I have read a huge amount on twitter and in blogs of late about the role of the private sector within the NHS. This commentary has been both as part of the wider picture of the changes happening within the NHS right now, and the ever increasing use of private ambulance services (PAS's) to prop up the traditional NHS services. I have tried to join in, but 140 characters is just not enough, hence this blog. Brace yourselves, it could be a long one!
I would like to make it clear from the outset that I am fully behind the NHS, and am horrified on a daily basis by some of the things that are happening that are slowly disintegrating the NHS as we know it.
I have made a few observations from what I have read. Firstly in regards of the debate about private ambulance services practising within the NHS. Many (and by no means do I mean all) of the people I observe who work for the PAS's seem to take any criticisms of these services or the way they are run and used as personal attacks on them as individuals, and seem unable to see the bigger picture or the point that some are trying to make. Some become quite aggressive with it, this is a shame as it just reinforces the negative view of them that people may develop. Thankfully this is not the case for all, and some of the more balanced individuals offer a different viewpoint which promotes the healthy debate of the issue.
In terms of the bigger picture, the public as a whole, and even many NHS employees, don't realise the longer term implications of the changes that are happening. PAS's are just the tip of the iceberg. The legislative framework that is currently being put together will force commissioners to go out to competitive tender for all services they believe could be potentially be provided by organisations other than the NHS. So no longer will they just be able to contract with the local hospital for everything without exploring alternatives. And lets be honest there can't be that many of the services the NHS provides that the private sector couldn't build a case for being able to do. Especially huge organisations such as Care UK, Virgin etc, with their highly paid lawyers and experienced tendering teams. We've all seen the results of Virgin taking on the government over the railway contract. Do we really want to see this repeated across our beloved NHS? Healthcare is big business!
So back to PAS's. People have very strong opinions about these, which tend to sit firmly in one camp or the other. I am slightly more unusual in being a little more neutral, and much of that is due to the viewpoint I have. Because I work in commissioning I can see both sides of the coin and the reasons that they may be used by trusts. I would like to add however I'm not a health commissioner, so I'm not the one tendering NHS contracts out to the private sector. I thought I'd get that in quick to avoid the stoning I may be subjected to if found guilty. So how do I see it, and what do I think?
The system of targets we have in the NHS these days sits firmly at the root of the problem. Changes have been made to other aspects of NHS provision, such as the changes to out of hours GP services etc, this makes it harder for the public to access and shifts demand to other areas such as A&E and ambulance services. When demand increases on the ambulance service, this makes the targets harder to hit. When demand increases on A&E this results in over capacity and delays in ambulances being able to hand over. Which makes targets even more hard to hit. What happens when targets aren't hit, the Trusts get fined, which leaves less money to pay for the services, ultimately resulting in less staff to meet the targets. Ever decreasing circles......
So what is the answer? The top and bottom of it is that a PAS crew is cheaper than an NHS crew. Their hourly rate may be comparable, but the rest of their terms and conditions won't be. The NHS pension scheme alone is extremely expensive in terms of the employers contribution. Not to mention the 6 months full pay and six months half pay that NHS staff get when they are sick. They also get 25% on top of their basic pay as a shift allowance. Then there are the overheads of the NHS infrastructure, that doesn't come cheap either. That's before you start to make comparisons about training provision and the cost of this. I'm not saying that the NHS staff shouldn't get this, I personally think they are worth every penny! I'm just making the point that it doesn't come cheap.
In my job I see staff in a lot of different organisations, NHS, Local Government and many different and varied private and third sector (charities) companies. I have been involved in TUPE transfers of staff and have seen the different terms and conditions for staff. What I can guarantee is that none of the private organisations terms come anywhere close to the public sector ones. I've also seen cost breakdown for service provisions and where the money goes, overhead costs etc. So I do have a bit of an insight.
NHS Trust managers will be looking at this equation and concluding that they can have more PAS crews, for less than it costs to put additional crews of their own on the road. They will be proposing that if they use them for the less acute stuff, doctors urgent's, etc, this will free up their own staff to deal with the red calls and there is a better chance they will hit the targets and therefore maximise their income. This hopefully will give them more money to spend on service provision in the future, and maybe even more staff. Do I agree with it, no! I think the services should be adequately resourced and shouldn't need to have a fall back plan. Do I think we are stuck with it, yes! So if we are stuck with it lets get it right!
Where this falls down is the way these services are commissioned. I'd love to see the service specs, I'm guessing they are pretty vague. The key to getting a good quality of service from these companies is to be specific from the outset. Detail the minimum level training that staff at each grade MUST have. Detail the staff skill mix that MUST be on every vehicle. Detail the minimum standard of kit that MUST be on every vehicle, and that the staff MUST be trained to operate it. That way there will be consistency across the board with every company, and NHS crews will know what to expect from every vehicle that arrives to back them up.
I have seen a lot written about attitude of staff. In my journey through life I have experienced a lot of ambulance crews, mainly via work, but a few in my personal life also. I can put my hand on my heart and say I have seen good and bad in both NHS and PAS's. One such person with the worst attitude I have ever experienced from an ambulance crew was I'm sorry to say, an NHS employee. Thankfully he is a rare breed! There are also those in the private sector that for whatever reason couldn't get into the NHS, or didn't cut in once they were in, and those who are in the uniform for the wrong reason and a little bit of power goes right to their heads. Thankfully generally these also seem to be in the minority.
Some people use the argument that all of these private services are regulated by CQC, and so all must meet certain minimum standards. I'm a little more sceptical about this, lets be honest CQC regulated Winterbourne View and had assessed them as meeting the standards, and I'm sure everyone is aware of what went on there. They also registered a dom care agency in Birmingham who employed staff who weren't even CRB checked. I personally think the organisation who holds the contract should be monitoring that they are getting what they pay for, and not just relying on the CQC perspective.
The problems come from the private companies trying to be ever more competitive to win the contracts, they come in with cheaper prices, and this means they have to cut corners somewhere. They have very little wriggle room with staff hourly rates so those savings have to come from elsewhere. Compromise on training? Compromise on quality and amount of kit? This isn't the fault of the staff on the ground floor, its the owners and managers, and the way the services are contracted.
I don't know what the answer is. But I do know that we are going to have these companies, so they need to be commissioned, managed and monitored properly. Then everyone knows what they are getting and what they can expect. If we are going to make the system work, we have to have consistency! The general public have a right to know what to expect when they dial 999. The public need to be able to trust in the service in order to respect it and use it correctly! Don't get me started on that, there's a whole other blog there in itself! All ambulance staff have a right to expect a certain standard from their colleagues, whether they be NHS or private. And everyone needs this to be able to work together seamlessly for the benefit of the patients when the chips are down.
I could rant on for hours more! So I will make one last point......
I believe this is just the start, and that similar scenarios will begin to be increasingly played out across the wider NHS as time goes on. This debate and many other similar ones will continue!
Please feel free to leave a comment and let me know what you think, I'd love to hear what other peoples views on the matter are!
Cx
Tuesday, 23 April 2013
Monday, 15 April 2013
Baby powder and Walnuts
It was a sunny Sunday morning and I didn't have a hangover.....bonus! The absence of hangover was however only due to the fact that I was working an early, so decided to have a rare Saturday night in. I hate working Sunday mornings in admissions. You'd think Sunday mornings would be a piece of cake, not too busy, the Saturday night entertainment having been dealt with and it being too early for the Sunday lunch session to have taken effect. If you are thinking this........ how wrong you are!
Its the Church effect! Anyone who has ever worked in emergency medicine will tell you how busy Sunday mornings are and how dangerous a place Church is on a Sunday. Every Sunday morning sees a steady stream of patients through the doors that have been taken ill / collapsed / had heart attacks all whilst in church. Honestly the place must be really bad for your health!
So we're having a pretty average church shift, with the odd left over drunk to entertain us a little. Its about mid morning, the doors open and in wander a grinning ambulance crew with a stretcher containing a frail looking OAP.
"This is Doris, 83, she lives at Apple Tree Grove residential home. Doris has Dementia and when the staff were assisting her this morning they noticed, well a foreign body down below."
Before they could say another word they were directed to a cubicle.
It was quickly discovered that Doris's foreign body was in fact a Johnson's Baby Powder container, inserted vaginally, opening end up. The verdict was reached that it was quite straight forward one to deal with. Remove the offending article, and as long as it wasn't open and the entire contents deposited inside it would be a fairly quick turnaround and Doris would be Apple Tree Grove bound again in no time!
The doctor was summoned and the surgeon on take this particular morning was only about four feet nothing tall, OK so that's a slight exaggeration but you get the picture? He arrived complete with head torch, looking for all the world like he was about to go caving!
The Baby Powder was quickly removed and a quick inspection showed no evidence of leakage. It happened to be the Sister supporting the doc on this case, and she showed Doris the container and asked her why she'd had it down below. The reply.........
To keep the walnuts in of course? What a silly question!
The doc looked at Sister and shook his head, she just smiled and suggested it might be a good idea if she held his feet in case he fell in. His torch came in handy after all! It's a bit like caving too I guess?
And as Sister pointed out to him, if she was convinced enough to put the baby powder up there, who's to say there wouldn't be walnuts? Nutcracker anyone?
Its the Church effect! Anyone who has ever worked in emergency medicine will tell you how busy Sunday mornings are and how dangerous a place Church is on a Sunday. Every Sunday morning sees a steady stream of patients through the doors that have been taken ill / collapsed / had heart attacks all whilst in church. Honestly the place must be really bad for your health!
So we're having a pretty average church shift, with the odd left over drunk to entertain us a little. Its about mid morning, the doors open and in wander a grinning ambulance crew with a stretcher containing a frail looking OAP.
"This is Doris, 83, she lives at Apple Tree Grove residential home. Doris has Dementia and when the staff were assisting her this morning they noticed, well a foreign body down below."
Before they could say another word they were directed to a cubicle.
It was quickly discovered that Doris's foreign body was in fact a Johnson's Baby Powder container, inserted vaginally, opening end up. The verdict was reached that it was quite straight forward one to deal with. Remove the offending article, and as long as it wasn't open and the entire contents deposited inside it would be a fairly quick turnaround and Doris would be Apple Tree Grove bound again in no time!
The doctor was summoned and the surgeon on take this particular morning was only about four feet nothing tall, OK so that's a slight exaggeration but you get the picture? He arrived complete with head torch, looking for all the world like he was about to go caving!
The Baby Powder was quickly removed and a quick inspection showed no evidence of leakage. It happened to be the Sister supporting the doc on this case, and she showed Doris the container and asked her why she'd had it down below. The reply.........
To keep the walnuts in of course? What a silly question!
The doc looked at Sister and shook his head, she just smiled and suggested it might be a good idea if she held his feet in case he fell in. His torch came in handy after all! It's a bit like caving too I guess?
And as Sister pointed out to him, if she was convinced enough to put the baby powder up there, who's to say there wouldn't be walnuts? Nutcracker anyone?
Saturday, 13 April 2013
First day of the rest of our lives.
This is an opportunity! Whatever happens today will change future events. The future pivots around You, Here, Now! So do good for humanity. Be extraordinary!!
Earlier this week we took the Teen to the Dr Who Experience in Cardiff. She is a huge anorak, and massive Who fan. She loved it! Secretly so did I, but shhhh don't tell anyone! At the start of the experience are a bunch of clips taken from various shows and the quote above is taken from one of them, and adapted a little. The point of this is it really struck a chord with me, while sat on a little wooden bench in a small corner in Wales.
Earlier in the week at work I had two people crying in the space of a day. Either this means I'm a real cow for making them both cry, or they both trusted me enough to confide in me and cry on my shoulder. I'd like to think it was the latter rather than the former. Both of them are people I no longer just consider to be work colleagues, but are in fact friends. Both have an awful lot going on in their lives both at home and at work. And I have cried on both of their shoulders at some time in the past. I see it as an honour that they both chose to call in that favour, and that they know they can do that any time they need to.
One of them has reached a bit of a crossroads in life, and at work. I totally get this, and she knows that, having been there myself very recently. We talked a lot about all of this and where she would go from here, then just as we were about to head back to reality she said a sentence that may just have been the trigger for what will change her life. Nothing big, quite simple in fact. She said to me, "Do you know what my dream job is? To be a Midwife." That was it, that was the moment, the opportunity, the point in time that her future pivots around.
We talked about how actually she's never had a better opportunity to do it, and she'll never get a better one again. She's gone away, discussed it with her partner and made enquiries. She's so lucky, she is going to follow her dream! The quote at the top just seems so apt for her.
I'm not able to follow my dream now as it is no longer physically possible. So I'm working on getting a new dream, its early days yet though. Do I wish I'd followed my dream years ago when the opportunity was there? Yes and no. Yes because it was my dream job, and I know I'd have loved doing it, well at least for a while. And no because all of the other things I've done have brought me to the point in life I'm at today. Without that I wouldn't have many of the amazing people that I have in my life, and wouldn't have some of the people I love the most in the world. So in a small way I do regret not doing it, but I wouldn't turn the clock back now.
What I am doing now is making the most of the opportunities I have. I am terrified about starting my new job. I'm going into a totally different arena, dealing with a service that is completely new to me, in a team where I know nobody. I'm leaving behind everything I know, wonderful people and everything I'm comfortable with! To say I'm heading a little out of my comfort zone would be a massive understatement. The old me would never have even considered it.
The new me knows that this is an opportunity. That my future depends on this very thing. That my journey through life is about to change massively. That it all pivots around me, here, now! I want to do good, if not for humanity at least for my little bit of it. I want to do what I do well. Today really is the first day of the rest of my life. I will do my very best to Be Extraordinary!!
Watch this space..........
C x
Earlier this week we took the Teen to the Dr Who Experience in Cardiff. She is a huge anorak, and massive Who fan. She loved it! Secretly so did I, but shhhh don't tell anyone! At the start of the experience are a bunch of clips taken from various shows and the quote above is taken from one of them, and adapted a little. The point of this is it really struck a chord with me, while sat on a little wooden bench in a small corner in Wales.
Earlier in the week at work I had two people crying in the space of a day. Either this means I'm a real cow for making them both cry, or they both trusted me enough to confide in me and cry on my shoulder. I'd like to think it was the latter rather than the former. Both of them are people I no longer just consider to be work colleagues, but are in fact friends. Both have an awful lot going on in their lives both at home and at work. And I have cried on both of their shoulders at some time in the past. I see it as an honour that they both chose to call in that favour, and that they know they can do that any time they need to.
One of them has reached a bit of a crossroads in life, and at work. I totally get this, and she knows that, having been there myself very recently. We talked a lot about all of this and where she would go from here, then just as we were about to head back to reality she said a sentence that may just have been the trigger for what will change her life. Nothing big, quite simple in fact. She said to me, "Do you know what my dream job is? To be a Midwife." That was it, that was the moment, the opportunity, the point in time that her future pivots around.
We talked about how actually she's never had a better opportunity to do it, and she'll never get a better one again. She's gone away, discussed it with her partner and made enquiries. She's so lucky, she is going to follow her dream! The quote at the top just seems so apt for her.
I'm not able to follow my dream now as it is no longer physically possible. So I'm working on getting a new dream, its early days yet though. Do I wish I'd followed my dream years ago when the opportunity was there? Yes and no. Yes because it was my dream job, and I know I'd have loved doing it, well at least for a while. And no because all of the other things I've done have brought me to the point in life I'm at today. Without that I wouldn't have many of the amazing people that I have in my life, and wouldn't have some of the people I love the most in the world. So in a small way I do regret not doing it, but I wouldn't turn the clock back now.
What I am doing now is making the most of the opportunities I have. I am terrified about starting my new job. I'm going into a totally different arena, dealing with a service that is completely new to me, in a team where I know nobody. I'm leaving behind everything I know, wonderful people and everything I'm comfortable with! To say I'm heading a little out of my comfort zone would be a massive understatement. The old me would never have even considered it.
The new me knows that this is an opportunity. That my future depends on this very thing. That my journey through life is about to change massively. That it all pivots around me, here, now! I want to do good, if not for humanity at least for my little bit of it. I want to do what I do well. Today really is the first day of the rest of my life. I will do my very best to Be Extraordinary!!
Watch this space..........
C x
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