investing in quality is the best way to reduce costs in the long term.”

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Asked which one policy they would most like to see health secretary Jeremy Hunt scrap, nearly a third of trust chief executives named the rule which sees trusts paid only 30 per cent of the tariff for any non-elective patient admitted over 2008-09 levels.

Foundation Trust Network chief executive Chris Hopson said the FTN was “arguing very strongly, direct with Jeremy Hunt” that for many trusts the 30 per cent marginal rate was “simply unsustainable and has to change”.

This is the fourth quarterly chief executives survey carried out by HSJ/Capsticks. A comparison of results from quarter four of 2011-12 and quarter three of 2012-13 shows the hospital sector’s confidence in maintaining and improving quality is largely intact.

Asked how confident they were in maintaining and improving quality over the coming 12 months in the first survey they gave average scores of 7.5 and 6.2 out of 10 respectively.

The most recent survey showed only small differences, with average scores now 7.1 and 5.9.

But the results show that as they negotiate their 2013-14 contracts hospital chief executives still have a low opinion of the new commissioning landscape.

Asked how realistic commissioners’ assumptions were about activity and finance for 2013-14, respondents gave a score of just 3.3 out of 10.

 

 

Which one policy would you most like to see Jeremy Hunt abandon or reverse?

“The tariff of 30 per cent for emergency admissions – it is unjust and is driving acute care into a crisis.”

“18 weeks [referral to treatment limit], it’s unaffordable but where to start, the whole reforms are a costly mess.”

“The 5 per cent-plus year-on-year efficiency requirement.”

“Any qualified provider.”

“Agenda for Change.”

“I would like serious PBR reform to align incentives better.”

“Inadequate cancer tariffs so nearly all specialist cancer activity is loss making.”

“Inter NHS pseudo-competition.”

“Punitive use of CQUIN payments for too many objectives.”

“Use of competition as a driver for quality.”

What other concerns are adding to your workload?

“Planning the rebuild of our main hospital knowing that public funds aren’t available to support it and other things.”

“Lack of pace of change for the development of community services.”

“Managing the finances swamps everything else.”

“I need a higher calibre of non-executive directors.”

“Winter. the system is unprepared and seems to be relying on acute sector and ambulances again.”

“We will have to work with our new commissioners to look at re-tendering the community services contract that we currently hold. This will be incredibly time-consuming and potentially very destabilising for the staff involved and could reduce the quality of our integrated acute/community approach to delivering care.”

“Lack of decision-making by the new teams in the old SHAs. Even on important and agreed priorities, they are laden with process and nothing is moving.”

“The key question arises over the lack of experience and in some instances competence of those in senior leadership positions in the NHS Commissioning Board and clinical commissioning group structures, it’s a recipe for total disaster.”

“Trying to work out how the health services we provide can be sustained over the next three to five years.”

 

Peter Edwards assesses the latest chief executive barometer

The latest barometer suggests an erosion of provider chief executive confidence in certain areas as winter bites and the 2013-14 commissioning round gathers pace.

Hospital chief executives are midway through negotiations with their commissioners for the 2013-14 contract at the moment and the results show a very low level of confidence in the realism of commissioners’ expectations for next year. This is compounded by low confidence in the availability of expertise, resources and support to enable those commissioners to carry out their role effectively.  Overall, it looks like the first year of the new commissioning organisations will be very challenging.

Although chief executives are confident that they can maintain the quality of services over the next 12 months, they are less confident that the quality of those services can be improved. If the Francis Report results in a drive to improve service quality, it is unclear whether providers will be able to respond effectively to this challenge.

The barometer also suggests that consultant job planning may come under further scrutiny in the months ahead. There is a relatively low level of confidence that hospitals are as safe at the weekend as they are in the week. This may lead more hospitals to move towards seven-day consultant cover. At the same time, CEOs are not very confident that consultants are using their 2.5 “supporting professional activities” increments to benefit the trust. Managing the medical workforce effectively to achieve maximum benefit for trusts and their patients will continue to be a CEO priority. 

Finally, the Any Qualified Provider policy is top of chief executives’ wish list for Jeremy Hunt to abandon or reverse in 2013.  This reflects increasing concern amongst providers that AQP introduces significant uncertainty about future activity levels, leading to difficulties in predicting income or workforce requirements.

Peter Edwards is senior partner at Capsticks.