1st June 2015

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Dr Mark Porter

In conversation with Roy Lilley - this is warming up to be a really good 'conversation'!

Chair of the BMA - just how relevant is the BMA; does anyone listen to them
Is the BMA a busted flush?  The British Moaners Association or the British Machiavellian Army?

Let's find out.  Health Chat at the King's Fund 18th June Details here.

The right answer 
News and Comment from Roy Lilley

We have to go back to 1954 to find the derivation; Charles Erwin Wilson, Eisenhower's Secretary of State for Defense said it. Recognising there would never be enough troops to keep 'Russia in check' the strategy changed to nuclear led, giving, more 'bang for the buck'. Today we think of it as meaning better value for money.


Appearing on the BBC Marr show on Sunday morning Simon Stevens used the expression to illustrate his intention to get better value for money for the NHS.

The uncharitable (and I do not wish to be) might say he tripped himself up by using the phrase. When challenged about management costs in the NHS Stevens pointed out it cost threepence in the pound to run the NHS. It's difficult to see how the NHS can be any leaner. More patients for the pound, more care for the cash? Tricky.

Stevens revealed he is still a devotee of the lost art of public health. Yes we have got to stop eating sugar. If only we knew what contains sugar. My simple solution; eat nothing that comes out of a packet or a box.

In the interview Stevens was pushed on the issue of the moment; the cost of agency and Locum staff. The reasons for the problem are well rehearsed; poor planning and not enough investment. We all know Trusts and others cannot drive down cost by themselves, they need help.

Help from the centre is likely to run into trouble with the competition and markets madmen. Solution?

It looks to me that it would be possible for Monitor and the TDA to announce guidance; in the persuit of their statutory, fiduciary duty of best value for money, no Board may spend more than x% of their turnover on agency or Locum costs. Over time x% could become x% minus 10% and so on. Variations could be allowed to embrace special circumstances. If Trusts cannot spend the money agencies cannot charge it.

Knowing our readership as I do, I will be amazed if several of you don't email me a formula by lunchtime!

There is no immediate, easy solution to the NHS staffing crisis but there are two things that must be done.

The clodhopping CQC have to be reigned back. Safe staffing levels in NICE guidance have become a dangerous and reckless starting point. I have seen from the evidence of my own eyes they are codswallop. Furthermore, what might be realistic in a glamorous urban teaching hospital is not achievable for Trusts who are the prisoners of out of the way geography and melting health economies.

I would take a punt that the majority of wards cannot claim to be reassuringly, properly safely staffed. They may be staffed to a set of baloney standards that satisfy the finance department and keep the Nurse Director on side. They are not safe to deal with the unexpected and the exigencies of complex nursing and often frail patients with a cat's cradle of comorbidities.

They are not safe to the point where back to back eleven and twelve hour long shifts don't leave the front line of care jaded, frazzled and distracted. They are not safe to the point that agency staff 'put in a shift' and don't know where the toilets are, never mind the resuscitation trolley. Safe to the point where regular staff become familiar with the patients, understand their foibles and special needs. Not safe because handovers become a glimpse of a mystery tour into the unknown.

Second, we need to admit we have a national staffing crisis.  Politicians are in denial.   It needs a national response. A coordinated, concerted effort for the NHS to become the employer of choice, to fund training places and work through the dilemma; is nursing academic, qualified and vocational or can it be vocational and trained.

Whatever else Tarzan plans, to sort out the jungle that the NHS has become, nothing, none of it, zilch matters more than protecting the frontline, funding it properly and making it fun to work there.

No healthcare system is better than its nurses and the AHPs who support the infrastructure of care. Maybe Stevens is right.  Bangs and bucks; a few well placed bangs and bucking the system... the right answer.


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18th June 2015
King's Fund
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