“The floggings will continue until morale improves.” That’s clearly the way management is viewed in today’s crisis-ridden NHS. It seems set to drive away yet more vital staff from front line posts as they see no sign of support from senior management.

Life for NHS management was stressful enough before NHS England’s new boss Amanda Pritchard opted to throw in her lot with the scurrilous Daily Mail, welcoming their vicious campaign to vilify “lazy” “overpaid” GPs as offering ‘a strong voice for patients’  and “highlighting the devastating decline in the number of patients able to see their doctor in person.”

The supine willingness of NHS England’s chief executive to slavishly endorse Sajid Javid’s so-called package of ‘support’ for GPs that amounts to just £30,000 per practice, but also includes counter-productive and ill-informed plans to ‘name and shame’ surgeries failing to deliver enough face-to-face appointments and the threat to send in ‘hit squads’ and impose cash penalties on surgeries that “refuse” to see more patients in person makes it clear as day that she would just as happily throw trust bosses under the bus next, if the going gets tough.

Ms Pritchard’s cynicism in joining in the right wing jamboree of abuse against GPs (endorsed in the Mail by two obscurely-funded right wing “think tanks,” the so-called ‘Tax Payers Alliance’ that resents every pound spent on public services and the Institute for Economic Affairs which wants to replace the NHS with an insurance system) is underlined when we look at the proposals for primary care set out by Pritchard and NHS England in Operational Planning Guidance on September 30. 

This asks “systems” to: “support practices with access challenges so that all practices are delivering appropriate pre-pandemic appointment levels, including face-to-face care as part of a blended access model.”

NHS England doesn’t mention the fact that in June 2021 GPs delivered 3.5 million (15%) more consultations than in June 2019 before the pandemic; or that the reason for the increase is 6m additional telephone consultations per month than 2019 – in line with NHS England’s own Long Term Plan and its agenda of “digital first”. Without the use of telephone triage to deal swiftly with easier cases and select the patients who need face to face consultations, the number of consultations is likely to go down significantly.

The Guidance promises “shortly” to set out details of continued investment to support general practice capacity and improve access – which turns out to be Javid’s £250m package of reallocated funds, with strings. 

But the Guidance specifically stressed the importance of telephone and online consultations:

“Building on the successful deployment of remote consultation systems during the pandemic, systems are asked to continue to support PCNs and practices to optimise the use of these technologies, including by funding advanced telephony, to improve experience for patients and practice staff.”

So the message is clear for NHS management: stick to NHS England’s own guidance and you will be shafted as soon as anything goes wrong. The entire Guidance document is an exercise in denial, impossible demands and empty platitudes about “supporting the health and wellbeing of staff”.

The promise on waiting lists, which have now passed 5.7m as they continue to increase, is a demand that NHS management “maximise elective activity and eliminate waits of over 104 weeks (2 years)” by March 2022: “The aim is to return to – or exceed – pre-pandemic levels of activity across the second half of the year …”

But NHS England must be aware that most acute trusts are well short of pre-pandemic capacity, with thousands of beds still closed, thousands more occupied by Covid patients, and thousands more again unoccupied either for infection control or because staff have been diverted to Covid work. The Guidance is largely silent on how trusts lacking beds, staff, revenue and capital are supposed to haul themselves back to previous levels of activity.

They are asked to “work closely with independent sector (IS) providers”: but many of these private hospitals are finding lucrative work from self-pay patients seeking to escape long delays on NHS waiting lists, and will be less and less interested in taking NHS-funded patients at lower rates.

The guidance also suggests that one in eight outpatient referrals should be delayed by use of “advice and guidance requests” and all systems are asked to show how they are cutting back on referrals “with assessments to monitor the impact on avoiding referrals” (p7).

And while Pritchard has ignored BMA warnings, and joined the hue and cry over GP face to face consultations, the Guidance required hospital doctors to “continue to grow remote outpatient attendances where clinically appropriate with an overall share of at least 25%,” and “consider options for digital-first elective care pathways that reduce demand …” (p8)

NHS England also makes clear that extra funding will only be available to the trusts that are already coping best with demand – and least in need of it: “systems that achieve completed RTT pathway activity above a 2019/20 threshold of 89% will be able to draw down from the Elective Recovery Fund.” Some of this money will be available to fund private hospital treatment, but not to assist struggling NHS trusts. (p8)

On cancer care, the Guidance admits “diagnostic and treatment volumes are not keeping up with restored levels of demand at a national level, meaning more patients are waiting longer.” But it offers no extra resources, just a requirement to “return the number of people waiting for longer than 62 days to the level we saw in February 2020 (based on the overall national average) by March 2022.” (p9)

On mental health, too, NHS England notes briefly the mismatch between demand and resources:

“We estimate at least 1.5 million people have been accepted for / are eligible for care but are yet to receive it.” (p10)

But the ‘Guidance’ offers only a series of impossible demands, requiring trusts to “accelerate” the recovery of face-to-face care in community mental health services; reduce out-of-area placements, long lengths of stay and long waits in EDs for mental health patients and – not even pretending that these are NHS provided services – “continuing to increase access to “children and young people’s NHS-funded community mental health services” and “NHS-funded talking therapies”.

The complete insensitivity of NHS England to the rising tide of scandals besetting maternity services up and down the country, and their indifference to the safety issues arising from the lack of qualified staff is indicated as the Guidance adds:

Systems are asked to continue to prioritise action to make maternity care safer and more personalised.” 

And, as the Health and Care Bill plans to strip away the legal right of vulnerable patients to have their needs assessed before being discharged from hospital, NHS England makes clear that from March next year there will be no central funding to support so-called “discharge to assess” schemes, and stresses that: “Systems should plan to implement hospital discharge arrangements that are sustainable and affordable from core NHS and local authority expenditure into April 2022.” 

Oh, and somehow from existing staff and resources “Two-hour community crisis response teams are expected to be providing consistent national cover (8am-8pm, seven days a week) by April 2022 across every ICS.” (p12)

The final show of denial is in the Guidance on urgent and emergency care, which notes “sustained pressure” but simply demands trust bosses wave a magic wand to:

“reduce the number and duration of ambulance to hospital handover delays …” and “eliminate 12-hour waits in EDs.”

Systems are asked to develop effective integrated operational delivery plans” which “must ensure that there are robust and effective assurance and escalation processes to rapidly identify and mitigate against bottlenecks and risks from across the system.”

We can expect any manager that fails to be ruthlessly pilloried by the right wing press and ministers, with Amanda Pritchard joining in. 

It’s shameful, but it’s today’s senior management refusing to speak truth to power … and preferring to join in the bullying and abuse of hard pressed staff on the front line.


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