The must-read stories and debate in health policy and leadership.

Poor perceptions of exceptions

It has been two years since the implementation of the (controversial) 2016 junior doctors’ contract and so it’s high time to take stock of one of its key elements. If used properly, exception reporting should support safe staffing and protect junior doctors’ rights, but HSJ’s investigation has revealed discrepancies in the data reported by trusts and reports of bullying and intimidation from senior doctors not to report.

Even in the early stages of the investigation, it was clear there were huge differences in how trusts collect the data – and some of it didn’t make sense. How, for example, could any trust employing junior doctors have no exception reports, as four claimed to? Meanwhile, trusts employing a lot of junior doctors had fewer exception reports per doctor and, while it could be they are just unusually well-staffed, this seems too good to be true in the current NHS climate. 

Chair of the British Medical Association’s junior doctors committee Jeeves Wijesuriya said, as far as he was concerned, a “red flag” is a lack of reports, rather than too many. Senior leaders from trusts with a high number of reports told HSJ they encouraged junior doctors to speak up and one guardian of safe working at Tees, Esk and Wear Valleys Foundation Trust said they implemented a log allowing trends in exception reporting to be spotted.

The investigation also revealed that, in some cases, technology lets junior doctors down. One anonymous doctor working in London said the system for reporting breaches is bureaucratic and they’re often not set up properly on it. The guardian of safe working at Cambridge and Peterborough Foundation Trust said problems with the national reporting system drove him to create his own, which has been well received by trainees.

Two years is a short space of time in the NHS, but the current and ongoing review of the junior doctors’ contract must focus on how to ensure exception reporting is being used properly.

Current deficit

It’s not always easy to see what finances look like across a sustainability and transformation partnership area, so it’s great to see a clear explanation of what is going on in Kent and Medway appearing in local NHS organisations’ board papers.

However, what appears is not good news. The STP area is likely to end the year with a significantly larger deficit than it hoped at £113m against a plan of £77.3m, with limited scope to turn that around in the final months of the financial year.

The four East Kent clinical commissioning groups account for much of this, and more recent governing body papers for them suggest there has been further deterioration in their positions. That does not necessarily mean the STP wide deficit will increase, as some of this is likely to mean larger payments to their main acute provider, East Kent Hospitals University Foundation Trust. But some of their overspend is in areas such as continuing healthcare, which is not likely to be offset by other NHS organisations’ year end positions in the same way.

And, more worryingly, across the STP, organisations are failing to hit their savings targets, which are likely to be £12m short at year end.

There is no easy – or quick – solution. Local care plans are being implemented across the patch but big reorganisations are taking longer than planned – notably the East Kent emergency and specialist services plan (which will see changes in all three of the area’s acute hospitals) and stroke services. One side effect of this uncertainty is difficulty recruiting staff to areas which may face disruption and the resulting locum and agency costs (the STP has been trying to standardise some rates and reduce temporary staffing costs but that has been challenging, to say the least).  

Unlike other STP areas, Kent and Medway has few organisations heading for a significant surplus, and limited opportunities to exploit the extra sustainability funding which can come with accepting larger control totals. A large deficit this year is a given; thoughts will now be turning to what is possible in 2019-20.