Essential insight into England’s biggest health economy, by Ben Clover

Holding the line on agency pay

London is not Cumbria, it does not have mountains or watercourses which make travel difficult.

So what has stopped the capital’s NHS from achieving a flat pay rate across its agency staff?

A proposed new pan-London rate was due to start this week.

The previous system, attempted from April, has not been very successful, with departures from it becoming commonplace.

Once a trust starts offering more than its neighbours for shifts the deal is basically over, and organisations have to adapt fast.

As the most recent chief executive report at University College London Hospitals Foundation Trust dryly put it: “Our initial adherence to pan-London locum rates hurt our urgent treatment centre performance.”

Another chief executive told London Eye they were at the mercy of a large neighbour when it came to paying the London rate - once the neighbour abandoned it they had to follow suit or have an unsafely staffed unit.

So why is it like this? Why is an issue as important as safe staffing operating across a region in such a chaotic, potentially dangerous way?

Well, organisational islandism. Trusts are distinct legal entities responsible only for the care they provide, if it’s a choice between your own unit being fully staffed or St Next Door’s, you are strongly incentivised to choose your own. An organisational issue. A side-effect of the quasi market in the NHS.

Secondly, the effect of an actual market: there’s not the workforce, so trusts’ bargaining position is poor.

The relative scarcity of staff means they can vote with their feet on whether the new lower rate, painstakingly created by the London Procurement Partnership, was enough.

It’s essentially a pay negotiation of the worst possible kind – episodic, time-limited, information-poor, safety-critical.

So that’s another two national system issues, pay negotiations and workforce planning, that make for an understaffed unit on a wet Tuesday night.

But is it all the government’s fault? No.

Employers are effectively in a game of chicken as the clock ticks down towards the shift start.

This issue would be more easily managed if all London’s hospitals were centrally controlled and literally banned from paying more – though, clearly, there would be downsides to that.

And although they’re not, providers could act a bit more collegiately.

You can’t really blame them when serious incidents can happen as a result of insufficient staffing, linked to pay but London Eye would be interested to know which trusts blinked first.

As one reader commenting on that story points out, the more remote a team’s booking system is from the unit the more it misses nuance and erodes goodwill.

It will be interesting to see how the pan-London rate II pans out.


Local trust or regional trust

You’re lucky if you live in London, in lots of ways, but partly because the population density means there are some really good doctors and hospitals here.

Take King’s College Hospital, for example: Many, many problems but still an international centre of excellence and a much referred-to tertiary provider.

So it’s a bit of a system failing that they had to cancel out-of-area urology referrals in the face of increased demand.

That work now goes to Guy’s and St Thomas’ Foundation Trust and Lewisham and Greenwich Trust.

The trust said this was “a timely and effective response to the significant increase in urology referrals across the country as a result of Public Health England’s public health campaign in July”.

Firstly, a better managed national system might give providers a bit more notice that a campaign from one of its arms-length bodies was about to send referrals rates rocketing for a particular condition (unless it was one of those off-the-cuff, spur-of-the-moment public health campaigns).

Second, I’m not sure it’s actually allowed to restrict referrals in this way. The right for patients to choose their provider still exists and is enforceable.

More practically, King’s is a specialist provider with long-established referral flows from the rest of the south-east. It surely has a responsibility beyond just south-east London? (Although maybe not under the actual terms of its governance, to cite some other old and unfashionable rules). A quick look at the list of governors for the trust shows a lot of representatives from south east London, and none from further afield, where a significant slug of its work comes from.