Category Archives: Finance

It started in a setting that I observed and wrote about for the last few years, every now and then the NHS rears its ugly head. My look into this started when the Labour party has created a £11.2 billion fiasco that involved IT. When it comes to governmental IT issues, the UK does not score that high. In addition, when you drain a resource in one path, the other path tends to fade away and there were always politicians who claim they could do better, yet experience for over 20 years have shown me that they tend to remain clueless on the matters at hand. The moment they accept it, they go have lunch with friends who all see opportunities and before he/she knows it, the required scope has grown by 250% and soon thereafter it becomes too large to manage. From there onward it goes from bad to worse and that is how the NHS got sliced and diced (just one of many issues plaguing it).

So when I saw ‘Shock figures from top think-tank reveal extent of NHS crisis‘ (at https://www.theguardian.com/society/2018/may/05/nhs-lowest-level-doctors-nurses-beds-western-world) I was not convinced that the Guardian had even ruffled the top layer of feathers here. So I took a look. Now, the article is linked to the King’s Fund that has the numbers (at https://www.kingsfund.org.uk/publications/spending-and-availability-health-care-resources). The work by Deborah Ward and Linda Chijiko is actually really insightful, and an amazing read. So let’s take a look and they do not disappoint, the start gives us “Although it can be difficult to find data on health care resources on a comparable basis across countries, international comparisons can still provide useful context for the debate about how much funding the NHS might need in future. There is also precedent for this approach – for example, when Tony Blair famously pledged on the ‘Breakfast with Frost’ programme in 2000 to get health spending up to the European Union average“, I have to consider the value of adding flair of Blair, but it is fair enough (or was that flair enough). Yet, data is everything and proper data rules the setting, this paper recognises that and that is a massive victory.

It is important to add (pasted) the following, because it shows the value to a much larger degree.

“Alongside the UK, we have chosen to look at a selection of 20 European or English-speaking countries drawn from across the OECD. For some analyses, data was available for only a subset of these countries. For some indicators, data was only available for services delivered by the NHS and did not include resources in the private or voluntary sectors.

List of UK comparator countries in this report

Unweighted averages and medians have been used throughout this report to summarise data for the collection of countries as a whole. The amount of people who relied on weighted data cannot be underestimated on stupidity to some degree, as we get raw numbers we see that weighting would look better, yet less accurate. In this we do recognise the danger we see with ‘each country is given equal importance regardless of the size of its population‘, especially when we consider that non-rural Denmark tends to me limited to Copenhagen, and rural Netherlands (if there is any rural part left) tends to reflect Birmingham population numbers on average, so when we also take into consideration the truth of ‘The median and unweighted average are often very similar across these analyses, though the median will be less affected by extremely low or high values‘, we know that we are looking at something serious, but in the micromanaged parts (bordering rural/non-rural), there will be the sliding of values at times, not on a national scale, but where we consider certain parts per nation do not properly reflect internationally (the Netherlands vs France or Canada vs Germany).

Now we take a look at certain segments. The first one is “Under the Organisation for Economic Co-operation and Development (OECD)’s new definition of health spending, the UK spends 9.7 per cent of gross domestic product (GDP) on health care. This in line with the average among the countries we looked at but is significantly less than countries such as Germany, France and Sweden, which spend at least 11 per cent of their GDP on health care“, Sweden stands out as it has a much more refined social based system, so there is a shift there, yet as Sweden has 3 cities (Stockholm, Goteborg and Malmo), whilst the rest are basically villages some no larger than 1600 people (2 of them), the rest are between 2,500 and 140,000 in size, so in that regards, the population spread required an approach that differs from several nations, especially when you consider a place like Skellefteå and Lulea in the north. To give a little more reflection Skellefteå has 33,000 people over 8.39 square miles another 40,000 live outside of the ‘city’ limits. So it is 3,900 persons per square mile that in comparison against Birmingham that has 10,391 Ashton Villa fans per square mile. Different solutions are needed, and more often it the hardware (ambulance/helicopter) is very different especially in the winter season (in Sweden) where they actually have a white Christmas and often a white Easter as well.

Now we get to what initially was considered an issue by me, but that was because Denis Campbell Health Policy Editor of the Observer messed up a little (likely unintentionally). You see the article in the Guardian gives us “They reveal that only Poland has fewer doctors and nurses than the UK, while only Canada, Denmark and Sweden have fewer hospital beds, and that Britain also falls short when it comes to scanners“, now what is stated here is true, yet by stating “Britain falls short in several ways, especially when we compare ourselves to the Unweighted average. When we do that when it comes to nurses, only Spain, Italy and Poland have a less fortunate situation“, the Unweighted average gives a proper light per 1,000 population and that is where we need to look at the start and the King’s Fund research is doing that splendidly and shows that ‘spendingly’, the UK falls behind. It falls behind more and more is still speculative, yet if the coming 3 Financial years do not show a massive increase (read: change to the NHS approach) that will become a worsening situation for the population requiring nurses, doctors and equipment.

In the reports, I find one thing missing, that is, it would be a good idea to have that, you see, in the part Medical Technology, the CT Scanner part is partially flawed, Australia scores massively high, which is nice as I am on that island, but I also recognise the part missing there, even as there is a proper notice given with ‘Data for the UK only includes MRI and CT units in the public sector, so these comparisons should be treated with particular caution‘, the missing element is not the numbers, but the distance. As Australia is an ‘island’ nearly the size of Europe, it has its own problem, most of Queensland is rural territory and when you consider that Australia is twice the size of India, the amount of technology they have is often a burden on the size of that nation and the mere fact that the 5 large villages (Sydney, Melbourne, Brisbane, Adelaide and Perth) merely represent 65% of the population, the rest is rural.

Yet the more I read on this report, the more I respect it, it clearly shows issues that the NHS UK has, partially due to its own flaws (the report does not show that). It shows at the end that there is space for jobs “There are approximately 100,000 vacancies for clinical staff in the English NHS, and nearly half (49 per cent) of nurses do not think there are sufficient staff to let them do their job effectively“, but it does not show the ‘elitist’ approach the UK has had for decades into allowing transference of other nurses (from other nations) to become part of this workforce, yet the impossible standards that the UK have used to stop that falls short of the shortages and lack of services now thrust upon the people in need of medical services. The second part is seen (at https://improvement.nhs.uk/documents/2471/Performance_of_the_NHS_provider_sector_for_the_month_ended_31_December.pdf), here we see: “Providers have not met ambitious cost improvement targets and it is critical that these plans are recovered before year-end

Providers set out plans to deliver a total of £3.7 billion savings this financial year. The sector has outperformed the wider economy by delivering an implied 1.8% productivity improvement. This was supported by cost improvements of 3.3% – equivalent to £2,139 million of improvements in the first nine months of the year, £97 million higher than the same period in 2016/17“, so how to read that? They need to show better for the same amount, they were unable to deliver and they still got paid? Is that how it reflects, because that is merely the setting of a disastrous business model, in that the elitist overkill hire approach of nurses will never be in a proper setting in that way, or solved which would be nice too.

So when we see: “By Q3 the sector had achieved 65% of the forecast efficiency savings for the year – to meet the forecast outturn, providers will need to significantly step up the delivery of CIPs in the final quarter. However, the same pattern was seen in 2016/17, so there is evidence to support the increased delivery in the final quarter“, which sounds nice, but they would still come short by no less than 20%, so even as we complement them by getting better in the home stretch, they still did not make the delivery they promised and no matter how ‘ambitious‘ the goal is, a goal not met remains a failure. So when we do address the shortages on all levels and the setting on how ‘some top think-tank‘ gives us ‘shock figures‘, it still revolved around a much larger mess that has not been addressed for the longest of times and is still nowhere near up to scrap.

The goods we need we see on page 51, with the setting of ‘Nursing vacancy position‘ we see how most other failures are shown to fail merely due to shortages, the fact that the NHS has 35,000 vacancies also shows on how timelines cannot be met, when we see that in regard to the shortages nurses to the job of 1.4 nurses, there will be more burnout and more delays on every field. Throwing money at it will not really solve the issue, because this is the one field where we see the direct impact of service levels versus the impossible demand of nurses. So when we accept that the nurses program requires a larger overhaul in setting the stage we see that this is te first field where the military are actually becoming part of the solution.

How speculative can we get?

Here is a warning that matters, because the changing of settings is essential to shaping the future. Consider two places the first (at https://www.army.mod.uk/who-we-are/corps-regiments-and-units/army-medical-services/queen-alexandras-royal-army-nursing-corps/) where we are introduced to Queen Alexandra’s Royal Army Nursing Corps (QARANC), as well as the recruitment (at https://apply.army.mod.uk/roles/army-medical-service/army-nurse). Now consider that the army is charged with the setting of training all applicant nurses to serve the NHS. So immigrants and optionally their children get a short access path to serve the UK on medical terms and it comes with complete processed nationality (after initial screening is passed). So families get the option to become British and part of the society they moved to. Now, this will not always work, yet if you see a 35,000 shortage and you get to lower that by 1,000 each year? Let’s not forget that the shortage is not going away any day soon, so any approach we can take we should consider. Now this is not for everyone, and more importantly an army nurse is still a military function, yet in this setting, there will be training in English, UK values, medical training, language and more importantly the years to come will show whether they have what it takes, in the end we use a structured system to infuse the NHS in operational ways, in addition, as the there is a growing need at the NHS, we see other parts where such reflections would grow the power of the NHS indirectly.

Both logistical and engineering sides of the Military could spell equal options to grow the NHS, or at least grow the ability of taking care of itself sooner rather than later. When we consider that the cost of agency nurses are close to astronomical (at http://www.kentonline.co.uk/medway/news/trust-spends-11m-on-temporary-nurses-180427/) gave us “Medway NHS Foundation Trust spent more than £11m on temporary nursing staff last year, a Freedom of Information request has revealed“, so when we consider that, is calling the army to aid in setting the boundaries back by a fair amount that much of a farfetched call? When we also see “There is a shortfall of 40,000 nurses across the UK, which has been driven by a lack of nursing training places in recent times“, is my call to call in the army and its instructors that much of a leap? Now we can all agree that it does not work on all fronts, but we can either stare at the missing beaches we have now, or start creating our own beachheads and see if we can see how new solutions could be implemented. There is no certainty, only the certainty that at the present course there will never be a solution that is what needs to be addressed. We need to accept that the current approach towards solving the NHS issues is not realistically set. When we look at merely one source (at https://www.nurseuncut.com.au/how-australians-can-get-nursing-jobs-in-the-uk/), we see the language that is given even after you get the NMC (the Nursing and Midwifery Council), you passed the tests, you have shown that you are who you are, your medical knowledge has been assessed, we then see “The hard work isn’t over after this point though, as you will obviously still need to find an actual job within the NHS. Fortunately, there are places designed to help – such as agencies like Nursing Personnel, where you can find a range of jobs across different disciplines and in different UK cities“, so we see that the agencies are set as a buffer, filling their pockets, so they never ever want to see that changed. In addition there is “Following this, you must apply for and then receive a valid work visa to ensure you can legally work in the UK. Finally, when all the pieces are in place, you can begin your new nursing role. Good luck!“, So even after that path is taken, after you get your NMC pin, there are still two iterations to get through, even as the Army, or even directly via QARAN, we could see that the entire path, towards the NMC, especially by those who have a nursing degree. That was never an option? Not even as I discussed such a path almost 4 years ago? When we see the shortage and the non-actions in this, can we even have faith that those around the NHS want anything fixed? It seems that they get ‘rewarded’ no matter what, especially the agencies, so when we see the money in that, why would they want to fix it? I say start by fixing this for the nurses first, which will get delays down and will give additional rise to finding as the agencies get less work, it also states that the invoices form them disappear meaning that millions become available. More staff and alternatively also more equipment could be the beginning to solving two issues to a larger degree. After that we can start looking into addressing the shortages on doctors, yet I also feel that once the nurse shortage is addressed, the doctor shortage might partially take care of itself. Even as the Financial Times reported last year that almost 400 GP’s a month quitted the NHS, addressing the nurses shortage will lower that number and when there are enough nurses we will see that it might lower to almost zero (speculative), yet as one fixes two other issues, we will suddenly see that when nurses reach above the unweighted number of 10, other numbers are guaranteed to shift too, because as agencies make millions less, those millions will shift to optional beds, medication and technology. Suddenly the UK will not look so bad overall. Now, let’s be clear this is a path that would take no less than 3 years to see certain parts turnaround, but it is a realistic path with a realistic curve of improvement. So even as we get served “Portsmouth Hospitals NHS Trust has 9,264 4 hour breaches (25.5%)“, we can also see from the other numbers that a larger extent is due to a shortage of nurses, so when we accept that they could climb to 85%-90%, we see that the entire setting suddenly looks less grim, so even as we need to realise that there is a setting (based on location) that the overall need of 95% performance is ideal, the question becomes is it a realistic setting, when all matters are equal it might be, yet at present all things are not equal and that is the part that requires attention, it is not the top 5% made that sets the standard, it is the acceptance of those in the 90%-95% range that requires merely some scrutiny, the question becomes, which one alteration might get those in the 90%-95% range there? I believe that nurses are merely one part, technology is the second part and as we deal with nurse shortages, there is a setting that technology gets fixed to some degree in the process. This paper (Spending on and availability of health care resources: how does the UK compare to other countries?) does not answer it, but gives light to the path that requires attention, the paper gives a path to investigate and that is equally massively important, so when we consider figure 2, can the change between New Zealand (10.3 nurses) versus he Netherlands (10.5) above the unweighted average of 10.4 show that difference of attaining the ‘revered’ 95% score or higher? Because of ‘irregularities’ that national needs tend to have, it is a cautious approach, yet the idea that it solves it is one thing, yet the one part not shown here (hence I took these two reports) is that even a we accept that they cannot be used in comparison, the setting of getting the 95% mark is still an essential statistic (by some) and if so, we accept that we go by the Unweighted average as a mere indicator, is that the right indicator to use (read: rely on), or is there a number missing? Is there a ‘Nominal Coverage‘ missing that is an indicatory number that aids us towards the A&E 4-hour standard setting and the attainment of the 95% score? Now it remains indicatory as there will always be a shift towards nominal nurses and actual nurses, but we need to start somewhere and if additional nurses are the first requirement to start turning this around, these numbers will become a lot more important, that part is not addressed (which was never the setting for Deborah Ward and Linda Chijiko), yet it is an issue for the NHS and the writing and results by these two ladies, might be a first step in actually getting there. When we look at the simplicity of it, was it really that far-fetched? I am merely asking, because my flair for oversimplification can be overwhelming for a lot of ‘experienced analysts’.

Yet, my mere focus has always been, how can we fix/improve the current NHS?

It is the path to solution that we need to care for, how it can be fixed, if it can be fixed. I have forever opposed the Jeremy Corbyn approach to throw money at it, because in the current setting the only one getting a better deal are the agencies and they are already cats that are way too fat. Hence I look at the directions where training and education sets the pace and in that pace we need to find opportunities for the NHS to pick the fruits form the yard, it is merely a different set of spectacles, the spectacle is not merely about the presentation, it is about setting the right focus, because focus shows us where the flaw is and where we can initially start the focal point of repairing the situation.

The weird part is that Canada, the UK and Australia have similar issues, so there is a foundation of repair missing which is equally a worry. In all this someone is getting rich, is it so hard to look at those getting rich and why that is? The fix could have been underway as early as 2014, the fact that it is nowhere there is worthy of many more questions, yet the bulk of those who could ask them, do not seem to ask them visible enough for all people to wonder how certain matters could be fixed and when one is fixed how much the other problems diminish, an equally important question. Even if it is merely for the reason that not finding these answers could kill you, either in an ambulance, or in a corner of a hospital awaiting a nurse to get you to the proper place for treatment, would that not be nice too?