HSJ Weekly Catch Up: Exit plans, relevance of CMA, increase in nurse staffing

Some good news?

The latest workforce data has revealed a rare glimmer of good news about staff, with the number of nurses working in mental health and community sectors showing year on year growth for the first time in almost a decade.

At the same time, the number of adult nurses continues to rise, reaching record levels of 182,000 in October 2018 – the highest level since 2009. So, finally some positive news on workforce growth at a time when shortages are all we seem to hear about.

A significant point to note – these increases in nurse staffing levels are still being dwarfed by increases in demand both inside and outside hospitals.

Plan B for Bedford

When Luton and Dunstable Hospitals Foundation Trust first announced it was acquiring Bedford Hospital Trust in September 2017, it raised some eyebrows – not least because it said the merger would be done and dusted in six months.

Fast forward 17 months and it is still dragging on, with the acquisition having been pushed back twice over funding.

Without it, the whole merger may be doomed.

Is it time for the region, now formally an integrated care system, to scramble together a plan B?

The spectre of Stafford

Six years to the day the Mid Staffordshire Public Inquiry Report was published, health and social care secretary Matt Hancock spoke at a patient safety conference responding to a review of the fit and proper person test – born of a recommendation from the then Robert Francis QC, now Sir Robert.

The spectre of Mid Staffs loomed over Mr Hancock’s speech, as he reiterated the desire to make the NHS the safest healthcare system in the world but warned of the dangerous costs for the NHS of not reducing avoidable harm.

The health secretary said the government had accepted two of the seven recommendations of the FPPR review, carried out by Tom Kark QC – one to establish a central database of senior managers’ experience and history, and the other to develop core competencies for senior directors to be assessed against.

On the other five recommendations, including creating a new body with the power to bar people from sitting on NHS boards, the government has delayed its decision. This is despite the Kark review making it clear the current fit and proper person test is not preventing poorly behaving managers from working in the NHS.

The wrong message

The Care Quality Commission’s suggestion that clinical excellence awards be routinely withheld from consultants at special measures trusts, uncovered by HSJ, has raised eyebrows.

The proposal, which was not adopted by the advisory committee on CEAs to the Department of Health and Social Care, would have seen the consideration sit alongside other measures in the assessment process.

While some people felt penalising specific doctors for organisational failure would not be fair, others pointed to specific examples where consultants could be said to have contributed to the state of the trust.

If the CQC had found specific fault with individual senior medics and they were then given significant bonuses, you can see how it would “send the wrong message”, as the CQC’s chief inspector of hospitals Ted Baker put it.

The committee on CEAs hands out considerable amounts of money – more than £134m in 2017-18 – and a long-discussed reform of the system is now part of stalled consultant contract renegotiations.

Exit plans

With the UK fewer than 40 working days away from leaving the EU, the NHS nationally is ramping up its exit prep.

This week, the government’s operational response centre has gone live. This means the Department of Health and Social Care, NHS England, NHS Improvement and Public Health England will work together to respond to “any disruption” that results from a no-deal Brexit.

As part of this, Keith Willett, de facto commander of NHS England’s EU exit strategy, told providers they will “shortly” be asked to start collecting data about how they are coping with the impact of Brexit.

In other news, HSJ has warned of a Spanish nurse exodus due to a little known Spanish regulatory law. 

However, with one trust warning that it is about to lose all its Spanish theatre staff over this issue, the department may have left it rather late.

Two trusts, one chair

Two major London acute providers are going to share a chair for at least the next two years.

Sir Hugh Taylor, currently sitting at the head of the boardroom table at Guy’s and St Thomas’ Foundation Trust, is to chair King’s College Hospital FT as well on an interim basis.

It is an unprecedented move for trusts of this size and importance. Sir Hugh is taking on a trust with a somewhat challenging financial position – it anticipates a year-end deficit north of £140m – and some performance issues too.

This is the first clear effort to integrate the two providers since an abortive 2012 attempt to merge them, with South London and the Maudsley, into a super-provider turning over what would now be more than £2bn.

The case for competition

The debate over competition and its benefits for the NHS and healthcare have raged since the 1990s and beyond. Following the disastrous reforms pursued by Andrew Lansley and David Cameron between 2010 and 2013; under Simon Stevens and Jeremy Hunt policy swung decisively in favour of collaboration and integration. 

So confident, seemingly, are Mr Stevens and NHS Improvement’s Ian Dalton in their view that the NHS long-term plan last month advocated removing the role of the Competition and Markets Authority in NHS provider merger and acquisition. This will require legislation but it is clear the regulators see the CMA as an unnecessary barrier to improvement.

Enter stage left a detailed study by the CMA examining the fundamental question of whether competition helps, or hinders, the level of harm in the NHS.

While the mechanics of the study are impressive, the final conclusions seem a leap too far. According to the authors, a merger resulting in a monopoly could increase mortality by 550 per cent and harm rates by 182 per cent.

Meanwhile, the timing of the report – so soon after NHS England advocated chopping the CMA’s role from mergers – is interesting to say the least.

A complex problem

The row over mortality and culture at the cardiac surgery unit at St George’s Hospital has been high profile. But, at the most recent meeting of the trust’s board last Thursday, there were welcome signs of improvement.

The board walk around visits saw the chief executive, medical director and a non-exec take a trip to the unit. They observed a unit that seemed less fractious under its new associate medical director than it has done previously.

However, a very large review of mortality at the unit has yet to conclude. Roughly half of the decline in its year-end forecast deficit (£11m of a £22m deterioration) has come from lost income and increased costs as a result of less complex work coming to Tooting.