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Editor's Blog 16th October 2008: NHS Alliance conference - day one

In Bournemouth for the NHS Alliance conference, hoping and expecting it will live up to its reputation for lively and outspoken debate. So this blog will update throughout the day.

We wake to the interesting policy context of the Annual Health Check.

2007-8 Annual Health Check – improving but mixed picture
The headline figures from the Healthcare Commission’s final Annual Health Check are impressive. The survey shows sustained improvement across much of the country, although the rate of improvement on overall ratings has slightly slowed for both trusts rated at the polar ends of the scale - excellent and weak.

By comparison with performance two years ago (the first year of the Health Check), however, sustained improvement is more noticeable for both quality of services and use of resources. The only exception is in the ‘good’ category for quality of services, where the 2007-8 figure of 34% of trusts is identical to the figure for 2005-6.

Between 2005-6 and 2007-8, the number of trusts rated ‘excellent’ for quality have risen from 4% to 26%; ‘fair’ has dropped from 50% to 34%; and ‘weak’ have declined from 9% to 5%.

For use of resources, the figures for the same period are a meteoric rise from 3% to 24% ‘excellent’; ‘good’ more than trebling from 12% to 37%; fair dropping from 47% to 37%; and ‘weak’ falling off a cliff from 37% to 5%.

57 trusts achieved the ‘double-excellent’ standard for both quality and use of resources (by contrast, there were 19 in 2006-7 and only two in 2005-6). However, the six trusts rated ‘double weak’ (Royal National Orthopaedic Hospital, Scarborough and North East Yorkshire NHS Trust, East of England Ambulance Service, Great Yarmouth and Waverley PCT, Brent PCT and North Yorkshire and York PCT) will be “having the boys in”.

As ever, foundation trusts performed well. 89 per cent of FTs were rated ‘excellent’ or ‘good’ for quality, and 99 per cent of foundation trusts were rated as ‘excellent’ or ‘good’ for use of resources.

However, Prime Minister and Master Of the Financial Universe Gordon Brown will find uncomfortable reading on both of his health policy priorities – healthcare-associated infections and GP access.

The survey highlighted ongoing issues around infection control procedures. 25% did not put adequate systems of infection control in place, and according to the Commission’s figures (which use a different methodology from the DH figures), just over half of trusts failed to meet the Government’s target to reduce MRSA bacteraemias.

The figures have also generated controversy around access times to GP appointments.

Healthcare Commission chief executive Anna Walker spoke of “a dramatic decline” in the number of PCTs where GP appointments were available within 48 hours – although the methodology is disputed, as this year, the figures are based on patient-reported experiences of access to an appointment, as opposed to the Healthcare Commission using a combination of self-certification by GPs and an anonymous telephone survey in previous years (news of which passed round the GP community like wildfire, probably distorting access as a result when other surgeries keep slots free in case they are rung).

The survey found just 31% of PCTs meeting the GP access target – last year, the figure was 80%. Such a dramatic decline prompted Healthcare Commission head of assessment Gary Needle to observe that he could not rule out GPs having lied in previous years about their levels of compliance. Dr Hamish Meldrum, BMA chair, described the figures as “misleading”.

Registration with the new Care Quality Commission (CQC) begins in April 2010, and while the figures found two-thirds of trusts (and 70% of hospitals) met all the national core standards (with another 25% ‘nearly’ meeting all core standards), that leaves 10% of hospitals and trusts still some way off the mark.

Professor Sir Ian Kennedy, chair of the Healthcare Commission, told the Financial Times “if they don’t meet these core standards, the Care Quality Commission could withdraw registration or impose tough penalites such as fines or operating conditions”. Baroness Young, chair of the CQC, described the chance of an entire hospital being refused an operating licence as “very unlikely”.

And could we be facing the first quality reconfiguration? Noting that the new figures found London's health services in deterioration (with 48% 'excellent' or 'good, down from 55% in 2006-7), Anna Walker told The Independent, "NHS London is right to encourage PCTs to work together and there may be a case for reconfiguring services."

In exciting news elsewhere, the Christie and Central and North London Mental Health FTs are no longer alone in revealing they had money in Icelandic banks. They have been joined by providers of financial data to non-FTs in the Annual Health Check, the Audit Commission.

Quis custodiet ipsos custodes?

Mid-morning,after first plenaries
I'm sitting with Bob Sang, and neither of us can quite believe the session that has opened the NHS Alliance 2008 conference 'Vision Into Action'. Not only had Michael Dixon talked approvingly of Joseph Stalin, David Nicholson endorsed Martin Rathfelder of the Socialist Health Association's comments that "in every one of the the last 18 years, the people running my local NHS care more what you think about them and less what I think about them". Indeed Nicholson told Rathfelder, "you're absolutely right - this is one of our biggest problems".

Oh yes, and David Nicholson wants to support leading edge risk-takers. Whose risk? Icelanic bank-type risks? There is a lot more to do with risk than merely rewarding it.

Camilla Batmangelidjh of Kid's Company gave an impressive and moving insight into the attitude of the desperately vulnerable and excluded children who come to her charity, emphasising the importance of the personal contact and empathy in the caring transactions. She focused on the importance of individual moral courage.

Michael Dixon: 'tell me and I’ll forget, show me and I’ll remember, involve me and I’ll understand'
Dixon's address was the usual mixture of good sense and good quotes (T S Eliot - "between the vision and the reality falls the shadow"), but underscored by a note of real anger. Paraphrasing Oscar Wilde, he drily observed of the non-progress of PBC (highlighted by the DH's quarterly survey), "to lose one year may be considered a misfortune; to lose two looks like carelessness - possibly fatal".

He also borrowed the Chinese proverb 'tell me and I’ll forget, show me and I’ll remember, involve me and I’ll understand', referring to the slow-to-no progress of clinical engagement. Another no progress area was the Alliance's third annual summary of hospital discharge information, which again found worryingly low levels of compliance with what has been part of the national contract since April, and ongoing risks to patient safety.

Dixon concluded, "our NHS must make all its managers, all its clinicians and all its patients feel like VIPs, not like the recipients of others' cant and self-congratulation".

Controversy in Nicholson's comments on GP and PCT collusion blocking new surgeries in under-doctored areas
Sotto voce, Nicholson had dropped a quote from Nye Bevan into his speech as a throwaway line "This is my truth", after admitting to delegates that in the past, NHS managers "huddling together for warmth sometimes talked abut clinical engagement, when what we really meant was 'how can we get doctors and nurses to do what we want them to do?'".

The morning session, and particularly questions from the floor, revealed evidence of a front-line disconnect with the rhetoric of PBC liberty coming up against inflexibilities ay PCT and SHA levels. If Nicholson's expressed desire to see more local freedom and dynamic action is sincere, he should be very concerned about impediments facing PBC from SHAs and PCTs.

Nicholson's proposed four changes to support PBC all sound good - co-production, subsidiarity, clinical engagement and system alignment. Yet delegates repeatedly expressed scepticcism in questions about access and the new GP-led 8-8, 7-day-week ... oh sod it, polyclinics.

Nicholson "in my career as a NHS manager, we tried three times to get increased capacity to under-doctored areas across the coutry. What happened was that it failed three times. A cosy conspiracy of PCTs and general practice overcame it. This (move to polyclinics) was at the end of that process"

His response to questions about access was instructive: "in my career as a NHS manager, we tried three times to get increased capacity to under-doctored areas across the country. What happened was that it failed three times. A cosy conspiracy of PCTs and general practice overcame it. This (move to polyclinics) was at the end of that process".

In a subsequent press conference, NHS Alliance chair Dr Michael Dixon said of Nicholson's allegation, "I think it's a bit unfair to say that PCTs and GP practices colluded. Frankly, I think some of the problems in practice-based commissioning are because they don't collude enough."

Alan Johnson under par
The likeable Health Secretary Alan Johnson looked slightly unwell, and his speech, though full of warm words about primary care, had little content on how the problems around commissioning in primary care will be solved.

Johnson - "We recognise that we haven't done enough to support practice-based commissioning and that PCTs should do more to encourage practices to get involved"

He publicised the access improvements in general practice, highlighting the 152 polyclinics (one per PCT as well as the funding for over 100 new practices in the most poorly-served areas. He also repeated his attack on the Conservatives' maths on polyclinics.

And he launched that integrated care pilots prospectus, inviting delegates to get involved. "We recognise that we haven't done enough to support practice-based commissioning and that PCTs should do more to encourage practices to get involved ... the Alliance is such a powerful force for progress. You not only know the route we ought to follow - you've helped to clear the undergrowth."

Johnson also emphasised in responses to questions that as a trades unionist, he would not be repoening negotiations on the agreed comprehensive spending round, repating Gordon Brown's promise that health and education would not be affected.

Britnell: supporting PBC with four freedoms
In an engaging and energetic presentation (but alas with the common NHS curse of over-busy PowerPoint slides), Mark Britnell outlined the four key freedoms being introduced for practice-based commissioners via the world-class commissioning assurance framework.

Emphasising PBCers' freedoms and rights, he outlined the rights to clinical information, management information, management support and financial support -  with new incentive freedoms for advanced PBCers who want to go further faster.

He added that obvious barriers remain  to PBC progress – clarity of roles and responsibilities; capability and capacity for PCTs and PBCers; poor governance; confused relationships; motivation and engagement.

Britnell repeatedly stated his openness to dialogue about how much regulation and rule-setting people wanted from the centre, adding that his personal instinct was to do less and allow conversations to produce organic solutions.