Living la vida locum

Since the General Election we’ve seen bold statements on reducing agency spend in the NHS.  It’s an area with great potential savings, but it also depends on shifting agency and locum work back onto a permanent basis.  Unfortunately, the government’s stance on working conditions and contracts will drive more doctors into locum work, jeopardising the savings and creating a more mercenary NHS.

Speaking in June, Jeremy Hunt announced a crackdown on the agencies “ripping off” the NHS.  Reducing agency spend carries none of the political difficulties of service reconfiguration or overt front-line cuts, making it low hanging fruit for the Health Secretary.  A month later when grilled by the Health Select Committee, Simon Stevens said that reducing the agency bill was the “single most important thing” that providers could do to stabilise budgets.  Training more staff will alleviate this in the long run, but Simon Stevens rightly points out that making these savings will require converting agency posts into full time equivalents.

The reasons these doctors, nurses and other staff have gone to agencies or locum vary.  Sometimes it’s to pursue other part-time work or research, or time needed for family.  Pay can also be higher for locum work at the earlier stages of a career, especially when helped by nifty tax tricks.  A bigger factor for doctors is likely to be the freedom locum can offer on working hours and locations, especially the ability to take more holiday when needed and to set a work life balance.

In contrast, the new junior doctors’ contracts define ‘social hours’ as including Saturdays and up to 9pm in the evenings.  The tweets in the #iminworkjeremy campaign reinforced how many unsocial hours are already worked, not to mention that doctors regularly work beyond their hours or through the breaks.  A petition for a motion of no confidence in Jeremy Hunt received 100,000 signatures within the first day, triggering a debate in Westminster Hall over NHS contracts and conditions.  As seen in that debate, politicians of all parties are happy to acknowledge that the NHS is run off good will, but the approach taken to hospital workers seeks to turn this good will into contractual obligation on the sly.

Jeremy Hunt has threatened to impose the contract anyway, putting strike action into the minds of some junior doctors.  This antagonistic approach will gradually create a mercenary attitude in hospital workers, who will play the market forces of excess demand to get their pay.  If the NHS is set up to extract as much as possible from its staff, we should expect them to extract what they can from the NHS.

DevoBlog: health in the recent devolved elections

The recent elections in the devolved regions haven’t captured much attention in the health sector. It’s easy to forget, with so much going on with DevoManc, that 10 million people in the UK already have health systems that are devolved to an even greater extent. Being from Northern Ireland myself, I’m always keen to share a regional perspective – whether or not it’s asked for! But I also think that with different health policies being tried and tested around the UK, there are opportunities for everyone to learn a lot, if they’re willing to listen.

Health is a huge area of spending for devolved administrations and a priority for voters, but receives less debate in devolved elections than in Westminster. One reason is that even with their powers, the devolved administrations have all maintained systems which are free at point of use and funded through direct taxation. On its key principles, the NHS remains national and as a consequence, so does the political and media discussion about it.

As a regional politician, the best way to get the public’s attention is through very specific and tangible policy pledges. It’s no coincidence that all three devolved regions have famously adopted free prescription charges. Devolved governments cannot borrow and although Scotland has significant tax powers, the SNP has not yet used them to mitigate the austerity to which they object. This has meant that devolved party manifestos focus on specific and tangible pledges, with less effort spent on ‘visions’ or overarching approaches. Where there was a more distinctive approach adopted in Wales, this met with limited success.

Prudent Wales

Health was devolved to the Welsh government in 1999. Unlike England, NHS Wales does not have a ‘purchaser-provider’ split and the private sector plays a smaller role in services. Wales faces a more acute ageing population challenge than most regions in England in addition to higher levels of deprivation, which make it more comparable to the North East of England according to the Nuffield Trust than to the whole of England. Mark Drakeford, Minister for Health and Social Services in Wales, has set out a goal of ‘“Prudent Healthcare”:’ in Wales. The principles included such as “Do only what is needed, no more, no less; and do no harm” are in stark contrast to the grander language of the NHS Five Year Forward View in England. The strategy has drawn criticism as avoiding the real debate on rationing, but England might have lessons to learn from its language in terms of expectation management.

In politics, often the best defence is an attack, and the Conservative Party has taken this approach with Welsh Labour’s management of the NHS since 2010. At times in the last parliament, Conservative backbenchers appeared better informed about health in Wales than in their own constituencies. Welsh Labour have been in government since devolution in 1999 and will likely continue as a minority, having missed out on a majority partly as a result of the Welsh electoral system.

At the end of the last Welsh Assembly Plaid blocked Labour’s e-cigarette bill, feeling that their support was being taken for granted. This isn’t a problem that has gone away for Labour which was unable to nominate a first minister last week, in the face of united opposition from all the other parties. If assembly support no longer comes cheap, Labour might have to be more receptive to the other parties’ manifesto pledges such as Plaid’s 28 day standard for cancer diagnosis or the Lib Dem’s independent commission into the future of health services, in addition to pursuing its own ‘Prudent Healthcare’ approach.

Satisfied Scotland

The NHS in Scotland is divided up into 14 health boards which manage and provide both health and social care in their geographic areas. The Scottish Government set out its strategy for health in its ‘2020 Vision’ published in 2011, which included the integration of health and social care. Legislation to implement this came into effect in April 2016. An OECD report on health systems in the UK found that despite many innovative policies in Scotland, there was limited evidence of significant improvements to outcomes. The public does, however, seem to be more content, with survey results showing that NHS Scotland receives higher rates of satisfaction than other health services in the UK, doubtlessly assisted by a higher level of funding per capita and the highest number of GPs per head.

The SNP is now two seats short of its majority in Holyrood, but this is still a strong result given Scotland’s electoral system. With fewer votes than the Conservatives, the Labour party has over the last decade moved from being the natural party of government, to opposition and now to third place.

The SNP has retained its focus on tangible pledges, such as prescription charges, and went into the election with its headline ‘baby boxes.’ There is consensus among parties in Scotland to protect health spending, with the Conservative party suggesting a novel approach of linking it to inflation and the Westminster block grant. It remains to be seen exactly how much funding this turns out to be.

Patient Northern Ireland

Health and Social Care in Northern Ireland is provided by six regional ‘Health and Social Care Trusts’, created by merging 19 smaller trusts in 2007. These trusts are managed by the Health and Social Care Board (established in 2009) on behalf of the Department of Health, Social Services, and Public Safety (DHSSPS) in what might be the most confusing set of acronyms in any devolved administration! This all seems set to change soon – the DHSSPS was renamed last week to the ‘Department of Health’ and the Health and Social Care Board might be abolished, its functions moved back into the department. Like NHS Scotland, health and social care are in theory integrated, but in practice Northern Ireland has struggled to keep patients out of acute care settings – England might want to take heed that integration is not always a panacea. There are also severe problems with performance: the region’s waiting list target is 52 weeks compared to 18 weeks in England. Despite having a lower target, it’s still being missed!

Elections in Northern Ireland are followed by weeks or months of negotiating a ‘programme for government’, greatly reducing the relevance of manifestos. All five of the main parties will have the option of being in government under the d’Hondt mechanism, but it is still speculation to say which parties will claim each ministerial role. The DUP will have the choice of remaining in control of health, which is significant given that Ministers can controversially pursue their own agendas.

Health is one of few areas where there is agreement between the parties, the DUP’s pledge for £1billion additional spending on health up to 2021 was soon matched (or copied) by Sinn Féin. The two main parties will dominate the programme for government, but the funding will ultimately depend on whether budget cuts can be made elsewhere to fund this which is difficult when each party is fiercely defensive of their departments. Government in Northern Ireland has the added uncertainty of whether devolved institutions will continue to operate at all. When last year’s Stormont crisis left the region with no Health Minister for several weeks, Simon Hamilton had to momentarily ‘unresign’ in order for NICE approved treatments to be funded!

Evidence and illegal drugs – a toxic mix

Nick Clegg recently revealed a manifesto pledge to hand responsibility for drugs misuse policy from the Home Office to the Department of Health, calling the current policy idiotic because addiction should be treated as a health problem, not a criminal one. The aim is to bring policymaking closer to the evidence. Unfortunately, past experience in this area doesn’t bode well for his success.

In 2002, Labour reclassified cannabis from a class B to a class C drug, with David Blunkett explicitly citing his two sources of evidence as the home affairs committee and medical experts on the Advisory Council on the Misuse of Drugs. Faced with political pressure in the run up to the 2005 election, Tony Blair referred the decision back to the ACMD. Notably, Blair still justified this using emerging medical evidence on ‘skunk’, a more potent variety of cannabis. The ACMD reconsidered cannabis in the light of this evidence, but concluded in 2009 that cannabis should remain a class C drug.

This advice seemed to land on deaf ears. Labour Home Secretary Jacqui Smith announced that cannabis would be re-classified and from that point, the relationship with evidence became largely antagonistic. The ACMD’s then chair, Professor David Nutt, eventually resigned from the ACMD at the request of Alan Johnson, who said that he had confused the boundary between science and policy.

Scientists can assess the physical, mental and social harm caused by drugs, but politicians will have to get involved when it comes to assigning those considerations weight. I’d hope that a Minister for Health might do a better job of this, but far more significant changes will be needed in UK politics before we have a chance of reaching a truly evidence based approach to drugs misuse.