Registrar’s reflections – February 2018

Dear fellows

It has been a rather traumatic couple of months in the NHS since my last missive and it has been an inauspicious start to what should be a celebratory year for both the NHS and the Royal College of Physicians (RCP). They say it is always darkest just before dawn, so let’s hope so (and ignore the lack of scientific evidence for that particular proverb). I will therefore start dark and hopefully be in dazzling sunshine by the end.

Have we just witnessed the manslaughter of trust in the regulatory process?

Some of the international fellows that read these reflections may be unaware of the recent case of Dr Hadiza Bawa-Garba, and if so there are many detailed descriptions of the course of events that can be read elsewhere (Google has it’s uses). In short though, she was a paediatric registrar who was convicted of gross negligence manslaughter of a 6 year old boy, Jack Adcock. She was working in similar conditions to those which many of us find ourselves in – short-staffed, pulled between sick patients and a broken IT system. Her consultant was not on site and she had recently returned from maternity leave with no induction to allow her to re-acclimatise to the hospital. She made unintentional mistakes (as we all do) and admitted to them.

Whatever the wrongs and rights of the decision to prosecute her by the Crown Prosecution Service (CPS) and the limitations of evidence available to the jury, she was convicted and given a suspended sentence. During this time she continued to work and was by all accounts a more than capable doctor. She was then assessed by a fitness to practise panel of the Medical Practitioners Tribunal Service (MPTS) part of the General Medical Council (GMC) and suspended from practising as a doctor for 12 months.

The GMC then took a decision that will, I’m sure, turn out to be an historic one. They decided to ask the High Court to overturn the panel’s decision on a point of law: the fitness to practise panel should not be allowed to give a lesser sentence than a higher court of law. The High Court agreed (lawyers are particular on such points of law) and Dr Bawa-Garba was then immediately struck-off.

This has resulted in many things. The system failings behind Jack Adcock’s death have been highlighted and their similarity to many NHS environments has weighed heavily on most UK doctors (who are already feeling pretty beleaguered). ‘It could have easily been me’ has echoed around UK hospitals. There have been varying accounts about the use of Dr Bawa-Garba’s appraisal documentation and reflections in her criminal case, resulting in trainees disengaging with the appraisal process and thus revalidation. Concerns have been expressed about the support of trainees by consultants in such settings. Finally, confidence in the MPTS process has been undermined and questions have been raised about the GMC’s ability to maintain the confidence of the profession.

Well, at least the point of law was made.

If any good can come out of this it is a rallying call to us as consultants to demonstrate more than ever that we are available to our team for support, that we want to help trainees reflect in a safe environment and create a culture of positivity without blame.

Busiest winter ever?

This time last year I debated whether the NHS winter crisis was the worst ever. It is too early to have an official figure for this winter, but a recent audit of acute physicians showed that 26% think it is worse than last (thanks to Nick Scriven, Society of Acute Medicine president and previous medical registrar office buddy, for this research). Given that my hospital was full to capacity for most of December I share their perspective, but I thought I would look at the available NHS data for evidence of trends.

Data for emergency admissions in the NHS up to 2016–17 provides some useful insights. As has been the case for almost every year since we survived the millennium bug, admissions were higher than last year and bed numbers lower. Because of reductions in length of stay, though, we have managed to cope. The chart below shows that since 2002 we have steadily increased the throughput of NHS emergency beds from 29 patients per bed per year to 59 in 2016–17. This demonstrates that, contrary to some commentators’ beliefs, the NHS has relentlessly improved its ‘productivity’ (a ghastly term) and efficiency over this time.

However, the data on average bed occupancy over January–March shows another steady trend over the past 7 years (for which data are available), having increased from 88.7% to 91.4%. These figures are often quoted in the media but it needs to be remembered that this is the bed occupancy at midnight in hospitals – a rather bizarre time to record it, but I suppose no one will have the time to do so in the day when everybody is too busy getting patients in and out of those beds. The NHS aims to have an occupancy of 85% (sorry if that made anyone spill their coffee) but year on year we move further away from that figure.

Occupancy is a bit like the ‘revs’ of a car engine. Most cars work efficiently at 1,500–2,000 revs, but you can push your foot down and get it to work harder and harder. This, however, comes at a cost: you run out of fuel earlier and/or the engine blows up. Hmm, let’s stop the analogy there…

Talking of cars and hospitals, there is a bit of a noise about car parking fees at the moment. Perhaps we should just take the signs that say ‘Full/Spaces’ and put them outside the hospitals. It would be a language everyone understands.

Is GIRFT right for care?

GIRFT is not the noise you make when you lift a heavy set of notes, but ‘Getting it Right First Time’. If you haven’t heard of it you soon will, as it is coming to all hospitals and most specialties soon. Its aim is to reduce variation and improve ‘productivity’ (there’s that word again – sorry).

Variation is part of life (statisticians could describe it as normal) and this is as true in healthcare as anything. The notion of ‘unwarranted’ variation is one whereby there is either underuse or overuse of a healthcare resource or there are avoidable adverse outcomes in the health or healthcare of a patient or population. Muir Gray is the Olympian of reduction of variation (‘champion’ undersells his efforts) and produced the first Atlas of Variation in 2009. This showed striking differences in health measures, healthcare use and outcomes in different populations. This theme has been developed by NHS England’s RightCare programme. If you want a good idea of the huge amount of information available, go to the map on the RightCare website ‘Focus packs’ page and click on your area.

Local commissioners and healthcare areas (eg STPs/ACSs/ICSs – explained later) use RightCare information and pathways to evidence and support changes. The latest thing to come out of RightCare is Co-ordinated Reallocation of Care (CROC), which aims to free up beds by identifying risk factors that lead to ill health and hospital admission. It seems like common sense and, if it drives healthcare systems to invest in public health and prevention, will be great.

However, the variation in ‘in-hospital care’ isn’t picked up by the RightCare programme and this is where GIRFT comes in. GIRFT has been led by Tim Briggs, an orthopaedic surgeon (shame on you if that brings out stereotypical images) and is simple in premise. A set of measures of clinical and financial outcomes is used to compare hospitals which are all inspected to investigate differences and support change. This has worked well for orthopaedic surgery – litigation costs, infection rates and bed use have all improved post-GIRFT – and has been mirrored in other surgical specialties.

GIRFT is now being rolled out to the medical specialties under the watchful eye of Tim Evans (who led the Future Hospital Commission). The task for the individuals that have been selected as GIRFT leads for the medical specialties is daunting. Medical care is much harder to measure variation in, particularly in non-procedural areas. Most of our in-hospital care involves general medicine, outcomes of which are hard to tease out, and there are almost no routine measures of outpatient activity and outcomes.

I spoke at a meeting of the medical GIRFT leads we held at the RCP a couple of weeks ago and was impressed by their positivity and willingness to tackle these difficult issues. They are also individuals with strong track records of leading change in their specialties, so I am hopeful the programme will have a positive impact. We just need to be careful that we don’t get too distracted by the measuring process – 35 different GIRFT visits to each of the 136 acute hospital trusts in England could lead to ‘visit fatigue’, and there will need to be close liaison with the Care Quality Commission (CQC) to ensure everyone is on the same page.

Rebuilding the NHS or moving deckchairs?

I try hard to keep on top of changes in the NHS organisation to help the RCP communicate with the right people, both locally and nationally. However, even I am struggling to keep up with the changes in terminology and acronyms currently at play. Some fellows have contacted me in the past to express concern about the number of acronyms in these reflections so I apologise, but my aim is to demystify.

Hopefully most of you will understand what an STP is (although the P has changed recently from Sustainability and Transformation Plans to ‘Partnerships’), some will know that eight of the 44 STPs have become Accountable Care Systems (ACSs) and some will understand that the proposal of two to become Accountable Care Organisations (ACOs) is a source of great concern to those that fear privatisation of the NHS. The latter shows the power of a name, ACOs being the name given to some large private care providers in the US.

The latest proposal is to use the term ‘integrated care system’, or ICS. Integrated care has previously been used to describe social/medical care, mental/physical health and primary/secondary health collaborations, so I guess that as we need to link all of those it is as good a name as any. Enjoy the name while it lasts.

Regarding the worry about privatisation of the NHS, from what I have seen and heard so far in ACSs the successful partnerships have very much been between local authorities and NHS providers, with NHS clinicians and local communities driving things forward. I worry more where such relationships have not been formed – leaving the door open for others to step in. The recent Carillion debacle has shown that private-public partnerships are marriages that need careful pre-nuptial diligence and regular counselling.  

Right, it is still feeling a bit dark so let’s draw back the curtains.

500 not out

Well, we made it to our 500th year. And hopefully (the above issues aside) the NHS will celebrate 70 years in July. In a moment of synchronicity it looks likely that in the next few weeks the RCP will reach 35,000 members and fellows – 500 for every year of the NHS.

I have been rereading through the history of the RCP as recounted by Louella Vaughan and Sir Richard Thompson in their books Grave and learned men and Ever persons capable and able. I had forgotten how important the RCP and Lord Moran were to the foundation of the NHS and also how different the RCP’s values were compared to the other companies and guilds when it was set up in 1518. Much is made of the aim to reduce quackery, but less of its aim to improve society’s health by physicians working together for others, rather than individuals looking out for themselves.

This is the ethos of the 2018 RCP500 Charter as we promise to put quality of patient care at the heart of what we do, support of our trainees and not shy away from leading change. It will be a special moment when we present the new charter to the Queen on 20 February when she visits the College. This is the first big event for our 500 year celebrations and there is a palpable buzz of excitement around the building (or perhaps that’s the William Harvey ‘ceaseless motion’ exhibition – worth a visit if you are in London). The president has banned me from wearing my Lycra RCP cycling top when the Queen visits, but if one is allowed to feel some pride about what we have achieved then I will wear that.

It’s not all doom and gloom

I had a very excited email last week from Ian Bullock, the RCP’s chief executive, who was in Zimbabwe helping facilitate a ‘train the trainer’ course for the East Central and Southern African College of Physicians (ECSACoP). In the room were 35 physicians – not many you might think, but this is half of all the physicians in the country. The fact that the RCP is drawing such a crowd and that our colleagues in Zimbabwe are so excited by the partnership and opportunities is brilliant.

When I was an undergraduate I lived next door to an architect student and was always a bit jealous of the models he got to build (I was an Airfix junkie). Some of that excitement was rekindled last year when we were looking at models of potential buildings for RCP North in Liverpool. Things have progressed and the designs for the building planned for 2020 came across my desk recently. I’m not allowed to show any pictures but suffice to say the dermatologists and rheumatologists should be happy with the nods they get in the design. I suspect, as usual, us gastroenterologists will be in charge of the toilets.

Finally, we have recently made some changes to the fellowship nomination process. It is now run three times a year and consultants that are not fellows are given the opportunity to provide evidence about their achievements in clinical, education and research settings to support proposal. This has thrown up some interesting ‘achievements’ and I hope the fellowship are reassured that Council did not consider ‘attended Buckingham Palace garden party in 2012’ a suitable achievement. I was impressed (and a little relieved), though, by the humbleness of one who declared he ‘did not want to beat his own trumpet’. None of us would want that.

That is it for another two months. Let’s hope there is even more to celebrate next time (he said as the sunlight dazzled off his imperfect dentition).

As always, comments are welcome.

Dr Andrew Goddard, RCP registrar