Friday, 3 February 2017

Your Life in Their Hands: or, local accountability in a time of NHS crisis, and the launch of 'Barnet NHS Needs You'.


Coming soon, courtesy of your Tory health minister: DIY NHS: In the interests of transparency,  Mrs Angry must declare that she is participating in a pre-launch trial.

Let's continue the theme of the last post, shall we? The last post, on what appears to be the Last Post for health services in Broken Barnet. A place where, if we are not prepared to fight for it, the fair provision of healthcare is likely to become a privilege for those who can afford to pay - or those capable of kicking up an almighty stink.

As reported, Mrs Angry had been promised statistics on the latest waiting times for the various clinics and specialist services that we all may rely on, if we have the great misfortune to become unwell, in this borough. 

The information had not materialised, so Mrs Angry published the post anyway. As you might expect, this was visited by a deluge of readers, all clearly worried about the state of the local NHS, and interested in the activities of those charged with the responsibility for the management of the services we need: that is to say, Barnet CCG, the clinical commissioners. 

Mrs Angry must declare another interest here (see, Barnet CCG, this is how you do it, online, where everyone can see it): having made a formal complaint about the CCG, on several grounds, as a result of the recent, and continuing experience of failures in the care they are supposed to provide, and the process they use to do so. But this personal experience has led to a close inspection of the way in which our local NHS is being run, and what appears to be a concerted effort to obscure the real crisis facing our local services, with a serious lack of transparency and accountability to patients, residents and taxpayers in Barnet.

The figures now passed on in regard to waiting times are now available for you to read here, but I urge caution in the interpretation of the data as listed. I cannot put much faith in the accuracy of this data, for reasons I will explain later:




This is the second listing that was sent, since first requested. I had to query the first one because there were omissions: no data on the specialism that I had first asked about - that is to say orthopaedic services. The second one arrived with no response to the question as to why it had been omitted in the first place.

The picture that this information gives is bad enough, but I believe the truth, in regard to waiting time, is even worse - as does the NHS's own main source of information, as you will see.

In the second version you will see several listings under the category of orthopaedics. And rather curiously, the one which applies to me, ie Orthopaedics - Back Pain, is the only specialism which is admitted to have no 'slots' ie appointments, or available service on 'ERS', the online appointment process. At all.

Of course, I already knew that, as explained in the previous post. And they knew I knew that. And yet - I have, after kicking up an almighty fuss, eventually been referred to a private sector provider, which was not offered initially, but this does not feature on this list. Do they not want to tell us how many patients are referred to the private sector?


Is it a coincidence that the one specialism that they know I already know has no appointments and waiting lists that stop at 21 weeks, ie three weeks after the statutory limit, is the only one they do admit is that bad? And why did they withhold it from the original version?

But let us look at the figures here, even if, as we shall see, you may have reason not to rely on their accuracy. 

Let's look at the figures for the three hospitals that have most recently been expected to support the needs of Barnet patients: Barnet General, The Royal Free, and now Chase Farm - (which is actually in Enfield, and difficult to get to for most residents of this borough using public transport). These will be the clinics your gps are most likely to refer you to, as you won't know you have a right to be referred anywhere at all: I was given the options only of Barnet and Chase Farm, and still don't know why the Royal Free was not included.

For the most serious conditions, even these waiting times are worrying: 

No appointments at all at the Royal Free for Neurology - waiting lists of at least 11 weeks at Barnet, 13 at Chase Farm. 

GI and Liver, (Gastro): no appointments at all at Chase Farm, waiting lists at least 14 weeks at Barnet, and 11 weeks at the Royal Free. 

Colorectal surgery: no appointments at all at Barnet or Chase Farm - (or even UCLH, or Northwick Park); the Royal Free has a waiting list of at least ten weeks.

Urology: no appointments at Barnet or Chase Farm - only the Royal Free, but the waiting list is described as 17 + weeks.

To be clear: 'no slots' means no appointments, and the grey areas on the list are where that particular service is not offered. Mrs Angry was told that 'Sometimes there are slots on the provider’s own internal appointments system'. Sometimes? Cancellations, maybe, or when a patient has yelled down the phone at the referral service? Who knows.

Pain management? The one clinic you might expect to be prioritised, when there are such long waits to see a consultant for conditions which may well be causing you a lot of pain - a 20 week wait, and the Royal Free your only option - unless you are able to get to North Middlesex Hospital in 12 weeks, or Watford, in 14.

A rough appraisal - and bear in mind Mrs Angry's forte is not numeracy or mathematic, even when not under the influence of morphia - would seem to indicate that, even when including the 'other options' that may not in reality be offered to most patients in Barnet, such as St Mary's and Watford General, there is a scandalously high rate of waiting lists with NO appointments available at all. 

Around a third of waiting lists, in fact, cannot offer an appointment, by these figures, which are likely anyway to be an underestimate. And when you look at the figures for the three most commonly used Barnet hospitals - the rate is even higher. 

This is totally unacceptable.

But to what extent can we rely on these figures? How can we check? 

Well, one way is to check the NHS's own data, freely available at the NHS Choices website. This data is updated daily.

If we look up cardiology at Barnet General, which we have been told has only a five week waiting list, we may be surprised to find this alarming statistic:



That red exclamation mark is because 19 weeks is one week beyond the statutory limit. And there is an apparent discrepancy here between the 5 week waiting time given by Barnet CCG, and the 19 week one admitted by the NHS here. Which figure is right? 

The NHS must provide treatment within 18 weeks of referral by gp, according to the rights defined in its constitution. Here would appear to be an admission that Barnet General is in breach of that limit. And why does the local CCG give a lower estimate? 

Now let's look at urology: according to the local CCG's figures, Barnet and Chase Farm have no appointments, and at the Royal Free, the waiting list is '17+' weeks. Here we learn the RF and Barnet are currently 2o week waits for almost all patients.





Confused? So am I. We are given waiting list times for RTT, 'referral to treatment', and 'average' times til you are handed a first appointment, which is not treatment but an appraisal. And caution: what do they mean by 'average'?

Even more confusingly, under the heading 'average waiting time for first outpatient appointment, there appears to be instead information about 'patient safety alerts'. 

To step aside from waiting lists for a moment: this alert system is very interesting - or rather misleading. 

Patient safety alerts rapidly warn the healthcare system of risks. They provide guidance on preventing potential incidents that may lead to harm or death ...

That lovely green tick, and cheery 'good' is not what it seems: according to the note: 

Green icon = good: the hospital has recorded that it has completed the required actions for all Alerts where action should already have been completed ....

But:

The Central Alerting System (CAS) relies on self-certification. Trusts are responsible for the accuracy of the information they provide. CAS is not a performance monitoring system, and therefore definite assertions of 'compliance' cannot be made based on CAS data alone; the response data can only be viewed as an indicator.

So a hospital trust is issued with a 'Patient Safety Alert', in regard to the provision of services that are not reaching the required standard. They then say that they have complied, and give themselves a clean sheet, without proof, or fear of scrutiny. 

This seems to be par for the course, with healthcare provision, and the provision of data on waiting times, both in terms of the NHS trusts, and the local CCGs. Processes created to obscure the truth, and the deployment of a language that prevents communication of facts, rather than explain them. 

Hard not to feel dismay, for example, after the decoding of references to 'Never Events', in the NHS and CCG data. What are they? An invitation to a corporate healthcare event in Neverland, courtesy of Peter Pan and Wendy, where no one grows old, or dies - or falls ill, and becomes a burden on the NHS? 

No. This is a useful euphemism for fatal cock ups, like cutting off the wrong limb, injecting someone with a lethal dose of the wrong drug, or leaving a medical instrument in your body, after an operation. (102 national incidences of the latter, in 2014/15).

Your life in their hands. The NHS managers, and their political masters, that is, not the hard pressed doctors, nurses and other staff.

Do you feel reassured?



But we digress.

I recommend, if you need a referral, that you do your research using the data provided on the NHS website, before trusting your referral to the local management service and 'ERS', the online referral system. In fact, look at it before you visit your gp. And demand that you are given every choice available, not limited to one or two.

In the previous post we looked at the local CCG, and what appears, from their website, to be a marked reluctance to be transparent in all its activities, and in regard to performance. 

The CCG website has a Publication Scheme page, in which we find a link to 'our governance standards and codes of conduct', and some admirable statements: 

The Barnet CCG Governing Body has agreed to adopt the Standards for members of NHS boards and Clinical Commissioning Groups Governing Bodies in England as published by the Professional Standards Authority for Health and Social Care.

These standards put respect, compassion and care for patients at the centre of leadership and good governance of the NHS in England. These standards bring together the essential attributes expected of all leaders in the NHS in England in their personal behaviour, technical competence and business practices and are based on seven core values:

Responsibility
Honesty
Openness
Respect
Professionalism
Leadership
Integrity

The standards challenge members of the CCG Governing Body to take responsibility for their own behaviour, to challenge the behaviour of others, and to recognise and resolve conflicts of interests.


I'm sorry to say that in my opinion, the website itself does not comply with a reasonable standard of openness.

Many categories of information that ought to be in the public domain are available only by referral to their FOI procedures: these include -

Procurement and tendering procedures
Contracts currently being tendered
List and value of contracts awarded and their value
Clinical Governance
Audit Reports
Service user surveys
Internal Communications guidance
Policies not published
Information we are currently legally required to hold in publicly available registers
Main contractors and suppliers
Assets registers and information Asset Register

These areas of information should not be hidden behind the Freedom of Information request process, but be published and put in the public domain: Audit and Clinical Governance are serious matters that we have a right to inspect, and not see withdrawn from public access.

Those links which should be active, and up to date, but are not, include:

Expenditure over £25,000: despite stating ...

As part of our commitment to openness and transparency in respect of public expenditure we publish details of our payments over £25k.

... there is nothing after July 2016.

The link to the Annual Report is to 2014/15, also the Engagement Report: to find a link to the current Annual Report you need to search through until you accidentally light upon it on the publications link. 

The Gifts and Hospitality page 'can't be found'.

And the Register of Interests here has not been updated since November 2015. This is unacceptable, especially when, for example, you have Board members who also have connections with Barndoc, one of the service providers to the CCG.

Officers too, have external business interests which have been published in 2015, but not been updated. Why not? 

This is a failure in openness, and transparency, and not in line with the CCG's own stated values. As the CCG's own policy on Conflicts of Interests acknowledges, it has a duty to: 

Ensure that for every interest declared, arrangements are in place to
manage the conflicts of interests or potential conflict of interest, to
ensure the integrity of the group’s decisions making process;

Ensure the Gifts, Hospitality and Sponsorship Register is maintained
and reported to the Audit Committee at least annually; and

Ensure the Register of Interests is published on BCCG’s website and

made available on request. 

Registers and declarations are presumably being kept up to date by all participants, but in the interest of transparency, these should be kept up to date on the website, where we can all inspect them - and they are not.

The CCG may not be very good at being accountable to the residents of Barnet, but it seems that they are about to find out that such complacency is no longer sustainable.

After writing the previous post, Mrs Angry was pleased to hear of the emergence of  new campaign group, Barnet NHS Needs You, set up by the local Labour LCF: (Local Campaign Forum), a group which includes representatives from all three constituencies in Barnet - and four local GPs. 

This week they highlighted the totally inadequate funding allocated to Barnet to implement the new government demands for 7 day GP access:

Barnet will get just £1.90 per person in NHS funding to support extra hours and seven-day-a- week GP services this year, compared with £5.42 per person in Enfield, £4.75 in Haringey, and £3.78 in Camden. Islington gets more than three times as much as Barnet with £5.84 per person.

Frankly, as it is, many gps in this area cannot provide easy and quick access to appointments: any funding should go towards supporting and improving the current provision, not stretch such constrained resources to impossible targets, out of a politically driven policy meant to use gps as scapegoats, and distract us from the crisis in care that has resulted from the Tory government's policies of privatisation and deliberate underfunding of the NHS.

It is good to see a local campaign group ready to take on the defence of our local NHS: in fact it is desperately needed: who else is there? Who oversees and scrutinises the provision of healthcare in this borough?

The local Health and Well Being Board is stuffed full of Tory councillors - no Labour members allowed - and members of the CCG, and North Central London Health Overview and Scrutiny Committee, which could have Labour appointees from Barnet, if their Tory colleagues agreed, naturally does not, in line with the usual Barnet Tory objection to the principles of democracy, fairness - and accountability.

Up to us, then, isn't it? More details on the new group will be posted here, as when the launch begins.




Sunday, 29 January 2017

NHS SOS: or, how to hide a crisis in healthcare, in Broken Barnet



Mrs Angry may have mentioned, once or twice, that she has a bad back. 

Has done for about 15 years: a tendency to problems with discs, and trapped nerves. And now she is in her twilight years, and in a general decline, with a spine that is falling apart, this is becoming something of a major problem, to the extent that for last few weeks, she has been completely incapacitated, and hardly able to do anything: walk, stand for long, sit - sleep, work. 

Things were so bad at Christmas, at one point, she actually packed a bag of necessities, and picked up the phone, thinking she would have to call an ambulance, & be admitted to hospital, as the pain was unbearable. At its worst, only the reports of the current A&E crisis, with patients dying on trolleys, and the Red Cross being called in to help, dissuaded her from such a move.

What do you do in such a situation, if you live in Broken Barnet? Call your gp? 

Not mine. Doesn't do house calls. 

Go to see him?

Couldn't have got to the surgery, even if there were any immediate appointments, which there rarely are. These days you ring up for one, but find they have all gone, within a minute or so of the line being answered. You are invited instead, if you need an urgent appointment, to arrive at the surgery the next morning before 8.30, and queue outside, in the cold, like vagrants applying to the workhouse, in the desperate hope of maybe being granted an appointment sometime within the next 48 hours. Of course this means that the patients who feel the most unwell are most likely to have to come and queue in this way, which really is intolerable.


Why is this necessary, anyway? If a practice is so overwhelmed with patients it cannot provide easy access to appointments, why do they continue to advertise for new patients? Is it because they receive a payment for each registration? Is the effect of this unlimited recruitment detrimental to the standard of care offered to patients? I would argue that it is.

If there are no appointments with your gp, you may go to a walk in clinic - if you can walk, or get into a car, which I could not - and chance your luck. After a long wait - impossible for me to sit that long - you may see a nurse practitioner, if not a doctor (they usually don't wear ID, so you have to ask who and what they are). If you end up needing some sort of x ray, or test, the chances are you will then be sent on to Barnet A&E, of course, with another long wait.

And what happens in A&E?

A couple of years ago, late at night, I was obliged to go with my son to Barnet General A&E, as he was in excruciating pain, a complication of a health condition. We arrived at ten pm. After waiting some time in metal chairs, even though he was writhing in agony,& needed to lie down I had to summon Mrs Angry to demand he be allowed to let through to the cubicles - which were not fully occupied anyway. He was immediately given strong pain relief, and had a scan. And blood tests were taken. And then we waited. 

Blood test results were going to be delayed, we were told, because the clocks went back that night, and that always meant the IT system went down. Always? In A&E? 

Mrs Angry poked her nose in again. Why is this tolerated? Who are your IT contractors? They didn't know. 

The scan results, we were told, were delayed because they were in a queueing system, in Australia. Excuse me? No consultants on call to interpret them, as the trust has a private contract with a company in Oz, to whom scans are emailed, and then some technician sitting at a screen on the other side of the world has a go at guessing what's wrong. But they had clients all over the world, and we had to wait our turn at the end of a long queue. 

The results didn't turn up until 8 am, ten hours later. In the meanwhile, after four hours of waiting, I went to the loo, came back to my son to, only find he was being made to get off his bed, and move. What's going on? Oh: he is being discharged to another unit? Why? To free up a bed. What unit? This 'unit' turned out to be a chair, next to a nurse's desk, round the corner from the cubicles, where we waited a further three or four hours, despite the discomfort and exhaustion of my son. I went back to check the cubicles several times during that time: only a third of beds were in use. 

And then it dawned on me what had happened. 

Have you moved him because of the four hour target, I demanded? 

The nurse said nothing - it was not her fault - but looked at me in embarrassment, indicating I was right. They were throwing him off a bed, to sit in a chair, round the corner, in the dark, for hours, so as to be able to avoid another statistic which proves that our local A&E could not reach the 4 hour targets. 




A&E: moving targets

And if this was a regular procedure, enforced by managers, then of course the failure in targets was in reality far worse than the statistics suggested. We made a formal complaint about his treatment: nothing much was achieved, of course, because NHS trusts are effectively accountable to no one, over such matters. 

That was then: now here we are in 2017, with a crisis in A&E provision, and patients left in corridors, as so many years of Tory underinvestment and political assaults on the NHS has fatally wounded the system upon which we all rely. 

No point in going to A&E now, then, this Christmas: and not able to see a gp or get to a 'walk in' clinic.I could hardly get out of bed, let alone walk to a walk in centre, or queue outside the surgery.

After Boxing Day, the pain was so acute, I tried calling the practice to see, in desperation, if the gp would take pity and come out. It was closed, for several days over the festive period. 

All I had were some painkillers, which the gp had prescribed by phone, which is another favoured arrangement - you ask them to call you, a few hours later they do: you guess what is wrong with you, and they ask you what you want to do about it. Give me drugs. Here you go.

In desperation, and entirely against my principles, for the first time in my life I resorted to paying for a private gp to come out, at vast expense, to give a pain relief injection, which was thankfully helpful, and got me over the worst point. 

A few days later, having lost the feeling in most of my foot, and increasing numbness in my leg, as well as severe pain, consulting him in desperation again at the company where one of my 'overburdened' gps, I noted, works, as well as at our NHS practice, the private gp said I must get a lumber MRI scan. 

I knew there was no chance of getting one urgently in Barnet, so I paid a fortune for one to be done privately, the same day, (under no pressure, it should be noted) as by then I was terrified there was something seriously wrong. The scan confirmed the problem was with a combination of issues, mostly to do with displaced discs, one of which, right at the base of my spine, was particularly bad, and causing the worst of the symptoms. So what now? The course of treatment done privately would cost thousands - not possible for me. 

Have to go to the gp to be referred. Email gp - ask for referral. He says I must make an appointment with him in order to do so. Ring surgery. Receptionist, (one of the type that appears to think any approach by a patient is some sort of impertinence), says there are NO appointments at all. In the foreseeable future.  Eh? What, ever again, in the history of time? I didn't say that. Well, after protesting, and stressing that the gp had told me to make one, one was suddenly found - the next week. More delay. 

Somehow I managed to get to the appointment, and made it absolutely clear what an impact on my life the problem was having, that I couldn't move, walk, rest, sleep, work: that I was exhausted, and the pain was intolerable. Result: more handfuls of painkillers and an agreement to refer me to a consultant. Urgently. How long would that take? Maybe four to six weeks. I looked at him in horror: I can't wait that long. Maybe it would be faster, he shrugged, if I was lucky. Little did I know then that six months, not six weeks, would be a more accurate estimation. Yes, for an urgent appointment. Read on.

I could go to Barnet or Chase Farm. Barnet would be better, I say, as I can't easily get to Chase Farm (in Enfield) in this state. You'll go to whichever you get, he said. Well, ok: yes. 

Just a few days before, I had read an article in the Guardian about private companies being used by health authorities to handle referrals - and block as many of them as possible. Did Barnet use such a service? Yes, they do. Oh. Will this cause any problem? No, he didn't think so. But most referrals are not referred on, are they? He thought they were. Mrs Angry knew otherwise, and told him that someone had forwarded to her an FOI request which shows only around 20 per cent go to specialists, the rest being 'triaged' and dealt with in alternative ways.

A few days later, however, there seemed to be good news: a letter arrived from the referral management service (RMS) - log in details so as to make an appointment. Ok. Go to website to do so. Yep - says urgent referral. Comes up with Barnet and Chase Farm. And then - what?

A statistic sitting below the hospital details - both of them, Barnet and Chase Farm back clinics:



I read and re-read this several times. That couldn't be right, could it? Because we know there is an 18 week statutory limit for waiting times. 21 weeks would be a breach - and 21 weeks for 92% of patients ... would be a scandal.

Still: I had an urgent referral, so that would not apply to me, would it?

On to the next step, to book the actual appointment. Which is when I really had to stop and stare at the screen in disbelief:




No appointments? At all?

Not limited availability: no availability. 

Urgent or otherwise. 

None at all? Ever? 

Clearly this was because they do not make appointments beyond a limited point of demand - perhaps the statutory limits, thus hiding a backlog of referrals - including urgent ones - that cannot be dealt with, in the current state of things, by our two local hospitals. 

Again: this is nothing less than scandalous. Both in terms of the lack of provision, and the process of deliberately hiding the true level of demand. It is from the same approach to management as the fudging of A&E statistics: calculated to give a false report of the crisis facing our NHS, due to the government's underfunding - and the fatal introduction of market values, and unrestrained privatisation. 

What next, though? Back to Step I? As far as I could see, I had no alternatives on offer - this couldn't be right, could it? 

Maybe it was because I was trying to book at the weekend. I tried again the next day: same result. 

I rang the Patient Advice and Liaison Service (PALS) for help: they said that this was not acceptable, and that the gp should be contacted, straightaway. I emailed him and asked as advised, that if the NHS cannot provide me with any appointment, at all, let alone urgent, that I could be referred to a private provider with a contract to supply such services in this sort of situation: but no reply until, after another email, a message was sent late the next day, saying I had to contact the referral service myself, all he could do was refer me again, and 'He states that he cannot refer you to a private consultant via NHS funding'. Oh. Well: this was not true, as I was to discover, or at least he may not be able to, but the referral service can - but I was also dismayed that my own gp could not attempt to find me any provision, but that I was expected, in my state, to spend hours negotiating the system in order to find some sort of treatment.

I made a formal complaint about the failure in the referral appointment system to the 'NHS North East and East London Commissioning Support Unit', which is apparently the body which is meant to oversee Barnet CCG's provision of services. This has had to be updated, throughout the week.

I rang the referral service. The phone was answered by a young man. He said he had no clinical experience. How could he assess my needs, therefore? Could I speak to someone who was qualified to do so? Nope. They only had a doctor there in the evening. Manager? not available. I persisted, until I did get to speak to someone. I made sure she knew a. that I had made an official complaint and b. that I was writing about my experience. After some time, I learned that I had a right to be referred to other options other than Barnet or Chase Farm. In fact, as I now know, the NHS constitution gives you the right to specify any provider. Shame my gp did not tell me that, nor does the online appointment system make that clear. 

Only trouble was - there were still no appointments, anywhere, anytime soon. Whipps Cross? Where is that? Essex? How do I get there, like this? And not anytime soon anyway, let alone urgent. 

No appointments, apparently. Royal National Orthopaedic Hospital, an obvious choice, and not far away in Stanmore? No response as to whether or not there were any. Chelsea & Westminster, but not for a long time, was the reply. 

What about the Royal Free, in Hampstead, which is actually my nearest major hospital? They don't have a back clinic? Oh come off it: are you saying there are no orthopaedic doctors at the Royal Free? 

Um: well there are, but they call it something else, she said. Comes under rheumatology. 

I don't care, I said, trying not to lose my temper, what you call it: I just want to see a specialist, quickly, and not spend any more weeks like this, in constant pain, forming a dependency on painkillers which don't work for longer than an hour at a time, unable to move, or sleep, or ...

Oh: suddenly, after searching the wide open landscape of NHS provision, within London and the Home Counties, and possibly beyond, the manager remembered the existence of a private hospital, a short distance from where I live - which apparently has a contract with local NHS providers. 8th February ok?

Ok: yes thank you. So my gp was wrong, and this is an option, after all? 

Yes. Except ... they may reject my referral. She claimed this was not uncommon. Even though they have a contract to supply services to the NHS? Yes, if the case was 'too complex'. If my referral is rejected, I commented, I will be asking for statistics on exactly how many referrals are made to this provider, and how many are refused. She said she would get confirmation the next day, if successful, and - fortunately - it was. Even better, I could go on the 3rd of February, as my needs were urgent. Marvellous. Which doctor, or clinic was it? She said she didn't know: it didn't matter, just turn up and they would direct me.

And then I got the letter, a day or so later. 

Looked up the consultant, and was confused. He wasn't an orthopaedic specialist. 

He dealt with pain management, and anaesthesia.

I rang the referral service. The manager I had dealt with was not there. Another woman listened, and said she would ring the hospital. She claimed there was only an answerphone. That was Friday afternoon, and that was how it was left. I have no idea what happens now.

I updated my complaint, and gave in to despair at the impossibility of ever sorting this out. *

*Updated Monday: 

After a morning making strenuous and exhausting representations to the Barndoc run 'referral management service', eventually, after a lot of argument, the appointment with the right specialist was retrieved. I was told there may be a 10-12 week after the initial appointment for any treatment. The idea being, presumably, that you are left to recover slowly, and in great discomfort, over a matter of months, and cure yourself, without causing too much expense to your local CCG

Earlier last week, I had tweeted about my experience, and included @barnetCCG, without much hope of any response. I did receive a response, from their 'communications manager'. Yes, they have a communications team - we may not have enough money for local NHS services, but we can afford to pay for spindoctors for our local Clinical Commissioning Group, to manage their reputation, and make sure no naughty bloggers alert residents to the state of crisis in NHS waiting lists?

He wanted to know if we could discuss the issues (not on twitter, clearly, was the idea, ie let's shut you up). I emailed him to say no thank you: I've made a formal complaint about the CCG's failure to provide me with an NHS appointment, the breach of statutory waiting limits, the referral process etc. 

They didn't let it go. A day or so later, I had an email - my address clearly passed on, without my permission, to a woman whose job is 'Head of Programmes – Demand Management
Barnet Clinical Commissioning Group'. She wanted to discuss my tweet. Which one? By now I was deliberately updating the story, putting the matter where it should be, in the public domain. Could she call me? If you must.

A long conversation ensued. To be fair, she listened carefully -  of course I pointed out, again, that I had made a formal complaint, and that I would be writing about the issues raised by my experience, but clearly, from her response, she knew that already. She appeared not to know how the ERS, online referral system, worked in practice, rather than theory - and accepted when I offered to send on copies of the screenshots published here, as if she could not quite believe what they said. She thought there were clearly flaws in the referral process that could be addressed, like - information leaflets given at the point of referral by gps, as I pointed out patients probably do not know their rights under the NHS constitution. And gps should be reminded that patients have the right of referral to any provider, and not, as I was, led to believe. that there were only two options.

Well, tinkering with the process is all very well: better information is a good thing - but the real issue unaddressed is the failure to provide appointments - any at all. Not much point having a referral process if there is nothing to refer to, is there? 

And how widespread is the problem? Someone contacted me, after one of my tweets, and said it was common for gps in this area to re-refer, as appointments were so hard to secure. Anecdotal evidence, of course, but if true, this means that each re-referral masks the underlying problem, and prevents the politically damaging statistics that would accrue as a result of unlimited waiting lists: if, for example, the waiting time to see a back specialist is admittedly already in breach of statutory limits for 92% of patients, on one referral, and there are no appointments at all, what is the true picture, if we were able to include re-referrals? Lists that are many months long, and maybe more than a year from time of first referral by a gp? 

Who knows? Probably no one. Ignorance is bliss, if you are an NHS manager, or a Tory health minister. 

A&E targets, waiting lists: the deliberate suppression of the real level of demand is absolutely insupportable - but who is speaking out against this, or holding them to account for it? No one in Barnet, as far as I can see, which is why they are getting away with it.

Who are they, you may be wondering? Well, it would seem that as Barnet CCG holds responsibility for commissioning services for residents of this borough, the responsibility is theirs to ensure that provision is good enough, and certainly that it complies with statutory requirements. Does it? Not in my case. But how wide a problem is it? I think we should be told, don't you?



Dr Debbie Frost, Chair of Barnet CCG

In conversation with me the CCG's 'demand manager' had let slip that gps should know the current state of waiting lists as they are all sent monthly bulletins with the relevant statistics. Oh: may I please have a copy sent to me? Yes, of course. Although there will be a new one out soon, would I like to wait for that? I'd like that as well, to compare with, but in the meanwhile, could I have the current one? Yes. 

Despite several reminders, and agreement to send this on - it has not been forwarded. 

Draw your own conclusion.

There is reference, incidentally, on the Royal Free Foundation Trust's website to NHS waiting lists - this trust now has responsibility for a wide area, and includes Barnet and Chase Farm hospitals - in the absence of much information elsewhere, this statement is interesting, albeit rather curious: 




So 90 and 95% are the targets for patient waiting times. Yet ERS referrals to at least two clinics within the Trust's area are actually failing at a rate of 92%, and 21 weeks. What about the performance of the rest?

And what a clever statement here, my emphasis: 'A total of 92% of patients who are actively waiting for treatment should not have waited longer than 18 weeks'.

Well no - they shouldn't have, because there is a statutory obligation for them to be seen within that period, but the point is - did they wait longer? Please tell us the truth.

Back to Barnet. 

Our CCG has a website, which I would urge all Barnet residents to look at - and examine. 

There would appear to be no current information available here on the performance of the services they are paid to commission on our behalf - that is to say in a form easily accessible to most residents and patients.

If you are a stroppy citizen journalist with severe back pain, and no appointment with a specialist, however, and feel motivated to look at the papers relating to the last Governing Body meeting, on 26th January, there are some interesting reports - or rather - oh: they would be interesting if they contained data that could be scrutinised, unlike the 'Access KPIs and Mini Data Sets', in which all the most vital information appears 'to be confirmed', or not stated. There is listed an annual report for 2014-15 here: 



But this page 'can't be found', which is rather unfortunate, isn't it - especially when there is no Annual Report for 2015-16? Or perhaps I've missed it, in my drugged up stupor.

I've just noticed another page which can't be found either: 'gifts and hospitality' - not really very impressive to see this: and who knows how many other links are the same?



Oh: hang on, by googling have found a draft copy now: very interesting - wonder why the website hasn't published this? Let's see. 

Lovely diagrams.

Hmm. Oh dear. Oh look:

Barnet CCG is in deficit, or was up until May last year.

They admit they are not compliant with standard targets on 'Referral to Treatment Incomplete Waiting Time Performance'.

They boast of  a key achievement being the elimination of the historic backlog of patients waiting over 18 weeks to be treated, in regard to the Royal Free services (complex definition - don't ask). Mrs Angry imagines this achievement is due to the wonderful system of not giving appointments at all, as explained above. Well done. Pat on the back. 

Ah, but ... here is a story from 'Enfield Today', which describes a crisis in backlog cases in 2014: in the previous year, we learn, the local NHS trust ...

'had stopped reporting the numbers of patients waiting longer than 18 weeks for treatment to NHS England because of a major data quality problem'.

A major data quality problem. Dear me. 

Looks like that 'major data quality problem' may have recurred, doesn't it? 

Despite the fact that Barnet CCG was then, in 2014, given additional support, 'underpinned by "legal directions', by NHS England.

Still. Back to the last annual report (draft) and - there is more good news:

Given the potential risk of harm to patients waiting for long periods of time before treatment, the CCG also introduced a robust clinical harm review process.

In other words, they may not be able to grant you an appointment, but they will make a show of worrying about the fact you might drop dead before you are treated. I am paraphrasing, of course, because I am losing the will to continue. Oh dear. Hold fast. Here comes another load of ... 

In order to monitor progress, the CCG initiated an RTT Task & Finish Group (oh, hoorah: we like these, in Broken Barnet - the perfect vehicle for never accomplishing anything, but looking as if you are doing something about it) ... which meets monthly and has a clear remit to monitor the delivery of recovery and improvement plans until targets are met. This work has also overseen the reduction of patients waiting in excess of 52 weeks for treatment.  Erm - 52 weeks: a whole year? Yep. At the start of the year there were 195 patients waiting more than a year, and by March 2016 this historic backlog of 52 week waiters had been reduced to 1.  

Let's hope the other 51 weren't the victims of 'clinical harm' - or worse.



An historic backlog of waiters, before being 'reduced' by Barnet CCG

The draft report gives a link to a Register of Interests, which, it is claimed, is updated bi-monthly, but seems, from the listings given, not to have been updated on the site since July 2016. 

We also learn that there have been issue with conflicts of interest, and whistle blowing:

Raising Concerns and Managing Conflicts of Interest

In May 2015, a member of staff raised a concern about conflicts of interest around the
commissioning of primary care services. There was a concern that GPs had not fully declared their financial interests. In addition in November 2015 two members of staff wrote letters to the Secretary of State for Health and NHS England about the recruitment and remuneration of interim staff. 

Two reports were commissioned to look into these matters.

The details given, in this report, of the remuneration of CCG senior staff are very interesting.

The Chair of the CCG Board, Dr Frost, earns £120-125,000 a year. 

In regard to senior officers - despite the deficit, Mr Matthew Powls, Director of Planning and Performance/Chief Operating Officer, takes home a whopping £290-295,000- or rather 'an agency' does.

Another senior officer, a Mrs Elizabeth James, Director of Clinical Commissioning/Interim Joint Chief Operating Officer is on £200-205,000, through another agency arrangement. Ms Sarah Thompson, another Director of Clinical Commissioning, is on £85-90,000. Etc, etc. Why do we need two directors of commissioning? And two Chief Operating Officers? Are these posts subject to any kind of performance evaluation, again bearing in mind the deficit, and other failures, such as missed targets? While ordinary doctors and nurses and other, less well paid NHS staff struggle so valiantly to keep our healthcare system going, despite such demand on resources, frankly this level of expenditure to me seems utterly unjustifiable. 

The CCG performance data which is otherwise available in statistical form in the minutes of last year's meetings is hard to follow, but does not anyway represent an accurate or clear picture: referrals to treatment, 'RTT", for example, includes, but does not specify, the percentage of referrals to consultants, or the full range of providers, and we already know from the FOI response that most referrals - 80% - are 'triaged' off to treatment other than specialist services:

The RMS receive the majority of GP referrals. Exclusions include two week wait cancer referrals, mental health and some community referrals.

The RMS process approximately 7,500 referrals a month. For 2014 / 2015 this was a total of   90,732 referrals sent to the RMS.


80% of these are triaged and the remaining 20% are not triaged and sent directly on to specialist services.

It is worth looking at another document published on the Barnet CCG website, if you look for it - the declarations of interest in regard to the members of the Governing Board - here specifically for the January meeting, in a committee room at Hendon Town Hall - the perfect venue, of course.

The first declaration is from the Chair, Dr Debbie Frost, who states that she is a gp in Mill Hill - and that one of her practice partners is also the Chair of Barndoc Healthcare Ltd. Rather surprising, that the Chair of the CCG, and the Chair of one of CCG's major contractors are partners in the same gp practice.

Two other members of the CCG Board are local gps who are shareholders in this private company. 

Three members present at the meeting, out of ten in total, therefore, have links to Barndoc.

What is the significance of that, you may be wondering? 

Well, Barndoc is a private, for profit company, one that is commissioned by the CCG to provide certain services to Barnet patients. Out of hours care: very important. And also very important ... the Referral Management Service. 

Not much is said about this function, on the website, and most patients probably have no idea it exists. Or what it does, or that there is any need for it at all - after all, it used to be the case that your gp referred you by letter directly to a consultant. 

Those days are gone. 

In the new era of market opportunity in the NHS, there is profit to be made from 'managing' referrals - and filtering out those deemed unnecessary. Hence these referral companies, and all the other 'for profit' enterprises springing up everywhere.

Although profits are, according to Barndoc's website, 'reinvested in improving patient services and care', there are of course large budget expenses that must be met before any profit can be made, all of this detailed in the filing history and accounts at Companies House, (information that is required to be in the public domain) - staff salaries, directors and consultancy payments, some billed to local gp practices: take a look.



There is of course no implication that any of this is anything other than lawful, and transparent. One would expect that these members recuse themselves from any discussions that would relate to services provided by Barndoc, and I am sure we would receive full assurance that this is the case.

But is there not a reasonable argument to put, that there is an inherent conflict of interest in the Board of Barnet Clinical Commissioning Group including members of a private company commissioned by that group, a company whose delivery of contractual obligations are not openly scrutinised, in a way easily accessible - or comprehensible -  to members of the public: the patients, residents and taxpayers who rely on those services?

If waiting lists in Barnet are not meeting statutory limits, then the CCG which has responsibility for commissioning the healthcare for which referrals are made needs to challenge such failures, openly, robustly and objectively, in terms of provision, and process. When members of that CCG are actively involved with the private company that is meant to manage the referral management process, can we be sure that our best interests are being safeguarded? If there is not any conflict of interest, is there still a risk of perception of conflict? Have these risks been assessed, and audited?

And most of all, who is going to ensure that there is full transparency, and accountability, to patients in Barnet, in regard to the provision of NHS care? 

Not our local Tory MPs, who prop up a government that could not care less about the provision of care, in health, or any public services. 

Not our local press, who don't seem interested in investigating any serious issue, any more.

Over to you, then comrades in Barnet Labour: time to step up - and speak out. 

In the meanwhile, I have plenty of time on my hands to lie here writing about it my own experience, from the sharp end, as you can see: in great discomfort, but fortunate enough not to have my life in danger -  but for many people waiting to see a consultant, lengthy delays can and will cause extreme distress, and could have serious consequences. 

We must act now, for their sake: acknowledge the problems we face, and do something about it.

Overworked gps are not always able to detect when an illness or injury is life threatening, and expedite the referral. In some cases, waiting months to be seen by a specialist may quite literally prove to be fatal. 

So: residents of Broken Barnet - the NHS, in your borough: your life in their hands - are you happy with that thought? 

If not, you'd better be prepared to do something about it.