Cowper’s Cut 299: Will the Government’s 5% solution for consultants suffice?

I’m old enough to remember PM Rishi ‘The Brand’ Sunak’s NHS pledge.

Prime Minister outlines his five key priorities for 2023

Prime Minister Rishi Sunak outlines his top five priorities in a speech he made today, 4 January 2023.

GOV.UKPrime Minister’s Office, 10 Downing Street

No: not the one from January 2023 about cutting NHS waiting lists, that subsequently saw them rise by another half a million.

The one promising that “there will be no more talks on pay” with the medical trades union leaders.

The funny one.

Ahem.

Guess what?

Indeed there were more talks on pay.

And the BMA Consultants committee is now putting the offer off an extra (almost) 5% to their members.

Fixing pay for consultants in England

Consultants have seen their real-term take-home pay fall by over a third over the last 14 years. We’re calling for this to change.

The British Medical Association is the trade union and professional body for doctors in the UK.

Specifically, the offered deal ends current local Clinical Excellence Awards, providing 1.5% of the offered extra 4.95%.

The BMA statement says, “the offer includes total investment of 4.95% that will be used to reform our pay scale structure. This will see a reduction in the number of pay points from eight to four and reduce the number of years it takes a consultant to reach the top of the pay scales by five years.

Jam tomorrow

“It also increases the starting pay for new consultants and secures an increase for the top pay point. This increase is in addition to the 6% uplift awarded earlier this year. If accepted these changes will be implemented in April 2024 but pay increases backdated to January 2024.  

“As part of this investment, funding for new Local Clinical Excellence Awards (LCEAs) will be moved into basic pay. This will result in this money becoming consolidated, pensionable, and subject to uplifts as determined by the outcome of the DDRB process. 

“The moving of this money from new LCEAs represents approximately 1.5% of the 4.95%. Therefore, the contractual entitlement to access an annual awards round will stop from 1 April 2024. However, there will be no impact on consolidated, pensionable LCEAs awarded prior to the reforms in 2018. These awards will also no longer be subject to a renewal process.” 

Notably, the BMA consultants’ committee is not recommending theis deal to its members, as the RCN did to theirs back in March.

What local CEAs have been doing

There is some interesting stuff going on here.

Local Clinical Excellence Awards are often used to incentivise people to do the undesirable administrative middle-tier managerial jobs that frankly, medics simply don’t want to do and the budgets have been cut to hire middle managers.

So LCEAs enable trusts to reward staff who spend some of their free time helping to run clinical audit, education and quality improvement projects. It’s depressingly instructive that these things are not funded, but we are where we are.

There is also a perception that LCEAs have been used to lure consultants to less obviously popular trusts (the unspoken deal being ‘come to work here and we’ll put you on a 12 Programmed Activities job (better-paid) and push you up the LCEA scale’). Anecdotally, consultants in district general hospitals find it easier to get LCEAs that those in the big urban teaching hospitals.

There is something attractive about loading the benefits towards the more junior consultant workforce, which the proposed deal does. The down-side is that as LCEAs go, the cry ‘hands up who wants to be the on-call rota co-ordinator?’ may in future be met with tumbleweed.

The demographics of NHS consultants speak to the structure of the deal. NHS England's work on retaining doctors in later career stages shows that "consultant grade doctors are mostly aged between 45 and 54 years, with 42% of consultants falling in this age bracket. Almost a third of consultants are aged between 35 and 44, and a further 21% are aged between 55 to 64 years.

“… When compared with the average retirement age across the UK economy, which currently stands at 65.4 years for men and 64.3 years for women, doctors are seen to retire from the NHS workforce much earlier, with data from March 2022 showing an average retirement age of 61.9 years for male doctors and 61 years for female doctors.

“… the NHS Staff survey 2021 shows that 25.5% of medical and dental staff answered ‘agree’ or ‘strongly agree’ when asked if they often think about leaving their organisation, a proportion that has increased over the last three years, from 21.4% in 2020 and 22.5% in 2019.

“Furthermore, data from the 2021 NHS Staff Survey also indicate that a third of the medical and dental workforce ‘often’ or ‘always’ felt burnt out because of their work.”

It is notable that, if accepted, the BMA will agree to end its 'rate card' for overtime and locus work.

The RCN are furious

‘Appalled’ nurses ‘more likely to strike’ after doctors deal, warns RCN

The Royal College of Nursing has reacted furiously to news that medical consultants have been offered a new pay deal for 2023-24, saying nurses are now more likely to strike.

Health Service JournalDave West

In a wholly-predictable corollary, the Royal College of Nursing (which recommended its March 2023 deal to its members) released a furious statement. Readers will recall that the RCN was tied into accepting the Government’s revised pay deal by the acceptance of almost all the other Agenda For Change trades unions on the NHS Staff Council, and that RCN members did not give a mandate for further strikes.

That could now change. Royal College of Nursing chief nurse Professor Nicola Ranger told Health Service Journal’s Dave West, “today’s news will ignite our members’ fury further, making nursing strikes more likely in the future. Nursing staff will be appalled by this announcement and where it leaves them.

“The Government has shown it has the political will to reform pay for some of the highest earners in the NHS – while our members are left with the lowest pay rise in the public sector … It’s galling that almost 12 months since nursing staff took the unprecedented decision to strike, our pay dispute remains unresolved, and the government continues to undervalue our profession.”

The nursing workforce

Some remarkable figures emerged in the Nursing and Midwifery Council’s latest update to the Register.

The associated Rishi Sunak promo video is, erm, quite something.

Is Victoria Atkins the Tories’ Alan Johnson?

Rishi Sunak could miss NHS waiting list target over strikes, says Victoria Atkins

New health secretary Victoria Atkins says strikes by medics have delayed 1.1 million appointments.

BBC NewsSam Francis & Rachel RussellBBC News

As we head towards the end of the Conservative And Unionist Party’s long period in government, the temptation to look for parallels with figures and scenarios from late-stage New Labour is considerable.

And like Oscar Wilde, I can resist anything except temptation.

So the question is this: is new Health But Social Care Secretary Victoria Atkins going to be the Tories’ Alan Johnson?

There are, in truth, worse fates: Johnson found himself a rewarding post-politics career as a memoirist, and managed not to be hated during his time in office. He was appointed as Health Secretary by the incoming PM Gordon Brown to replace the activist and Blairite ultra Patricia Hewitt.

Alan Johnson took over with the strong implication that being emollient was good, and that success would be getting media NHS stories to be ’news in brief’ items appearing after page 10. And he achieved all this.

In one aspect, Atkins is doomed to fail by her own self-test: she told the BBC’s Laura Kuenssberg Show that avoiding an NHS crisis was her "number one priority this winter".

COVID: Almost 40% of over-65s not yet taken booster jab for Christmas

The NHS is urging eligible people to come forward for their COVID and flu jabs in time for the Christmas season. The health service warns circulation is most widespread over the coldest months, so early jabs are important.

Sky

This is not going to happen: the NHS lacks extra capacity, and there are anecdotal reports of flu vaccine shortages, topped with pleas from NHS England for those eligible for Covid and flu vaccines to take them up. Nearly 40% of over-65s have not yet done so: online bookings for both vaccines close from 15 December.

Atkins’ emollience towards doctors is in sharp contrast both to her SOS predecessor Steve ‘The Banker’ Barclay and to PM Rishi ‘The Brand’ Sunak, whose allegations of medical militancy did their cause little good. She told the BBC, “I would very much ask consultants to look at this settlement because actually it is a very modern contract, which I hope they will find acceptable. We have an enormous amount of goodwill at the moment from the BMA and from others, and I'm keen to encourage that”.

Atkins also claimed that the Government is "throwing everything we can" at resolving the industrial disputes in the NHS, which makes a person wonder why they didn’t do so much, much earlier.

Is ‘Media Wes Streeting’ a Sphinx without a secret?

Wes Streeting isn’t stupid. At all.

He is a self-made working-class man, who comes from a background that didn’t give him many traditional privileges. A principled guy, who absolutely refused to serve under Jeremy Corbyn. An assured debater and media performer, and fairly clearly destined for a strong future in politics.

To some extent, I understand what I believe Streeting to be playing at when he is making his regular noises about big, scary NHS reform.

Partly, he is sincere in believing that the NHS needs to change and improve radically to be fit for the 21st century.

He’s right about this diagnosis, but his publicly proposed course of treatment as delivered in his media utterances is so opaque and questionable that I needed to open this section by setting out why I say that he’s not stupid. Because to a hell of a lot of people whom he is going to need onside, he is coming over as really quite stupid.

But a great deal of ‘Streeting’s Reform Noise’ is motivated by trying to ‘take back control’ of the media narrative about the future of the NHS.

And in reality, he’d do much better to take far less advice from Alan Milburn on this topic.

Why Labour believes Australia has the answer to fixing the NHS

During visit to Sydney to see ‘urgent care’ neighbourhood clinics, Wes Streeting hails country’s approach: spending less but achieving more

The TelegraphLaura Donnelly,

Sure, some of his recent work with the Boris Johnson Fanzine on this piece about Australian ‘urgent care’ neighbourhood primary care clinics is to some degree standard-issue ‘tanks on lawns’, we-want-a-big-majority stuff.

To some extent, it’s genuine desire to learn from good practice. Australian health minister Mark Butler claims that these new clinics (open 8am to 8pm) significantly reduced pressures on emergency departments. Butler suggests that around half of presentations to A&E are classed as “semi or non-urgent”, and areas with these new units have seen the number of such cases turning up in EDs fall by 20%. One-third of cases are dealt with at weekends; one-fifth in the evenings; and one in three patients are children under the age of 15, Butler said.

Because Streeting isn’t stupid, he knows that what he says about NHS reform and what key groups (in this case, primary care staff) hear can easily be two different things. In this regard, his choice to work with the BJF as the messenger was, in Yes, Minister-speak, courageous.

There are no direct quotes from Streeting involved, but the piece overall (by former HSJ news editor Laura Donnelly) is repeatedly critical of the British Medical Association.

Nor is it wrong to be so: the BMA’s campaign against polyclinics in the late 2000s was a particularly parochial piece of political opportunism and self-interest, which has aged heroically poorly.

The questionable bit of judgment here is that the industrial action over pay has shown doctors’ support for the current BMA leadership to be at something of a 20-year high. The medical profession’s anger, discontent and weariness are all very real indeed.

There is already a perception among medics that Streeting has been ‘GP-bashing’ in his comments on primary care reform to date. A policy of treading carefully would have been wise.

In these circumstances, the piece’s references to “reforming the GP contract to reduce bureaucracy – instead of a system where family doctors are measured and paid against compliance with hundreds of targets” feels very inadequate. Contract reform may be necessary (though QOF achieved some very good things that would’ve been less likely without it), but it is certainly not sufficient to attract more doctors into, or to return to, primary care.

In this context, suggesting that there will be a new wave of 8-8 primary care ‘multicentres’ leads straighten to the obvious rejoinder: ‘sounds lovely; who’ll staff them?’ Until Streeting and his advisors have a convincing answer to that, their hypothesis of a solution does not sound credible.

The Alan comeuppance

It was majestic stuff.

Honestly.

Matt Hancock tells inquiry there was ‘toxic culture’ in No 10 and he was ignored when he tried to raise alarm about Covid – live

Health secretary at start of pandemic responds to claim his department was seen as ‘ungovernable’ and had ‘clear lack of grip’

The GuardianAndrew Sparrow

Alan’s evidence to the Covid19 Public Inquiry, both days of it, was superb. A nation starved of fresh Alan content for whole weeks since SAS: Who Care Who Wins was (temporarily) sated by a day and a half of The People’s Partridge.

The nation’s sweetheart was cut down early by the Inquiry’s KC Hugo Keith pointing out that Alan’s Pandemic Diaries were not a contemporaneous document, but a retrospective ‘greatest hits of me’ compilation, ghostwritten by a professional journalist. (Well, by Isabel Oakeshott. It’s sort of the same thing, up to a rather limited point.)

At one point, The People’s Partridge sought to make out that some of Chief Scientific Officer Professor Patrick Vallance’s diary entries were written after the event: Keith countered that the vast majority of Vallance’s diary entries were written on the day.

Alan’s hypothesis that the Department For Health But Social Care was an efficient and well-oiled machine pre-pandemic is not coherent with what the vast majority of people in and around the NHS thought. Stevens-era NHS England had been the place where ambitious and talented people wanted to work.

DHBSC was not important or powerful again until Alan’s ‘taking back control’ amendments to the Stevens/NHSE-requested changes that became the 2022 Act. Yet he told the Inquiry, "we had a can-do attitude in DHSC".

Government counts mailouts to hit 100,000 testing target

The government changed the way it counts the number of covid-19 tests in order to hit its target of 100,000 tests per day by the end of April, HSJ can reveal.

Health Service JournalNick Carding

Ahem.

At one point, Mr Hancock said he didn't read the minutes from SAGE at the start of the pandemic. Hugo Keith: "Did anyone know that the Secretary for Health was not reading the minutes day in day out from the sole Scientific Advisory Committee on Emergencies?" Hancock: "I don't know".

At another, Mr Hancock claimed that he wasn't told early enough that there was asymptomatic transmission. The Inquiry shows him evidence from CMO Chris Whitty and CSO Patrick Vallance that they made it "pretty clear" that there was: Hancock responded by philosophising over what is meant by "pretty clear".

The People’s Partridge referred to having told PM Boris Johnson that an immediate lockdown was necessary on Friday 13 Match 2020. Keith noted that Hancock does not mention this in his Pandemic Diaries, and that Hancock surely would have wanted to mention something this significant.

Hancock claimed not to have had full access to his papers when writing the book. Keith quotes Pandemic Diaries’ claim that the account it contains has been “meticulously pieced together” from formal papers, notes and WhatsApp messages, adding that the inquiry has seen no written evidence that Hancock did tell Johnson on 13 March there should be a lockdown.

Keith asked Hancock if he is sure that that is what he told PM Johnson. Hancock replied, “I can remember it.” Hancock subsequently added that he sent the PM an email on 13 March proposing a suppression strategy, calling this “hard evidence” showing he was pushing for a lockdown. Hancock added that this email came to light after his book.

Hugo Keith replied that the inquiry is aware of that email, and asked Hancock if he uses the word “immediate” or “lockdown” in that email. Hancock said that he did not have the email in front of him.

Ooops.

You wouldn’t want this if you were accused of being a liar.

Mr Hancock’s reputation for veracity was not exactly enhanced by Full Fact re-publishing a greatest hits of their fact-checks of The People’s Partridge’s incorrect pandemic-era claims.

Hugo Keith KC went on, "others who have given evidence to us have claimed you spoke mistruths; surprised people with announcements they had no warning of and had no evidence to support them; and (of) being over-excitable". Hancock’s frequent arguments with Mr Keith’s questions did not greatly advance his cause.

Hancock was asked about PM Johnson’s attitude to releasing restrictions in the summer of 2020, and he claimed the PM was balancing competing arguments. Mr Keith then read him a quote from Panedmic Diaries about the PM’s “chaotic lurching around” on the issue, which was not congruent with the answer Hancock had just given. “There are different degrees of diplomacy with which you can answer a question”, Hancock simpered in reply.

The protective ring

Matt Hancock says lockdown should have happened three weeks earlier - BBC News

The ex-health secretary says it was clear in February 2020 that action was needed to prevent Covid infections.

BBC News

Keith quoted Hancock’s claim from a press conference in May 2020 that "right from the start we've tried to throw a protective ring around care homes", and followed up with a quote from former deputy chief medical officer Professor Jonathan Van Tam: "my view is a ring is a circle without a break in it."

Hancock conceded this point.

On the second day of Mr Hancock’s evidence, there were some kickers of exchanges: this one highlighted discussion about the ‘rule of six’.

Rajiv Menon: "Can you see that?"

Matt Hancock: "Of course I can see that, I can read, thank you".

RM: "Helen Whateley is saying there's no rational for children being exempted from the rule of 6. And you're saying No 10 do not want to shift an inch on this. Is that right?"

MH: Sundry waffle, then "we couldn't release rules on children because we needed to keep R below 1.. If we didn't do this more people would die".

RM:, "The inquiry has seen evidence that at this time SAGE was pushing to exempt children from the rule of 6. I'm afraid that contradicts the evidence you've just given, doesn't it?”

MH, "I haven't seen that evidence". [The evidence he had just been shown on-screen.]

There was a lot more on care homes.

To avoid any trivialisation of the matters, read Professor Christina Pagel’s Kiss thread in response to Alan’s implied claim that’s the NHS was “not overwhelmed”.

Read the whole thing.

Including the end bit, about how it is now.

It’s harrowing just to read this. To live through it?

And then to have to listen to Alan’s evasions and equivocations?

Recommended and required reading

Demos’ new report on harms caused by poor communication in the NHS.

The Financial Times picks up on data from the National Joint Registry and the Royal College of Opthalmologists about NHS England outsourcing more eye, hip and knee operations to private providers than ever before.

BMJ Quality And Safety article on how safe remote GP consultations are.

Intriguing Financial Times piece on the 'ultra-diagnostics' industry for the very rich.

Piece on data and patient safety by James Titcombe and colleagues.

The new 'Strategic Framework' for NHS Commercial.

Former NHS Improvement chair and Test And Trace boss the noble Baroness Harding of Winscombe is to become the first senior steward of The Jockey Club.

The splendid Dr Phil Hammond has a new series about what doctors do, starting on BBC Radio Four.