Sunday, March 1, 2015

Clash of the levers

By now, you must have read it. Sir Bruce Keogh's frustration at the lack of progress at 7 day services is palpable  His views are not new and rarely if ever will you meet a clinician who has not agreed with the principle- and many a forest has been razed at trying to extol the importance of it while also laying out reasons why it cannot happen. NHS IQ have been trying to squeeze out the kernels of examples - trying to exhort others to follow suit..the reality has however been laid out starkly by Sir Bruce himself- progress has been slow if not painfully slow.

The man himself, predictably has copped some flak on social media. I have a simple rule in life- I try to stay away from judgements of folks if I haven't met them- the baseline is simple, all other views are prejudiced or biased. I also do have a degree of respect who do take up senior leadership positions- simply because of the extent of the challenge in front of the NHS- to expose yourself to criticism and be bold enough to raise your head above the parapet takes a significant amount of courage- its much easier to be a keyboard warrior. And I must say I have always liked Sir Bruce- Why? Because all those years ago, when the "great and good" of the diabetes world gave me a lot of flak, played politics, made snide comments when we were trying to change our way of working..I met him in a meeting and he took some time to listen. At the end, he said simply.."Do it- its the right thing to do". A flake of support meant a lot- so after all these years I haven't forgotten either.

The stalling of the 7 day service isn't surprising - especially when you are now mostly banking on good will for folks to extend their work to 7 days. Money is out of the question- so that leaves us with good will. The erosion perhaps started when you moved from a block contract for Consultants (I pay you a certain salary- and you do what patients need) to the session based one (we will pay you/monitor you per sessions done). Everything started to become more..business like. Patients became "clients", Trusts ran "Customer support sessions" while lots of the old school professionals looked with a sense of doom.

Today we have an odd situation. The call is to stop the "unsocial hour payment"- at the same time, you need to bank on goodwill to ask folks to work more. Which way to turn? The levers clash against each other. can you give time off in lieu? Of course- but then who covers the work when the person concerned is away...the levers clash again. Performance monitoring? A middle manager is keen to know how many patients were seen in X clinics but becomes uncomfortable when asked whether the extra patients added to the list or the adhoc patients seen somewhere else would be rewarded. We performance manage negativity, unevenly- the faith is gone, the trust is not there- so when you ask for a goodwill gesture, the levers clash again.

The chess pieces are well and truly set- those who believe the new contract will solve it..dream on. It would perhaps make it financially a bit easier- how do you define emergency- stay tuned for disputes up and down the country as regards definition of that- the legality etc etc- this will get messy. You want to force it..in the era of MSPs- you sure you want to push your Consultants to walk away with the business of PbR and join the GP groups? Heaven forbid.

Our story of rolling to 7 day services has had all of that- a team which believed it needed to do so, a CCG who backed that, a game of chess with management, use of existing financial levers such as Best Practice Tariff- and a sharing of work load amongst all the nurses and doctors. However, the freedom to make career moves must be given the leeway that a family needs, if doing weekends is tough for a single parent, then that deserves the respect it needs- not finger pointing or blaming. We live our own lives, in our own bubble...why judge others based on that?

However, as ever, the chickens are now coming home to roost. You wanted healthcare to be a business, patients to be customers, each activity to be a transaction...the shopkeepers are now saying that they they will decide when to keep the shop open.
The 7 day service needs investment- not just for doctors but a multitude of groups- we will "work differently" or " lets work together" are all fine powerpoint bullet points- neither does it pay the bill nor make up time for the hours lost with the family. Always think what you wish for...never relegate a healthcare professional to a tick on a spreadsheet...as when the time comes to ask for a favour. ask for a good will gesture, the levers clash. Gratingly so.

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