As part of our redesign of the community health and social care system in our area we are trialling the Buurtzorg model of community care in the most rural part of our CCG.The “Dales Project” will integrate health and social care in an area where we struggle to find carers, and staff spend a lot of time in their cars driving along slow rural lanes from patient to patient. The model is compelling. Having care delivered by self managed teams of highly qualified nurses who work closely within individual communities has been shown to improve the experience of care for patients AND reduce overall spend on care. You can read more on the RCN website at:
http://www.rcn.org.uk/__data/assets/pdf_file/0003/618231/02.15-The-Buurtzorg-Nederland-home-care-provider-model.-Observations-for-the-UK.pdf
Interestingly it also improves job satisfaction for staff. We are running the pilot for 18 months at least. It will be interesting to see the outcomes.
I found myself thinking about the staff aspect. It seems the staff in The Netherlands feel they do a more enjoyable job, providing more holistic care to patients rather than simply delivering the “nursing role”. Maybe there are lessons from that we might usefully apply to other areas of the NHS. Why are people not wanting to be GPs? Community nurses? Is it that as we skill-mix roles to squeeze the most cost effectiveness out of the system, we inadvertently design roles that no one wants to fulfil? Does working at the top end of your competency make the role too stressful and difficult to sustain into the longer term?
When I was a young GP I did my vocational training in a rural practice in Derbyshire. The practice fulfilled a wide role in the community, we regularly visited elderly isolated patients, delivering not just their medicines but provided an important social focal point and even delivered their groceries if necessary. Those long gone regular visits allowed us to help sustain people in their own homes, working with the glue of the local community to support and cherish those frail people. We would now have been called their care co-ordinator. When I first came to Catterick we syringed ears, took blood, did all our own on call. I remember examining a little boy with ear ache on Christmas Day in our living room. We knew our patients. Was that time wasted? Certainly they were roles that could be and are now fulfilled by other people with different training and who cost less than a GP. But did we lose something along the way? I remember a patient who I saw occasionally over the years for relatively minor things, all of which could have been delivered by someone else. But then one day she came to confide in me that her husband who had dementia had been assaulting her. She had told no one. She was a retired officer’s wife. You didn’t complain. She told me I was the only person she could tell because she knew and trusted me. Another patient developed motor neurone disease and they felt able to discuss with me the most personal of issues around their disease because of the relationship we had established over years of managing their hypertension and sharing stories of our children’s exploits. I very much treasure those memories and that way of working. I worked long hours on-call every other night and every other weekend but it felt good. Now the job is much more challenging, fewer hours of highly intensive work. Is the “decision density” of the modern GP role just too much to sustain for 30 years?
Our CCG has the best patient satisfaction for general practice of all CCGs nationally. People often ask me why. The GPs here still provide predominantly medically-led small practices where personal continuity of care is still alive and well. It is changing as it is everywhere, is it one of those things you don’t know what you’ve got till it’s gone?
Is our rush to define roles where everyone works to the top of their pay grade, to maximise efficiency for the system actually designing jobs that no one wants because they aren’t satisfying, are too stressful and don’t work on a human level? If the model from The Netherlands shows this is a cost effective nursing model that also delivers better satisfaction for both patients and staff should we just pause a little and reflect before we rush headlong into more skill mixed roles for primary care too?
Tuesday 14 July 2015
Thursday 4 June 2015
You can't do the job without the right people...
People have been asking me what I think the biggest threat to the NHS is in the next five years. My answer is simple: workforce.
I have been talking about if for the last few years. It is a crisis. I am glad it is now hitting headlines although we must resist the temptation to think that fixing what is broken is either simple or quick.
We simply don’t have enough people in the NHS or social care and we don’t have them in the right places.
There are issues everywhere you look. Lets start with the bit I know best: GPs. So many things have come along that conspire together to encourage those already in the service to leave: revalidation, changes to pensions, reducing incomes, increasingly busy days, endlessly negative press ( and yes that does get to you after a while)All the while fewer are joining us. Why? Well some of the issues are the same.. negative press, busy stressful work, other less stressful options. In a meeting I attended a while ago with someone from GP Education they said the issue with GP work stress was “decision density” I have never heard it called that before but completely get what he was talking about. AS a GP you make so many decisions every day: in every consultation, every phone call, every visit, every path result. This is often done with limited clinical information. Referring patients on to hospital unnecessarily risks flooding an already creaking system, wait and you risk missing something significant. It is stressful .A GPs work is much more decision dense that other areas of medicine. Now I am no longer a practising GP I miss the patients very much but I don’t miss the intensity of work you do every day. As more nurses and other professionals enter general practice they do more of what was GP work and GPs spend a much higher percentage of their time doing the really tough stuff. It is good use of their skill base definitely but it is stressful too.
Our area is very rural, another issue now. Young doctors used to choose to work here: pretty countryside, good schools, nice market towns. Now most of them are settled before they leave medical school ( we worked such long hours that we lived in hospital accommodation and socialised with each other for years after qualification) so they mostly choose to stay close to where they trained, which of course is in cities. So suddenly we have fewer people on our GP training courses and then fewer still who are choosing to move to work here afterwards.
At the same meeting someone asked if the fact that a greater proportion of GPs are women now has meant that as fewer want to be full time and this creates a further issue. The evidence apparently shows that neither male nor female GPs choose full time practice anymore, in equal numbers. So the issue is not that women don’t want to be full time GPs but that neither men or women do.
So as older GPs retire there aren’t people queuing up to take their places….
Okay then.. find other people to fill the roles, you may say.. .well we are trying but it turns out that isn’t easy either. There aren’t lots of trained unemployed advanced nurse practitioners, paramedics or physician assistants. To add to the mix practice nurses demographic data shows us an older group of nurses who are also close to retirement and not a surge of younger nurses coming in to the service to take their places. We know there are similar issues with nursing recruitment and retention. And having nurses in first contact roles gives them the same pressures and issues as GPs. A practice told me recently that the indemnity insurance for nurse practitioners had gone up from £750 to £7500 per annum in a year, no doubt to reflect the added risks they now take in these “first contact” ( seeing patients who haven’t been assessed by a GP first) roles.
This is just a snapshot of issues facing primary care.These and other issues exist in hospital medicine, nursing and caring. Most importantly the NHS isn’t seen as a fun or exciting place to work. It is seen as hard, poorly funded, tough work. So why join ? Would I join now? I have absolutely loved being a GP and feel so fortunate and privileged to have worked in the profession for 30 years but I find myself hesitating to recommend it and that makes me sad.
How do we change things? We need to openly and honestly accept the issues, and that they can’t be solved quickly, whatever the political rhetoric. It requires brave central action to increase medical training places, nursing places – perhaps consider more vocational routes into nursing, and the safe gradual development of other models of caregiver with full evaluation of impact...We need clarity about what the new roles are able to deliver and what are their limitations.
As a local economy we need to think about the building blocks that will entice new people to come to a rural area and those who grew up here to return, to make it an exciting vibrant place to live and work.
We need to make general practice medical and nursing roles and community nursing roles more attractive. After all we have no system to coerce people to work in unpopular areas ( as they do in other countries), not that I am promoting that idea but if we don’t then we have to make it a positive and attractive choice.
We need to fund it all properly so people get a fair pay for the job done.
This is a marathon not a quick sprint.
We need to be able to tell the story of why it is great to work here..and believe it.
I have been talking about if for the last few years. It is a crisis. I am glad it is now hitting headlines although we must resist the temptation to think that fixing what is broken is either simple or quick.
We simply don’t have enough people in the NHS or social care and we don’t have them in the right places.
There are issues everywhere you look. Lets start with the bit I know best: GPs. So many things have come along that conspire together to encourage those already in the service to leave: revalidation, changes to pensions, reducing incomes, increasingly busy days, endlessly negative press ( and yes that does get to you after a while)All the while fewer are joining us. Why? Well some of the issues are the same.. negative press, busy stressful work, other less stressful options. In a meeting I attended a while ago with someone from GP Education they said the issue with GP work stress was “decision density” I have never heard it called that before but completely get what he was talking about. AS a GP you make so many decisions every day: in every consultation, every phone call, every visit, every path result. This is often done with limited clinical information. Referring patients on to hospital unnecessarily risks flooding an already creaking system, wait and you risk missing something significant. It is stressful .A GPs work is much more decision dense that other areas of medicine. Now I am no longer a practising GP I miss the patients very much but I don’t miss the intensity of work you do every day. As more nurses and other professionals enter general practice they do more of what was GP work and GPs spend a much higher percentage of their time doing the really tough stuff. It is good use of their skill base definitely but it is stressful too.
Our area is very rural, another issue now. Young doctors used to choose to work here: pretty countryside, good schools, nice market towns. Now most of them are settled before they leave medical school ( we worked such long hours that we lived in hospital accommodation and socialised with each other for years after qualification) so they mostly choose to stay close to where they trained, which of course is in cities. So suddenly we have fewer people on our GP training courses and then fewer still who are choosing to move to work here afterwards.
At the same meeting someone asked if the fact that a greater proportion of GPs are women now has meant that as fewer want to be full time and this creates a further issue. The evidence apparently shows that neither male nor female GPs choose full time practice anymore, in equal numbers. So the issue is not that women don’t want to be full time GPs but that neither men or women do.
So as older GPs retire there aren’t people queuing up to take their places….
Okay then.. find other people to fill the roles, you may say.. .well we are trying but it turns out that isn’t easy either. There aren’t lots of trained unemployed advanced nurse practitioners, paramedics or physician assistants. To add to the mix practice nurses demographic data shows us an older group of nurses who are also close to retirement and not a surge of younger nurses coming in to the service to take their places. We know there are similar issues with nursing recruitment and retention. And having nurses in first contact roles gives them the same pressures and issues as GPs. A practice told me recently that the indemnity insurance for nurse practitioners had gone up from £750 to £7500 per annum in a year, no doubt to reflect the added risks they now take in these “first contact” ( seeing patients who haven’t been assessed by a GP first) roles.
This is just a snapshot of issues facing primary care.These and other issues exist in hospital medicine, nursing and caring. Most importantly the NHS isn’t seen as a fun or exciting place to work. It is seen as hard, poorly funded, tough work. So why join ? Would I join now? I have absolutely loved being a GP and feel so fortunate and privileged to have worked in the profession for 30 years but I find myself hesitating to recommend it and that makes me sad.
How do we change things? We need to openly and honestly accept the issues, and that they can’t be solved quickly, whatever the political rhetoric. It requires brave central action to increase medical training places, nursing places – perhaps consider more vocational routes into nursing, and the safe gradual development of other models of caregiver with full evaluation of impact...We need clarity about what the new roles are able to deliver and what are their limitations.
As a local economy we need to think about the building blocks that will entice new people to come to a rural area and those who grew up here to return, to make it an exciting vibrant place to live and work.
We need to make general practice medical and nursing roles and community nursing roles more attractive. After all we have no system to coerce people to work in unpopular areas ( as they do in other countries), not that I am promoting that idea but if we don’t then we have to make it a positive and attractive choice.
We need to fund it all properly so people get a fair pay for the job done.
This is a marathon not a quick sprint.
We need to be able to tell the story of why it is great to work here..and believe it.
Tuesday 19 May 2015
Reflections on Dementia
My mother died in December 2014. She was 94. She had a stroke, in the end but has struggled with dementia for 5 years before that.
Over the last 4 months as I have sorted through the paper and the processes that follow death and necessarily provide time for reflection, I have thought a lot about her, and about what I have learned as I watched her live with her illness and die. I am a GP. I understand the pathology. I have watched patients go through the same inevitable decline as an interested and concerned bystander but it is different when it is someone you love.
I saw the best and the least that the NHS provides.
I have felt proud and frustrated and angry at times.
These things I know:
Hospital is not a good place for people with dementia. So unless people really really need to be there – keep them away. The ground people lose when they are there away from the familiar and the safe is rarely if ever made up. Each time my Mum was admitted it didn’t matter how kind/ thoughtful/caring ( or not) the staff were she came home smaller than before she went in. Each time she had no treatment to speak of. The reasons for her admission were never clear and were usually more about the person sending her in than her.
So my advice to GPs, both in and out of hours , to community nurses , paramedics is- BE BRAVE –keep people at home if you can. Challenge the system. Don’t see hospitals as risk free places of safety if you aren’t sure. They aren’t! Admitting someone to hospital may make you feel you have done the safe thing but you critically underestimate the impact of your decision on their future functioning. In the end it has to be an assessment of the balance of risks. Hopefully if there are good domiciliary services in place keeping people like my Mum at home will be an easier choice.
Look for other ways to deal with aggressive behaviour don’t reach for the prescription pad. It took me a long time to realise that if my Mum was aggressive it was usually because she was frightened. What frightened her? New people, too many people all at once, people coming when she wasn’t expecting them, not coming when she was. Help care workers understand. When my Mum was unaffected by dementia she was a tolerant educated woman who lectured me about internationalism, delivered United Nations days in schools to help young people understand the UNs aspirations for a fairer world, marched against intolerance of any sort, embraced family members who came out around their sexuality.. and yet when she was admitted a nurse on the ward stopped me and told me she was a racist. New carers complained she was rude and abrupt. She was frightened because someone who she wasn’t expecting came to see her and she said something inappropriate. She wasn’t racist but she grew up in a white world and when that environment was all she was able to remember, anything else was frightening to her. Medicating her made her sleepy and more disorientated and it didn’t help. Asking staff to be on time, let her know who they were and why they were there, not crowding her,. making sure she had the same carers each day and not a parade of different people, that those who came in contact with her were given the tools and the training to understand rather than take offense.. made her aggression go away. Simple things aren’t they?
Help loved ones understand the process of dementia. It helped me to realise as Mums memory failed that it wasn’t that she forgot me but she forgot the architecture of her life. I have a grandson who is now nearly a year old. One day I visited my daughter and Artie and as I walked in he beamed at me…. It was a “hello I know I know you” smile. He didn’t know I was his gran but he knew I was familiar. I then went to see my Mum and the smile was the same. She didn’t know I was Vicky her daughter because just like Artie she didn’t know what a daughter was anymore. When we took Artie to see her she turned to me and said “did I have babies?” A question to me as someone she knew and felt comfortable with without any understanding of it possible implications for me. It helped me to understand those things, however sad….I was not offered any support from anyone ever. Maybe people just saw the GP capable daughter…… but there were times …I found books to read… on line resources but some are better than others…. Someone to guide me through what they offered would have been helpful and I would have wasted less time.. someone to listen might have helped in the dark days and there were many of them…
Develop the extra care model We were so lucky my Mum was living in an area where extra care was well advanced and they have developed the model to include people with dementia. It meant she was in her own “home” and never had to go to a nursing home. I am certain it meant she lived better for longer- surrounded by the anchors of her past, even if by the end she didn’t recognise what they were.
Pay carers properly. It is an amazing thing they do. The best are kind, patient, generous. They have to do tough stuff every day. They deserve so much more than minimum wage. The living wage must be the minimum mustn't it? Good carers keep people better, keep them away from hospital and out of nursing homes…. It is better for people and surely it can’t but save money…If we as a society value our most vulnerable people we must value those we charge with caring for them.
Support families to allow their loved ones to die at home, if that is what they want to do. We look back on the week my Mum had at home after her stroke and before she died with a sense of calm achievement. WE did a good thing. Together we loved and nursed her and said our goodbyes. It was intensely emotional. It was made possible by those who gently and quietly supported us. I will always be grateful. It helped us with the grief of losing her.
It is Dementia Awareness week. I read that dementia is now the number one cause of death for women and the fourth for men. My generation are witnesses to our parents struggle with the disease and I wonder how it will form and change our approach to our own care as we get older.
Over the last 4 months as I have sorted through the paper and the processes that follow death and necessarily provide time for reflection, I have thought a lot about her, and about what I have learned as I watched her live with her illness and die. I am a GP. I understand the pathology. I have watched patients go through the same inevitable decline as an interested and concerned bystander but it is different when it is someone you love.
I saw the best and the least that the NHS provides.
I have felt proud and frustrated and angry at times.
These things I know:
Hospital is not a good place for people with dementia. So unless people really really need to be there – keep them away. The ground people lose when they are there away from the familiar and the safe is rarely if ever made up. Each time my Mum was admitted it didn’t matter how kind/ thoughtful/caring ( or not) the staff were she came home smaller than before she went in. Each time she had no treatment to speak of. The reasons for her admission were never clear and were usually more about the person sending her in than her.
So my advice to GPs, both in and out of hours , to community nurses , paramedics is- BE BRAVE –keep people at home if you can. Challenge the system. Don’t see hospitals as risk free places of safety if you aren’t sure. They aren’t! Admitting someone to hospital may make you feel you have done the safe thing but you critically underestimate the impact of your decision on their future functioning. In the end it has to be an assessment of the balance of risks. Hopefully if there are good domiciliary services in place keeping people like my Mum at home will be an easier choice.
Look for other ways to deal with aggressive behaviour don’t reach for the prescription pad. It took me a long time to realise that if my Mum was aggressive it was usually because she was frightened. What frightened her? New people, too many people all at once, people coming when she wasn’t expecting them, not coming when she was. Help care workers understand. When my Mum was unaffected by dementia she was a tolerant educated woman who lectured me about internationalism, delivered United Nations days in schools to help young people understand the UNs aspirations for a fairer world, marched against intolerance of any sort, embraced family members who came out around their sexuality.. and yet when she was admitted a nurse on the ward stopped me and told me she was a racist. New carers complained she was rude and abrupt. She was frightened because someone who she wasn’t expecting came to see her and she said something inappropriate. She wasn’t racist but she grew up in a white world and when that environment was all she was able to remember, anything else was frightening to her. Medicating her made her sleepy and more disorientated and it didn’t help. Asking staff to be on time, let her know who they were and why they were there, not crowding her,. making sure she had the same carers each day and not a parade of different people, that those who came in contact with her were given the tools and the training to understand rather than take offense.. made her aggression go away. Simple things aren’t they?
Help loved ones understand the process of dementia. It helped me to realise as Mums memory failed that it wasn’t that she forgot me but she forgot the architecture of her life. I have a grandson who is now nearly a year old. One day I visited my daughter and Artie and as I walked in he beamed at me…. It was a “hello I know I know you” smile. He didn’t know I was his gran but he knew I was familiar. I then went to see my Mum and the smile was the same. She didn’t know I was Vicky her daughter because just like Artie she didn’t know what a daughter was anymore. When we took Artie to see her she turned to me and said “did I have babies?” A question to me as someone she knew and felt comfortable with without any understanding of it possible implications for me. It helped me to understand those things, however sad….I was not offered any support from anyone ever. Maybe people just saw the GP capable daughter…… but there were times …I found books to read… on line resources but some are better than others…. Someone to guide me through what they offered would have been helpful and I would have wasted less time.. someone to listen might have helped in the dark days and there were many of them…
Develop the extra care model We were so lucky my Mum was living in an area where extra care was well advanced and they have developed the model to include people with dementia. It meant she was in her own “home” and never had to go to a nursing home. I am certain it meant she lived better for longer- surrounded by the anchors of her past, even if by the end she didn’t recognise what they were.
Pay carers properly. It is an amazing thing they do. The best are kind, patient, generous. They have to do tough stuff every day. They deserve so much more than minimum wage. The living wage must be the minimum mustn't it? Good carers keep people better, keep them away from hospital and out of nursing homes…. It is better for people and surely it can’t but save money…If we as a society value our most vulnerable people we must value those we charge with caring for them.
Support families to allow their loved ones to die at home, if that is what they want to do. We look back on the week my Mum had at home after her stroke and before she died with a sense of calm achievement. WE did a good thing. Together we loved and nursed her and said our goodbyes. It was intensely emotional. It was made possible by those who gently and quietly supported us. I will always be grateful. It helped us with the grief of losing her.
It is Dementia Awareness week. I read that dementia is now the number one cause of death for women and the fourth for men. My generation are witnesses to our parents struggle with the disease and I wonder how it will form and change our approach to our own care as we get older.
Monday 23 March 2015
Are we privatising the NHS?
Last week we announced that following a robust and detailed competitive dialogue we have awarded a contract for our community and urgent care services in Whitby to Virgin Care. The response to this announcement has been fascinating….
We set out to get the best for Whitby. We spent much time developing a joint view with patients and the public and the local health staff about what we wanted….we warmed up the market, encouraging providers both local and national to participate.
We choose competitive dialogue because although we knew it would be a resource intensive thing to do it would give us the best chance to find the right provider for the job. What is competitive dialogue? Well rather than the process being mainly paper driven (providers simply supplying written answers to questions) and then holding a single interview, competitive dialogue is a series of detailed (four hour) face to face conversations with each of the potential providers developing within them the details of our joint ambitions for the services.
By the time we arrived at the decision making phase we had talked to each of the final two providers for 34 hours! We also assessed them through written submissions which included each provider answering a long series of questions marked by pairs of subject matter experts (37 in total) including a patient and public panel. We visited places where the organisations already provide services to talk to staff, patients and commissioners of those services. The visiting team included CCG staff both managerial and clinical, members of staff from the Whitby services, a member of the public and a local councillor. Those visits gave us the chance to triangulate information we had received in both written and verbal interactions with the providers. 70% of the marks were allocated to the assessment of quality of care including patient experience, with the remaining 30% covering financial capability.
How did we deal with conflicts of interest? We were told that our GP Federation had developed links with one of our potential providers therefore the GPs working for the CCG who are all members of a single federation were “conflicted” and couldn’t be part of the process. We held separate Senior Management Teams to cover the Whitby work which excluded them, and we brought in clinical advice from other CCGs where no conflict existed to support decision making. Although I have been a GP in this area for 26 years I no longer work in primary care so I was able to lead without issue.
In the end the process led us clearly and simply to the answer. One provider could offer us the best service for Whitby. They are ambitious. They have a track record which is strong for engaging and involving patients in everything they do and for empowering and developing staff to improve the quality of local services.
Are there challenges? Of course. When you do a job like mine you know what you are taking on. I am a public servant. I follow the rules laid down for my organisation by Parliament. I am also an individual with my own private views and opinions. I vote. As I do my job I am bound to reflect privately on issues that chime with or challenge my personal views. I learned a great deal through this process and yes, it challenged some of my personal views.
Whilst we were visiting the Virgin Care site in Surrey we asked staff what it was like to work for a private company. One of the nurses told me that she sees herself as an NHS nurse offering NHS care to NHS patients, employed by a private company. She commented one of her most challenging encounters had been with a GP. She thought that was a bit much considering that GPs are themselves private providers! It made me think….I see myself as NHS through and through, and yet as a GP partner in a practice for the last 26 years I have been a profit-making partner in a small private business, as all GP partners are and have been since the birth of the NHS. We made decisions week by week which affect how much of our money we invest in staff and services and how much we take home in our pay packet. It is profit/loss at the sharp end.
In conversations with Whitby staff someone said they were sad an NHS organisation wasn’t able to offer something as credible and ambitious as a private organisation. It made me reflect on our process and consider if we had done everything in our gift to stimulate and develop the market both private and NHS, and I am confident we did: we held several open events, made many conversations both formal and informal.
What about the staff? Our NHS staff in Whitby will transfer to the new provider with their terms and conditions of employment intact and will be able to stay in the NHS pension scheme. More importantly as they develop and progress and their roles and pay change and as new staff come they will also be able to choose between NHS terms conditions and pensions and those of Virgin Care. Staff at the site we visited talked enthusiastically about great opportunities to develop and progress they had been given since Virgin took over for all staff groups. A nurse told us that she had been dragged” kicking and screaming” to work for Virgin but she had had to eat her words because they were a good employer who cared about staff and patients.
It is easy, isn’t it; to somehow think NHS providers occupy an ethical high ground. But do they?
The Kings Fund, an respected independent UK Charity that works to improve and develop healthcare wrote recently on this subject they said:
"For-profit, non-profit and NHS providers can provide high-quality care and equally all sectors can fail to do so. Whether a provider (public or private) makes a surplus/profit from its trading with the NHS does not automatically mean that quality of care is compromised. The Fund’s view is that who provides the service is less important than the quality and efficiency of the care that is provided."
In conversations since the announcement people have quoted to me programmes and articles about the shortcomings of private providers. However, they are not alone. How many are there about NHS providers if you look for them? The system we work in isn’t perfect. Sadly there is poor performance in all sectors. We must and do strive to improve the quality of the services we offer our patients and we are committed to continuing to do that.
Will the political landscape and thus our framework change? Possibly. The private sector involvement in the NHS has been sanctioned by both major political parties when in government. Will it change? It may. It isn’t a certainty, but if it does we will manage that. That is our job.
So when people ask me, am I privatising the NHS ? my answer is a simple one. As a public servant my job is to improve the quality of our services and I use the framework given to me by Parliament to do that. I do not make policy. I am not a politician. So no, I am not privatising the NHS. I am doing my job.
We are confident the robust and clear process we have been through will lead to real improvements in services for patients in Whitby. We will to continue to work closely with the patients, public and staff as commissioners of the service to shape and develop services over the next 7 years. The proof of the pudding as they say will be in the eating…
We set out to get the best for Whitby. We spent much time developing a joint view with patients and the public and the local health staff about what we wanted….we warmed up the market, encouraging providers both local and national to participate.
We choose competitive dialogue because although we knew it would be a resource intensive thing to do it would give us the best chance to find the right provider for the job. What is competitive dialogue? Well rather than the process being mainly paper driven (providers simply supplying written answers to questions) and then holding a single interview, competitive dialogue is a series of detailed (four hour) face to face conversations with each of the potential providers developing within them the details of our joint ambitions for the services.
By the time we arrived at the decision making phase we had talked to each of the final two providers for 34 hours! We also assessed them through written submissions which included each provider answering a long series of questions marked by pairs of subject matter experts (37 in total) including a patient and public panel. We visited places where the organisations already provide services to talk to staff, patients and commissioners of those services. The visiting team included CCG staff both managerial and clinical, members of staff from the Whitby services, a member of the public and a local councillor. Those visits gave us the chance to triangulate information we had received in both written and verbal interactions with the providers. 70% of the marks were allocated to the assessment of quality of care including patient experience, with the remaining 30% covering financial capability.
How did we deal with conflicts of interest? We were told that our GP Federation had developed links with one of our potential providers therefore the GPs working for the CCG who are all members of a single federation were “conflicted” and couldn’t be part of the process. We held separate Senior Management Teams to cover the Whitby work which excluded them, and we brought in clinical advice from other CCGs where no conflict existed to support decision making. Although I have been a GP in this area for 26 years I no longer work in primary care so I was able to lead without issue.
In the end the process led us clearly and simply to the answer. One provider could offer us the best service for Whitby. They are ambitious. They have a track record which is strong for engaging and involving patients in everything they do and for empowering and developing staff to improve the quality of local services.
Are there challenges? Of course. When you do a job like mine you know what you are taking on. I am a public servant. I follow the rules laid down for my organisation by Parliament. I am also an individual with my own private views and opinions. I vote. As I do my job I am bound to reflect privately on issues that chime with or challenge my personal views. I learned a great deal through this process and yes, it challenged some of my personal views.
Whilst we were visiting the Virgin Care site in Surrey we asked staff what it was like to work for a private company. One of the nurses told me that she sees herself as an NHS nurse offering NHS care to NHS patients, employed by a private company. She commented one of her most challenging encounters had been with a GP. She thought that was a bit much considering that GPs are themselves private providers! It made me think….I see myself as NHS through and through, and yet as a GP partner in a practice for the last 26 years I have been a profit-making partner in a small private business, as all GP partners are and have been since the birth of the NHS. We made decisions week by week which affect how much of our money we invest in staff and services and how much we take home in our pay packet. It is profit/loss at the sharp end.
In conversations with Whitby staff someone said they were sad an NHS organisation wasn’t able to offer something as credible and ambitious as a private organisation. It made me reflect on our process and consider if we had done everything in our gift to stimulate and develop the market both private and NHS, and I am confident we did: we held several open events, made many conversations both formal and informal.
What about the staff? Our NHS staff in Whitby will transfer to the new provider with their terms and conditions of employment intact and will be able to stay in the NHS pension scheme. More importantly as they develop and progress and their roles and pay change and as new staff come they will also be able to choose between NHS terms conditions and pensions and those of Virgin Care. Staff at the site we visited talked enthusiastically about great opportunities to develop and progress they had been given since Virgin took over for all staff groups. A nurse told us that she had been dragged” kicking and screaming” to work for Virgin but she had had to eat her words because they were a good employer who cared about staff and patients.
It is easy, isn’t it; to somehow think NHS providers occupy an ethical high ground. But do they?
The Kings Fund, an respected independent UK Charity that works to improve and develop healthcare wrote recently on this subject they said:
"For-profit, non-profit and NHS providers can provide high-quality care and equally all sectors can fail to do so. Whether a provider (public or private) makes a surplus/profit from its trading with the NHS does not automatically mean that quality of care is compromised. The Fund’s view is that who provides the service is less important than the quality and efficiency of the care that is provided."
In conversations since the announcement people have quoted to me programmes and articles about the shortcomings of private providers. However, they are not alone. How many are there about NHS providers if you look for them? The system we work in isn’t perfect. Sadly there is poor performance in all sectors. We must and do strive to improve the quality of the services we offer our patients and we are committed to continuing to do that.
Will the political landscape and thus our framework change? Possibly. The private sector involvement in the NHS has been sanctioned by both major political parties when in government. Will it change? It may. It isn’t a certainty, but if it does we will manage that. That is our job.
So when people ask me, am I privatising the NHS ? my answer is a simple one. As a public servant my job is to improve the quality of our services and I use the framework given to me by Parliament to do that. I do not make policy. I am not a politician. So no, I am not privatising the NHS. I am doing my job.
We are confident the robust and clear process we have been through will lead to real improvements in services for patients in Whitby. We will to continue to work closely with the patients, public and staff as commissioners of the service to shape and develop services over the next 7 years. The proof of the pudding as they say will be in the eating…
Monday 2 February 2015
musings whilst swimming...
At a time of challenge and difficulty in the system where should our ambition be? To simply survive day to day? To keep our heads above the flooding torrent’ or do we at the same time as treading water and keeping going aim to do something different to re-route the water, stop it from washing away everything in its path and leave behind a soggy mess? When I was young I went to a college where we provided beach life saving patrols to our local area in the summer. So I learned to swim in the sea. The number one lesson was don’t rush to swim towards the calm bit of water you can see ahead because when you get there it will be just as choppy as the water you are swimming in right now. Learn to swim in choppy water. To make progress when the waters are cold and rough you need to be resilient, skilful and keep your eye on the destination.
There is so much turbulence now…. An election coming that is too close to call and likely who ever takes the helm to mean changes for health.. because somehow there always are…Services under pressure…recruitment right across the system in crisis..
Primary care and the staff who work within it have choices to make…about whether they are architects and builders of something new or simply allow themselves to get washed away ….The response from primary care to my October blog about my Mums care has been fascinating…. Those who felt it was a call to arms to fight to the status quo, build something better.. and those who are simply too tired, too worn down to do anything but reply that my mother’s care was safe at least…safe in the smallest sense.. on that day sending her into hospital was the most risk averse decision…. And that is true if you don’t factor in the risk of hospitalisation for a frail elderly woman.. the risk of infection, falling, a steep worsening of memory…but in the end that is her risk.. not theirs… Is it wrong to want the best rather than accept the average? But it feels like the energy to change is being sucked out of primary care..and a cold hopelessness is creeping in.
It made me sad… I have never accepted the hopelessness argument ( it is all hopeless and I can’t do anything to change it) and have always wanted to make it better. I am a striver.: for every problem there is a solution. Whose job is it then to fight for primary care? The “ Forward View” describes a compelling vision for primary care, who designs the road map to get us all there? Will we in primary care expect this to be done to us? For us? In spite of us? Do we embrace change or abdicate our responsibility and then blame those who make the changes?
Will CCGS DO IT? Co-commissioning primary care. Is that the way forward? Well it seems to be the only option around. CCGS seem keen as do GPs but is that because we will be good at it or because of the lack of capacity in areas teams to do anything? We as a CCG have struggled with the idea and whether it is right. We can talk about conflicts of interests policies to make it safe and I am sure they will help.. but the public don’t understand the NHS Architecture and why should they ? It is absurdly complex… and they see Federations of GPs providing services, CCGs of the same GPs commissioning care, and we can tell them it is all governed and transparent but when I do that I see blank looks and disbelief on peoples faces. I see risks to the clinical leadership in CCGS too because the easiest way to deal with the inherent conflicts are to simply reduce the influence of the GPS within CCGs, but I believe doing that risks a return to PCTS. Our strength and success is built around the real partnership between managers and clinicians and the public working together to change things….
The vanguard initiative ( this is central NHS money being given to "pilot" sites around the country to try out new ideas) will be interesting. To succeed it must allow local areas to work to their own agendas, and resist the temptation to impose structures and timeframes to meet national and political imperatives. The changes envisaged are huge and to be successful it must be clear to everyone participating what the task is.. what the challenge is.. what the future should be before we talk about structures and payment mechanisms… lets get it right for once please…we should know how to do this….function first then form….time to get the buy in from the people who are actually doing the caring first… hurry… won’t help.. people need time to understand and be willing to change..We know this.. Let’s hope that the Vanguard money will be spent to support local development of new ways of working and not a straight jacket of central control as so many of these initiatives have been in the past… a good idea that gets lost in translation….
Most importantly we have to develop a system that safeguards quality and continuity for those who are frail and have complex problems, provide timely and accessible acute care and creates an environment that will attract doctors nurses and other health professionals to choose it as their career into the future…because it is rewarding, challenging but not exhausting and is fun… ambitious enough? I think so!…time to keep swimming…..
There is so much turbulence now…. An election coming that is too close to call and likely who ever takes the helm to mean changes for health.. because somehow there always are…Services under pressure…recruitment right across the system in crisis..
Primary care and the staff who work within it have choices to make…about whether they are architects and builders of something new or simply allow themselves to get washed away ….The response from primary care to my October blog about my Mums care has been fascinating…. Those who felt it was a call to arms to fight to the status quo, build something better.. and those who are simply too tired, too worn down to do anything but reply that my mother’s care was safe at least…safe in the smallest sense.. on that day sending her into hospital was the most risk averse decision…. And that is true if you don’t factor in the risk of hospitalisation for a frail elderly woman.. the risk of infection, falling, a steep worsening of memory…but in the end that is her risk.. not theirs… Is it wrong to want the best rather than accept the average? But it feels like the energy to change is being sucked out of primary care..and a cold hopelessness is creeping in.
It made me sad… I have never accepted the hopelessness argument ( it is all hopeless and I can’t do anything to change it) and have always wanted to make it better. I am a striver.: for every problem there is a solution. Whose job is it then to fight for primary care? The “ Forward View” describes a compelling vision for primary care, who designs the road map to get us all there? Will we in primary care expect this to be done to us? For us? In spite of us? Do we embrace change or abdicate our responsibility and then blame those who make the changes?
Will CCGS DO IT? Co-commissioning primary care. Is that the way forward? Well it seems to be the only option around. CCGS seem keen as do GPs but is that because we will be good at it or because of the lack of capacity in areas teams to do anything? We as a CCG have struggled with the idea and whether it is right. We can talk about conflicts of interests policies to make it safe and I am sure they will help.. but the public don’t understand the NHS Architecture and why should they ? It is absurdly complex… and they see Federations of GPs providing services, CCGs of the same GPs commissioning care, and we can tell them it is all governed and transparent but when I do that I see blank looks and disbelief on peoples faces. I see risks to the clinical leadership in CCGS too because the easiest way to deal with the inherent conflicts are to simply reduce the influence of the GPS within CCGs, but I believe doing that risks a return to PCTS. Our strength and success is built around the real partnership between managers and clinicians and the public working together to change things….
The vanguard initiative ( this is central NHS money being given to "pilot" sites around the country to try out new ideas) will be interesting. To succeed it must allow local areas to work to their own agendas, and resist the temptation to impose structures and timeframes to meet national and political imperatives. The changes envisaged are huge and to be successful it must be clear to everyone participating what the task is.. what the challenge is.. what the future should be before we talk about structures and payment mechanisms… lets get it right for once please…we should know how to do this….function first then form….time to get the buy in from the people who are actually doing the caring first… hurry… won’t help.. people need time to understand and be willing to change..We know this.. Let’s hope that the Vanguard money will be spent to support local development of new ways of working and not a straight jacket of central control as so many of these initiatives have been in the past… a good idea that gets lost in translation….
Most importantly we have to develop a system that safeguards quality and continuity for those who are frail and have complex problems, provide timely and accessible acute care and creates an environment that will attract doctors nurses and other health professionals to choose it as their career into the future…because it is rewarding, challenging but not exhausting and is fun… ambitious enough? I think so!…time to keep swimming…..
Wednesday 31 December 2014
Farewell
My mother had a stroke early on Tuesday morning. It robbed her of the ability to move her right side, swallow and talk.
She had long been struggling with dementia and had become a small and mostly absent person. Gone was the campaigner for peace, who has survived the London blitz, helped set up the UN after the war, become a passionate educator and a mother of three, who marched against the Iraq war when she was 70 and wore a CND peace badge until she didn’t know what it meant anymore. Many people have written about dementia, but until you watch how the disease slowly and terribly diminishes someone you love day by day it is hard to really understand.
We had found a copy of an advance directive my mother had written and signed in 1997 some weeks previously when going through her papers and bills. It made things easier. It was very clear. Nothing heroic and “if I get dementia definitely no treatment for infections or other significant illness”. So we kept her at home. The staff at the extra care flats where she lived were brilliant. They cared. They kept her comfortable and spoke with tenderness and caring as they washed and turned her.They took care of us too. They stayed beyond their normal shifts and volunteered to sit with her to cover some of the night time so that we could sleep so only people my mother knew would be there if she woke distressed. As my sister said in her euology they truly are "the Angels of Rosemary Court".
We had moved her to a different general practice after problems with the previous practice who had shipped her into hospital unnecessarily and never seemed able to give her any continuity of care over the 10 years she was a patient there. The new practice, despite taking over her care at such a difficult time were fantastic, they listened. They immediately assigned her to one GP (because that is what they do for everyone) who explained to me how to contact her and what to do when she wasn’t there. They visited her before the stroke even though we hadn’t requested a visit, to get to meet her and assess her. They visited her after the stroke and were respectful of my mother’s wishes. They were supportive but unobtrusive. They contacted the nursing teams, out of hours, and the carers in the building. They were in daily contact with us throughout. They were exactly what a general practice should be.
The community nurses were great. They responded quickly always, came regularly and when promised, managed her care with gentle kindness and sensitivity both in hours and out of hours. Their expertise meant she was peaceful and comfortable for all but a few hours when we struggled to control excessive secretions but in the end sorted that too.
My mother died peacefully 6 days after her stroke. She was surrounded by her family, her photos and diaries and memories. We nursed her and when she roused she knew we were there at her side. We told stories about her life, read her diaries, looked at old photos and we became reacquainted with the person she had always been before old age had diminished her: the bright, articulate, opinionated, fiercely loving sometimes difficult woman who was my mother. I don’t think we would have had that if she had died in a hospital bed in the hurly burly of an acute ward. It was a gift to have those days with her.
We were given that gift by those who helped us care for her, the carers, the nurses, the GPs.
Much is written about the NHS and the social care. How it fails, how it needs to do better. I have written about what goes wrong too. I think though it is important to remember that there is so much good that goes unheralded in the press: the care given every day to the most vulnerable and frail. Given generously without expectation of thanks. Individuals who go far beyond what they HAVE to do because they know it is the right thing to do. They are there because they care in a genuinely authentic way as an individual, not just a professional.
So thank you to all the unsung heroes of the caring professions!
I am very grateful to them all and proud of a service that can facilitate such a dignified and gentle end.
She had long been struggling with dementia and had become a small and mostly absent person. Gone was the campaigner for peace, who has survived the London blitz, helped set up the UN after the war, become a passionate educator and a mother of three, who marched against the Iraq war when she was 70 and wore a CND peace badge until she didn’t know what it meant anymore. Many people have written about dementia, but until you watch how the disease slowly and terribly diminishes someone you love day by day it is hard to really understand.
We had found a copy of an advance directive my mother had written and signed in 1997 some weeks previously when going through her papers and bills. It made things easier. It was very clear. Nothing heroic and “if I get dementia definitely no treatment for infections or other significant illness”. So we kept her at home. The staff at the extra care flats where she lived were brilliant. They cared. They kept her comfortable and spoke with tenderness and caring as they washed and turned her.They took care of us too. They stayed beyond their normal shifts and volunteered to sit with her to cover some of the night time so that we could sleep so only people my mother knew would be there if she woke distressed. As my sister said in her euology they truly are "the Angels of Rosemary Court".
We had moved her to a different general practice after problems with the previous practice who had shipped her into hospital unnecessarily and never seemed able to give her any continuity of care over the 10 years she was a patient there. The new practice, despite taking over her care at such a difficult time were fantastic, they listened. They immediately assigned her to one GP (because that is what they do for everyone) who explained to me how to contact her and what to do when she wasn’t there. They visited her before the stroke even though we hadn’t requested a visit, to get to meet her and assess her. They visited her after the stroke and were respectful of my mother’s wishes. They were supportive but unobtrusive. They contacted the nursing teams, out of hours, and the carers in the building. They were in daily contact with us throughout. They were exactly what a general practice should be.
The community nurses were great. They responded quickly always, came regularly and when promised, managed her care with gentle kindness and sensitivity both in hours and out of hours. Their expertise meant she was peaceful and comfortable for all but a few hours when we struggled to control excessive secretions but in the end sorted that too.
My mother died peacefully 6 days after her stroke. She was surrounded by her family, her photos and diaries and memories. We nursed her and when she roused she knew we were there at her side. We told stories about her life, read her diaries, looked at old photos and we became reacquainted with the person she had always been before old age had diminished her: the bright, articulate, opinionated, fiercely loving sometimes difficult woman who was my mother. I don’t think we would have had that if she had died in a hospital bed in the hurly burly of an acute ward. It was a gift to have those days with her.
We were given that gift by those who helped us care for her, the carers, the nurses, the GPs.
Much is written about the NHS and the social care. How it fails, how it needs to do better. I have written about what goes wrong too. I think though it is important to remember that there is so much good that goes unheralded in the press: the care given every day to the most vulnerable and frail. Given generously without expectation of thanks. Individuals who go far beyond what they HAVE to do because they know it is the right thing to do. They are there because they care in a genuinely authentic way as an individual, not just a professional.
So thank you to all the unsung heroes of the caring professions!
I am very grateful to them all and proud of a service that can facilitate such a dignified and gentle end.
Tuesday 18 November 2014
transformation.. .transformation...transformation....
Have you noticed that everywhere you look in the NHS nowadays everything is “transforming” it is the latest overused buzz word…. What does it really mean? It isn’t some magical process that comes along and changes everything overnight then goes away again… our experience of real redesign and improvement of complex interdependent services is much more about a series small steps leading to an ambitious goal…
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
.
moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
.
moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
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