Wednesday, 18 January 2017

Vote of no confidence in the Chief Nursing Officer of NHS England

On Wednesday, the governing Council of the BMA will take the unprecedented step of debating a vote of no confidence in the Chief Nursing Officer, Professor Jane Cummings. I am the member of council that has proposed the motion of no confidence. I took this step on the basis of Jane Cummings' recent interview with the Telegraph, in which she quite rightly called for more investment in community care, but at the expense of cuts to acute care NHS beds [1].

This is a dangerous and negligent approach in the context of an ongoing crisis in the NHS with many hospitals on blacks alert (hospitals at full capacity, closed to further admissions), routine operations being cancelled including cancer surgery [3], a lack of provision of mental services, a collapsing social care system, and general practice in meltdown. If she had based her argument solely on the idea of investing in community & social services to help deal with the major problem of delayed discharges (patients fit to leave hospital, but lacking necessary social care discharge arrangements), then I would have supported her. However, she did not call for extra investment to achieve her goal. On the contrary, she called for yet more NHS "efficiency savings" by openly supporting the Department of Health policy of Sustainability and Transformation Plans (STPs). 

These plans are driven by a mandate to achieve a further £22bn of NHS "efficiency savings" by 2020, which will not only reduce funds for acute care, but also inevitably result in cuts to the very community services that she supposedly wants to bolster. Not surprisingly, all of the 44 STP "footprints" (regions) have plans to save money by closing services.

Worse still, Jane Cummings should know better, because she was involved at senior level, in the previous Government's £20bn "efficiency savings" program called the "Nicholson Challenge" or QIPP (Quality, Innovation, Prevention, Productivity), which lasted for four years and only achieved £16bn out of the £20bn target. Sir David Nicholson, the former CEO of the NHS, who had the responsibility to deliver the "Nicholson challenge" has stated that this level of "efficiency savings" wasn't repeatable. And you only have to look at the current state of the NHS to understand why - the "Nicholson challenge" has crippled the NHS. It is one of the main reasons why the NHS is in its current crisis. Even Andrew Lansley, the former health secretary, thinks the NHS needs more money. 

Yet, Jane Cummings thinks that STPs are the way forward with another £22 billion worth of efficiency savings on top of the previous £20bn. She is clearly completely out of touch with expert opinion. The Health Select Committee and the main health think tanks have stated this is unachievable without compromising patient care and safety [4]. Since her her employer, NHS England states
"A core role of the Chief Nursing Officer will be to drive quality improvements in patient safety and patient experience", her support for STPs and £22bn of "efficiency savings" is clearly incompatible with her role as Chief Nursing Officer.

The CNO also has a responsibility for NHS finances and efficiency and it is now becoming clear that excessive "efficiency savings" are actually making the NHS less efficient according to health economists from the Health Foundation [5]. For example, NHS staffing has been cut to the bone which has led to a spiralling locum bill for doctors, nurses and other healthcare professionals. In addition, the current crisis in emergency care has led to the cancellation of routine operations, with significant financial consequences for NHS trusts. Moreover, the £200m cut to the public health budget has also damaged the most efficient and cost effective way of reducing demand for healthcare - tackling preventable diseases.

One therefore has to question why Jane Cummings has taken the position to defend a government policy that will inevitably harm patient care. Clearly, she is an employee of NHS England and has a responsibility to her employer. However, this must be balanced against her professional judgement about patient care, the state of the NHS, the health of the nation, and the greater good. Politicians have a long standing record of using clinical leaders in important positions to back their positions. Nigel Lawson, the former Tory Chancellor of the Exchequer under Margaret Thatcher, expressed this very well in his diaries [6]. In relation to Thatcher's NHS reforms, Lawson stated:

"The professionals, once they knew it was going on, wouldn't be backwards in giving us their advice, and more fruitfully we could always get the opinions of politically well-disposed practitioners informally".

The public trust nurses and doctors and therefore politicians are keen to use them to promote bad policies. It is therefore vital that our clinical leaders are able to speak truth to power and don't succumb to this political interference. The culture of "yes men and women" has damaged the NHS over the years and must be challenged. This is why I think a vote of no confidence is so important. Jane Cummings must be held to account for her actions. She is either guilty of supporting a government policy that will clearly harm patient care, or she is guilty of lacking understanding & knowledge of the consequences of another £22bn of NHS "efficiency savings". Either way, I think her position is now untenable.

NHS staff up and down the country are working incredibly hard to keep patients safe, often under very stressful and intolerable conditions. Despite this, patient care is clearly being compromised and lives increasingly put at risk. In fact, we know that "exit block" in A+E departments increases mortality, so it is very likely that lives have already been lost and will continue to be lost [7]. 
NHS staff and the public deserve better and shouldn't have to put up with this type of misguided leadership.

[1] Cummings interview. Telegraph:
[3] Cancer operations now being cancelled amid NHS crisis, surgeons' leader warns. Telegraph. https://www.google.co.uk/…/cancer-operations-now-canc…/amp/…
[5] Hospital finances and productivity: in a critical condition? http://www.health.org.uk/…/HospitalFinancesAndProductivity.…
[6] View from No11. Nigel Lawson's diaries. https://mobile.twitter.com/…/sta…/719107080834129920/photo/1
[7] Exit block in emergency departments. RCEM http://secure.rcem.ac.uk/code/document.asp?ID=8263

Dr Clive Peedell

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