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.

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.

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