Peterborough Hospital PFI

The Private Finance Initiative (PFI) uses the equivalent of a full operational lease used by many governmental authorities in the UK. Financiers form a company borrow the money to (re)build a new hospital. The PFI company then leases back the building to the local Hospital Trust, but there's a kicker. As part of the deal the PFI company also gains exclusive rights to provide services such as facilities management within the hospital. It is a very very expensive method of financing the hospital (re)build.  In recent year Governments liked this method of financing because it does not show up on the capital borrowing total for public finances, it is in effect a future operating cost. These contracts go on for 30 - 50 years. 

It would be much cheaper for the public purse if the Government was honest and just borrowed the money up front and built the hospital using their own managers. In the news today is yet another report of a Hospital Trust struggling to pick up the bill for a PFI. Peterborough and Stamford hospital Trust have been criticised by the National Audit Office for poor financial control and mounting debt.

Much of the unplanned cost comes from the provision of services not included in the original contract. Minor changes such as moving a phone or installing an extra shelve must be be purchased via the PFI company. As there is no competition these costs are greatly inflated by the PFI company.

The consequences of the "overspend" caused by the PFI is that hospital staff including nurses are made redundant. Clinical services are cut back.   Peterborough Hospital PFI was agreed in 2007, it is a very nasty financial legacy left by the Labour Party Government at the time. I've seen estimates of £800 Million required to rescue the hospital finances.

Aftermath of NHS Walk-In Centre closure

I've written earlier about the death by attrition of an NHS Walk-In Centres (WIC) in the United Kingdom. The concept of a nurse led WIC is to provide primary health care to patients who walk in off the street without appointment. The nurses are highly skilled, highly trained and carefully selected. They are examined in physical assessment skills, their work is routinely audited for best practice. They work to careful designed medical protocols which allows them to assess and manage the majority of minor illnesses. The nurses are also trained to recognise conditions which should be referred to specialist medical practitioners. The senior nurses in the team usually posses Master degree level of medical training and take separate training and assessment to be allowed to prescribe medicines.

I'm keeping track of one WIC which was closed down and the team transferred to a local A&E department of an Acute Hospital Trust. The highly skilled primary care Matron who had led the WIC nursing team was within a few days forced out of the job and was replaced by a less senior A&E nurse who had no training in primary care.

In the past 6 months the skilled WIC nurses now working under A&E management have been subjected to a programme of bullying and repeated comments that they lack the competence to undertake primary care work. The people harassing the nurses have little or no primary care knowledge/experience. There have been arbitrary bans on the WIC nurses performing the role they'd practised many years before in an autonomous way. Note that the WIC team previously had a very low rate of complaints of medical mistakes. Make no mistake, the Acute Care A&E management is trying to force the WIC nurses out of their jobs while retaining the budget funding for their primary care work.

This may all sound like internal politics, but it has a serious impact on service to the local public. The WIC in question used to have about 400 visitors a day. Some of those would be streamed away without medical treatment, but most patients were seen in less than an hour.. The local A&E now regularly breaks the four hour rule for treatment and has a much higher error rate. Skilled Nurse Practitioners like this person are the type of experienced nurses being forced out.

Edit 27th Aug 2012: Or look at Suffolk NHS who posted on their web site: 'Only visit A&E if you are dying' a few months after the decision to close their minor injuries unit and transfer the staff to A&E.

10th Sept 2012: I lose no tears over Andrew Lansley getting the sack as the Health Minister. Sadly the NHS will continue to suffer the effects of the chaos he's caused for many years.

Signs of further UK NHS destruction

Further evidence of the Andrew Lansley programme of destruction for the NHS emerge:

Hospital waiting list "recategorisation" 12th June 2012; patients are being dropped off waiting lists for operations.

NHS Care being rationed. BBC report 19th June 2012; access to some operations being restricted.

This will all get worse when the control of funding is passed to the committees of freelance General Practitioners under the present Andrew Lansley plans.

Lack of hospital beds in UK

It is sad that I feel duty bound to use my blog as an author to raise the problems I see with the UK's National Health Service, but where else can one get one's views in the public view? The bloated administration of the NHS is sucking the lifeblood out of the service where administrators with no clinical experience are on six figure salaries. At the same time skilled clinical staff are losing their jobs.

Take for example the reported shortage of hospital beds (BBC article - Nick Triggle). The Government deny there is a shortage, but if you talk to any A& E Matron and you will hear a very different story. Patients are regularly kept waiting because of bed shortages. The hospitals employ "Bed Managers" whose sole job is to chase the clinicians in the hospital wards to discharge patients early.

The problem with hospital beds is that a "bed" has become a unit of accounting in hospitals. The bean counters find it very convenient to work out the "cost of a bed" by taking the total running costs of a hospital ward/unit and dividing it by the number of beds. Don't forget they also impose the "management overhead + PFI costs" into those running costs. It is not just the medicines, doctors, nurses and ward staff. The bean counters then have an easy to use spreadsheet figure called "bed cost". The cost figure gets absorbed into the management mythology and the people using it forget the original components of the cost.

When senior hospital management realise there have/are going to run out of money they'll introduce cost cutting measures. Some bright bean counting spark will say "if we cut 20 beds from the service we'll save a lot of money over five years". As a consequence patients lose access to those beds, but the overhead hospital costs never go away.  Let's be plain about this: A hospital bed only costs about £5,000 When a hospital "closes" a bed, they don't sell the bed to reclaim the money. The hospital still has to pay infrastructure costs, floor rent, the administrators costs are still there, the PFI costs remain.  The action doesn't reduce the number of patients, people still get sick.

The hospital planners/administrators need to get away from the concept of a "bed cost" and use more realistic accounting methods. 

Here's another view of the problems by a Doctor.

Absolute stupidity of NHS Reorganisation

Before the last general election in the UK the leader of the Conservative Party declared that he wouldn't impose yet another re-organisation on the NHS if he was elected as the new Prime Minister. Promptly on arrival as the new PM he handed control to a dubious politician called Andrew Lansley. This silly man promptly set about reorganising the National Health Service. He has this "bee in his bonnet" that is he removes layers of management from the NHS and hands control to General Practitioners (Doctors) they will magically reduce the public costs of the NHS. This man Lansley has the stubbornness of a dead donkey and the listening ability of a beach pebble when it comes to listening to the views of the massive majority of the health care professionals. Just about everyone says scrap the new new re-organisation.

Here's some of the problems:

• The GPs are independent contractors (I have a letter from the Dept of Health confirming that); their own profit comes first. Giving them control of the purse strings give them the opportunity to avoid any measure that would reduce their profit.
• The GPs won't have spare time to run the national organisation or even local ones. They'll just re-employ the bureaucrats who used to run the defunct Primary Care Trusts. It won't save money.

Here's a real life example of the changes in progress right now. A friend of mine is a Nurse Practitioner. She's a highly skilled medical practitioner who has a cluster of medical degrees, over 30 years experience who works without the need for clinical supervision at the level of GP/Registrar. Her costs are about half that of a highly paid GP. As a direct consequence of the re-organisation she is being made redundant. Well not exactly redundant, the patients she used to see are being redirected to the local A&E department. The cost the public purse per patient has increased by a factor of three and queues will lengthen in the A&E. 

This senior nurse's redundancy settlement has yet to be agreed, but by the Departmental rules the additional cost to the public purse will be close to £500,000 if an unfair dismissal claim is to be avoided. Meanwhile the same group of GPs who pushed for the closure of the Nurse Practitioner's department are looking to employ her on a freelance basis at a Doctor's rate of pay. The nurse didn't ask for the re-organisation and she doesn't want to be made redundant. She is a strong proponent of the NHS. How many times is this type of situation going to be repeated throughout the NHS?

Black Hole devours nurses

I've earlier written about the death of an NHS Walk-In Centre, I'm now watch the terminal stages of this process in one location. It's nothing new I've seen it before and I'm sure the remaining Walk-In Centres will suffer a similar fate.

This is a direct consequence of Andrew Lansley's misguided leadership of the NHS. Abolition of the Primary Care Trusts have left Primary Care Walk-In Centres without any real sponsors. The General Practitioners (GPs), who now hold the purse strings in advance of actual parliamentary approval, will not save the Walk-In Centres because it disturbs their Edwardian business model of private practice partnerships.

No, the WIC I'm watching has been handed over to the black hole of a local A&E department of an Acute Trust Hospital. The once highly efficient team of Primary Care Nurses is being torn apart. This is a team which has worked for 10 years, rarely breaching patient time waiting targets and almost zero serious patient complaints. Nurses who were trained to work as autonomous practitioners who are qualified and able to assess medical conditions and to prescribe treatment. Their clinical leader has been elbowed away and replaced by an A&E nurse manager who has no experience of Primary Care medicine. The remaining Primary Care nurses are looking for new jobs having been told they are "not competent" by someone who has no experience in their skills. The GPs who once worked as part of the team are refusing to work with the new management. Within a few months little trace will be left of what was once a strong team.  

One remaining question  is what happens to the funds assigned to the WIC Nursing team? Does it get buried in the A&E hoard? What happens to the (average) 200 people who used to go to the Walk-In Centre? Their needs don't go away.

Update May 2012:
The Matron of the A & E Dept which absorbed the WIC has resigned. She's tired of the bullying from senior managers and clinicians, meanwhile the Matron of the now closed WIC is in the final stages of redundancy. It all seems a silly waste of resource to me.

Lansley's NHS

Andrew Lansley has published his plan for privatisation of the NHS, ooops I mean health reforms. They cement my view that the concept of the NHS Walk-In Centre is thoroughly dead. There is no mention of Walk-In Centres in the Primary Care bit of the plan (item 44), the GP lobby in the Lansley advice coterie is getting its way. They are determined that the public will attend their [private partnerships] surgeries at a time convenient to the well paid  GPs rather than the needs of the public. People go to Walk-In Centres because they either can't get the service they need from their GP or the quality of service is so bad that they seek an alternative.

Meanwhile I've been contacted by a Nurse Practitioner (30+ year's experience, Masters degree in medicine) who tells me his future employment is so uncertain that he's stopped buying a season ticket for travel to work. He now only buys a weekly rail ticket.

Rats or Birds?

One of the signs that something is wrong in an organisation is when several senior managers leave of thier own choice in a periods of a few months. A recent article in the Guardian Newspaper highlights a case in the Barts Hospital in London UK. The guy in question has worked at the place as a skilled surgeon for many years. Suddenly he finds it an unacceptable place to work! There have been several instances of senior administrative and clinical staff (5 out of 14 orthopedic surgeons) finding employment at an alternative location more attractive. Is it rats leaving a sinking ship or is it birds flying away before an earthquake? Has someone broken the spiritual backbone of the place? It is very difficult and expensive to repair a damaged corporate psyche. Maybe there is a programme of cuts using an experienced aggressive "Turn Around" Director?

The same kind of thing has happened in the North Staff's hospital. Now the administrators had to draft in Army Medics to keep their A&E  department running. Professional medical staff such as surgeons and specialist nurses will be caution about joining to work at a hospital with a damaged reputation.

It is a pity, because BARTS does some good clinical work caring for the patient. For example they're the only hospital actually checking the safety standards of surgical instruments. See the worrying Panorama programme in July 2011. They also do good work in research in Prion infection on surgical instruments. Perhaps the problem is the way the administrators engage with the clinical staff? Is there a climate of bullying? Are we getting value for money from these highly paid administrators?

Another senior nurse goes from UK NHS

Yesterday a highly skilled senior Cardiac nursing sister left the UK NHS. She'd worked at a central London hospital for many years. During the period she self-funded BSc and MA degree qualifications in medicine. She was managing a ward of critically ill cardiac patients. Tired of the clinical nurse staffing cuts under Lansley, the excessive unpaid overtime (12 hour days) and professional bullying abuse from some doctors/managers she decided to leave. She could no longer tolerate the disrespect from her Acute Hospital Trust employers.

She's looked around and has found a senior post in a middle east hospital. She's instantly doubled her salary, has paid for accommodation and it is all tax free.

It is fascinating yet unsurprising that the Acute Trust Board discuss a survey on staff concerns and conclude that people are happy. In reality the medical staff are angry and frustrated. It is time for the board members to get away from the board room and go actually meet the workers. Such bullying can have severe financial consequences.

Death by attrition - Walk-In Centre

I'm watching the death by attrition of an NHS Walk-In Centre:-

• Buildings closing (scheduled to be demolished quickly after);
• Alternatively buildings given to a GP practice; even though they are a private concern;
• Primary patients directed away without treatment ("Go to your GP or another clinic such as sexual health");
• Any vacant position arbitrarily removed, regardless of the reason for the vacancy.
• Senior nurses bullied and excluded from management meetings to encourage them to leave;
• Senior nurses made redundant;
• Junior nurses told their jobs are being regraded (downwards) with no real consultation;
• Overnight working in A&E (not primary care) imposed regardless of contract;
• Nurses diverted to streaming duties in A&E;
• Nurses joining a union for the first time ever;
• Specialist computer systems for patient consultation records abandoned and no further maintenance paid.
• Services like Emergency Contraception cancelled - "go to another clinic" even though it is closed and the patient would need an appointment. 
• Senior administrators making arbitrary clinical decisions
• Budgets diverted away to other purposes.

All of this happens without consultation with the public and little warning to patients. All that is left is a deskilled shell nominally called a Walk-In Centre where a couple of nurses share a room somewhere in a larger department.  The PCT or Acute Trust claim the Walk-In centre hasn't "closed".

I've now seen this happen in four different locations over the past couple of years. It is a sickening waste of the public money invested in the creating WIC infrastructure and in the cost of building and training a skilled team of nurses. The public are left with no improvement of services as a result and the workload (queues) in the local A&E increase as a consequence.

One point never successfully handled under if retaining the patient records. They are supposed to be maintained safely and accessible for at least 25 years. This is an enormous cost risk, with the nurses dispersed there is no one able to dispute a legal medical claim. It is another consequence of the Lansley blind bull in a china shop leadership.

This happening in many places in the UK..

Edit: 17th April 2012

I recently had a chest infection which needed treatment with antibiotics to help it clear up. I've not troubled my GP for the past 15 years but I was not surprised to find I could not get an appointment until the following Monday (I was phoning on a Wednesday).  The receptionist's advice was to go to A&E dept or to the local Walk-In Centre. The local walk-in centre is one of those which has closed to be replaced by a ghost service located in another GP Surgery. I wasn't working so I drove to the WIC and was seen by a Nurse Practitioner within half an hour during the normal working day.  However I note that the opening hours have been cut down considerably and there is a map on the wall showing the "Catchment Area" street by street, within a radius of one mile. Proper Walk-In Centres do not have catchment areas! They deal with whoever comes through the door

The next closest Walk-in Centre by time of travel was open in December 2012, but it is now closed and the site is a car park.

More about NHS WICs

My blog piece on NHS Walk-In Centres has generated some interesting, if uninformed, comment so I’ll extend the article somewhat.

The idea of the Walk-In service is that patients can walk in from the street if they want medical advice, after treatment the patient walks out. The Walk-In Centre does not deal with A&E cases, though it is not unknown for ambulance crews to deliver patients to a Walk-In Centre where the condition is minor. The general rule is that if the patient has broken bones, needs a stretcher or has chest pains they get directed to A&E.

The WIC consultation is designed to be a one shot process. To assess and treat if appropriate; the WIC procedures are not designed for follow up sessions. If follow up is necessary the patient will be referred back to their own GP or to acute medical practitioners in an appropriate local hospital. The WIC may offer associated services such as a phlebotomy clinic (taking bloods), but not as part of their routine assessment process.

Mostly the cases for assessment and treatment are where the patient presents with headache, high temperature, colds and flu.  They are cases that would otherwise clog the waiting areas of the local GP or A&E Department. The WIC normally has a qualified medical prescriber present during their open hours, the usual route for patients to obtain medicines is to visit a local pharmacy, but the WIC will also hold a stock of common medicines for on-site dispensing.  When the WIC practitioner recognises a serious underlying condition the person will be referred back to their GP or in urgent cases on to the local A&E department. These referrals routinely represent a very small proportion of the cases handled.

The Walk-In Centre is normally led by a senior primary care nurse practitioner (Matron).  The lead nurse will usually manage both nurses and administration staff. Where appropriate the lead nurse /Matron will also employ a part time salaried GP to handle cases that need the skills of a GP but patient cannot for some reason attend their own GP. Most primary care nurse practitioners (PCNP) are qualified to MA degree level in an appropriate medical discipline with additional training specifically to work as a Nurse Practitioner. They will usually have at least 10 years experience of actual practice in the primary care area. They are decidedly not “Practice Nurses.”

The nurses in the walk-in centre are trained in medical assessment. They are expected to take comprehensive notes recording how they reached a diagnosis in each case. Those records are personally signed as a legal record by the nurse. The WIC matron regularly audits the patient records for quality for the nurses and the salaried GPs. Nurses are provided with detailed written rules as to how to perform their work. They are not permitted to perform such work unsupervised until they’ve been given a written sign off of their competency. They are also encouraged to routinely consult with their seniors when they have any uncertainty. A recent study in the litigious USA showed that less than 2% of Nurse Practitioners were mentioned in medical claims. In the UK the training and supervision is more intensive.

The concept of the UK NHS Walk-In Centre was created in the late 1990s by the Labour Government. It was a time when the public in some locations found it notoriously difficult to obtain a consultation at their GP’s surgery. GP surgery hours were limited and normal working people would have to take time off work for a 3 minute consultation with their local doctor when they finally achieved the minor miracle of getting through to the GP receptionist phone. Most GPs are not directly employed by the NHS, they act as sole practitioners or partnerships that have few actual constraints on how they deal with patients or which actual hours they are available to patients. GPs will contract with a local primary care trust to provide services, but it remains the fact that GPs are their own bosses.  The design of the Walk-In Centre service was to counteract that lack of service. WICs were specified to be open daily (364 days a year) from 0700 through to 2200 and thus not just constrained to working hours.

In the past few years WICs close to acute hospitals have been performing an additional function in reducing the waiting queues at the A&E departments. A skilled nurse(s) from the WIC would be stationed in the local A&E department adjacent to the waiting area to perform first line triage of attending patients. Those with minor conditions are advised (not mandatory) to visit the near-by Walk-In Centre to receive quicker appropriate treatment

The death of the NHS Walk-In Centre

One of the better changes introduced to the UK National Health Service (NHS) was the concept of Primary Care Walk-In Centres. They were located primarily in urban or city locations and were available to the public from 7am to 10pm for 364 days a year. In other words they were available at a time convenient to the public rather than a time convenient to local General Practitioners (GP).

The Walk-In centres were staffed by teams of highly skilled primary care nurses and led by autonomous Primary Care Nurse practitioners. The procedures and skills of the nurses, who were qualified to prescribe a full range of drugs and medicines, mean that they could deal with 98% of the cases without the need for a medical GP. For those few where the nurses could not handle a GP would be be employed on a part time basis by the lead Nurse Practitioner.

No appointment was necessary, people could literally walk in off the street and receive a medical consultation. Those with long term medical conditions would be given any necessary urgent treatment and referred back to their GPs for long term primary care.

The concept was extremely successful:

• The costs were low. A WIC patient consulation was about £25 cost to the NHS. If that patient had gone a GP it would have cost at least the NHS at least £35. If the patient couldn't get to see a GP and decided to go to the local Accident and Emergency the minimum cost to the NHS would be £105.
• Waiting times were good. Patients were seen within an average of 20 minutes or less in a fully staffed WIC.
• The GP practices in the UK are run by independent contractors. They could turn patients away or close for the day at the whim of the GP Partners. The WIC teams were obliged to stay open, requiring permission from the local Primary Care Trust (PCT) and the Dept of Health before they could close.
• The WICs helped to reduce queues in the local Accident and Emergency departments when patients with minor ailments were "streamed" away from the Hospital to the Walk-In Centre.
• The WICs had a very low medical error/claim rate.

Sadly now most of the Primary Care Walk-In Centres have now been closed and their skilled teams of nurses dispersed. There are other reports on the Internet. In some cases the closures are hidden by the retention of a couple of junior staff and assigning them to a local GP or an A&E department. With the GP led Walk-In Centres you will see the daily open hours change from 0700-2200 to something like 0800-1900. In some cases the nurses are transferred to Acute Trust (Hospital) where the nurses role is subtly changed from being trained autonomous medical practitioners who diagnose and prescribe. Now they have to double check any decision with expensive doctors.

Originally the funding of the WIC team came centrally from the Dept of Health, it was ringfenced and could not be diverted to other purposes. Subsequently the ringfenced funding was merged into the general funding of the Primary Care Trusts. Opponents of WICs soon diverted the funding away from the WICs and the closures started. Remember the WICs often dealt with the failures of the GPs. They were seen as a threat to their profits. When the Conservative/Liberal coalition government came to power the scourge of the NHS in the shape of Andrew Lansley was released. He decided to wipe out the Primary Care Trusts and to hand the financial reins to the local GPs.  GPs see WICs as financial competition. It signalled the end of the PCT funded Walk-In Centres. Some have been absorbed by the budget hungry Acute Trusts (hospitals) to act as a streaming front end to A&E purely intended to prevent breaches of the waiting time targets. The Acute Trust, typically struggling under the financial burden of a PFI project, gains the funding from the Walk-In Centre, but the public lose the benefits.

These facilities are closed without public consultation, possibly leaving a ghost service to protect against public follow-up. The health administrators hate having their closure plans examined in public. Hundred's of thousands of pounds will have been spent in creating each of these Centres. It is often wasted. In one case the building was handed over to a local GP (private) in another the buildings will be demolished to provide parking spaces.

The consequence of these widespread WIC closures in London will be felt with greater queues in A&E, particularly at the time of the Olypmics 2012. Some of these walk-in centres were due to provide support to visitors. Here's a BBC report of a typical example in Surrey. They used to have a local WIC but it closed. You'll see a similar pattern in Croydon, New Cross, Whitechapel (E1), Homerton, Canary Wharf, Liverpool Street, Victoria and many other locations such as Stapleford, Ashfield, Leeds, Derby, Bradford, Salford, Harrow, Nottingham, Kirby, Trafford, Bromley, Manchester, Southampton , Barnsley, Warrington York Haverhill (Suffolk) Loughborough

An attempt to close Peterborough WIC.

Update: Late Nov 2011  One of the Walk-In Centres scheduled for closure soon,  as usual had a busy day as people attended for treatment yesterday. Many of those people would have gone to the local A&E Dept. Needless to say, the nearby A&E Dept managers are wetting themselves at the prospect of a 40% uplift in visits when the Walk In Centre closes. The A&E waiting time targets are going to be shattered, they already fail to meet waiting targets frequently enough as it is on present levels of patients.

Update Feb 2013: To make matters worse the local A&E Departments, which were protected by the Walk-In-Centres taking part of the load, are getting closed down as part of the service cuts. The (private) GP led Walk-in-centres open just 13 hours a day 8 - 7pm compared with Nurse led (NHS) 16 hours and the GP WICs have significantly reduced staff levels.