Mr Flory said in the quarterly update on performance that he was “disappointed” that the NHS as a whole had missed its target to see 98 per cent of patients in accident and emergency departments within four hours.

He said: “We have had one of the coldest winters for over a decade, placing greater demand on services. Ambulance services experience elevated demand in winter and it is critical that the NHS maintains high levels of service and ensure the timely handover of patient care from ambulance to hospital.”

Mr Flory told HSJ that he expected most hospitals to recover their position over the remaining months of the year and so, overall, the NHS would still meet the 98 per cent target for the full year. However, he underlined the importance of better winter planning.

The forecast surplus remains £1.74bn, with only seven organisations forecasting real terms deficits – down from 11 in September.

From:
http://www.hsj.co.uk/news/2009/03/flaws_exposed_in_nhs_winter_planning

It is almost beyond belief. In just two decades or so, the National Health Service has gone from having virtually no formal management structure, just administrative staff, to this week’s announcement that out of a total staff of 1.36 million, 39,900 are managers.

Let me put that in context: there are 5,000 more people now employed to tend to organisation than there are consultants – a mere 34,900 – tending to the sick.

And if that were not enough to savour, new figures from the Incomes Data Services show that chief executives of NHS foundation trusts now earn an average of £158,000. Across the board at executive level within the NHS, salaries rose by 7.6 per cent in foundation trusts, and 5.7 per cent in non-foundation bodies. It is the starkest of all illustrations of just how far the pendulum has swung from medicinal to managerial.

Not that I am against management, nor high salaries – far from it. I am a passionate believer in management. In my career, as a former chairman of Granada, Allied Domecq, and the Arts Council, I spent much time analysing, writing about and teaching management skills. But in the case of the NHS, what we need are far fewer – albeit far better – managers.

I do not base my opinion on the latest statistics, which the labour Government is defending as making a “significant contribution to tackling unemployment” – a rather curious reason for hiring more managers in my view – but on the six months I spent advising Brian James, the chief executive of Rotherham Foundation Trust hospital for a BBC documentary in 2006.

The aim was to see if proven management techniques could overhaul one hospital’s waiting lists, where more than 200 patients were waiting longer than the Government’s recommended 18 weeks. I wanted to see if we could come up with a template for hospitals all over the country.

The experience was both salutary and shocking; the hospital staff, including management and consultants, was eager to make it a better, more efficient place. There was enormous goodwill and huge pools of talent.

But there was simply no process to pull it all together in a cohesive, sensible way.

When I meet people in the health service now who saw the BBC series, they say the same thing: how typical my experience was of their own hospital – and how the problems I identified persist throughout the NHS today.

I’m afraid this failure of management explains how a hospital such as the Mid-Staffordshire NHS Foundation Trust, which saw 400 needless deaths between 2005 and 2008, continued to function for so long before someone noticed.

It explains why the care of seriously sick children at Birmingham Children’s Hospital was so gravely compromised as the Healthcare Commission found earlier this month. It also goes some way to explain the appalling treatment received by four disabled people whose deaths were investigated by Health Service Ombudsman and the Local Government Ombudsman whose report was published this week.

Yes, you will get senior people at any hospital – or in any organisation – who lose the plot, who manage things badly.

But while Health Secretary Alan Johnson is blaming the recent spate of crises on “understaffing and poor management”, it is the lack of any normal system of checks and balances on a much wider scale that leads to failings of this magnitude.

In any “normal” organisation, there would be a “normal” management process. The whole would be broken down into constituent parts: one hospital would report to a head of a group of, say, 10 hospitals, who in turn would report to a regional manager, before reporting to national level. Progress would be measured, mistakes noticed and rectified promptly. That’s how huge and successful companies such as Tesco manage.

The chain of command is clear so that it is easy to spot when something is going right or wrong – and to implement change when necessary. Follow-up meetings along the chain are so regular that problems get picked up when they are still manageable, and lessons learnt in one part of the group can be applied simply throughout.

In the NHS, staff may spend hours filling in paperwork and ticking boxes to cover their backs. But who is assessing what they do? Who follows it up afterwards? Some Foundation hospitals don’t have to report to anyone who will challenge their procedures – as long as they are filing their regular reports. Trusts may appoint chairmen but I discovered they cannot control, and have little influence over, chief executives. No one ever sits down and asks: “How did it go last month?” No wonder it is chaos.

I understand how this culture of multiple managers develops; I think chief executives get to a point where it is easier to manage other managers than it is to deal with medical and nursing staff, especially consultants, who can be resistant to being told what to do by those with no medical background.

Instead, chief executives surround themselves with a safe set of managers who tell them what they want to hear, and perhaps they look to hire more – for business development or finance or new initiatives. Increasingly, the man or woman at the top of the tree is distanced from the reality of leading doctors, nurses and other staff, and delivering care to patients.

In Rotherham, I tried to persuade Brian James to have fewer managers – and I do think he took my suggestions on board. Certainly, recent figures show Rotherham to have among the lowest waiting lists for inpatients in the country.

But that is the exception: the NHS as a whole continues to employ ever greater numbers of managers with no clear evidence that it is being managed better as a result. I want to shake it all up.

We need a system in which regional heads must account for a budget, a cure rate, waiting lists etc – certain defined measures – every month. If they don’t succeed or improve over time, they will find themselves replaced.

Health professionals need managing, they need rules, regulations, vetting; they need someone examining how they are handling their waiting lists. They need praising or criticising where necessary; and they need great leadership to help them change. It might take five or six painful years but I don’t think it would take much additional money.

It is galling to think that we, the public, are paying for the current highly risky system – in which some hospitals are brilliant and some dire.

With good management, none of them would be dire. That’s the truth of it. I’m not a fan of centralisation, but you do need a reporting system that can reveal why hospital A is not a patch on hospital B which is just 15 miles down the road.

The news is not relentlessly grim; the NHS has improved in the past five years – indisputably so. Targets have worked to a degree as they have focused attention on areas that really needed attention. We have also made great advances in the treatment of many diseases, especially cancer.

However, we still rank behind other European nations despite the billions and billions of pounds this labour Government has given to the NHS since 1997. I would argue that poor management is a factor in this. Until we learn to manage the NHS more effectively, we will never have the health service we pay for – and deserve.

From:
http://www.telegraph.co.uk/comment/personal-view/5062266/Cure-the-NHS-with-far-fewer-managers.html

Patients are to be allowed to post comments about their GP surgeries on the NHS Choices website later this year as the labour government adds online reviews of council and childcare services to the existing ability to review and rate hospitals on NHS Choices.

Gordon ditherer Brown, the prime minister, said the government had “clearly got the balance wrong” when online businesses such as Ebay, Amazon and Tripadviser offered higher transparency through consumer review than did taxpayer funded public services.

However, Colin Talbot, professor of public policy and management at Manchester Business School, said the government appeared “to have got the balance wrong” because it was investing large sums of taxpayers’ money in centralised projects that the independent sector appeared to do at least as well.

Since 2005, for example, patients have been able to comment on hospitals, mental health and primary care trusts, hospices and independent sector hospitals on Patient Opinion (www.patientopinion.org.uk), a social enterprise founded by family doctors.

Feedback can be left on all organisations, but 60 in the NHS subscribe to help fund the not-for-profit group’s £400,000-a-year turnover.

Professor Talbot said that at a time when public spending was under pressure, it seemed wrong to spend taxpayers’ money setting up a new centralised organisation rather than partnering a business that offered independence from the government.

There were other websites that also rated doctors and hospitals.

“Patient Organisation is a not-for-profit social enterprise – something the government says it wants to encourage – and is more likely to be trusted because it is independent of the Department of Health,” he said.

“Organisations that subscribe are far more likely to change what they do because they value the feedback they have decided to pay for, than they are to respond effectively to a bunch of anonymous comments passed on from a Department of Health website.

“It would be perfectly possible, and almost certainly much cheaper, for the government to support an organisation like this, while preserving its independence, rather than risk the elephant of the department sitting on it and squashing it.”

Dr James Munro, research director at Patient Opinion, said it hoped to sign a contract with the Department of Health this year to work with mental health trusts.

“We are hoping to work with NHS Choices more closely,” he said.

From:
http://www.ft.com/cms/NHS Choices

Health Direct points out that the NHS choices was reviewed in our post on August 13, 2007
NHS Choices- massive inaccuracies mar GP patient website

Dr Trefor Roscoe, a GP in Sheffield, said the public were in danger of being “grossly misled” by the information on GP surgeries on the NHS Choices website. “According to the site we still open on Saturday morning which we last did about six years ago.”

He added: “ We all share the desire for patients and the public to be as well informed as possible but this is gimmicky and over simplistic and may cause unnecessary worries.”

Heath Direct notes that the Blog Doctors goes further. NHS Choices is described as thus: I have just spent ten minutes looking around NHS Choices and, as you would expect, I hate it. It is utterly dishonest. The last ten years has been about removing patient choice, not increasing it.

The lifestyle advice the site gives is trite and patronising, and at times downright offensive.

NHS chief executive David Nicholson and Department of Health workforce director Clare Chapman appeared in front of the public accounts committee yesterday afternoon for its inquiry into NHS pay modernisation.

Committee member Richard Bacon, a Conservative MP, said he was “puzzled” as to why the DH did not know whether the pay system, introduced in 2004, had resulted in planned yearly productivity rises of between 1.1 and 1.5 per cent.

He said: “You went to great efforts to set up an all singing, all dancing pay system and yet you can’t tell us specifically what it has done.”

Turnover and vacancy rates

Mr Nicholson said Agenda for Change was an “enabler” that had led to improvements in turnover and vacancy rates and encouraged trusts to create new roles.

It was difficult to identify how many of the improvements had resulted directly from the simplified pay system and how many were due to other policies such as expanding the workforce, he said.

Accountability

Mr Bacon asked how the DH planned to hold trusts to account for improving staff efficiency.

Mr Nicholson said this was achieved through the tariff, which would probably require 3.5 per cent productivity increases next year.

Knowledge and skills framework

MPs also asked why many trusts were still not adopting the knowledge and skills framework, designed to support NHS employees’ career progression.

Mr Nicholson said: “It’s proving more difficult than the people who designed it thought. It’s generally well regarded by both managers and staff. There are issues about its complexity.”

Work was being done to simplify the framework, he said.

The inquiry was set up following the National Audit Office report NHS Pay Modernisation in England: agenda for change, published in January.

http://www.hsj.co.uk/news/2009/03/nhs_chiefs_forced_to_defend_agenda_for_change

Two of the chief executives – Julian Nettel at Barts and the London trust and Tara Donnelly a West Middlesex University Hospital trust – have resigned amid concerns about the performance of their trusts, which have missed financial and patient access targets. There are also question marks over when or even whether their trusts will achieve foundation status.

The resignations follow instability at NHS London after the departure of director of commissioning, improvement and innovation Paul Corrigan and provider agency chief executive Malcolm Stamp. The strategic health authority is also reported to be under pressure from the Department of Health over the performance of London trusts in general.

A spokesman for West Middlesex trust said Ms Donnelly had resigned after eight patients had needed to wait more than 12 hours to be admitted to the hospital through accident and emergency.

Although no patients were harmed, the trust did not tell the strategic health authority – a crucial performance issue in the eyes of NHS London.

“Ms Donnelly resigned after eight patients waited more than 12 hours to be admitted to the hospital through accident and emergency”.

In a statement, trust chair Sue Ellen said: “Tara, as leader of the organisation, recognised the seriousness of this and therefore decided… to step down.”

West Middlesex Hospital was categorised as a “financially challenged trust” in 2007 but was moved out of this category in 2008. It is now forecasting a deficit of around £1.5m – significantly less than the £9m it reported in 2005-06.

Foundation status

Like all SHAs, NHS London has attempted to assign each of its remaining provider trusts with an expected date to reach foundation trust status before December 2010. But West Middlesex has not been given a date pending the outcome of a north west London-wide review of capacity and demand for hospital services that has fuelled speculation that it could be rationalised or merged with another organisation.

Barts and the London has not been given a date either – primarily due to concerns its £1bn hospital private finance initiative will be unaffordable.

From 2013 PFI repayments will eat up some 16 per cent of its turnover in facilities costs alone, just as NHS resources are expected to get much tighter. The hospital tariff assumes that facilities costs are equal to around 6 per cent of a hospital’s turnover.

Barts also faced problems with a new IT system that left thousands of patient bookings unprocessed.

A fellow London acute chief executive told HSJ Mr Nettel’s decision to leave the trust after just 17 months in the post was “worrying”. He said he was “highly regarded by his colleagues” so his early departure suggested no one could solve the £590m a year trust’s problems.

Other leavers

In separate developments, Mayday Healthcare trust chief executive Helen Walley has announced her early retirement and South West London and St George’s Mental Health trust chief executive Peter Houghton is to be seconded – most likely to a senior role at NHS South East Coast.

And last Thursday NHS South East Coast chair Graham Eccles announced he would resign after a memo he wrote on a confidential briefing on mixed sex wards and PFI was leaked to the Conservatives.

The Conservatives used the memo to attack the labour government, saying it showed the health secretary had admitted the government “got it wrong” on mixed sex wards, and that there was “no plan B” alternative to PFI.

Mr Eccles’ interim replacement will be Colin Tomson of Eastern and Coastal Kent PCT.

DEPARTURES

Tara Donnelly- West Middlesex University Hospital trust- February 07 – February 09

Peter Houghton- South West London and St George’s mental health trust- July 06 – February 09

Julian Nettel- Barts and the London trust- September 07 – February 09

Helen Walley- Mayday Healthcare trust- May 06 – April 09

Graham Eccles- NHS South East Coast- August 06 – January 09

From:
london_acute_trusts_face_shakeup_as_bosses_hand_in_their_notice

His stricture to NHS finance chiefs came as hospitals were told that they will only receive a basic 1.7 per cent increase in the price the NHS pays per treatment next year and no more than 1.2 per cent the year after – in spite of an average 5.5 per cent a year increase in the cash that primary care trusts are to be given to buy the care.

Hospitals and other services covered by the price list will be able to secure an additional 0.5 per cent by hitting quality standards. But the below-inflation increase in the tariff, will put huge pressure on NHS Trusts to improve productivity before much reduced spending growth after 2010.

Failure to do so would put NHS waiting times and other services under pressure.

Alan Johnson, health secretary, indicated on Monday that the NHS hoped to carry over about £1bn ($1.5bn) of its present £2bn surplus into those tough spending years. Just £800m of the existing surplus would be drawn down over the next two years, he told MPs in a statement.

Carrying over £1bn on what will by then be a £110bn budget would help “deal with the days when it rains hard,” Mr Flory said last week, as he declared that the NHS had to “get fit for the tough years” to come.

On the labour government’s published spending plans, most analysts believe the NHS will be lucky to see 1 per cent a year real growth after 2010 – a fraction of the 7 per cent increases of recent years and the 3 per cent current level.

Mr Flory said before then the NHS will have to deliver “a decent part” of the £5bn of extra efficiency savings that the Treasury is seeking from across government in 2010.

The Royal College of Nursing called for all the surplus to be used as it represented money that “could have been spent on frontline care”.

However, Mr Johnson, with an eye on the longer term, described drawing down only £800m of it as “prudent”.

He added that “substantial savings” needed to be made by driving up the quality of care so that errors and waste were reduced.

The warning that a marked increase in productivity was needed came as the health department conceded that while waiting times have been tumbling and activity rising, NHS productivity has still fallen sharply on the most recent figures.

One important reason for that is generous pay deals, which have consumed almost 30 per cent of the increase in resources.

According to the Office for National Statistics, NHS productivity fell 2.5 per cent a year between 2001 and 2005, though the health department argues that the measure does not adequately pick up quality improvements.

A memorandum to the Commons health committee also showed huge capital underspends in recent years, not least on Connecting for Health, the troubled NHS information technology programme.

With suppliers only paid when systems work, the IT programme underspent by £1.2bn between 2005 and 2007.

The NHS underspent by more than £2bn more generally on capital over the same period, with NHS organisations unable to achieve big increases in spending that had been envisaged.

http://www.ft.com/cms/s/0/3da09dd4-c57e-11dd-b516-000077b07658.html