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

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Welcome to London Eye

This is the third edition of HSJ’s new email briefing on the NHS in London.

London Eye will feature a look at what’s going on in England’s biggest health economy. London has the best and worst regarded hospital trusts in the country. It has excellence and dysfunction in commissioning and primary care. I will cover all of this.

Please get in touch to let me know how I can improve it, and to tip me off about stories you think I should cover:

Relationship breakdown at Imperial

London Eye recalls a remark left beneath the web version of a story we published on the creation of East London behemoth Barts Health Trust.

The commenter said the trust would be unmanageable by a chief executive, who would find it impossible to stay on top of more than 1,000 consultants.

How much of a chief exec’s job is “staying on top of” consultants is open for debate, but specialised services and surgeons in particular have a reputation for being more difficult to manage.

There was abundant evidence of difficulty over the past week in the case of renal surgeon Nadey Hakim. Evidence in the form of depositions made to the Central London Employment Tribunal by the distinguished surgeon and Imperial College Healthcare Trust – his once and future employers.

The employment judge ordered Mr Hakim be reinstated to the post Imperial sacked him from after the west London organisation lost a claim he brought for unfair dismissal.

It’s not so much the verdict that will be of interest to managers (the trust had failed to prove that cynical disregard rather than oversight had led to a dangerously old pancreas being given to a transplant patient – but had acted as if it had) but rather the steps taken since his suspension.

The trust had said the allegations made by Mr Hakim against his colleagues on the small transplant team during the tribunal meant he could not be allowed to rejoin.

However, the employment judge had ample evidence that the relationships between the surgeons there were already poor and that the culture was “dysfunctional”. A team of mediators was already working with Mr Hakim and his colleagues.

Mediators working with surgical teams must have interesting stories to tell.

The trust also claimed there was no vacancy for Mr Hakim to return to, as two new surgeons had been recruited while the surgeon was on suspension. It argued this was because the small size of the team placed extra pressure on those who remained and his absence needed to be covered quickly.

But the judge said Imperial had not provided sufficient evidence that the posts had to be permanent rather than temporary – so pending an appeal by the trust Mr Hakim is going back to Hammersmith Hospital.

This is unusual.

As the surgeon’s PR company pointed out on behalf of his lawyers – reinstatements after a dismissal happen in less than 1 per cent of cases.

How this will play out with those who led the internal investigation into Mr Hakim, including Imperial’s medical director Julian Redhead (appointed to that role after the judgement was issued), remains to be seen.

Either way, the two judgements in the case are well worth reading for an understanding of relationships and how governance works when they break down.

The other junior doctor dispute

What happened at England’s most challenged accident and emergency?

For January a London trust claims the unfortunate title of worst-performing accident and emergency unit.

North Middlesex University Hospitals Trust was only in the bottom 10 per cent for A&E performance in Q3 of this financial year, achieving 78.5 per cent against the national target of 95 per cent.

In January this slipped again to 66.4 per cent, taking it to the bottom slot nationally.

Attendances have been higher than planned all year but length of stay started to really get away from the trust in December – just as the same thing was happening with elective patients.

Admissions had been running above the 17 per cent planned rate all year but in August went above 20 per cent and have stayed there for the rest of the financial year to date.

Other expressions of this pressure were 37 60-minute ambulance breaches in the month alongside a record 33 30-minute ambulance breaches.

But none of this tells us why – and, as it was explained to London Eye, the cause was unusual.

Lots of places find it difficult to staff their A&Es but North Middlesex’s problem came from the deanery.

The body in charge of student education visited in July and told the trust it had to offer more supervision and training to the junior doctors working there and use them less for service provision. Moves to redress this imbalance have inevitably seen a dip in productivity.

Hopefully, January’s 66.4 per cent marks the nadir for North Middlesex’s A&E performance and it can recruit staff from other providers.

But it would be interesting to know if sweating the junior doctors at the expense of their training was an issue more widespread than just this one corner of north east London.