More money........

It has been a hectic week. We have had 2 public meetings so far, the first in Thirsk and the second in Hawes. It was good to be able to go out and meet people and explain to them directly the challenges we are facing as a community.

And of course we got to talking about money. No, the issues around maternity and paediatrics at the Friarage are not about SAVING money or cost cutting. But every issue in the NHS will have money in it somewhere.

One of the options we are looking at would require extra investment of considerable magnitude and that would be hard to find, because there is no NEW money in the system so to put it into these services would mean taking it from somewhere else. So then we have a series of questions:

          Where do we take the money from?

          Who makes that choice?

If we assume every service needs the money it has right now to function and would probably be able to be better if it were given more money, how do we decide?

There are services that are less “popular” or politically sensitive (less people to complain if we took money away)  but often these support our most vulnerable and disadvantaged and we have a duty to care for them.

We don’t have the answers. Only more questions!  If by some miracle we were to be given the money we needed to do this, would that be the best use of the money?

Going back to talking about the overall NHS funding issues:

North Yorkshire as a community has spent more on health care than it has been given for years. Last week I wrote about the funding formula and this is probably the reason we don’t cope within the money we are given, but the bottom line is we have to find a way to live within our means. Over the last few years the PCT has balanced it books each year by what is called “non recurrent means” which really means by borrowing from other wealthier PCTs by asking them,for example, to pay a bill on our behalf by being given a loan. The problem is that then that loan becomes the first call on next year’s money, and then we have to borrow again to pay that back and so round and round we go.

To change this we think that we have to change the system in a fundamental way. We know that people would prefer to have their health care as close to home as possible. We also know that hospital care is the most expensive. We think there are people in hospital now who could, with the right help and support, be at home or in a local community hospital. We want to invest more in community services like district nurses and therapists, then work really hard to keep  people out of hospital by taking care of them locally.  We also want to get those who do go into hospital out as soon as possible and care for them near or at home.

It sounds easy, doesn’t it? But believe me it is more complicated than it seems.  Doctors and nurses need to work differently - maybe in different places, learn new skills, make new working relationships.  It can take longer than a year and during that time we might need to put extra money in to get it all set up whilst the old system is still churning on. Somehow we never seem to get enough time to do that. But we are going to try.

There are two more meetings next week: one in Colburn and one in Richmond. I am sure I will have more money conversations. Many people think we should pay for the extra staff to make the in-patient service safe to continue at the Friarage, even if that is an “inefficient” use of money (lots of doctors employed to work with very few patients) and won’t necessarily make the service future proof.   Maybe we should.  If we did, we would need more money so we don’t have to stop doing other equally important things.  The only solution seems to me to be a political one. There is no funding in the national allocation formula to address the issues caused by rurality. This is an issue about rurality.  I am not a politician.  I am a GP.  Maybe our politicians can find an answer.

Money money money

Next week we begin the engagement roadshows around the locality about the future of paediatric and maternity services at the Friarage. Over the last few weeks I have had many conversations with lots of people : county councillors, patients, friends, relatives,  people in shops about these issues and one issue that comes up over and over again is that this is all about money.

How money moves round the system though is a mystery to most of the people I have talked to, so I thought it might be helpful to blog about money: how the NHS is funded and how the bills are paid. It is complicated and has taken me some time to understand it. I will do my best to keep it simple but bear with me! I will also do it in several bits so it doesn’t get too boring….

Firstly our money comes via the Strategic Health Authority from the Department of Health. The amount we get each year is decided using a national formula. The formula works around the concept of “weighted populations” and that weighting is affected mainly by deprivation. The logic behind that being that people who live in deprived areas of England have higher health needs than those living in affluent areas.

Our budget comes to North Yorkshire as a whole and is then divided between the 5 clinical commissioning groups using the same formula.  As North Yorkshire is a relatively affluent area we get low weighting. Within the Yorkshire and Humber SHA we receive the lowest per person funding and Barnsley PCT receive the highest. The figures for 2012/13 are: North Yorkshire receives £1477 per person per year compared with Barnsley PCT, which receives £1903 per person per year.

There is no weighting for “rurality” so we don’t get any extra money to help us with the issues which face us around delivering services to remote rural areas. The PCT has raised this issue many times in the past. The answer has always been that there is no evidence that delivering services to rural areas is more expensive. However as hospital services are pulled into larger centres by issues of safety and working practices I think it is likely to become a bigger issue.

So as a health community we have to manage on the money we have. We have a duty not to overspend. With that money we (the CCG) have to buy all the health services people use.

Hospitals are paid using a system called “Payment by Results”- each time a patient goes to see them, either as an outpatient, for planned surgery or as an emergency. Each “episode” of care is documented and costed according to a national tariff (like a menu) and the bill each month is sent to us for payment. We check the bill and pay them the money.

Each year we produce plans which estimate how much care we will have to buy in the coming year. We base this on what happened last year and doing our best to guess what other things might affect how many people need hospital services.  It is hard to foresee everything that might affect how many people go into hospital. There are new treatments which are developed all the time which mean there is more we can do for people. This is great but it costs more money!!  Also the percentage of people who are over 65 goes up each year and we know older people tend to use hospitals more than younger people because we all tend to develop more illnesses as we get older.

We also plan how we are going to save money each year by improving the efficiency of services, making it simpler and easier for people to get good care etc.

We set a “contract” with each hospital. Obviously all our contracts can’t add up to more than we have to spend for the year.

However we all know about the best-laid plans!!!! Whatever we predict we are going to spend we have to pay for each person who goes to the hospital even if more people use the hospital services than we planned.

Okay.. enough for this week I think. I will continue next week .. explaining where we are with finances year on year and our plans going forward!

Hand in hand

I have been visiting my daughter who is living in the USA whilst her husband is on a military posting there. My kids treated me to a manicure for mothers' day. So on a sunny Sunday morning I found myself sitting in a salon in a casino hotel in Vegas listening to my beautician tell me about her life. She works 60 hours a week doing 2 part time jobs. She used to have a full time job and “benefits” –which I quickly discovered meant health insurance-but the recession meant her hours and  her benefits got cut and she had to take on a second job. 2 part time jobs = no health insurance. She saves each month so she can afford to have routine screening by her GP but was scared about developing a long term illness like heart disease or diabetes or, worse, something life-threatening like cancer. She is my age, has worked hard all her life  and her son is in the US Airforce. She is one of millions of people in the USA who are frightened about getting sick because it would mean financial ruin and possibly premature death. It made me realise that we are so lucky in this country to have such a great health service that is free to everyone when you need it. And yes it isn’t perfect, and we need to work to make it better, but it is still the envy of the world.

In our locality issues around the future provision of paediatrics and maternity in our local hospital have united a community: People talking and working together to try to make the best of something they hold dear. In the USA health care divides people into the “haves” and the “have nots” based on the ability to pay. In the USA there would be no community group working in their own time to reflect the views of local people, no GPs and consultants keen to come out into the community and talk about the issues.  Decisions in the USA would be made by insurance companies and hospitals driven only by profit, with no sense of public service.

I left the salon with lovely bright red nails, and a renewed commitment to the service where I have worked for 25 years and am proud be part of. The solutions to our problems may not be easy to find but at least as a community we can struggle to find them together.