3 Headlines, 2 Primary Conclusions, 1 Inevitable Outcome

With Catastrophic Effects for Current Staff

Today is an interesting day. In the last 24 hours we have seen the emergence of 3 distinct news reports that, taken together, virtually require us to conclude something rather alarming and of very personal importance or implication. It could be argued that each of these items taken individually is significant enough. However, it is the story laid out by putting all three together that should have even the most optimistic individuals pausing for thought and considering their options. One of the stories concerns just a single Trust and you cannot help but feel for the thousands of staff affected. However, this Trust’s circumstances are sufficiently similar to many others that we would have to conclude it is ‘early’ rather than ‘isolated’ and that is a very scary thought for the rest.

The Bigger Picture Story

In an externally, if not intentionally, shared Board paper, St George’s University Hospitals Foundation Trust has indicated its intention to deal with its financial decline by cutting its pay bill by 10% by March 2017. It has indicated this will be achieved by not filling vacancies as they occur. The level of delusion in this ‘strategy’ comes from simple maths. A 10% reduction in 6 months by not recruiting to new vacancies (not recruiting to existing vacancies will not ‘reduce’ the pay bill from its current level), requires a 20% staff turnover (worse actually but we’ll stick to the simplistic summary version) rate assuming the exodus is fairly evenly distributed across staff types. The monumental implications of this news item would be dwarfed by news of a Trust with a 20% annualised staff turnover rate, although ironically, the current news item could well contribute to that. However, that’s not the bigger picture ticket we need to buy.

This is an indicator of the current state. This is a Trust that is so “backs against the wall” that it feels it has no other choice but to cut its most valued commodity and more significantly, the commodity that allows it to fulfil its primary purpose – the delivery of care to its patients. Not only will achievement of this intention undermine that most sacred of requirements, the effects of loading more work onto existing, already beleagued staff will be to undermine morale beyond breaking point, resulting in a further exodus, spiraling sickness rates and a near-complete withdrawal of any discretionary effort. Organisational death is not too strong a term. St George’s is far from unique in its circumstances. This CURRENT state of affairs should be ringing alarm bells in every staff member across the provider sector.

We also learned that the Summer of 2016 saw worse performance in Accident & Emergency than the majority of recent winters. During the summer months just 90.6% of patients were seen in four hours, against our target of 95% in four hours. Let’s compare this to recent winters:

  • Summer 2016 (June – Aug) – 90.6% seen in four hours
  • Winter 2015-16 (Dec to Feb) – 89.1% seen in four hours
  • Winter 2014-15 (Dec to Feb) – 91% seen in four hours
  • Winter 2013-14 (Dec to Feb) – 95% seen in four hours

There is much speculation as to why this is so but the commonly used causes remain; delayed discharge or transfer of care, coupled to increasing demand, increasing complexity of that demand (the ageing effect) and perhaps a higher than average rate of leave. Again, this is a marker of current state – at the height of the summer, we are in worse condition than in some of the worst winters. However, this is not JUST about current state, as we know from recent winters that the level of pressure was already sufficient to result in large scale major incidents, tents in car parks and a demand on agency staff that we are no longer permitted to leap to. It begs the question as to just what will happen when we add the frail, elderly, often lengthy-stay pressures of winter to this already fragile state. The effects of this current state almost certainly give rise to our third news item.

We learn today that elective waiting times are yet again lengthened, with admissions at their lowest for 3 years, long waiters at their highest levels since the early days of targets themselves and waiting lists swelling continually. It is easy to discount this news as less significant than not coping in A&E but that ignores the reality that elective care is the financial life-blood of Trusts and if the capacity to do it is declining, then so are Trust finances, itself a precipitator of measures that further impact capacity. And therein we have the 3 Horsemen news items and their collective meaning. Let’s summarise.

We have Trusts so beleaguered that they are reducing headcount (forget the means) to cull costs, itself impacting on the capacity to do fee-earning work but more damagingly setting those Trusts up for a catastrophic loss of drive associated with exodus of good people and the loss of morale (and even health) in the remaining ones. Coupled to system pressures and adverse changes in social care, we see this ALREADY producing worse-than-winter performance at the height of a warm summer. The effect of this is to thoroughly undermine elective care, starving Trusts of vital lifeblood cash. Add this together, and you have the perfect conditions for imminent collapse as winter-pressures emerge, through the repeated effects of the above spiral – no cash = slash staffing = collapse in capacity = divert resources to emergencies (hang on, essentially) = further collapse in elective care = no cash. Feel free to repeat that cycle as many times as you think it might take to result in system annihilation. I wouldn’t consider using the fingers on your other hand… or any thumbs… or many fingers.

Primary Conclusions

My title suggested that there were just two. This masks the myriad of conclusions already alluded to and indeed considered when examining primary ones. Ultimately, we must all acknowledge what this is telling us. We have to consider from two primary perspectives:

  • Where we now are – the true current state of play
  • Where that is heading – a true, no denial and delusion, assessment of how this will turn out

I will not waste words on beautifying what can only be truly described as stark. Considering the above, along with 10+ years of examining policy, responses to policy, past and recent system behaviours, their effects, I conclude the following:

  • We are at a point where, for many Trusts, any further decline has nothing but unrecoverable consequences, in financial but more importantly human terms
  • Further decline is inevitable at a system level and probably for greater than 90% of Acute Trusts (and if you disagree with this point, I’d politely suggest that this is denial and delusion, not a considered, authentic opinion from looking at the key data sources)

What I think, regardless of how important it is to me, my decisions and actions, is obviously of only secondary concern to you. However, I’d suggest that what you think, how you respond, what you conclude and consequently the decisions and actions you take, litterally hold some of the most important aspects of life in the balance. It does justify some very, very careful thought.

Personal Implications

Without question this has implications. Perhaps an analogy might illustrate this. You are in a boat, in a storm and it has a hole in it. You and your team recognise the severity and there is no point in arguing about what we should have done ‘earlier’ because although the National Hurricane Center gave us some warnings, we are now in that storm, in our boat and it is leaking. So we pull together and bail. However, the storm is increasing in intensity, not decreasing. So we bail faster. It reaches Category 5 on the Saffir-Simpson Hurricane Scale and we are now all bailing at the fastest possible human rate with no respite, to ‘just’ stay afloat. You may or may not have had a moment to reflect that there doesn’t appear to be a meaningful solution coming down from the bridge and their constant requests to ‘bail faster’ would be beyond irritating if you weren’t preoccupied with just trying to stay afloat for the benefit of those around you. And then something happens…

The bridge sends word that they have analysed their woes and conclude that the boat is sinking due to too much weight and, not having any other menaingful cargo to jettison, it is implementing a rapid rate of removal of your fellow bailers. It does say, don’t worry, we won’t get rid of the fit and healthy ones, we’ll wait until some collapse and we’ll just not replace them. So here you are. In a Category 5 storm, with rapidly rising water in YOUR boat and the bridge have just announced reducing the bailers. What does it mean to you? What do you do?

For you personally, I’d say these are possibly the most important questions you’ll face and you will realise immediately that none of the answers look particularly palatable. I could make suggestions but today I am not going to do that. For one, I am not you, in your circumstances. I am not being cruel. In fact, I am going to ask you to engage in a personal exercise that I hope will leave you with explicit clarity but only in one dimension – a true starting point.

A Very Personal Exercise

I would like you to meaningfully reflect on and answer the following questions:

  • If the storm continues to increase, what would the effects be on you, your family, your health & wellbeing and your passion for healthcare?
  • Do you see the storm decreasing?
  • Do you see any meaningful support from the system?
  • Is our social care system likely to increase or decrease the storm conditions over coming months and years?
  • Is your ‘bridge’ taking sensible and meaningful measures to address the holes? (Sensible would mean not trying to fill them with wildly unsustainable more for less tactics)

The purpose of these questions is to be able to answer the ULTIMATE question, for you. It is this:

When you consider the above, just how sensible or sustainable is ‘not acting’ for you, your life and family?

You shouldn’t rush that reflection. Take the weekend. Think broadly and deeply. Think personally, not generically. I would hope that by Monday, you’ll have come to one of two distinct conclusions:

  • that taking no action remains the most sensible and right course of action i.e. its an active choice not to act, for YOU
  • that the consequences of taking no action are now sufficiently explicit that action is an absolute necessity, even if you don’t yet know what that action is

If by Sunday night you are in the second group, perhaps we should ‘talk’ on Monday and at that point we need to start the process of ensuring that those actions are safe, sensible and very, very carefully thought through.


Hopefully Some Hope

If you are returning to this article after reflecting, I am guessing it is because it at least resonated enough to have you considering whether you might need to do something. I am also guessing you are a bit unsure and it feels a bit scary. I don’t underestimate how uncomfortable it must feel, not to mention anger- or depression-inducing, or both. How do you find the right path?

Well, it depends on your circumstances, degree of certainty and your ability to separate the emotional responses from the more rationale reasoning. More importantly, it is very difficult to step back from your own circumstances, objectively.

So, I am setting up a coaching-based support process to help individuals evaluate their circumstances and receive help to set a path. If you are interested in hearing more, please just drop me a line to andrew@growmedical.co.uk

If you are a little unsure (about even getting in touch), can I suggest you find individuals that know me and ask them about my passion, motivation and insight, both system and behavioural. I can’t control who you ask, so you know their opinion is a true one.

I hope to hear from you if you feel ready,

Andrew Vincent


Some Other Potential Options

The goal of the article is to provide you with useful guidance as comprehensively as possible. However, we also get asked whether we can help. We can to an extent, and here are a few options.

Boundaries & Control

We have three basic options:

Understanding More Deeply

If you wish to get started on determining just how much trouble we are in, we also have three options:

Decision-making, Choices & Your Head!

We have a special half-day programme that is designed to address the very issues that this article highlights. It’s information, it’s therapy, it’s coaching, it’s supportive, it’s confidential and it’s very, very honest. It’s also booking quite fast because numbers are limited and the first one turned out to be a revelation to some of those attending, who have become our passionate advocates for the second one. Have a look. Not for everyone. But for some people, it’s life-changing (or rescuing).

7 responses to “3 Headlines, 2 Primary Conclusions, 1 Inevitable Outcome

    1. Hi Y. Thank you for your comment. Correct, unashamed. I also write unshamedly from a position of trying to help people understand what is happening around them and to them. Inevitably, if I have any impact at all, it is going to cause some individuals to want to do ‘something’ and many of those not to know what that something is and how to do it. I can assure you that I would write (and have) without including any links but every time I do, I am asked to include pointers by individuals that would like some help and direction. It’s a tough call. I could leave it out but I suspect it might disappoint as many as when I leave it in.

  1. Interesting sitting in the hospital at the weekend bailing furiously.
    I can do no more It makes little difference what insane plans and cuts are made,.
    My ultimate move ,due to me being only a few years of retirement will be to put my underpants on my head, a pencil up each nostril and say ‘wibble wibble’ and retire on mental health grounds.

    1. Hi S. You do indeed show your age 🙂 and I too remain a Blackadder fan. I am definitely with you about the insane plans and cuts. Having spent 10+ years looking at this unfold in detail and adding in the behavioural science element too, having all too many predictions come true, my personal view as you probably gathered from the article is to believe that this is unrecoverable at a system level. If anything, you response just illustrates that. If we are losing experienced people, whether physicially, or in engagement terms, then we are losing. Period. However, my primary concern is no longer recovery of the system, it is two-fold:

      – Preserving those that are finding their lives shattered as they ‘try’ to keep things going
      – Preparing individuals and services for what might be on the other side of HealthCRASH

      I don;t think HealthCRASH is debatable anymore, and I wrote this article before Ms May announced (declared) no new funding for the NHS (and in fact she hinted at what I think looks like cuts).

  2. You need to produce this in dark print as bailing your boat without respite makes it very hard for the beleaguered crew to read. Clear communication another NHS failure …..l

  3. You write well Andrew and are drawing our attention to something crucial. I can say that your courses are well-worth attending for those wishing to understand all this more and perhaps even try to do something about it.

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