HSJ Live 05.03.2014: BMA consultants' leader calls for 'principled' contract negotiations

2.05pm The Royal College of General Practitioners (RCGP) has been awarded more than £380,000 from the Department of Health to develop a unique online information ‘hub’ to help GPs improve the support and services they provide for carers.

The hub will collate all the information GPs, primary healthcare staff, practice teams, commissioners and Health & Wellbeing Board representatives might need to identify and support carers, bringing together RCGP resources as well as signposting to external resources. Health professionals will be able to use it free of charge.

The hub will have information about the needs of carers, right from the initial diagnosis through to the end of the condition or even end of life, with a focus on depression. It will also offer guidance about what questions to ask carers, what rights they have and what support is available. The aim is to link a range of supplementary resources on disease specific conditions including dementia, end of life care, cancer and mental health.

Carers are a hidden healthcare army in the UK. Current estimates suggest that 12% of all adults are carers.

The RCGP Supporting Carers in General Practice programme has been running for several years and aims to ensure that carers get access to the resources and help that they need.

The Department of Health grant will also continue to pay for up to ten regional GP Champions for Carers who will aim to change the culture around identifying carers in primary care by engaging with practices, practice networks, Vocational Training Schemes, CCGs, Health and Wellbeing Boards and commissioners in their allocated regions. The GP Champions will work alongside Carers Trust Expert Practitioners and Carers UK’s Carer Ambassadors.

Dr Sachin Gupta, RCGP’s clinical lead for the project, said: “There are estimated to be over six million carers in the UK, many of whom are not getting the help or access to resources which they need. I am excited about the RCGP Supporting Carers in General Practice programme, which will go some way to increasing the identification of carers at an earlier stage, ensuring that they are fully supported from the outset.”

Care and Support Minister Norman Lamb said: “GPs and their staff are often the main point of contact for patients and the people who care for them, so it’s really important that they recognise and understand the impact of caring on carers. Initiatives like this provide healthcare professionals with information and advice on how best to identify and support carers so they do not have to shoulder their caring responsibilities alone.

“More and more people are becoming carers and we want to create a fairer society where people are properly supported in this vital role. That’s why we’re legislating to give carers new rights in the Care Bill so that, for the first time, they will have a legal right to support for their eligible needs, putting them on the same legal footing as the people they care for.”

One carer whose life has been transformed by the support she receives from her GP surgery is Elizabeth Hoggarth, aged 77, who cares full-time for her 81-year-old husband Allen who has osteoarthritis. They live in Pudsey, West Yorkshire.

Kathleen said: “I can’t speak highly enough of my GP surgery for the care and support they give me and my husband all year round. We get the appointments we need, even at short notice, and they invite us for regular health checks.

“There’s also a special carers group that meets every two weeks which gives me the chance to ask questions to the practice staff. It’s a huge comfort knowing they are there to give advice. It’s also a great opportunity to meet other carers in the same boat and to share our experiences. It really is these little things that make all the difference to take some of the strain away from the pressures of caring full-time. I hope that the excellent services that we receive can be replicated across the whole country.”

Two new interactive and innovative e-learning courses to help GPs to identify and support carers were developed using last year’s Department of Health Carers grant and have now been officially launched by RCGP as part of its Online Learning Environment. The courses, which have been written by GPs, are free for all healthcare professionals.

Supporting Carers in General Practice www.elearning.rcgp.org.uk/carers builds on the existing Supporting Carers action guide produced by the RCGP in collaboration with the Carers’ Trust. It targets GPs and other community healthcare professionals, exploring how to involve carers in decision making in order to prevent unnecessary admissions to hospitals and residential care homes.

A second e-learning course, Taking Action to Support Carers in Practice Teams, www.elearning.rcgp.org.uk/carers focuses on four key areas: Problems faced by carers; Identifying carers; Supporting carers; Implementing a practice action plan.

Those who successfully complete either of the courses will receive an e-Certificate which can be added to their CPD log to help them meet their requirements for revalidation.

1.50pm Dr Peter Nightingale presents the best tweets from HSJ and Marie Curie Cancer Care’s Twitter chat on the role of partnership working in end of life care. To see a selection of his favourite contributions - click here.

1.35pm Graham Dupree, head of healthcare property at Mills & Reeve, has written a comment piece examining the Department of Health’s strategy to improve GP premises. He writes that GPs are under pressure from the Care Quality Commission demanding investment in more suitable buildings and a lack of funds to build them.

1.28pm This afternoon MPs will be holding a debate looking at the Francis Inquiry one year on. For more details - click here

12.45pm For the first time ever, apprentices will be able to train directly towards becoming a nurse, the government announced today.

A group are developing a degree-level apprenticeship which will widen access to nursing. It will be targeted at the brightest and best health care assistants who have proven they can give high quality care to patients, but do not have the academic qualifications necessary to get on to a nursing degree.

The new apprenticeship will make sure there is an opportunity for talented care workers to progress into nursing, giving them a route to advance their careers and a chance to use their vocational experience of working as a healthcare assistant to enter the nursing profession.

skills and enterprise minister Matthew Hancock said: “We want the new norm to be for young people to either choose to go to university or begin an apprenticeship. This announcement is another step forward in making this the case.

“I would like to thank the organisations involved in this trailblazer project, and hope their future recommendations for the degree level nursing apprenticeship will provide the NHS and private providers with a group of highly skilled and confident nurses.”

As part of their commitment to making the NHS more compassionate, Ministers have given the go ahead for a working group to develop a brand new apprenticeship standard. The scheme is one of the recommendations in the independent review carried out by Camilla Cavendish in the wake of the Francis Inquiry into the tragic events at Mid-Staffordshire NHS Foundation Trust.

Health Minister Dr Dan Poulter said: “NHS and social care support workers have a long history of delivering high quality, compassionate care to patients and their families.

“This new apprenticeship will help healthcare support workers who have demonstrated a track record of delivering high quality care to get on in life, and break through the glass ceiling that has in the past prevented people from poorer backgrounds from entering nursing and other healthcare professions. We are supporting people with a record of hard work and dedication to our NHS to progress their careers and get on in life.” 

As part of the requirement that all new nurses must have a nursing degree, the apprenticeship will have the degree at its core. The trailblazer group who are developing it will be looking at how ensuring that on completion, apprentices will have all the skills, knowledge and confidence they need to perform nursing duties well and confidently, meeting their employer’s and professional registration requirements.

Dr. Terry Tucker, of Barchester Healthcare said: “We are delighted to be involved in the development of this apprenticeship standard for nursing. We have been working towards this for over two years by developing great career pathways for our ambitious carers. It builds on the success of our apprenticeship programmes and offers motivated people the opportunity to advance their career into nursing.”

Tracey Cottam, Director of Transformation and Organisational Development of Royal Devon and Exeter NHS Foundation Trust said: “We are delighted to be involved in this important initiative. This underlines our commitment to enabling our healthcare assistants to become registered nurses through a vocational pathway that will be designed to meet professional registration requirements.  This will help us to meet current and future demands for high quality healthcare.”

12.40pm Five hundred women every year could benefit from a new drug which has been added to the Cancer Drugs Fund to treat advanced cervical cancer.

The drug bevacizumab (Avastin) is already used in the treatment of other cancers, however this is the first time it will be available on the Cancer Drugs Fund (CDF) for advanced cervical cancer.

It is routinely available on the NHS in England before any other country in the world.

Cervical cancer is the most common cancer in women under 35 and its incidence has risen by approximately 15 per cent in the last decade in the UK with 2,900 women diagnosed in 2010.

NHS England’s Chemotherapy Clinical Reference Group (CRG) has made the medicine available after trials showed bevacizumab could extend the lives of women with advanced cervical cancer by nearly four months compared to chemotherapy alone.

The Chemotherapy CRG is working closely with clinicians and representatives of the pharmaceutical industry to ensure a rapid review process for new drugs that may be appropriate for inclusion on the Cancer Drugs Fund list.  The review process looks at the available evidence regarding a drug’s efficacy, plus data relating to its safety.

Professor Peter Clark, Chair of the Chemotherapy CRG, said: “This new addition to the list demonstrates NHS England’s commitment to achieving maximum benefit to patients from the £200 million Cancer Drugs Fund.  The process of updating the list is led by cancer specialists, and should ensure that patients benefit quickly when new drugs become available that are backed by good evidence from trial data.”

Robert Music, Chief Executive of Jo’s Cervical Cancer Trust, said: “The addition of bevacizumab to the Cancer Drugs Fund is very positive as for women who receive a late stage diagnosis of cervical cancer, the prognosis can often be poor. When this is the case, any extra time that can be provided through new drugs becomes extremely valuable. We hope this will result in extended survival without impacting on quality of life for those facing non-curative treatment.”

The Cancer Drugs Fund provides an additional £200m each year to enable patients with cancer in England to access drugs that are not routinely funded by their local NHS.  The national Cancer Drugs Fund list is a single national list of approved fast-track drugs giving uniform access to treatment across the country.  From 1 April, NHS England took on responsibility for the operational management of the Cancer Drugs Fund, creating for the first time a single national system for deciding which drugs are available and for which conditions.

11.00am The Daily Telegraph leads on research that found that people who eat diet rich in animal protein could as suseptiable to similar cancer risks to people who smoke 20 cigarettes a day.

Professor Tim Key, an epidemiologist at Cancer Research UK, said: “Further research is needed to establish whether there is any link between eating a high protein diet and an increased risk of middle aged people dying from cancer.”

The Telegraph also reports on Jeremy Hunt speaking at the NHS Expo yesterday.

The health secretary said: “I believe that we have only barely scratched the technology revolution that is about to hit everything we do in healthcare and particularly everything that happens inside the NHS.”

He said the health service could learn from how the retail, banking and travel industries have cut costs while improving customer service.

Pregnant women could be offered more reliable non-evasive tests for Down’s Syndrome soon, The Telegraph reports.

Elizabeth Duff of the National Childbirth Trust, said: “The potential for new and, above all, non-invasive approaches to screening is an encouraging step forward.

“It is vital, however, that these tests remain an option for parents-to-be, and that they are kept well informed of their right to refuse if they wish.”

More from The Telegraph, a girl, 14, died after an ambulance was sent to a different address and took double the time is should have to reach her, an inquest heard.

10.50am Outgoing NHS England chief executive Sir David Nicholson has said he “bitterly” regrets not doing more to engage with the families of patients who died as a result of care failings at Mid Staffordshire Foundation Trust.

“When the Healthcare Commission reported on Mid Staffordshire… I went to [Stafford Hospital],” he said yesterday. “I didn’t seek out the patients’ representatives and the people who were in [campaign group] Cure The NHS. I made the wrong call.”

10.40am Chair of the BMA Consultant Committee, Dr Paul Flynn, has today called for the experience, professionalism and value that consultants bring to the NHS to be better recognised in helping to meet the challenges facing the health service.  Speaking to consultants from across the UK at the BMA’s annual Consultants Conference, Dr Flynn said:

“As consultants we are the guardians of the care of our patients [and] we have a duty to use our voice to promote a culture in the NHS within which the highest standards of patient care can flourish.

“Consultants who often will have a 25-year career in one organisation, are in it for the long haul, and can bring their experienced perspective to counterbalance the short-termism that is all too prevalent in NHS management.”

On ongoing contract negotiations for consultants in England and Northern Ireland, Dr Flynn said consultants were pursuing a ‘principled’ approach which put ‘the interests of patients first’ and sought to protect a safe and productive work-life balance for consultants.

He highlighted the fact many consultants were already working excessive hours to deliver patient care:

“Central to considering any changes in working practice is ensuring that consultants are able to give their best and are not hindered from doing so by fatigue or burn-out.  Those of us who were junior doctors before the New Deal do not want to see a return to the days when the health of patients and their doctors was put at risk by excessive hours and poorly-designed rosters.”

Dr Flynn highlighted the fact staff morale is now the biggest concern for trust financial directors. He also condemned the treatment many consultants experience when speaking out over concerns about patient care. He said:“We believe that an important part of the role of consultants is to advocate for their patients and to raise concerns on their behalf when services or Trusts fall short.  But all too often we have seen consultants who do so labelled as troublemakers or dysfunctional and treated adversely by their employer.”

On the issue of consultant pay, Dr Flynn said remuneration should be driven by fairness and questioned the decline of doctors pay compared to that of NHS managers:

“The real terms value of consultant pay is now lower than it was before the 2003 contract was introduced.  What sort of a message are we sending the brightest and best students when the pay of NHS managers climbs by 13% since 2009 while that of consultants is outstripped by inflation?”

An extract from his speech is below:

We have been clear that we will participate in a principled negotiation whereby we make our principles explicit and are only prepared to look at solutions that meet those principles.  The principles that we have applied we have derived from our professional values and the foremost of these is that we put the interests of patients first.  In practice this means that urgent and emergency care, the care of those who most need it, must have a higher priority than the expansion of routine services across seven days.   When we consulted our members they told us that many in acute specialties are already involved in this work and that they accepted it was an integral part of our professional role.  Like the emergency medicine consultants in a major London Trauma Centre who themselves initiated and drove forward a move to 24-hour consultant presence to enable them to deliver the best care for their patients. So we will look at what is needed to ensure that we meet the needs of those patients who require our help most urgently but we will not accept a contract that does not give this the highest priority in consultant job plans.  Urgent and emergency work must come first, no matter how attractive additional income from Payment by Results work may be to an employer.

Central to considering any changes in working practice is ensuring that consultants are able to give of their best and are not hindered from doing so by fatigue or burn-out.  Those of us who were junior doctors before the New Deal do not want to see a return to the days when the health of patients and their doctors was put at risk by excessive hours and poorly-designed rosters.  Already many consultants work well beyond their contracted hours – I recently heard from a vascular surgeon in the Northwest who because he and his colleagues provide a seven-day on-call service for vascular emergencies is consistently working excessive hours to provide his patients with the care they need, when they need it.  So our principle is that there must be safeguards in the consultant contract to protect both doctors and patients.  

It is unrealistic to expect that current numbers of consultants can support seven-day services as well as all our current activity.   Burn-out of consultants is in nobody’s interest and significant expansion of consultant numbers will be required if the NHS wishes to provide seven-day services.  We are clear that the standard consultant contract must remain a 10 programmed activity contract with any additional hours being entirely voluntary.  Consultants must have job plans that allow them to maintain a proper work-life balance to enable them to continue to do the highly demanding job that they do, assuring the quality of patient care.

Colleagues, this is probably a good point to mention some of our work on job planning training.  There is no doubt that whatever is the outcome of the negotiations, job planning will still be of crucial importance to consultants.  We know from surveys of members how poorly this is often done and, jointly with NHS Employers, we have begun to roll-out training events building on the joint job planning guidance. Despite the demands of his role as Chairman of the Representative Body, Ian Wilson, has led this work for us and I would like to thank him for making it happen. 

As part of the contract negotiations we are considering whether the current pay system should change.  In this, our over-riding principle is fairness.  Fairness should mean that those who contribute the most should receive the most but also that the system should recognise the changing contribution that comes with experience.  As I said before we are negotiating in a challenging financial environment but the government must recognize the huge added value that enthusiastic and well-motivated consultants bring to the NHS.  In a recent Kings Fund survey of trust financial directors, they highlighted the huge financial challenges that Trusts are facing but the greatest concern they identified was that of maintaining staff morale.  The real terms value of consultant pay is now lower than it was before the 2003 contract was introduced.  What sort of a message are we sending the brightest and best students when the pay of NHS managers climbs by 13% since 2009 while that of consultants is outstripped by inflation?  The affordability of NHS staff pay that is so often referred to, must not render a consultant career an unattractive option.  Part of our sense of professionalism is that we work to ensure that a career as a consultant is one to be proud of.  If we want to ensure that high performing school leavers and medical students will continue to aspire to a career as a consultant then we must have a pay system that provides this, and not one that makes this crucial form of public service appear a shabby alternative to a career in the financial sector.

We believe that an important part of the role of consultants is to advocate for their patients and to raise concerns on their behalf when services or Trusts fall short.  But all too often we have seen consultants who do so labelled as troublemakers or dysfunctional and treated adversely by their employer.   We must not create a pay system that can be used to bring pressure to bear on consultants who highlight the inconvenient and uncomfortable truths to their employers.  Although there are many other ways that the system must support staff to raise concerns about patient care, we must remain free to raise concerns without the fear of being punished by the withholding of pay and we will ensure that this is the case in any future pay system.

Colleagues, I hope this gives you some sense of the direction we are taking in the negotiations.  There is still a long way to go and considerable challenges to overcome but I do believe that there is the potential for a wise agreement that can support better care for our patients while ensuring that a consultant career remains rewarding and one to be proud of.  In going forward we will have to be open-minded to contractual change, as long as it meets the principles we have set out, principles drawn from our professionalism.  I hope that in the debates and workshops today that you will reinforce and develop these principles so that we can better reflect the aspirations of consultants.  I believe it is too early in the process for us to set out end-points and I hope that you will resist the urge to do so, but instead give us guidance on the principles that are important to you.

Colleagues, the year ahead is certainly a crucial one for the Consultants Committee but I believe that if we stick to the principles of our professionalism we can achieve results for our patients and our colleagues. 

10.35am The Guardian’s front page carries an account from a doctor working at a busy A&E department - she recounts the pressure as staff are “pushed to the limit”.

Saleyha Ahsan, from Queen’s Hospital in Romford discusses how stretched doctors are as a result of target culture.

10.30am Looking through this morning’s newspapers:

In The Times: The NHS must copy banks and budget airlines by using the internet to give a better service while cutting costs, Jeremy Hunt said yesterday.

The health secretary said the way patients accessed their GPs had not changed while other areas of life had been revolutionised by technology.

The Times also reports that a teenager died from an asthma attack after an ambulance went to the wrong address, an inquest was told yesterday.
Elouise Keeling, 14, collapsed during an Air Cadets sports day at RAF Brampton near Huntingdon, Cambridgeshire on June 25 last year.

An ambulance was called but was sent to RAF Wyton, 10 miles away, by mistake.

10.25am The second annual round of individual Consultant Outcomes Publication (COP), with see new care areas included, increased transparency and greater patient-focus.

The three new specialties are lung cancer treatment, neurosurgery and urogynaecology. These join the 10 specialties that last year published nationwide patient mortality results for individual consultants based on national clinical audit data. Publication dates are still being agreed, but reports are likely to publish between June and November this year.

The 13 specialties will expand on the quality indicators published, including measures such as length of hospital stay. Last year’s pilot of 10 topics required consultants to opt-in to allow results of their work to be published, and more than 99% of results were available. This year, with COP now part of the NHS Standard Contract, 100% of eligible data will be included.

As last year, the work is commissioned by NHS England, with the Healthcare Quality Improvement Partnership (HQIP) again overseeing delivery of COP, working closely with NHS Choices, the Royal College of Surgeons, plus the specialist societies and clinical audit project teams for each specialty.

This year HQIP and NHS England are making a number of moves to ensure patients can more easily understand the results. Measures include:

• Patient-friendly representation of results on NHS Choices, linked to results for the department individuals work in and hospital Trust they practice in 
• Patient-focused guidance from HQIP for specialties, outlining elements that must be included in reporting, such as patient involvement in publication and clear outlines as to the nature and content of the results being published

The work is led for HQIP by Outcomes Director Professor Ben Bridgewater, the cardiac surgeon who has led consultant data publication in that field since 2005. He comments: “While we cannot show definitive improvements in care until we have published data for some time, last year we quickly saw the same improvements which led to improved standards of care quality in cardiac surgery and a reduction in mortality of more than 50% over 10 years. These include better data quality, improved management when complication rates are higher than expected, and the ability for all of those delivering care to benchmark themselves against defined national standards.”

10.20am Chair of the British Medical Association Consultant Committee, Dr Paul Flynn, has today called for the experience, professionalism and value that consultants bring to the NHS to be better recognised in helping to meet the challenges facing the health service.  Speaking to consultants from across the UK at the BMA’s annual Consultants Conference, Dr Flynn said:

“As consultants we are the guardians of the care of our patients [and] we have a duty to use our voice to promote a culture in the NHS within which the highest standards of patient care can flourish.

“Consultants who often will have a 25-year career in one organisation, are in it for the long haul, and can bring their experienced perspective to counterbalance the short-termism that is all too prevalent in NHS management.”

Seven-day services

Dr Flynn highlighted the vital role consultants play in shaping the delivery of patient care and said that consultants would not shy away from asking difficult questions on seven-day services and their affordability.

The BMA has repeatedly called for improved access to consistently high quality urgent and emergency care to be the priority for investment. Dr Flynn said:

“…We put the interests of patients first. In practice this means that urgent and emergency care, the care of those who most need it, must have a higher priority than the expansion of routine services across seven days.”

Consultant contract negotiations

On ongoing contract negotiations for consultants in England and Northern Ireland, Dr Flynn said consultants were pursuing a ‘principled’ approach which put ‘the interests of patients first’ and sought to protect a safe and productive work-life balance for consultants.

He highlighted the fact many consultants were already working excessive hours to deliver patient care:

“Central to considering any changes in working practice is ensuring that consultants are able to give their best and are not hindered from doing so by fatigue or burn-out.  Those of us who were junior doctors before the New Deal do not want to see a return to the days when the health of patients and their doctors was put at risk by excessive hours and poorly-designed rosters.”

Morale and fairness around pay

Dr Flynn highlighted the fact staff morale is now the biggest concern for trust financial directors.He also condemned the treatment many consultants experience when speaking out over concerns about patient care. He said:

“We believe that an important part of the role of consultants is to advocate for their patients and to raise concerns on their behalf when services or Trusts fall short.  But all too often we have seen consultants who do so labelled as troublemakers or dysfunctional and treated adversely by their employer.”

On the issue of consultant pay, Dr Flynn said remuneration should be driven by fairness and questioned the decline of doctors pay compared to that of NHS managers:

“The real terms value of consultant pay is now lower than it was before the 2003 contract was introduced.  What sort of a message are we sending the brightest and best students when the pay of NHS managers climbs by 13 per cent since 2009 while that of consultants is outstripped by inflation?”

7.00am Morning and welcome to HSJ Live. We open the day with a comment piece by Professor Edward Peck, pro vice chancellor and head of College of Social Sciences at Birmingham University, reviewing the history of transformation in mental health services over the last thirty years.

Professor Peck argues that some of the lessons learned over this period can be applied to acute transformation in the present day: “there are clearly messages…that can both inspire and instruct those leading the forthcoming changes in how to treat complex and long term medical conditions”.

He adds: “The transformation of mental health services shows us that whole scale system change produces unexpected results, new demands and perhaps unanticipated risks.”