Take a moment. There..can you hear it? No? Try again...yes...there it is..the slowly dwindling voices. Voices of the few who have fervently championed the cause of "working differently"..championed the cause of doing so with scant regards to the "ask for resources". Eager to capture the eye, they wanted to make the case that finance wasn't the issue...today..their voices dwindle. The hard facts of balance sheets strike hard...the ethos of working differently sits in pockets...down to sheer charisma of a few individuals..not across the system the NHS desperately needs.
But why is it so? Is it about the money itself or could different working close the gap? Here are some of the fundamental chicken and eggs facing us today:
Staff costs: whichever way you cut it, staff cost is an issue and a pressure. Solutions could be to reduce the costs itself by cutting staff or reducing salaries. Cutting staff involves asking the existing ones to work differently ( ah yes), sometimes going beyond the call of duty..banking on vocation. Problem? By dropping the salaries or changing the dynamics of work life balance, the staff doesn't play ball..so it all comes to a head. What about hiring cheaper options? Divisive, inflammatory arguments rage about efficacy...debates rage about roles of others ..bang goes the thought of a team working together to deliver efficiency. Or even working differently. Oh and there's plenty on morale and its impact on safety, clinical delivery etc etc
Goalposts: it was a Herculean task to get the workforce to deliver what they were previously doing...now there are add-ons. 7 day services..an aspiration of excellence- but go back to point 1 and the pressure cooker builds even more. Think of being asked to serve 5 people omelettes but with 4 eggs..somehow we were whisking them all together and cutting the omelette up to make it look like 5 pieces...now suddenly 2 more folks have turned up. That's a challenge,No? The desperate hope that someone isn't that hungry...ah those tricky breakfast parties!
Patient power: The world is now a different place. Blogs, articles, social media, patient leaders, patient representatives ensure patients have a voice..and with that comes shifting of expectations. The dialogue of want and need gets blurred...do patient leaders speak for many or for a few? The debate continues but one thing is for for sure...a realisation starts to dawn that not everything is deliverable. It creates frustration, angst...cue clashes with clinicians. Cue morale issues, cue burn out.
Evangelism: Beyond patient power, there is evangelism. Guided by personal experiences, they have championed, quite rightly, the issues of poor care. But has it been too niched? Has it resulted in funds moving around from where the system needs? Nurse staffing on wards have been emotive...any Trust around the country will tell you the costs it brings. Is it important to recognise something else needs to stop? If it was that simple, we would have it everywhere...we don't due to combination of lack of staff and realisation that to do so, it will deprive someone else of something. Charities shout "outrageous" and tackle their own niched areas...the reactionary responses from policy makers help a few but does ti take money away from many? Cost isn't an issue when patients are concerned...a fair point...but then ask the source of the money flow...is that the question to be asked?
Lack of headroom: Many clinicians will also agree that there is wastage in the system. To clear that, to get a fresh start, you need headroom. But there is none. Examples? To help deliver better flow in hospitals, you need better community support. Where do CCGs said get money for that when you are spending it on existing services, some non evidence based, fancy projects..but those that still continue? In the world of type 2 diabetes, to save money, you need to invest in prevention and structured education...where is the money for that when you are spending it on the tariff needed to pay for end organ complications such as heart attacks?
So there we are...what was softly spoken hushed whispers are now starting to gain voice. Think tanks, health economists, politicians of all hues, managers...heck even the public as per recent polls are starting to query the feasibility and more importantly resources. It's also very easy to dismiss such blogs as the one I am penning as one of the "doom mongers". Au contraire, you will struggle to find a team which works more "differently"...and I am telling you this..the aspirations are not under challenge, the resource to achieve that however surely is. We did what we did..with resources.
So where do we go from here? The screws are tightening and there is an impending sense of everything building inexorably....hospitals are jammed in summer and autumn...frayed staff are everywhere to see. No amount of spin and cheery messages can drown them out anymore.
Next week....I will try to cobble some suggestions as to what could work...targeting exactly the points made....in the interim, have a think yourself and suggest some..I am all ears.