A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 


In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.


Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 


You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 


I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.


The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).


So what is the use of MTI posts? 


The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.


If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.

©M HEMADRI

Follow me on Twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

Is the NHS Pension Scheme fragile?

Is the NHS Pension Scheme fragile?

THE NHS PENSION SCHEME

This is from NHS BSA FAQs ' http://www.nhsbsa.nhs.uk/3416.aspx

Where do the contributions go to?

The NHS Pension Scheme, is an unfunded occupational scheme backed by the Exchequer, which is open to all NHS employees and employees of other approved organisations. Pension contributions for individual scheme members are collected by NHS Employers and are forwarded to NHS Pensions Other income is also received, for example from people transferring from other pension schemes in the form of a cash equivalent transfer that buys a service credit in the NHS scheme.

The income is used to offset the payments that the scheme makes to pensioners or people leaving the Scheme.

Details of income received from 1995/96 to 2009/10 is available here.

Employers and employees pay contributions based on a percentage of pensionable pay. Every four years the Government Actuary conducts a full actuarial review and recommends contribution rates in their Valuation report to the Secretary of State for Health. This is based on the use of a ‘notional fund’ as if all income from the start of the NHS Pension Scheme had been invested. As a result the Scheme is unfunded as there is no actual asset for a ‘pension fund’ on the balance sheet of the pension scheme.

At each valuation any deficit or surplus in the notional fund may result in a recommendation to adjust the level of contributions from the estimated future cash flows of the pension scheme.'

‘‘……… there is no straight link between the pension contributions paid in and the pension paid out.’’


Commentary

So the NHS employees pay into a pension scheme that has no real money held in it, no asset, no pension fund. This income into the NHS pension scheme is paid out as NHS pension to past/retired eligible employees. Every four years the current employees of the NHS contribution into the scheme is adjusted and set so that the needs of the NHS pensioners can be met.

If you had a new financial entrepreneur offering you such a scheme, you would not pay a penny into it. In terms of the mechanics of how the scheme works it is like a Ponzi. The two differences between a true Ponzi and this one is that the NHS pension is ‘backed by the treasury’ and the primary intention is not to defraud using a fraudulent investment.

Wikipedia states

A Ponzi scheme is a fraudulent investment operation where the operator, an individual or organization, pays returns to its investors from new capital paid to the operators by new investors, rather than from profit earned by the operator.

Ponzi schemes sometimes commence operations as legitimate investment vehicles, such as hedge funds. For example, a hedge fund can degenerate into a Ponzi scheme if it unexpectedly loses money (or simply fails to legitimately earn the returns promised and/or thought to be expected)………

Promoters also try to minimize withdrawals by offering new plans to investors, often where money is frozen for a longer period of time, ……………………….

Further commentary

The NHS pension scheme is thought to be ‘gold plated’ which in common understanding means it is secure and provides higher returns than other pensions. It services its commitment by the current contribution of its payers. It has no corpus, no fund, no asset. The pension scheme has already changed rules by delaying access to pension for some. http://www.nhsbsa.nhs.uk/Pensions/4017.aspx

If the NHS is privatised or if less people worked for the NHS then their contributions could rise (according to the four yearly actuarial valuation) and if very few people are employed by the NHS directly then the NHS pension will fail to legitimately bring in revenue to service its commitment to pensioners.

In effect, paying into the NHS pension could be like paying National Insurance. National Insurance it is not actually insurance with defined benefits claimed against contracted criteria, it is additional tax with benefits decided by government policy. Similarly, the NHS pension, since there is no asset or fund, it becomes dependent on the country’s economy and government policy. There has been significant opposition to the NHS pension changes, yet because it is government policy defined, the government uses its authority to make the changes to cope with what is very fragile.

It is a worry but….

The biggest reassurance is that the NHS pension is backed by the treasury which means as a strong western economy NHS staff pensions are safe.

The concerns are loaded towards/against younger NHS employees. Many are worried about the sustainability of public sector pensions, the CBI in UK talks about a £1trillion pension black hole. http://citywire.co.uk/new-model-adviser/news/cbi-next-govt-must-ditch-1-trillion-public-sector-pension-burden/a392035

It is best to think of reform of the NHS pension by creating a ring fenced fund which is then backed by the treasury. That will be a sign of mature strong financial management which reduces the vulnerability of the NHS pension. With an aging population, with NHS being the largest employer in UK we are talking about a lot of old people who are or will be ex-NHS, any measure to make their support structures stronger will be worth its while.

©M HEMADRI

Follow me on Twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

Improving the morale of NHS Staff

Improving the morale of NHS Staff

The vital role of improving the frequency of positive emotions and using positive feedback as a source for improvement. Time for the public/patients to be a part of the action.

Bad news all around

Poor care, cover ups, whistle blowers, gagging orders, complaints, et al; we very often hear about all of them these days through profoundly sad media reports, social media (twitter, facebook, blogs) and reports of various organizations. If you are following the news recently its bad news everywhere with Mid Staffs, Francis, Tameside, Morecambe Bay, Keogh 14 at the extreme end and A&E crisis, GP OOH crisis, rationing of services etc at the moderate end. (It is a worrying state of affairs, isn't it when the GP and A&E crises are called moderate?)

Dealing with what is wrong

When things go wrong there are a number of mechanisms present to address them – the immediate boss, PALS, complaints, medical director, nursing director, chief executive and other directors. There is the healthcare ombudsman if your local systems cannot sort it out. There are national bosses, DoH, NHS employers, NHS confederations and others who are very willing to intervene when things go wrong. Medico legal specialist lawyers who are very willing to take up and chase anything from the trivia to the grievous. There are regulators CQC, GMC (for doctors), NMC (for nurses), Monitor (for foundation trusts, more recently for all trusts). There are plenty of important bodies all willing to tell us how to practice clinical care; the Royal Colleges, NICE, various specialty organizations and others. All of these people and organisations issue the euphemistic 'guidelines' which are basically rules/regulations which if not followed clinical staff will be in trouble.

The NHS tracks its complaints and publishes it – quite rightly so. NHS bad news is reported big time when there is a serious complication or death or when there is a serious let down of an individual’s expectations – quite rightly so. Openness when things do not go right is very comforting for the affected patient and families; it also helps organisations learn and improve.

The Impact of Constant Bad News

'Bad news' i.e. news about poor performance, negligence, criminality, never events, serious untoward events, harm, complications and bad behaviour of healthcare staff even after accepting that it is grossly under reported forms a small part of the overall picture of healthcare and NHS. Vitally important part, but small part.

Majority of healthcare staff are well performing, well behaved, caring and produce good clinical and social results for their patients. An overwhelming majority of patients get good results. This is of course no excuse or balance and cannot be used to justify avoidable problems or even to defend the impact of unavoidable problems.

Having set that out very clearly, let us look at the impact of negative feedback, negative experiences or negative behaviour that healthcare staff get constantly from their newspapers, from their managers and from their patients. 

Studies by psychologists have shown that the effect (value or impact) of negative emotion we feel is twice (2.25 times) as stronger than the effect of a positive emotion. Here we explore how this plays a part in the morale of NHS staff. Let us say the impact of praise (and we feel a positive emotion due to that) is +1 and the impact of non-constructive criticism (we feel negative emotion due to this) is -2. So if we praised a person once and criticised them once, the net effect on an employee's emotion is not 0 or neutral, the employee ends up with a mental state or mood or feeling of negative emotion which in our scale will be rated at -1. Let us assume we praise an employee four times in a day and have a go at them four times in a day the net impact is likely to feel negative emotion rated (+4 -8 =) -4 and if we repeated this for a whole week the employee will have a mental state which on this scale will be valued at -20 or full of negative emotions.

It is indeed no wonder that NHS staff suffer from a low morale. There is plenty of negative news in every media, constant pressure from government and managers. The complaints from patients have reached record levels. It is indeed a surprise that NHS employees have any morale at all.

What can patients (service users) do to improve morale?

We now know that poor morale and unhappy staff results in poor healthcare delivery. As patients we would want to prevent that. We know that majority of the times, majority of the patients get very good results. We know that negative emotion has double the impact on the mind than positive feedback. So as patients I think we want to be congratulating, thanking, praising NHS staff every time we get a good service and/or a good result so that positive emotion can flourish. We should try to do that at a ratio of positive to negative feedback of at least 3:1 (you see a positive:negative feedback ratio of 1:1 leads to low morale staff and 2:1 will lead to neutral morale staff). We know positive and happy staff often translates into good results for patients.

As a patient it is in our specific and direct self interest to increase positive emotion in healthcare staff when things are going right for us as it does most of the time for most of us.

As a manager that is what you want to be doing to your staff, being aware of the impact of positive and negative emotions and using the ratio to boost morale.

Let us take a hypothetical example of a treatment which has a 90% success rate and a 10% failure/complication rate (this will generally be high rate of complications); let us assume that all patients provided feedback with 90% thanking and praising the staff for the successful treatment we have had and 10% of patients complaining about their result. We may have staff in great mood feeling very positive about themselves and are likely to deal with complications/problems in a confident positive manner.

Positive feedback as a source of improvement

The NHS has no system of capturing congratulations and kudos. Complaints are logged, measured and acted upon. Congratulations are not formally logged, hence not measured and almost never acted upon. If a patient writes in with a complaint hospital looks not only for resolution but also to try and prevent it from happening again. If a patient writes in with a compliment it will be a very rare place to study it immediately learn the lesson and roll it out. We learn if at all, on how to avoid bad things, we do not seem to learn on how to improve on good things. My premise is learning to avoid problems puts healthcare providers in a neutral position; learning to improve on what is already working well puts healthcare staff in a strong position. Here is why we need to do it, if you slip from a neutral position you go into a negative situation; if you slip from a strong position you either become less strong or even (though there is a small chance of getting into neutral).

Well we know that it is not exactly very British to be loud, vocal and break into a song and dance to praise when things go right but if we knew what is good for us that is what we would do. It is very wrong not to complain when things have gone wrong, it is very wrong not to whistle blow, it is very wrong not put in extreme effort into getting care right and not remedying problems effectively when they occur. It seems to me now that it is also very wrong not to praise NHS staff when things go right. The silence of the majority could be a major reason for the low morale. It is time patients and managers made the effort to improve the morale of NHS staff, it seems a route to good care.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Notes: The strength of positive and negative emotions we feel and its impact is well described in N Taleb's Fooled by Randomness.

NHS Staff Survey - do we know what we are talking about?

The 2009 NHS staff survey is now out. The Academy of Medical Royal Colleges did some more analysis of the findings. Having looked at it, my reading of it shows that (Note that though I am using consultant response figures here, broadly similar inferences can be made from all other staff responses as well):

a) Though 50% of consultants agreed that they understand their role and where it fits in' 100% of consultants felt their role made a difference. That says a lot about clinical engagement and culture in the NHS. You don't know what your role is but you assign yourself such a high value that you know it makes a difference. If you did not know what your role was how can you made a difference! And wonder how they knew that they made a difference when only 27% felt they had a well structured appraisal (is the appraisal not trusted?).

b) 74% of consultants but only 50% of trainees felt that can contribute towards improvement.

There are many other interesting inferences that can be made and I am happy to share the analysis if you wanted.

What is very important for successful healthcare is for the people to be very self aware (soft skills) and have the knowledge on how to make improvements (technical skills of improvement). Healthcare is full of absolutely brilliant people with high qualifications and often very scientific minds who think that either they have the people and improvement skills already or such skills are not very relevant to day-to-day clinical practice. That gap needs to be addressed. It is possible to do so.

Find out how your place is doing http://www.cqc.org.uk