London Eye: What’s in Caroline Clarke’s in-tray?

Lots of praise from her colleagues across the capital as Caroline Clarke took up the London regional director job – but what does she face?

Although there are a few outlying trusts, Ms Clarke inherits a region whose performance outstrips England’s other six (as you may well expect – the capital has more specialist hospitals, more consultants, more private, research and training income).

But ambulance handovers are still a massive problem and mental health services across the board are struggling to do the basics, especially in child services.

On finances, 2023-24 is going to be the most difficult year for some time. 

While four of the five integrated care boards have submitted break-even plans, there’s not a lot of confidence among leaders that they’re going to be in any way deliverable, even before the question of covering unfunded payrises comes up.

And here’s the one that always gets mentioned but never gets dealt with: workforce. 

In London, specifically the primary and social care workforce.

It’s almost funny to watch commentators scratch their heads and say, “There are more staff than ever, why is productivity down?”

Because they’re withdrawing their discretionary effort is why. The unpaid overtime that was always there and which was never accounted for properly. That and the exhaustion and low morale.

Being told “you’re inefficient” after a deadly winter (up to 500 extra deaths a week from corridor care, the Royal College of Emergency Medicine estimates), that came after a summer that was as bad as a winter in the old days, coming after a winter that came at the end of a pandemic… well, it’d probably have an effect on your productivity.

And that’s before you get into the general increasing frailty of the patients (ageing population) and the specific increased frailty of patients (people not accessing services during covid or because of long waits and thus being in a worse state when they do). And that running covid-safe services made everything less efficient.

Plus London’s NHS staff increasingly can’t afford to live there, and near enough everyone went on strike at some point. Parts of north east and south east London were very fragile during the junior doctor strikes, and there is more industrial action on the way.

The Royal Marsden Foundation Trust said that if systemic anti-cancer therapy is not derogated on the next round of strikes then 80 per cent of day unit activity will be cancelled.

Morale is also poor among the ICB staff, according to the most recent staff survey. Only one London ICB (South East London) is in the top half of the table for staff recommending it as a place to work. Two (North East London and North West London) are in the bottom decile.

The David Sloman plan for the capital was for ICBs to do most of the heavy lifting on integrating services but Steve Barclay’s cuts might leave them quite vestigial.

Still only 46 per cent of London Ambulance Service Trust staff recommend it as a place to work, but that’s actually a pretty good score for an ambulance trust and it stayed the same year-on-year unlike virtually every other ambulance service in the country.

The LAS is getting new fleet and the early signs are that a change in culture at the trust is starting to bear fruit, in the form of reduced staff turnover.

Sticking with the survey, London’s smaller hospital trusts have seen the biggest dips in morale – North Middlesex University Hospital Trust, Kingston Hospital FT and The Hillingdon Hospitals FT had the largest falls in staff satisfaction, year-on-year.

(Speaking of North Mid, it is interesting its chief executive Nnenna Osuji is now the accountable officer for the trust, which was not the case when she joined and Ms Clarke was Royal Free group chief executive. You wonder if that puts Dr Osuji in the running to replace her in Hampstead, although another specialist trust boss was also linked with the job).

There are also significant strategic questions in the near future.

Whether south London’s specialist child cancer treatment services go to St Thomas’ or stay at St George’s, for one.

A decision is due by the end of the year but an earlier appraisal put St Thomas’ ahead. But this week the local MP for St George’s made her case for why the services should stay where they are. Rosena Allin-Khan said the move would be inconvenient for families and noted the new facilities at St Thomas’ would need £90m in capital funding, triple the cost of adapting St George’s.

Delegated specialised commissioning budgets could also be a headache for London, despite being put back a year from their planned start in April. London trusts do more than £1bn in non-London work a year. Some specialists have most of their patients come from outside the capital, in most cases paid for by NHS England direct. At worst, ICBs in other parts of the country might find themselves pushed to retain more of this work locally, at best it will be an administrative struggle.

Ms Clarke’s first meeting as regional director with London’s chief executives last week reportedly focussed on the need to better understand the patient population and how primary care and digital infrastructure is set up.

Although the agenda was likely set before she started, money and performance apparently did not come up. They soon will.