and how to mitigate it…
With the NHS in perennial financial crisis, this last week we learn from Jim Mackey, NHSI Chief Executive, that 2017-18 will require providers to find yet another 4.3% of savings, despite the majority stating quite clearly they were running out of new options. The Sustainability and Transformation process was designed to help undertake ‘patch-wide’ reform, supported by the Sustainability and Transformation Fund. However, we also learned from Mr Mackey that all of the fund had gone on deficit reduction (and then some), leaving us with a transformation need but no transformation fund, or, as we like to know it, wishful thinking. This brief article is about the impact of this apparently downwards spiral, in a tunnel with apparently no light at the end, on the medical profession and in particular their ability to maintain their own professional standards.
Dipping in to Non-existent Savings
So, if you are a Trust, faced with needing to save 4.3% and having to sign up to do so or lose your share of, and access to, emergency funding, where do you look? Typically, you stratify your options based on their ease of implementation and the fall out if they are pursued. After tackling the majority of low hanging fruit, a Trust will typically find itself with what appears to be Hobson’s Choice, where everything proposed appears to have consequences. When you reach this point, you are starting to choose the ‘least damaging’ rather than the ‘most attractive’ and that means they are all impacting people or services (or both).
In the stratification of potential damage, some core principles come into play, such as:
- Quality & safety come back to haunt you, especially in the reputation rear
- Operational capacity harm is a nil sum game because anything you save in cost you lose in revenue
- Things that have been done before tend to be viewed harshly if done again and again e.g. nursing cuts
- Gradual erosion is less painful than a landslide
Increasingly, finding costs savings where no savings are to be had, genuinely feels like debating a cost improvement plan for a plane; “shall we cut out a wing or do away with a fuel tank?” and STILL expect it to cross the Atlantic through increasingly volatile turbulence.
An Explosion of Erosion
So, the (hospital) wing has to stay and we are left with an explosion of gradual erosion in areas that can be rationalised as least harmful. I don’t need to persuade you of this as the evidence is all around you:
- Subtle tax and pension changes (erosion of net income without giving you a pay cut)
- Curtailment of Supporting Professional Activity – from 2.5, to 2, to 1.5PAs and onwards (downwards)
- Curtailment of coffee, whilst expecting you to work through breaks
- Curtailment of work-life balance, by expecting you to do ‘just a bit more’
- And so on…
Many of these initiatives undermine morale, enthusiasm and energy. That’s a real, bottom-line cost. It means any given group of people achieves less for a given amount of time. It is damaging. However, if you are an accountant, you can measure the cost saving but it remains difficult to quantify the morale. But what about when the underlying cost of the erosion is the professional status and capability of the medical workforce?
Cuts to SPA-time have undoubtedly reduced research, challenged non-hands-on clinical education and made it more difficult to engage in wider leadership-type activity, especially where it sits outside of the employing Trust. The increased clinic burden on reduced clinic resources is itself a concurrent eroder of much of the above too. We have seen this directly in individuals booking on courses and then being told by Trusts, at the last minute, they can’t be spared. I will never forget the individual that re-scheduled his Time Management course three times for this reason and then got called by his Trust ‘in an emergency’ half way through the day that he finally managed to get to.
But what are the consequences of foregoing professional development? Revalidation, springs to mind…
Consequently, and quite rightly, faced with eroding study leave budgets and even more quickly eroding study leave time or opportunity, doctors themselves go through a similar process to Trusts – what can I cut without suffering major consequences? Given the true purpose of the role and the personal consequences of getting it wrong, individuals quite justifiably place clinical learning above non-clinical. However, just like a wing or a fuel tank, both are important to the ongoing function of a successful healthcare system and the latter component becomes even more important in times of stress or crisis. Both components are part of revalidation.
Increasingly, individuals find themselves leading a £10+m clinical service, a complex, multi-professional clinical business, without understanding the ever-changing system in which it sits and have little training in the new skill sets necessary i.e. leadership, management, finance, influencing, change management etc. This frequently results in those same individuals doing the best they can, concluding it’s a thankless or hopeless task and relinquishing the role in two or three years, having ‘done their duty’. The harshness of conditions today demands more and more of both the leaders and their teams. There is a cost to anything less than an optimal approach… and it is frequently bigger than the time or cost ‘saved’ by avoiding what should be seen as ‘also’ essential.
The answer is not necessarily to see what is least harmful so much as exploring new ways of addressing both, within the time and financial constraints facing us. That requires innovation at all levels – professional, Trust and development provider. Innovation itself is problematic when you haven’t got time to adequately address the regular day job. With this in mind, we’d like to suggest ways to extend both clinical and non-clinical learning, some of which you may already be doing and some we are certain will be new ideas.
The Study Leave Stretch
Good use of study leave encompasses a balance between both clinical and non-clinical development, as well as a balance of focus between what’s professionally most pertinent and areas that you personally find stimulating, as long as they have relevance. The ideas are designed to encompass all of these.
Taking a Shared Approach
The majority of consultants work with a team of consultant colleagues, with many areas of their care focus common to all whilst some being a sub-specialty interest. An obvious, early suggestion is to create a series of internal study days, aligned with external meetings. For each designated period, a consultant would attend an external conference and capture as much of the learning as they can, which they would then make the focus of an internal study day (or morning, or evening etc) for the rest to benefit from, with them as ‘speaker’. The benefit of this is that nursing staff and juniors can be included too. 1 CPD day of external cost, many CPD days shared across the group.
We can’t claim the idea because we have seen nurses do this over many years, whereby one or two are sponsored to attend a congress provided they put together a series of presentations for the other nurses on their return. Run as a distinct sponsorship programme, it can contribute to nursing recruitment and retention too.
If, like me, you grew up with classroom or lecture hall learning, you may have concerns about online learning. We don’t blame you given that most early digital learning involved reading a screen, inviting the thought of “why not just read a book?” (which is a good use of study leave time, by the way, and cheap). However, not all e-learning is equal. For instance, the eMedicus (related company, just for disclosure) digital learning consists mostly of captured live learning with the slides and speaker presented together i.e. it’s VERY close to being in the room.
For a double-study-leave-benefit, seek out learning you can subscribe to as a package. For instance, I have a standing subscription to Lynda.com, which I use to develop my IT skills. It costs just £14.95 per month and although the courses are of variable quality, there are so many instructors for each topic, you just need to find the good ones. At £14.95, you can hardly go too far wrong. A great example of using this is with Microsoft Outlook. Improving your email management skills can take hours off your working week whilst also improving your professionalism in the eyes of others. Why not do an hour a month for say 6 months, with a target that each hour you do should be in something that gives you back at least an hour a month going forward – that’s at least a 12x return on the time for each hour spent for just £14.95 per month! (no, I am not on commission – it’s just very good).
Another excellent source of online courses in subjects like IT and business, both increasingly important to professionals in healthcare, is Udemy, which covers a vaste range of topics with tutors from across the globe. Given out international workforce in healthcare, Udemy also has courses in languages other than English too. We’ve inluded a link to this below.
Subscriptions and packages have been part of the eMedicus offering for a while – for instance huge clusters of learning focused on leadership & change. Already a fantastic way to get a huge degree of healthcare-specific learning for a low cost, your study leave budget can be extended further when things appear on offer. For instance, currently eMedicus is offering an Annual plan that gives access to ‘everything’ for less than even the cost of Lynda.com. It’s limited in numbers but for those taking it up, it also gives them the right to renew at the same subscription rate for some years to come. We’ve included a link!
Become a Provider
Applicable to both clinical and non-clinical learning, why not organise training that you too can benefit from, using the income from others to fund it? There are multiple ways of doing this depending on the degree of motivation.
At the REALLY motivated end of the scale, you make learning provision very much part of what you do, with people leading it and multiple events per annum. The learning opportunities you provide massively increase learning across your team, whilst the income attracted from outside parties pays the bills. At scale, you need to think about delegate management, payment collection and marketing, all topics that require serious thought and as well-organised plan. If that sounds like awfully hard work, consider a partner. For instance, Academyst and Grow Medical can support each of these aspects in return for a share of the revenue.
At the ‘just want cost-effective training’ end of motivation, the important consideration is in how to make it happen without the organising becoming the day job. For a number of years now, we have run what we call a Partnership Programme, whereby you gather a group internally and we bring training to you, offering the spare places to our very large contact list. The revenue from them, offsets the cost internally, so the internal individuals end up with an extremely low rate for being the hosts and front runners. With ease as a driver, we handle all payments and marketing except for gathering the internal group. Most groups use their in-house postgrad facilities to keep costs down.
The provider idea can be extended still further. With an increasing appetite for UK language and standard clinical training, a well-organised study day utilising respected speakers can be video-captured and made available for a fee. For this to work best, you really need a production and marketing partner, so that you can concentrate on running a great day and they can handle the technical bits. However, done correctly, the benefit is a long tail of income that can be reinvested in new events or alternative learning for staff.
Leadership of Learning
Every year, most departments get a new cadre of trainees, each of whom is looking for clinical learning, audit & research projects and leadership opportunities. Long understanding the benefit of trainee motivation, well-organised departments have an ongoing programme of audit work that they can plug their trainees straight into. So, why not take the same approach with training. What if each trainee was responsible for organising a learning event that had to deliver high quality learning, provide opportunities for internal staff and run at least at break-even, requiring some business innovation too?
Organising good learning is not for the fainthearted. It requires planning and organisational skills, networking and negotiation skills, marketing skills, financial management ability and drive. It requires a vision and an ability to engage others in that vision. As you reflect on the above, you can’t help feeling that anyone organising learning is undertaking a highly demanding, live leadership programme that can forever sit proudly on their CV. That leadership produces real benefit for the trainee but just as importantly, it brings both a combined, financial, reputational and learning benefit to the surrounding staff. And THAT’S the kind of learning innovation we need today – approaches that expand, rather than cut and which deepen the richness of learning without requiring ever deeper pockets.
Our approach to self-development has to change. We are at risk of personally falling foul of the austerity scourge that appears to be slowly ripping the heart out of healthcare. The personal risk is the loss of professional standing and even licence to practice, an outcome where being able to blame the system is of no consolation. At a practical level, where our approach becomes reductionist, we harm a whole system for the future.
The current erosion can be characterised by a frightening set of behaviours:
- Cheap trumps good, eroding the learning and skills benefit and promoting mediocrity
- In-house trumps external, reducing the inflow or exchange of new ideas and opportunities for networking
- Clinical trumps non-clinical, keeping us technically capable but increasingly under-skilled in leadership, management and interpersonal effectiveness
The responsibility for finding a better way lies with individuals and providers alike. Providers need to harness innovation to offer learning at scale, including economies of scale. Individuals and departments need to return to being both providers and consumers, whilst developing innovative ways of utilising their staff to help develop learning opportunities. If we simply believe the system is obliged to address the problem and wait, we just might be waiting a very, very, very long time.