Saturday, February 11, 2006

How much are NHS Chief Executives earning?

I must admit that I don't know. It is not as with doctors, that a dip in the British Medical Journal will tell you the scales of pay for all hospital medical staff. Oh no, I cannot help but feel someone is trying to hide something.

Anyway, I came across this article in The Guardian. The article was originally published in 2002, but The Guardian published a "league table" of earnings in their 2003 salary survey. For instance, the Chief Executive of the Homerton University Hospital NHS trust (London) got a 20.3% pay rise in 2003, from £79,000 to £95,000. The top earner was the C.E. of Guy's and St Thomas' NHS Trust (London), whose salary went up by a mere £7,000 to £178,000 in 2003. I have no idea how much these people are earning now, but it would be reasonable to assume it is considerably more. And then there are the special pensions schemes, and bonuses for achieving targets (such as cutting beds, services, staff...).

The average pay and pay increase of health trust Chief Executives in 2003 was £106,513, representing an increase of 9.1%. I can't remember what the pay rise was for the clinical staff at that time, but I know it was much less. I also know that the current (2005) pay scale for a newly qualifed nurse working in the UK is £17,610 to £19,437, and even a Grade G Sister/Senior Charge nurse, someone with many years experience who is in charge of a ward or clinic, only earns a maximum of £29,971.

It's disgusting. The NHS is becoming like George Orwell's Animal Farm. And I know who the pigs are.

Thursday, February 09, 2006

Fewer hospital beds, fewer doctors, many more managers

An Independent Audit of the NHS under Labour (1997 to 2005) has just been published by the King's Fund. I looked straight for what the audit found in relation to staffing, both clinical and non-clinical:

(a) Compared with 1987-88, the number of acute and general hospital beds have fallen from 180,889 to 136,123 in 2004-05 (a reduction of almost 25%).
(b) The number of doctors has supposedly increased from 86,580 in 1996 to 108,990 in 2003 (an increase of just over 25%). BUT, a significant proportion are only work part time, and because of the European Time Directive, all the junior doctors are doing far shorter hours; in reality, the "doctor hours" has actually decreased.
(c) Despite this, between 1997 and 2003, the number of managers and senior managers working in the NHS rose by 12,376 (from 21,434 to 33,810), representing an increase of 58%.

What the hell is going on?

Comparison with other developed countries also makes interesting reading. For instance, while the number of nurses within the NHS has increased, England still lags behind every country except Italy in terms of the number of nurses per 1,000 population. England also has the lowest number of practising doctors for every 1,000 people in the population of all developed countries.

So, if many hospitals are running at a deficit (because they are underfunded), and it is nurses and doctors who treat patients, and there are too few of them, why aren't we spending limited funds on increasing the clinical staff working in the NHS rather than on bureaucrats? Why not have a genuine 50% increase in the number of medical staff (doctors and nurses) who are available to look after and treat patients (forget about "head counts" which are completely misleading as many are part time, and those who are full time are working far fewer hours), and if we have to (and I am sure we don't, there are too many of the them already), 25% more managers rather than the other way round?

Tuesday, February 07, 2006

GMC treats us like criminals

At last it is being recognised that the General Medical Council, a body we as doctors have to pay for, is not there to help us but to attack us. What other professional organisation (a) encourages the public (i.e. patients we are trying to help) to complain, (b) publishes details of complaints with names, etc? The answer is none. We are paying for our own prosecutors and prosecution.

If you look at the GMC website, at the top on the left is the section "This month's hearings", telling you about current cases and recent decisions. A click on "Cases being heard this month" takes you to a daily timetable with the names of the doctors concerned. Click on the doctor's name, and you get a short summary of the case.

Click on "Recent decisions", and you get a choice of "Search fitness to practise decisions", "On-line doctor search", and "Interim orders". And all this available to every Tom, Dick and Harry who cares to look. To make matters worse, because the public are encouraged to complain to the GMC, the majority of such cases have no proper basis but are still featured at the GMC website.

Surely this is wrong? The Law Society, for instance, whose members take part in the Professional Conduct Committee circus, provides no information at all about disciplinary matters involving its members. Ironic, isn't it?

We all need to understand the GMC agenda. The GMC is not there for us, it is there against us. And we are paying for it. What is needed is an independent body whose role is to truly protect us from the injustices of the current health care system, from illogical managerial dictats driven by financial targets (and bonuses) to unjust patient expectations and complaints. And we need it now.

Monday, March 14, 2005

Patients discharged from A&E before they had been properly assessed or stabilised

Current government guidelines state that 97% of patients should be seen, treated and discharged from A&E within four hours of being admitted. The result? Almost half the casualty units in England told the British Medical Association that pressure to meet this target meant patients were moved inappropriately.

One hundred and sixty-three of England's 200 casualty units responded to the BMA's survey:

-52% said patients were moved to inappropriate areas or wards
-40% said patients were discharged from A&E before they had been properly assessed or stabilised.
-27% said care of seriously ill or injured patients was compromised by pressure to meet the target.
-18% said patients were "admitted" to A&E instead of to a ward so they could be counted as being transferred.

The chairman of the BMA's A&E committee commented that he was appalled to hear that some A&E staff are being put under intolerable pressure, even bullied, by their trusts as they attempt to treat and discharge patients within four hours. Is he really surprised with the current political climate where medical decisions are being overseen by bureaucrats?

Health Minister John Hutton responded that any doctor with a genuine concern about patient care or fiddling of figures had a clinical duty to speak to trust managers, their Strategic Health Authority or the Department of Health. Oh yes? Just look at what happens when doctors speak out - they will almost certainly be ignored, or even suspended as trouble makers. Do you remember the case of Nick Overton, Consultant Obstetrician and Gynaecologist in Wales, who was recently suspended for daring to speak out against ward closures? He is not the only one.

This is a prime example of the erosion of our professionalism where the care of our patients is being compromised for political sound bites. When will we stand up and stop this madness?

Saturday, March 05, 2005

Managing not to manage

Anyone involved with hospital medicine in the UK should read this report by Harriet Sergeant, written with the financial support of the Centre for Policy Studies and published in 2003. It was written following interviews with chairmen, chief executives, middle management, consultants, matrons, sisters, nurses, porters, cleaners and patients over an 11 months period in six hospitals (3 in London, 3 outside London). It is a damning report which verbalises what we all know - there are too many managers who have little insight into what is involved with clinical care, and who instead, are obsessed with targets (and presumably their bonuses). To some extent they have to be as the government showers unacheivable targets like confetti.

"Managing not to manage" contains numerous observations and quotations. Here are a selection:

Three years ago the Department of Health itself admitted it did not even know how many managers it employed or what their roles were. This year they have changed their definition of an NHS manager to make the increase in their numbers, one suspects, less obvious.

Unlike doctors, nurses or radiologists, management numbers have shot up. Between 1995 and 2001, the number of senior managers has jumped by 48%, and the number of managers by 24%.

By one estimate there are now 270,000 managers, administrators and support people working in the NHS – rather more than one to every one of the 185,000 NHS beds.

The problem lies not with doctors, nurses, cleaners or other staff, but the management and organisation of the hospitals.

If a private hospital was to have the same management-nurse ratio as the NHS it would either have to recruit a further 143 management, administrative and support staff; or sack 186 of their 240 nurses.

Management nearly always work in a separate wing or building to the hospital segregated by a lawn, a tennis court or, in one case, a Japanese garden. They are tranquil, often attractive places that have little in common with the hospitals they serve.

Again and again, chief executives told me their first priority was to appoint a new manager to ensure they were complying with the latest government initiative.

The Government has created a Kafkaesque situation. Hospitals are recruiting more and more managers to monitor care which fails to improve partly because of their appointment. It is not a new situation. Nearly every reform of the NHS has led to an increase in administrative staff.

The changes introduced by Keith Joseph in 1974 had needed, for example, a 30% increase in clerical and administrative staff. By the early 1980s some local health authorities admitted they had no idea how many staff they employed.

The people setting targets at the senior level suffer from, ‘a lack of real world delivery experience and this is shown time and time again.’

The wife of a member of the Cabinet, for example, had a minor operation on the NHS. She by-passed the waiting list and, for security reasons, did not go on the ward but had her own room. When she left, she presented her nurses with a bottle of bubble bath, ‘As if she thought we all took our baths together,’ remarked one.

Even consultants employed by the NHS are wary of using it. One who has worked in the NHS for 20 years said, ‘In the past we all knew we would get good care on the NHS. Five years ago I took out private medical insurance for my family. That’s what I think of the NHS.’

The TUC has certainly made its choice. In the past Bill Morris, leader of the TGWU, and John Monks, General Secretary of the TUC, enjoyed private medical insurance.

More than 3.5 million of the TUC’s 6.8 million members now hold some form of private medical insurance. It is a higher proportion than any other socio-economic group in the UK. Unison, the biggest trade union in Britain representing people who work in public services, displays on its web site what it wishes to deny to the general public: membership of a private health benefit scheme.

The chief executive of a Three Star hospital in the West country made the same complaint. The week after Milburn made his speech on foundation hospitals, they received a letter from Whitehall. Were they interested in foundation status? The note arrived on Tuesday. They had to prepare a response by 5 p.m. on Wednesday.

Another chief executive pointed out that four or five years ago, his hospital had to achieve fewer than 20 targets, ‘and we were pretty clear what the big ones were.’ Since then performance targets have risen to ‘a ridiculous level.’ At any one time he is responsible for achieving 420 targets.

In the financial year ending in March, 2002, remuneration for chief executives varied according to trust size from £72,500 to £114,500. More than half of NHS trust chief executives could have received double figure percentage salary rises last year and nearly a quarter 20% or more. But no one outside the hospital boardrooms will ever know.

A senior non-executive director described some of the managers in her trust as, ‘not up to the job.’ This did not mean she could sack them. ‘The NHS,’ she explained, does not like facing noise.’ Another remarked, ‘Time and time again I have said, “So and So is incompetent,” only to be reproved, “Yes but they are awfully nice.”’ The easiest way of getting rid of these ‘awfully nice’ people in an organisation as huge as the NHS is to promote them somewhere else.

The Government provided one hospital with £750,000 for an MRI scanner. But as the chief executive pointed out, ‘it cost us £1.1 million to install. Running costs are on top of that. The extra has to come out of our capital programme. So we have to cut out something else.’

So, in the peculiar NHS world where, as Frank Dobson remarked, ‘everything is a priority and nothing is a priority’, the chief executive of an NHS hospital asks himself one important question ‘I can’t afford to fulfil all these targets. So which five targets can I be sacked for?’

No other organisation worth more than £45 billion would allow £100 million units (the average cost of running a hospital trust) to be managed by people who have little or no management background except a diploma in health management.

A porter in the West Country had this to say on his hospital’s middle management. ‘We have 20 to 30 managers. Half of them don’t know what they are doing. They hang around the coffee shop and get in my way when I am trying to push a patient through.’ One of his patients, an entrepreneur, raised his head to stare, ‘If I had that many managers,’ he remarked to the porter, ‘My company would be bankrupt.’

Senior officials admitted they had no idea how many managers worked in the NHS or what were their roles.

And figures released in June this year by the Department of Health show the numbers of managers in the NHS soared by three-and-a-half times the rate that nurse numbers rose between 2001 and 2002.

In its 1995 yearbook, the Institute of Healthcare Managers listed 1,700 health service job descriptions. This year the figure has increased to an astonishing 5,529 and includes 41 different types of service manager and 50 different categories of project manager. They are all engaged in meeting Government targets, collecting data for the Department of Health, writing reports and checking their trust is compliant with various Government initiatives. What they are not doing is looking after patients.

The non-executive director explained, ‘We are forced to make appointments that should be way down on our list of priorities.’ When this happens ten times, the hospital finds itself with ten different initiatives, each of which requires a management department to implement them. ‘it’s a disaster.’

The constant re-organisations, I was told again and again, sap morale and breed cynicism. Since its inception 50 years ago, the NHS has been in a state of revolution. No NHS White Paper, for example, has ever been carried through in its entirety.

Middle managers made the same complaint as top management. Too much time is taken up by the, ‘obsessive desire for information’ from the Department of Health. ‘You’re ruthlessly pursued for information,’ said the waiting list manager of one hospital.

Hospitals are taking on administrators just to collect information. NHS management journals are full of adverts for information analysts, service planners, user and patient access managers alongside programme facilitators, emergency service facilitators and shared care facilitators. Statistics have to be collected weekly and sometimes even daily on emergency admissions, day case surgery, trolley waits, bed occupancy rates, numbers of cancelled operations and so on. The NHS Confederation pointed out that even getting the required detailed information on just one of these statistics can take up to 200 pages.

The Head of Treatment Management Systems in a hospital in the West Country agreed, ‘I am so busy reporting that I do not have time to get on with any work.’

Information gathering does not come cheap. Salaries for these new managers can reach £60,000. Their appointment at the expense of front-line staff goes part of the way to explaining the discrepancy between spending on health care and the benefit to
patients. Between 1999 and 2001 hospital funding increased by 21.5%, but the number of completed treatments rose by just 1.6%.

Clinical staff complained repeatedly of management stonewalling their ideas to improve patient care or increase efficiency. Years passed, meetings were held, opinions solicited but nothing happened. One young surgeon recalled being told to go away and write a business plan.

‘Good managers work with doctors – but so few do,’ said one auditor.

The Irish sister had scant respect for new nurses, ‘They picture themselves at a computer or with a doctor on his rounds. They are horrified to discover that 90% of their time is doing things for the patient.’

There is much more, so I urge you to read the whole report.

Sunday, February 06, 2005

Bureaucracy in the NHS is wasting billions of pounds

Having seen the front page of to-day's Sunday Times with the headline "Doctors: cancer care is in crisis", I came across the pressure group, Doctors for Reform. DfD was formed a year ago by 500 hospital consultants from many different specialities as an independent, non-party group which believes that the time has come to look at new ways to supply and fund healthcare.

Their launch leaflet included statement that:

"Doctors are beset with political targets and central direction, distorting clinical priorities". Quite true.

They suggest that any reform of health care should adhere to the following core principles:
-The fundamental NHS principle of care being universally and equitably available must remain.
-The primacy of the doctor-patient relationship, which politicians have undermined, must be restored.
-Management and administration must be more effective.
-Politicians must be removed from the day-to-day running of the health service.
-Patients must be able to exercise real informed choice about where, how and by whom they are treated.
Again, I agree with it all.

DfD propose to fund these reforms by a changing to a social insurance system.

"Social insurance is the type of health system used in countries such as France, Germany and Switzerland. The systems differ but all have the same key characteristics. All citizens receive health insurance in return for contributions usually made from salaries or, in the case of the worst off (in some countries) from taxation. Social insurance is compulsory and universal, and everyone is guaranteed access unlike with the system in the USA where people can choose whether to have health insurance or not."

How social insurance differs from the current National Insurance scheme in the UK is explained as follows:

"Under social insurance, health contributions are made to insurance funds, not Governments. Those funds are under an obligation to serve patients as their customers, meaning that patients are truly empowered."

Such a system would have an effect on the NHS:

"Social insurance is a mechanism to ensure that money follows the patient. If NHS hospitals can respond best to patients, offering the best services, then they will receive more resources. In countries such as France and Germany, the public sector operates at least half of all hospitals."

I am not sure about this one. Isn't this privatisation by the back door and the dismantling of the NHS? Why not use social insurance to fund the NHS alone and thus cut out government interference and political dogma?

I need to think about it. There is a lot more information at the website (see Links on the right of this column.

Tuesday, February 01, 2005

How many managers does it take to treat one patient?

According to a Kings Fund briefing in 2001, "The number of hospital beds has been declining ever since the establishment of the NHS. The total number of hospital beds in Great Britain fell from around 550,000 in 1959 to 450,000 in 1979, to 250,000 in 1999" ( I have even seen a figure of 149,000 in a BBC report in 2000 ( It may well be that changes in practice (e.g. shorter stay, day-case surgery, etc) means that the modern NHS needs fewer beds, but it is equally true that this cull in beds has been over zealous. Not surprisingly, an inquiry in 2000 concluded that 4,000 beds need to be introduced in the short term and a further 25,000 beds by 2020 just to maintain the status quo.

What about hospital clinical activity? The Department of Health publishes Hospital Episode Statistics annually, and recent reports are available at their web site ( For instance, a comparison between the financial years 1998/99 (A) and 2003/04 (B) shows the following changes:

Finished Consultant Episodes (FCEs): A=11,983,893 B=13,174,480 (+9.9%)
Ordinary admissions: A=8,563,098 b=9,417,004 (+10.0%)
Day cases: A=3,420,795 B=3,757,476 (+9.8%)
Total admissions: A=11,016,652 B=11,699,163 (+6.2%)
Total discharges: A=11,060,510 B=11,757,022 (+6.3%)

So, we are treating more patients in fewer beds. Fine.

But there is more. Binley's is a health & care information specialist who has been delivering specialist health and care information solutions to the public and private sector for over a decade. They provide analysis about the NHS, including data about staffing. This makes interesting reading. If you look at staff trends between 1997 (A) and September 2003 (B), you will find the following*:

No. of hospital doctors and dentists: A=62,048 B=77,210 (+24.4%)
No. of hospital and community nurses: A=300,468 B=364,692 (+21.4%)
No. of general practitioners: A=29,389 B=32,593 (+10.9%)
No. of dentists (excluding hospitals dentists): A=18,296 B=20,984 (+14.7%)
No. of managers and senior managers: A=22,175 B=35,321 (+59.3%)

So, we are treating more patients in fewer beds with more clinical staff. Fine. I am sure that patient treatment and care has improved as a result. But do we really need a 60% increase in managerial staff when there has only been a 10% or so increase in hospital clinical activity? Do we really need one manager/senior manager for every 3.7 doctor or dentist. I don't think so. Wouldn't the millions spent on increased management costs have been better spent paying our nurses the salary they deserve? I think so.

* Data taken from