Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern

Has there ever been a greater disconnect between national policy and the frontline? Want to tell me something? Contact me in confidence here.

Shaun Lintern, patient safety correspondent

If the cap fits

It is time to get real about the effect of the agency pay cap on service provision and patient care in the NHS. The Risk Register is hearing increasing reports from the frontline of the policy exacerbating shortages of doctors and nurses, pushing services in some areas to the brink.

We have seen Lancashire Teaching Hospitals Foundation Trust publicly link the collapse of its accident and emergency staffing rota to the unwillingness of locum doctors to work at the capped rates – and of course other North West trusts have apparently been happy to bend the rules and poach the staff. The effect of all this is that that trust has downgraded Chorley hospital’s A&E department to an urgent care centre from 8am-8pm.

Lancashire is not the only trust that has been forced into tough decisions by the scarcity of temporary staff. On Friday, I reported that Leeds Teaching Hospitals Trust had been forced to cancel liver transplant operations because of a shortage of critical care nurses. The trust told HSJ that the agency pay cap was a factor in its inability to staff wards, alongside the wider nursing shortage. I have also reported on trusts cutting night shift cover on medical wards and scrapping training because of similar difficulties. I have seen internal emails from these and other NHS trusts making clear the crisis situation now facing some departments.

NHS locum fees and agency rates have been running out of control for years. Stories of nurses and doctors working alongside agency staff earning triple the standard hourly rate or more have been common for a long time. There is even a market in helping locum staff to set up personal companies to draw down their locum fees, effectively reducing their tax bill significantly.

But in tackling this, NHS Improvement and Jeremy Hunt have gone too hard and too fast in a desperate bid to rescue the Department of Health’s budget. The so-called ”break glass clauses” – which allow trusts to pay over and above capped rates where patient safety is on the line – look great in theory. But in reality trusts are also under immense pressure to get their costs under control this year, so there will inevitably be those who leave the glass unbroken for too long.

NHS Improvement has warned trusts in the guidance issued alongside the introduction of the caps that not managing agency spending in line with targets and the caps could see trusts investigated. Even in day to day overriding of the caps trusts will need to seek permission and provide explanation to regulators. I think this is reminiscent of the kind of top-down approach from national bodies that Sir Robert Francis warned us about. On the ground ward managers may come under pressure not to do what is in the best interests of their patients.

Wards running with skeleton staff and patients caught in the middle.

And let’s not forget this all has its root in the simple fact the NHS is chronically understaffed – and some system leaders are in clear denial about that as well.

What are they thinking?

Next week junior doctors in the NHS will gather outside their hospitals to protest at the government’s plan to impose a contract. This time, however, they will stay on the picket line regardless of emergencies taking place inside – the first time doctors have ever turned the other cheek to emergency care. A watershed moment.

The British Medical Association been saying the government won’t negotiate with it. But frankly that position is disingenuous. The BMA still holds to its own red line that it won’t consider talking about weekend plain time pay – a position that hasn’t changed since talks collapsed earlier this year.

It would be a more honest position for the BMA to simply state that it believes the imposition is wrong and it is striking to try to force the government to rethink its plans.

The government is behaving no better than the BMA. It had its own red lines during negotiations that it too remains unwilling to abandon and so is pressing ahead with an imposition certain to do long term harm to NHS industrial relations.

The argument over the contract terms and conditions is now redundant. The BMA took a gamble that the government wasn’t serious about imposition, it walked out of talks in October 2014 and has strategically played this whole affair badly. It’s tragic for those junior doctors who just want this dispute settled. I fear nothing will now bring the government back to the table.

Meanwhile, early indications suggest doctors are already beginning to walk away from the most acute specialties with Health Education England reporting 230 fewer doctors signing up to the most pressured acute specialties. While overall the decline is smaller this should be a cause for concern. If it translates into hundreds of fewer doctors come August the DH better hope it has a contingency plan – which I am reliably informed it does not.

The BMA. The government. What are they thinking?

The NMC turns up two years late

The Nursing and Midwifery Council has imposed an interim suspension order on Liverpool Community Health Trust’s former chief nurse Helen Lockett over allegations linked to serious failings at the trust during her time there.

It’s a rare move for the NMC to take action against a chief nurse – the most recent case was that of the former Mid Staffs nursing director Jan Harry – who had retired by the time the NMC got round to striking her off the register in 2014. She left the Mid Staffs trust in 2006.

No allegations against Ms Lockett have been proven. The NMC action came about after a governance review by Capsticks identified some very serious concerns about the trust’s culture and care while she was in post. The Care Quality Commission also highlighted serious problems in 2014, an event that was followed shortly by the resignations of Ms Lockett, the then chief executive Bernie Cuthel and the HR director Michelle Porteus to resign.

So why didn’t the NMC act in 2014?