Sunday, 22 April 2012

Pensions - a hidden agenda?

The prospect, at 30-plus years' distance, of working into my late 60s and beyond is a daunting one. In fact, I feel exhausted at the prospect of it, and yet that is what we are faced with as a result of the NHS pensions reforms.

In considering this issue, it is important to separate out what it is that is troubling. There are three aspects that warrant consideration. Firstly is the sense of injustice that many within the health service felt that the pensions had been renogiated in 2008, and that the system was sustainable for the next generation.

Secondly, is the cost: whatever the system issues behind the affordability of the NHS pension scheme, it feels, on an individual basis, like a big hit to see one’s pension contributions go up from 8% to 12.5% in one month, as will happen this month. Whatever your social views, this is a difference that you will feel.

Finally, and most importantly for me, is the issue of autonomy:  I have always assumed that I would put myself to gainful employment for as long as I could. As someone who gets bored on a week off, I recognise the need to be active, to be productive, and to be part of something bigger. And the evidence supports this idea: elderly people who remain active, and in work, are healthier,
and live longer. Behind getting married, staying in work is the healthiest thing that men can do. Apparently, women do not gain the same survival benefits from marriage as men do. Make of that what you will.

Change is one of the most important ways of staying fresh. By having a go at something new, you can tackle the feeling that you are standing still, stagnating, growing old. But my big fear with the pensions reforms is that the option to look for new challenges may be subverted by the time one has to spend achieving a full pension. By the time you’ve put in your full work quota for the NHS, you may well be too exhausted to start on anything new.

Is it reasonable to expect a consultant once in post, to be prepared to do that job for the rest of his or her career? If it is, then the system needs to be prepared to deal with a high burn out rate. If it isn't, then the system needs to support its doctors and nurses move on to new challenges. Does it seem feasible that a doctor in their mid 60s can maintain the same drive and energy as someone in their mid 30s, new to the job and eager to impress?

And with the traditional career structure, the way it works is that there is really only one direction of travel. Each individual progresses as high up the ladder as they are able to, and that is the level they remain at until they retire, or get fired. Perhaps, if we are expected to work for longer we need to think about this differently. For example, if someone in their 60s is keen to carry on working, but would prefer to have a bit less responsibility and perhaps work fewer hours, the system does not really allow or encourage that person to do just that: they either work at their current level or they retire.

In reality, however, I don’t think that the new pension age is that relevant. In view of the successful passage of the health bill, I suspect that the reality for many of us over the course of our careers is that we will find ourselves at different times working for a range of different health providers. And although all staff will be TUPE’d on to the same terms and conditions that they received under the NHS when the services are first taken over by these new firms, it won’t be long before business conditions allow these terms and conditions to be changed. And with the natural turn-over of staff, new employees will be offered the standard terms of employment that each particular firm offers.

What this will probably mean for us, is that over the course of our careers we will pay in to a number of different pension schemes, each with slightly different conditions, and calculating our retirement income will be a much more complex matter.

I have to admit that this idea only occurred to me two paragraphs ago. Up until 5 minutes ago, I was seriously pondering how one finds the resolve to stay in the same job for 35 years. Then it hit me, that in the post reforms health service, more and more of us will spend time working for healthcare providers outside the NHS. And if I am right about this, then more and more of us will only spend part of our careers in the NHS pension. Perhaps, therefore the government missed a trick: if they’d realised this, they could have kept us sweet by saying that the pension age could stay the same, knowing full well, that once they are embedded in the health service, private organisations will offer different and less expensive pension schemes.

Perhaps this is the issue none of us realised: without realising it: the Health Bill also had pensions reforms built into it. How long will it be before clinicians are working on fixed term contracts, with renewal based on a number of performance indicators?

This is going to need more thought.......

Sunday, 15 April 2012

Do the numbers lie?

I hope you all had a nice Easter. I hadn't meant to be offline for so long, but you know how it is when you go away for a week and put your feet up: getting anything at all done can feel like it needs a superhuman effort.

Who knows, perhaps the rest will have recharged my creative juices, and leave you lot in line for some stellar commentary. Perhaps, but don't get your hopes up.

One of the stories that caught my attention last week was the news report that a high number of elderly patients are discharged from A & E in the middle of the night. This seemed to raise a few heckles, but the problem with this data was that it failed to inform us of whether there is actually a problem at all. The news report I heard acknowledged that with the way the data is collected, the category 'discharged patients' encompassed a range of scenarios, including patients who had died.

Sending a frail, elderly patient out of an Emergency Department to get a taxi home, without ensuring appropriate care arrangements is unacceptable, but we didn't need this data to highlight that. What was revealing about this particular news story was what it tells us about how we use information, and the lack of care that we take in interpreting it.

Let me explain - numbers tell a story, but the nature of that story is heavily influenced by the context that it is used. For example, hearing that 10,000 elderly patients (these are made up numbers) are discharged from Emergency Departments after midnight without appropriate care arrangements will be interpreted differently if one later finds out that of those 10000 'discharges', 7500 were patients who presented to A&E and then died.In this fictional scenario, without knowing more detail, one cannot know whether patients are being sent home inappropriately, or whether patients are experiencing excess mortality late at night in Emergency departments.

My suggestion is that we tend to use these raw figures as they are presented to us as a means of drawing our conclusions. However, without further work, such figures are rarely a suitable basis on which to base your opinions. The alternative, and more circumspect, use of data is to use it to form your further enquiry, and not to draw conclusions.

This issue is dealt with in a different guise in this week's New England Journal, where one of the topics of discussion is the current focus in American hospitals on readmission rates. On face value, it could seem as if a hospital with a high readmission rate is offering low quality care, as patients must be representing because their primary medical problem is not being dealt with properly the first time round.

This automatic conclusion needs to be challenged. For example, what if a hospital experiences really high readmission rates because patients' social care needs are not being met after they leave hospital? Or what if another hospital has a much higher survival rate that other hospitals for some conditions? The patients who survive are liable to add to the readmission rate, because where other patients didn't make it, they survived and went home, and are therefore in a position to be readmitted, whereas the patients who went to other hospitals are not.

So when someone gives you some figures that paint a dramatic picture, pause for a minute, challenge your instincts, and ask yourself if there is another way that this information can be interpreted.

Sunday, 1 April 2012

Challenge or regret? A look to the future

It’s disappointing that in the week following the successful passage of the Health Bill through Parliament, pasties and jerry cans go to the top of the agenda. Is this the calm after the storm, the deflation of defeat, or was this a brilliant piece of distraction from the government? If it was the latter, then they may be their own worst enemies, because they have come through this week looking like rather posh buffoons, completely dissociated from the ordinary lives of the people they are supposed to serve. Their only relief from the media mockery seems to have been handed to them by their biggest enemies, the Labour party, who somehow contrived to lose the safe seat of Bradford West to that political Weeble, George Galloway. One can only imagine the humilation of being defeated by the man who once praised Saddam Hussein for his ‘courage’, his ‘strength’, and his ‘indefatigability.’

If you can make sense of all of that political nonsense going on in one week, then please post your comment below.

But for many of us in the NHS, the passage of the Health Bill is not simply the end of an interesting episode, but rather the start of something big. We need to think about what this means for us both personally, or for us as professionals who are trying to deliver good healthcare to the populations that we serve.

I’m a bit conflicted on this matter. I am not a fan of the health reforms, because of the risks that I have written about before, but who can deny that this is an interesting time to be working in the health sector? We face unprecedented challenges in trying to deal with the inevitability of rising costs in the context of a societal desire to control the escalation of resources needed to feed the health sector. I don’t think that the reforms are the best way to solve the problem, but we are in a position now that means that we have to face the challenges of the future in the context of the organisational landscape laid out in front of us. And that is really interesting. It’s like trying to do front crawl with one arm tied behind your back, or writing with your non-dominant hand. I choose my smiles with some care: these are circumstances of complete artifice, and without rational explanation, to which the simplest solution is to stopping messing around and do it properly. But even so, trying to solve the problem is fascinating.

But this isn’t a game. The price for failure is high, and is counted in human costs. Enough suffering is built into the job of being a hospital doctor, without it being built into the way that we fund and provide healthcare. And this is where the conflict arises: I am excited at the prospect of working through these challenges, of thinking about how to best provide care to my patients over the next 30 odd years. But I am also a little scared of what it means to get it wrong.

Since the inception of the NHS, we have seen health outcomes and access to care improve, and the public have reasonably come to expect that year on year their NHS will get better. Even over the course of my career, I have seen better designed systems for commissioning and delivering care appear, and have watched my own ability to deliver decent medicine take off as both my knowledge and the facilities at my disposal have got better. All of the consultants I know who have retired have left with the knowledge that the care they gave at the end of their career was better than the care they delivered at the beginning. Some of this was knowledge, some of it experience, but a lot of it was technology and organisation.

What will my reflections be in 35 year’s time, when I retire? Will I be able to say that the NHS got better? Will I have to say that it got worse? Or will I say that I liked it when I worked for the NHS, but it’s been very different since it disappeared?

I don’t really mind change, but I’m worried about this one.