Have you ever seen Rafa Nadal play? Television never quite gives you the whole picture but at close quarters, it is just unbelievable. Every shot from the opponent is hunted down, every ball is chased down, every pass is attempted to be returned however hopeless the cause. Breathtaking, amazing...and he has always been my fav because of that. Acute Trusts remind me a bit about him nowadays. However hopeless the cause is, the chase is on..however improbable the target, the determination is there. Problem is in a system whereby the acute Trusts have always been the Federer, the one with the silky touch, the one with the flair, the one who doesn't need to overtly exert due to inherent natural resources..its a tough call having to revert to a Rafa style. I wont even go into the daily struggle as regards emergency door has become but I am going to talk about finances.
Just like QoF has been the lifeblood of GP surgeries, so has been PbR for trusts..and all was well as the money available simply meant the more you turned the wheel, the more you generated. Staff salary bill? No sweat..you do more, you code better, the Commissioners/PCTS will pay. Do more multidisciplinary clinics, the tariff is more..hidden behind the veil of patient care, multidisciplinary clinics sprouted...do more, get more..what could possibly go wrong with that?
And then 2010 happened...the squeeze began. PbR tariffs started squeezing, so let me give you an example of what that meant. Say you get 100 quid for the trust to see a patient and you see 10 patients..easy sum..you as a trust get 1000 quid. So the tariff changes to 90 quid..now you need to see 11 patients to generate roughly the same amount. No extra time for present staff..so to balance out even the existing wage bill (I am not even going to begin to overcomplicate issues with overhead costs added to wage bills), patients need to be seen quicker or as management whiz kids will tell you..more efficiently..in the same time. If you cant and stick to seeing 10 patients, then you have a loss of 100 quid per clinic..add that up..only way a business can survive? Yep, drop the staff...and what does that lead to? Less patients being seen...ergo more pressure on primary care. But did you say we could see more patients? Hang on..the Commissioners have got QIPP to reduce activity within Trusts. Some places have also got capped contracts..so doesn't really matter how many you see..you still get paid for those 10 patients..whether you saw 11 or 15. Did you say you could see more inpatients and get paid more for that? Nope, one of the only ways Trust can cut costs? Strip beds...and I wont even go into describing how tricky it is to have more beds with same number of junior doctors. Run Rafa Run..one more time.
Another one? Multidisciplinary clinics...better PbR...not any more..its being flattened out quick and fast. Let me give you an example...the PbR tariff for a single or multidisciplinary tariff for diabetes patients used to be significantly different...now they are exactly the same. Not the Commissioners fault..they are implementing what has been given. Impact?Clinical evidence and NICE says that all patients with foot ulcers should be seen by MDT clinics. MDT clinics cost more to a Trust as you have 2 professionals to see the patient together and thus both have salary wages. But if the tariff is the same for a single professional clinic, then with a business hat on, why bother? May as well bring the same patient twice to see 2 professionals separately..more money...but clinically? Wrong. Thus the incentive to do even the right thing clinically is being squeezed.Rafa..down the line..go on son.
I could go on and on..but if this was pure business, then I need to stop doing some things right now. I can turn this into a profit using present rules in a flash but as a doctor I cant and to emphasise strongly, wont. One more one from a general medicine point of view? When I go through finances with a tooth-comb, there are some patients I should simply refuse to accept because they cause a loss to my department...why would I want to risk putting my staff at risk? Try saying that to the 87 year old lady who has got past her acute medical issue but cant be discharged as social services haven't got the budget to deliver what she needs asap. Length of stay more than 48 hours? A loss in financial terms..Clinically though? Cant send her home sorry guv..went to med school also to have a humane side. Rafa...its on your backhand...puff those cheeks out...make another run.
But its not unsolvable...the system needs a revamp...question is who is innovative or bold enough to do it. With the revenue dropping and salary bills as they are, the crocodile jaws just get wider..we all talk about difficult decisions but struggle with them, as at the bottom of everyone's hearts, people know that there is not much left as regards managerial layers to strip off, no more assets to sell, no more efficiency savings to be made. When CCGs came to being, I remember some comments from GPs on social media..how they would get the money back from those evil acute Trusts..alas the penny has dropped now...even if the money to acute sector is shrinking, it is not being redistributed to primary care either.
We are now starkly in the territory of staff cuts, like it or not. Link that with the Francis report..and that ball down the line seems not worth chasing, doesn't it? But can acute Trusts be bold enough or even be allowed to make the first move? Competition rules and the existing of community trusts have lessened the potential to take control of community settings or services so why not join hands regards where certain specialties should sit? Are certain specialties better being under community trusts and look at non tariff based ways of working? It doesn't matter how many phone-calls you took...what matters is whether they made a difference to patients, right? See whether those specialties can be housed by the community trusts, buy some time back depending on what input needed for acute trust functioning? Use SLA, TUPE..so many options to explore. This isn't anymore the time to be cautious or conservative..if we don't get staff placed appropriately, we will lose them and harm patient care. Stop other real estate areas being used to build more hospitals...no..use existing ones a bit more effectively, work with nursing homes, work with residential homes...what can be done? Pay people for time, not get someone to bean count how many emails they have answered and pay them per email....so many options to explore. Stop recharging internally each others departments...you are in ONE trust...you rise and fall as one. Its a nigh impossible art trying to fathom out exactly which subspecialty has had what contribution to a patients journey...if only healthcare was that simple.
Its a dichotomy which all clinicians struggle with..surely money problems for the acute Trusts isn't why they went to medical school? It is though..and people always ask me why I get involved in managerial politics...I will be honest with you...that, my friends, is the only way you can make sure the staff is maintained to provide care to people..people who you want to get better..people who you went to medical school for.
Nadal never gives up..thats his calling card...I aint in any mood to give up the fight either...we need to be bold. PbR should be consigned to history..let us clinicians, managers and the rest work together rather than worry always about how much money to generate or lose.
Give acute Trusts the freedom to think broadly..this ship is not doomed..yet.