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President’s perceptions – budget day, cannabis-derived medicinal products, workforce and AI

RCP president Professor Andrew Goddard stresses the need for the chancellor's red box to contain something for social care in the Autumn budget, discusses the RCP's role in forthcoming guidance on cannabis-derived medicinal products and outlines why solutions to the current shortfall in NHS staff need to look ahead over the next 10 years.

Money, money, money

Today is budget day. I suspect that red box-holding photo opportunities don’t fill any of us with excitement. Today’s, though, is quite important for several reasons. 

Firstly, given the NHS has been given £20 billion over the next 5 years, it seems unlikely we will get any more. However, social care desperately needs some glimmer of hope for the future. I have become more and more convinced over recent years that unless we get social care funding and organisation better matched to that of the NHS, both will fail. Together with several other colleges and faculties we wrote to the chancellor recently to make the case – I hope he has taken some notice (although he did ignore me completely as he strode past me, entourage in pursuit, at the Tory party conference earlier in the month).

Secondly, the £20 billion specifically doesn’t include some crucial parts of the ‘NHS’. Public health is one. I really like the idea of a 10-year plan (and am waiting with bated breath to see what Simon Stevens comes up with), but surely public health has to be a crucial part of that. I was at the BAPIO [British Association of Physicians of Indian Origin] conference a couple of weeks ago and was asked to answer the question ‘is the NHS fit for purpose?’ I centred my answer around measuring performance against the NHS constitution. Looking after the sick is only one part of our function - which we actually do quite well. Improving health and staying healthy is a bigger part of the constitution yet seems a minor part of what we do. Investing in public health is the best NHS long-term plan. Let’s see if Mr Hammond gets that.

By the way, my answer to the BAPIO question? "Yes it is, but it is a bit overweight in places and there has been a lack of training for some important parts of the team. It seems unlikely we will win many matches in the coming (winter) season."

Thirdly, I’m really worried about pensions. Traditionally, the RCP has left pension lobbying to the BMA (we don’t do terms and conditions). However, I have heard more and more noise from consultants in their mid-50s over the past 6 months. People say they are planning on leaving the NHS if the taxes on their pension contributions get any more punitive. This would be a disaster as the NHS would lose wise, resource-efficient and hardworking physicians that it can ill afford to. General practice has already suffered from this brain drain. Therefore, given the clear and present danger to our workforce I’ve been telling every politician and senior NHS leader I meet that it is an issue. They get it, but worry that the Treasury does not.

It is ironic that I’ve had a Matt cartoon on my office door for many years (since the last pension changes in 2015) which has a pension adviser talking to a person and saying ‘don’t worry, your pension will be fine, provided you don’t do anything like retire’. I do worry, though, and will have to take a black marker pen to it and remove the ‘don’t do anything like’.

The drugs don’t work

There has been a lot of interest in cannabis of late. My medical school years were remarkably free of exposure to cannabis (although I’m sure this was not the case for the architect student who lived next door to me). My knowledge has rocketed, though, over the past year – I hesitate to say my mind has been expanded. 

This learning exercise has been in part due to the RCP’s support for a softer approach to the users of cannabis (but not the dealers) and more recently in reviewing the evidence of ‘cannabis-derived medicinal products’ or CDMPs for short. NHS England was challenged by the chief medical officer to come up with guidance on the use of CDMPs in medical conditions. They are commissioning NICE to come up with formal (funded) evidence reviews and guidance but as this process will take many months they asked us (RCP) to help out with some interim guidance in chemotherapy-induced nausea and vomiting as well as chronic pain.

We worked with our palliative care committee, our joint committee for clinical oncology (it is a joint committee with the Royal College of Radiologists), the Faculty of Pain Medicine and other pain experts. I had the dubious pleasure of editing all the comments as my last job as registrar. I was struck by two things in particular. Firstly, the evidence for benefit is really weak in these conditions whilst the evidence for harm is greater. Secondly, there is no quality control whatsoever for many CDMPs available outside of the UK. 

The NHS England guidance is out later this week. I’m sure we’ll get some flak for not being more positive about CDMPs, particularly from the pro-cannabis lobby groups. However, I believe the RCP has a good reputation because we stick to a common-sense evidence-based approach to things. The evidence base is poor and common sense says we must use CDMPs really carefully.

The only way is up (for workforce anyway)

I’ve had a bit of a challenge on social media about the call for a doubling of medical student numbers. I have been clear that this is about having a long-term plan for the NHS and thinking about workforce supply for 10–12 years' time. The current shortfall in staff, number of expected retirements in a decade, the change in demographics of the workforce and the increased demand all seem pretty obvious and there are hard data. The maths is simple (we’ve even provided my working out). I’m unrepentant.

Some of the critics have confused a long-term plan with a short-term need. I’ve also been clear on this. We need to improve the culture and environment of the NHS so we don’t haemorrhage staff we’ve invested in training (eg by not having punitive pension changes, having a blame culture etc). We also need to facilitate NHS jobs for those from the EU and beyond. The tier 2 visa cap lift sounds like it is going to stay (hooray). Next we need to ensure the Home Office doesn’t set the salary bar for ‘highly skilled workers’ too high. The migration advisory committee says that £30,000 is about right – I disagree. To any foundation doctors and specialty doctors out there – you are highly skilled!

One good bit of news recently was Matt Hancock’s announcement about regulation for physician associates (PAs). This is critical to allowing PAs to fulfil their potential. Given that in a couple of years we will be producing 1,000 new PAs per year, this is going to be the only expanding part of the workforce currently funded. I worry slightly that Brexit will act as an excuse to delay this legislation. We need to make sure this doesn’t happen.

Mr Hancock also made an announcement at a speech last week regarding the governance of Health Education England. HEE will now be accountable to NHS Improvement for some of its functions. I know this sounds a bit irrelevant but it is quite an important step. It brings the planning of the workforce and training thereof closer together (a good thing) but also risks loss of valuable experienced staff (the postgraduate deans for example) and opens the door to the bad old days of ‘the service’ raiding the education and training budget.

Stop in the name of love

The BMA have been rewriting their guidance on clinically-assisted nutrition and hydration (CANH). A draft of the rewrite was leaked to the press a couple of weeks ago and caused some consternation. It has been perceived by some as ‘normalising’ withdrawal of CANH and thus a form of assisted dying. The RCP has been involved in the rewrite and therefore I have had an opportunity to read the latest draft.

The press stories don’t seem to match up to what I have read (Daily Mail readers look away now). The new guidance seems to increase the responsibilities on clinicians to engage with family and carers to understand their patient better, seek a second opinion where there is doubt and ensure the (fairly frequently changing) law is followed. 

Best interest decisions can be very tough when there is a conflict between clinicians and families (and I have to say not my favourite bit of the job). The guidance isn’t going to change that but does lay out the points of law and a practical way to interpret it. The law states that CANH is a medical treatment, and as such doctors are a key part of the decision-making process to continue it or stop it. The courts are there as a backstop but it always feels like a failure when a case ends up there. 

Talking of big ethical dilemmas, we will be resurveying members about assisted dying early next year. Council has been thrashing out the questions and definitions – not quite as simple as you might think. We’re making good progress though.

Together in electric dreams

In previous blogs I have spoken about artificial intelligence and the need to engage with this rapidly expanding agenda. We have previously made strong contributions to the field of electronic records standards. However, we need to get engaged with the wider agenda of AI and digital technology and so are developing an RCP strategy for this.

We have already started to explore working with AI companies to increase the data on the effectiveness of new patient-centred diagnostic tools, especially in secondary care. Helping design and support prospective studies with real patients in a safe environment is key. We are well aware of the risks to our reputation in being too aligned to some of these companies, but given that many of our younger members of staff already use these technologies it is clear that they are here whether we like it or not.

I was interviewed for a BBC Horizon programme going out this week about this issue. Hopefully my scepticism was as clear as my pragmatism. In case they edited it out, I was blunt that we need to be on the pitch not shouting from the back of the stands and that we need to see studies in real NHS patients in real time.

My scepticism was not helped by my hospital’s electronic patient record going down in clinic last week. Luckily, I still have non-virtual thumbs to twiddle for 45 minutes – they were the only ‘digital’ things moving. Electric dreams can become electric nightmares.

It’s not all doom and gloom

Last week I met up with Tim Briggs, a fairly outspoken orthopaedic surgeon, who is the godfather of Getting It Right First Time, a national programme to reduce variation in performance. The new RCP registrar, Donal O’Donoghue, was also at the meeting and it transpired that Donal had introduced Tim at a meeting of kidney specialists in a memorable way: ‘Tim isn’t your run-of-the-mill orthopod. He doesn’t just think about the fracture. He thinks about the whole bone.’

Professor Andrew Goddard is the current president of the RCP. You can find him on Twitter at @bodgoddard.