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 ....


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:


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.