This Christmas

December has been busy, it always is, everyone trying to fit four weeks' work into two whilst making preparations for celebrating with family and friends.
And much is happening in the health world, we know now what our budget will be next year and the huge hill we have to climb over the next few years. It would be easy to get discouraged. When you look ahead the future seems impossibly bleak (not a good word to use at Christmas), massive, overwhelming challenges and everything you read spreads more doom and gloom.

And yet, last week we had our CCG Christmas do and it was a very upbeat affair. We know we are making a difference. Now. Those differences are important, they aren’t huge but they do matter. We have managed to improve ambulance response times in a rural area that have been stuck at very low levels (56% eight-minute response) for the last 15 years. How?

Partnership working with GPs and the ambulance service and a series of small schemes that stop patients being transported to A&E when they could be treated locally. In October they were up to 81%. We won’t maintain that during the winter we know but know we have a model that we will continue to improve. That makes a difference to people living in a very rural area, who worry that when they need it most an ambulance won’t be there in time.

We have integrated health and social care fast response at night now. What does that mean? Well in means that if an out-of-hours GP visits a frail older person in the middle of the night who isn’t very well but really doesn’t need to be in a hospital bed we have a service that can keep her at home, even if that means someone being with her for a few hours.

We have increased district nursing teams, which had been salami-sliced down to a skeletal service. And it is making a difference you can feel on the ground and measure as emergency admissions are at least holding steady.

And at the same time we think we can pay off our inherited debt and finally get our health economy into balance for the first time in many years.

What has this taught me? Transformation is incremental. It isn’t some big bang that happens overnight. It involves tiny steps. It is all about hearts and minds. It takes time. But it is possible to change things, if you focus on the now.

I don’t just want to tell people what we are planning to do, I want to be able to describe what we have done. I don’t want to spend all my time planning five years down the line whilst being too busy to change tomorrow. We are a little team and resources in terms of human energy and health are finite. There are choices to be made.

So when I think about those huge greys clouds tumbling towards us all over the next few years, my response is to focus on now. To make things different tomorrow, next week and next month. I don’t want to spend too much time worrying myself and our organisation because the risk is that the worry creates paralysis.


Yes I know it is important to have a vision for where you will be in five years. I remember though that I read an article years ago (can’t find it for this blog but know it existed!) which looked at five-year plans and their accuracy and basically very little of the detail in a five-year plan ever comes to pass because so much changes in the mean time.

What we need is a clear direction of travel. A high-level map that will help us find the way but will not insist we travel on the route we originally suggested if a better road is found in the intervening years. Will we be here then? Probably not. Will the NHS landscape have changed again? Definitely. What we do have is an opportunity here and now to make things better for the patients we serve.

Those of you who have read my blog will know I often write about my mother who is 93 and very frail. She has had a tough year, four falls, three emergency admissions, a stay in a nursing home, rapidly progressing problems with her memory and mood.

She is now in an extra care flat and finally she is doing OK. She is smaller than she was a year ago in so many ways but the consistency of the care support she now has and their infinite patience and sensitivity has meant she is coping, for now. What have I learned as her daughter and an NHS leader? Small steps and realistic goals will bring change.

So, happy Christmas. Let us celebrate. So much has gone well this year despite the headlines. We have much to do in the new year!

Health care and politics

Well, we ended up causing a bit of media flurry ( I wouldn’t call it a storm.. that would be a bit of an overstatement!). We didn’t set out to do that but these things happen. The issues underpinning this are worth a bit of unpicking.

We are in the middle of a complex public consultation about paediatric and maternity services in our local area. Not a fight we chose to have but one the local trust asked us to become involved in because the doctors and nurses were concerned about safety and quality standards in the hospital. It has been a long and sometimes challenging journey over more than 2 years. From the beginning we have chosen to do it differently- to get out there and talk to the public with the consultants- at playgroups, childrens centres and sixth form colleges, working with local interest groups and local politicians.

During the present formal part of this we have had about 250 people attend 9 meetings, out of a population of around 120000. After one of the meetings we lodged complaints with the county council about the behaviour of two local councillors. We did that the way we were supposed to, as it told us to on the website. We didn’t “go public” we wrote to the council formally raising our concerns. One of the councillors then chose to share the contents of the complaint with the local press and suddenly we found ourselves in the HSJ and everyone then has a view about the rights and wrongs of it all. Some think we are “naïve”, we need a thicker skin.

I am completely committed to democracy.. .that means I will do everything in my power to make sure that someone who has the opposite opinion to me has the right to express it, as loudly and fully as they wish to. I enjoy debate and discussion and the reasoned development of consensus. I am not intimidated by those who hold opinions entirely opposed to mine. That is how it should be. My job is to clearly express our views, our interpretation of the situation. In those discussions though, we should be able to express our views without unwarranted and baseless attacks on our motives and our integrity. The debate should be about the issues NOT the personalities. We were not “upset” by the behaviour. We are tougher than that. We felt however that behaviour of that sort damaged still further public confidence in all of us who work in the public sector. The people I was with that evening were clinical professionals: those nurses and doctors who have spent their professional lives dedicated to serving their local population to the best of their abilities. They have done so with integrity and professionalism. They were there to talk and to listen. The views they expressed were based on evidence and professional knowledge.


We as a CCG believe we must do the right thing, not the easy thing but the right thing. We are a values driven organisation and have explicitly committed ourselves to developing an open culture that is necessarily different from that pervasive culture of bullying and secrecy that has existed in the NHS for the last few years: the outputs of which are constantly in the news and bring shame to us all. We judge our progress and our success by our values: Integrity, Transparency, Collaboration, Focus, Action , Energy, and Courage.


In a wider context I see the need for same debate. Recently I had an interesting discussion with my kids, now young adults, and their friends about why they don’t vote. They tell me that have nothing in common with the politicians they see on TV: the jeering and point scoring during debates in the Houses of Parliament, the behaviours, the language, the endless sniping, the inability to answer a straight question. They have no confidence in any of them. Neither do they have much confidence now in those who run the health service, or education and social care, for that matter. Interestingly last week there were similar debates on the PM programme on Radio 4 after comments by Jeremy Paxman and Russell Brand.


If we are going to re-establish that trust we have to be different and that means BEHAVE differently. WE all have to behave better and expect better. If we tolerate poor behaviour we are in the end implicitly condoning it. If we as a CCG are committed to treating everyone we come into contact with well, to being open and honest, even when that is difficult, to be respectful and demonstrate integrity. We demand to be treated fairly. We do not expect to be given an easy ride. We enjoy robust and challenging debate. We do not need to be taken care of. But we should expect to be treated with respect. Why should we be accused of being naïve to simply expect to be treated decently? Whilst we as a CCG are busy trying to challenge and change the culture in our corner of the NHS we need also to focus on changing the culture more widely in public life.


It would have been easier to put up and shut up. As everyone has done in the past: oh it is just how they are..it is what you expect from politicians. Why should we do that? If we do nothing – nothing changes. It is important to be brave enough to challenge the status quo. That is why we chose to make that complaint. Not from a place of weakness but from a place of strength. We knew it might make waves but we wanted to put a marker in the sand that says we ( NHS, county councils, politicians etc) as servants of the people shouldn’t treat each other badly in public. It does none of us any favours. Is only makes us all look inept and petty. If we have to resort to personal comments about motives and lack of integrity we have already lost the argument AND lost the respect of the public who watch and listen to the pantomime. I would not tolerate that sort of behaviour in my private life so why should I condone it in my public life?


None of us, know what the public really think. Local politicians are voted in by small percentages of the public. We, in the NHS do consultations, surveys and focus groups but the truth we all have to face is that none of us know what the silent majority, those who don’t come to talk to any of us, really think. If we are ever to improve that situation we have to grapple with this issue, we have to persuade them it is worth participating, that collectively we are worth listening to. We therefore all have a role to play in changing the culture not just of the NHS but of our public life.

Changing primary care: The baby and the bath water

A lot has been written about primary care recently. Everyone who is anyone appears to believe it requires a major overhaul. I have always been a bit of a change junkie. I love the adrenaline that goes with shaking everything up and starting all over again. We were the first practice in the north to have a nurse practitioner, in fact we had to train our own because there weren't any courses in the north then. I ended up designing a course at York uni because of that in the following years to fill the gap. I believe in skill mixed teams working around the needs of individuals And I worked hard to keep the holistic part of general practice alive that I think is so fundamental to uk general practice. Alive despite a bigger team. I have worked to change health care and mould it to meet the challenges of life today and yet all the talk of radical overhaul makes me uncharacteristically anxious. I am wondering why.

It think it has to do with losing the relationship that builds over years between a GP and their patients. Lots of small encounters. Most of which could probably be done by someone less qualified but which build a human bond of trust and knowledge. I know it has all but disappeared in many places. People see different people with different skills each time they go and mostly I don't suppose they mind much. A member of my family had a sore eye this week. He made an online appointment and saw a doctor the next day. He hadn't seen her before but wasn't bothered and was treated effectively So does it matter that we no longer have that relationship between a patient and" their" doctor? I wonder sometimes if the phrase "you never know what you had till it's gone" will be the epitaph of general practice as we know it.

Let's look at the facts. Patients value primary care. Satisfaction rates are really high. Most other private or public services would love to have the kind of satisfaction rates GPs have. Primary care sees 90% of all NHS contacts every day and treats 90% of those without sending them anywhere else. Yes people struggle for appointments sometimes. There is real clinical variation that we need to confront and improve. Primary care is under considerable strain , but as Clare Gerada talked about that is because of real funding pressure which has resulted In a decrease in investment whilst demand rises.

Before we rush to new models based on the sound bites of important people who actually know very little about how the service works day to day can we first answer some simple questions. What is primary care for? What do we as a nation really value about the service now that we don't want to throw away in the rush for change?

My view is that primary care is : 1. A front door into urgent care. 2. Deals with minor illness 3. Manages complex long term physical and mental problems 4. Is a safe place for people who don't know where else to go for support and advice.

Now , you could take each aspect and give it to new service that deals with just that. There is already evidence from around the country of GPs running urgent care services alongside more traditional primary care. Let's stop and looks at them before we decide is the right model. In Bassetlaw such a service exists. Patients and staff like it but it hasn't solved the problem of demand in A&E round the corner. Minor illness services were available in Darzi centres and many of them are closing.

One of the joys of being a GP and I think one of the most important motivators for maintaining a work force in primary care is the on-going relationship with patients. Perhaps rather than analysing each patient contact and asking who else other than a GP could do that, we need to see each contact as part of a long term relationship forming the platform upon which you build what is needed when it is time to deal with big significant illness when trust and human factors become a huge part of the transaction between patients and their doctors. Each GP I talk to has their stories. I have mine. The young woman terrorised for years by the husband who planned for 4 years to leave him by educating herself and scrapping together savings from her housekeeping, her flight when he was posted away, her necessary complete break from her family and friends who had helped him find her during previous escapes. And I was the only person she confided in. She didn't trust anyone else. And a postcard 2 years later to tell me she and her kids were safe and happy. She didn't have a medical illness. And perhaps she would have found someone else if she had not found me. And perhaps it didn't matter and she would have done it without me but I like to think seeing her every few weeks for those 4 years gave her a safe place to express her fears and formulate her plans.

Or being able to pick up something unusual because you know the patient: the very eldery woman who had been a patient at our practice for years and came because she had had a little “wobble”. Very little to find clinically but she just wasn’t her usual self. If she had been assessed by people who didn’t know her they might have just thought she was mildly senile, we knew she wasn’t right. She had a cerebral bleed, not related to a fall but to a bony metastasis in her skull eroding a blood vessel.

I have could go on.

GPs also manage risk better than any other group of clinicians I know. Every day they make decisions using only the tools they have in their heads and their bags to filter the serious from the " got some time to sort this one out". Until you have done the job you don't really get that. Going home and thinking through that one nagging case of the day and wondering if you got it right. You can't send everyone on. The system wouldn't cope. It is our job to get it right every time. If we get it wrong we are rightly criticised. If we get in right no one notices. But that is the job and I am not complaining. I am just saying it is more complex than most think it is. May be can’t afford this model any more. Maybe we have to accept something different.

But before we change everything can we somehow have a real discussion about what primary cares job is, what we care about keeping, learn from what has been tried around the country, and really trial and evaluate new ideas before rolling them out.

Can we think about evolving primary care rather than revolutionising it? We all know that 70% of major change initiatives fail to deliver their stated objectives. ( I remember David Nicolson told me that when they first announced CCGs)

And try just this once to keep the baby whilst throwing out the bath water.

What does safety mean?

On 2nd September, our CCG launched a consultation about proposed changes to children’s and maternity services at the Friarage Hospital in Northallerton. I have written about this before. We have been doing this work for the past 2 years and it has been a bumpy ride. It’s a complicated issues and it’s difficult for the public to understand. This week I have been going back to basics in many media interviews to explain why we need to make changes to services there. I’ve explained that it really isn’t about money. As a CCG we pay for each patient that goes into hospital. No matter where they are treated, it costs us the same. It is all about safety and quality.
It is interesting isn’t it that despite all the publicity about safety in the NHS, when we did our engagement exercise people rated services being close to home above safety. I can only assume that is because we as a community still assume that if a service is there, it must be safe. And yet when I explain that is isn’t, people want to fight to keep it open anyway. The obvious conclusion is we mustn’t be very good at explaining what safety really means. So this time when I was interviewed I talked about reducing death rates and disability after illness. That evidence tells us babies born in obstetric units where consultants are present on the ward all the time have a lower chance of sustaining birth injuries than those where the consultants are on call from home. Children in other European countries who travel further to more distant large children’s units have lower child death rates than we do. Some people have said that is too blunt. Too scary! So my question is how do we get it right? Clinicians know what we mean by safety but it is clear others don’t. If parents had to sign of a form saying that they agreed to their child being admitted to a less safe service than there is at the hospital in the next town, would they sign it? I wouldn’t. And yet by our CCG sanctioning the continuation of a service we know to be less safe, we are effectively doing this on behalf of all our patients aren’t we?
Of course no service is completely safe. There is no such thing as 100% safety. But surely if we can see a way of improving safety from 94% to 97%, then that is worthwhile? Imagine if that increase of 3% saved your child or your baby. The Friarage is a lovely hospital; small friendly, quiet. Lots of one to one care. When things go well there is no better place to be. But when things go wrong I would rather my children, my grandchildren were safe is a bigger perhaps more impersonal environment where the expert teams who see and deal with emergencies every day are there on hand when we need them. So that means that if there is a small chance of that happening - if my daughter had a high risk pregnancy or my grandchild was hot, lethargic and not responding to the usual things that make little people better, I would drive further for them to be where it is safer. If I would do that for my own family, why would I not want it for everyone whose health care standards are now my responsibility?
How have we come to our conclusions? We have listened to those people who are experts in the field and know far more than we do. Consultants who have delivered care at the hospital for years and national experts whose job it is to understand what makes a service safe. They have all said we are doing the right thing. Hilary Cass President of the Royal College of Paediatrics and Child Health, The NCAT inspection team led by Professor Chris Clough and the whole consultant body at South Tees Hospital NHS Foundation Trust all agree.
And then we are left with a dilemma. We are accused of not listening to the public if we do not agree with them and instead do what we believe is the right thing to ensure the safety of our patients. Surely that is a fundamental principle we shouldn’t compromise on.
We can address issues of transport, of accessibility to other local trusts (some of which are as near for many of our residents as the Friarage is), we can improve community children’s nursing so many of the services some children have in hospital now can be delivered at home. But if we can’t compromise on safety will we always be accused of not listening to the concerns of those who campaign against us? And finally who speaks for the silent majority who do not respond to our invitation to talk to us? Are they with us or against us? I wonder what their views are about it all.

Get the Diagnosis right

When I was learning to be a doctor a very wise senior GP sat me down and told me that the secret of being a great diagnostician was to be a good listener. That surprised me. Not learning lots of clever examination techniques or learning to interpret fancy tests? No, You need to be able to do that of course but the most important thing is to listen to the story, because all the clues are there. Don’t be tempted to leave out the bits that don’t fit your working diagnosis , they are there for a reason. Work out why they are there and you will find the answer. Don’t interrupt the story teller, within a few seconds of them starting, give them time and you will hear all you need. And it works. As a GP sometimes I have literally bitten my tongue but I always tried to listen. This week a young man presented with intermittent abdominal pain and fever. He had symptoms for over 6 weeks. The GPs he saw ( and he saw 5) tried to tell him he had diarrhoea , but he said gently and with clarity, no not really… no one really listened to him or why he was there… some minor infection? IBS? Nothing to worry about, but he was worried. He was a fit young man, didn’t like doctors and rarely went to see them, had had several significant sports injuries and continued to play football despite pain. Something felt wrong. HE was given a myriad of medications. None worked and on reporting the ineffectiveness he was told to keep taking them and new ones were added. Then finally a documented fever of 40.4( no one picked up on the clear history of a fever because when he was seen before he didn’t have one). Well that isn’t normal and rebound so suddenly hospital and ? Appendicitis which turned out in fact to be a serious but rare infection which caused his abdominal nodes to be full of pus…he is okay now- home and full of the right antibiotics. Finally it was the senior surgeon who listened to the story without interruption or need to make it simple, who enjoyed the challenge of something out of the ordinary and found the problem he needed to solve.

And I wondered why did it take so long? Yes it was rare but the clues were there all along…we make dangerous assumptions based on prejudice. We excuse ourselves because we are busy but failing to listen in the end takes longer….

And I wonder do we listen to patients, to the public? To other clinicians? Do we listen to the evidence? In the complex world of health care do we seek the simple diagnosis, the simple fix and ignore the complexity because it doesn’t fit into a sound bite? Because when you identify how complicated and multifaceted a problem is it feels too big and scary to tackle whilst reducing it to something smaller and neater feels safer. But failing to diagnose the problems accurately is dangerous. Quick fixes may make us feel better because we have done something but ultimately don’t sort out the problem. The young man I mentioned was given antibiotics by the out of hours service doctor he saw for no particular reason and without a diagnosis. That was the wrong thing to do and it complicated the picture. Some problems take time to understand and then to fix a bit at a time. When we as a CCG are trying to do things differently do we listen well enough so we can actually define the precise issue we are trying to solve… do we as a system listen or do we just blindly stumble forward…It is a gift to be able to think freely…to look at an issue without the weight of a forgone conclusion…With so much pressure on the system now to make everything different really fast do we have the collective courage to do the right rather than the expedient thing? Don Berwick’s diagnosis was thoughtful, complex, clear. He has listened. It is really worth watching it. http://www.kingsfund.org.uk/audio-video/don-berwick-improving-safety-patients-england-full-presentation. Some have criticised it for being too woolly without enough concrete recommendations, but that is absolutely the point. It isn’t about implementing a new structure or a new set of rules. So much of what is wrong with the NHS is about a culture of blame, fear, and lack of transparency. We need to understand that and change it to pride, joy and openness. Doing that will take time and individual commitment from all those who lead the NHS. You don’t change how people feel and act overnight. More importantly will the system we work within give us the permissions we need to fix the problems fundamentally this time, or are we just in another cycle of short courses of ineffective medicines…

Give us a chance

It seems as though the NHS is never out of the news… and so very little of it is ever positive. So much of it though is rehashing things that have already hit the press in the past. This week we had the Select Committee report. It didn’t tell us anything we didn’t already know and we are working on it all. I sometimes want to shout.. please give us a chance.. .we have been here for 3 months… we know the issues we are trying to sort things out but the issues are complex and don’t get solved overnight and actually CAN’T be solved by centrally driven solutions. Each one is complex, multifaceted so you have to take each one and break it down in to all the little bits that don’t work, fix each of them and build it all up again into a service that works seamlessly. And that isn’t easy. Which is why is hasn’t been fixed before. Yes it is true that A&E is a pressure valve for the whole NHS ( actually so is primary care ) anywhere with an open front door is. But the reasons it is under pressure are complex…. A mysterious rise in the death rates of older people over the last 12 months, changes to the GP urgent care front door because of the introduction of NHS111, and general increase in demand across the service, more frailer older people, yes we need to change primary care, community care, GP out of hours care, how the ambulance service works, how social care works, and that is before we get to the A&E front door. WE are on the case. Changing things though actually means changing how people work and that isn’t like designing a new form it is about behaviours so it takes time. It doesn’t help then to have lots of structural things built over the work we are doing that require reports and attendances at meetings. Each of those requires someone who would otherwise be doing doing to be doing reporting and thus less doing gets done. Not rocket science is it? Maybe people just need to try to trust the system they have so recently designed and give us some time ( well a little more than 3 months) to get on with making things better.



And then there was the Keogh Report which I thought was brilliant. Simple. Succinct. Sensible. Coherent. And yes I believe described a way forward we could all sign up to and follow. So then came the recommendations from the new Inspector of Hospitals basically using that structure. Great I thought! But No! Why? Where are CCGs? We commission local services. We work every week with our acute trusts we know the details of every SUI, every never event, every case of hospital acquired infection. We discuss action plans and monitor compliance. We see trends. We live here. We hear from our local GPs and from our patient forums about their concerns and we feed them back to the hospitals and expect and get action. It is new and we are all just finding our feet but surely any new inspection regime should be co-hosted by the local commissioners, the ones who were there before the inspection team arrives and will be there when they leave… surely, surely we should be there too? If we really want to make this different we have to join up the dots. I don’t want to be in a focus group or submit a report I want to be there with the inspectors contributing with all the knowledge I will bring to the discussion and debate. WE had an NCAT review when we were considering reconfiguring our maternity and children’s services, the CCG with the NCAT reviewers worked together. It was good. It was obviously much smaller than a full inspection but as a model it worked really well. We will be the ones who work with the hospitals after the inspection to make things better, surely we should be round the same table. Why aren’t we? Are we invisible? Do people think we aren’t capable? Does everyone think we will be gone before this gets off the ground? Does the central NHS not think we are interested? WE are ALL about improving quality and safety in our service, our NHS. Please give us a chance to do our job.

A Child of the NHS...

I was born in 1955. I am a child of the NHS through and through. My father worked as a hospital manager i was born in St Georges Hospital Hyde Park Corner in London ( it is now a posh hotel!). I have worked in the NHS for my whole working life. Am immensely proud of it and of the amazing things it does everyday. I have absolutely loved my career and have been so privileged to work with fantastic people. We are united by vocation and a deep and fundamental belief in the underpinning values of what we are doing. We are here to serve.




We don't get it right all the time. Remember reading the first report on mid staffs and was moved to tears by the stories of the suffering. How could this happen in our beloved NHS? I am fortunate never to have seen that kind of neglect and wrong doing. What I know for sure is that most of the nhs which is a huge and complex organisation is not that. My patients tell me of great care, high standards, kind people. Not every time. But most of the time. People going beyond what they have to do because it is the right thing to do.



Recently I was told about a young man who is having lots of problems and was admitted to a young people's mental health facility over 200 miles away for assessment. His family were not happy and brought him home. The local team provided round the clock care for him at home until a more local and acceptable place could be found for him. Some of that meant being there with his family keeping him safe through the night. They were not paid extra. They didn't do on call normally they did it because it was the right thing to do. I heard about it by the by.. They didn't do it for glory or thanks they did it without hesitation because they care.



The NHS is facing challenges much greater than those it has faced before. The future feels more uncertain now than at any time I can remember. We need, I think on this 65th anniversary to pause and remember why we are all here. I have been at a meeting of people like me, GPs who have chosen to take on the leadership of their local NHS from across England and what struck me about everyone spoke to was that they were motivated by wanting to make it better, wanting to sort out the difficult ,the complex, the things that have been left undone and unresolved by others because they are motivated to make a difference. As a group we don't have all the answers but we are determined. The word bravery was used a lot And I think we will have to be brave. Brave and open and honest with our public however challenging that may feel at times. W can't offer them everything they might want but hopefully we might each of us can find a way to make our little bit of England better and over time that should add to something better.



I think it is easy to forget the miracle that is modern medicine. My mother, who I have written about recently is 93. Until very recently she was living independently. She would describe herself as fit and hasn’t seen herself as a major user of the NHS. She has had both her cataracts done, a hip replaced and wears a hearing aid. She couldn't afford to do any of that privately. Without the NHS she would be lame, blind and deaf. Shut off from the world. She would probably be dead by now. All of those things are routine, un-dramatic but they make huge differences to our lives. I have close friends who have survived breast cancer.



I could go on. I often think that when we plan change we forget to include those fundamental aspects of the issue that we take for granted and sometimes that means we lose them before we consciously even know they were at risk. Yes the NHS needs to change but can we all please remember why is was created in the first place. My sister lives in the states and has insurance but her care does not in any way measure up to the care she would get if she lived here. I spent a while in France recently and my experience of care there was that general practice was very primitive and there is a complete lack of any domiciliary care for frail or palliative patients and people die in distant impersonal hospitals because there is no alternative. But that is another story. We must not fall into the trap of believing everything is better everywhere else.



Aneurin Bevin is quoted as saying:



THE NHS will last as long as there are folk left with the faith to fight for it



As a child of the NHS I want to fight for it survival. We may not know how now to solve every problem but we can be united by a collective will to find those solutions whilst hanging on to the principles that underpin it. Will you join me?

We need to talk about urgent care..

I told my family about my blog…. They said I should write about our recent experience of urgent care , with my Mum. I mentioned it briefly in my last blog… The urgent care experience we had really underlines all the issues that face us collectively as a system…




It was Bank Holiday Monday ( it always seems to be..) my Mother, who is 93 and frail, felt dizzy. She didn’t feel well enough to stay alone at home. She was afraid she would fall, she has done several times before. She has carers who come in three times a day. They work for an agency. They don’t get paid for travel between clients. They tell me their only training is a DVD given to them when they start. They are always in a rush. Sometimes in a week she can have 15 different carers, and the turnover is huge. My Mum has dementia and new people make her anxious. So staying at home with the care she has wasn’t an option. Mum has been failing for the past few weeks and we had had several conversations with Social care that she needed a different place to live. Extra care probably, somewhere with resident care, but it hadn’t moved fast enough and following 2 previous hospital admissions in 3 weeks we were once again in a mess. My brother called GP OOH, or at least NHS111. What followed was a wearisome 50 minutes of repetitive questioning.. and holding…. Different people reading computerised questions.. did she have chest pain? weakness? Finally we spoke to someone who offered us a GP visit… I was an out of hours GP until very recently. I could triage a phone call safely in 8 minutes max.. although I usually had a good idea what was going on within the first minute. Is it surprising more of us are simply giving up and going to A&E

So the GP came… he wasn’t local and didn’t know much about local services. He didn’t think she was “acute” but clearly wasn’t well enough to stay at home. The Acute Trust refused to see her. The GP had no idea about intermediate care ( although the Acute Trust- who also manage community care say there is 24/7 access on their website) The only phone number the GP had for district nursing went to ansaphone. So now what? After 2 hours the GP phoned 999 for an ambulance and my Mum went to A&E. WE were advised NOT to go with her because if we did they might just send her home…

We were left feeling we probably should have phoned 999 straight away but we knew she didn’t need that really.

The next day I went to the acute medical ward at 9am. I knew the doctors would be there then I was informed, a little brusquely that is wasn’t visiting time and everyone was busy. I pointed out that my Mum has dementia and therefore is both confused and frightened so I would like to sit with her for the ward round…using some medical terminology and the Dr title helped I think as I was allowed to stay. We agreed my Mum wasn’t acutely ill but needed to be in a more supportive home environment. A social services assessment was arranged. I went to work… an hour away. I was then phoned to say the assessment would take place in 45 minutes on the ward. As luck would have it my daughter has a week off uni, lives in the same town and was free to go to be with her. My daughter then witnessed a row between the staff nurse and the social worker about how long it would take to organise a placement for my Mum, which only stopped when my daughter interrupted and asked them not to talk about her grandma like a piece of smelly baggage no one really wanted. The outcome: a short term nursing home placement and a long term change or residence hopefully to an extra care flat, if being in the nursing home didn’t lead to too much loss of independence and confidence whilst we waited. Her discharge was delayed ,even then, because the Doctor in change of her care decided at the last minute an echo might help… after 3 more days, an increasingly confusion and no echo and with the help of a very enlightened Sister, I all but kidnapped my Mum and took her to the nursing home…

We talk about the problems in urgent care. Lots of people have tried to look for who to blame. The problems like most in the health service as complex, wicked…. If they were simple we would have got it right be now. The evidence tells us older, increasingly frail people attend A&E with complex problems. In our own area we didn’t see much of an increase in numbers of admissions in November, December and January, and yet the hospital was really busy. The people in hospital were older and more frail and took longer to be sent home. So urgent care is linked inextricably to care for older people. Stopping them going into hospital in the first place and getting them home as soon as possible….Get that right and the A&E issues will diminish…ignore it and focus only on more A&E services and nothing will change… treating the increase in minor problems and the worried well is relatively simple…

And how long will it take us to realise the ONLY way to make NHS111 work for patients and the system is to have highly qualified people at the front end.. doing triage straight away. More expensive in terms of labour costs- YES but system wide it will save by reducing unnecessary blue light trips to overcrowded A&Es and most importantly will make the service better for patients.

And can all of us remember every day and every time that patients are just people in nighties and pyjamas, but they still need to be treated with respect and kindness.

Flowers for my Mother

Everyone is talking about leadership…. There are courses, books (one of the best have found is one called Intelligent Kindness by Ballatt and Campling which I really like) and conferences everywhere I turn. It is apparently the answer to IT all. Although I am not quite sure what the IT is. When is leadership something different from management? Is there really a difference between clinical and managerial leadership? It seems that clinical leadership is now the in thing…and I am glad about that because it has given me the chance to take on this role rather than be left to sit on the side-lines as I have done in various PCT roles in the past and people actually listen to what I have to say now which is novel! but what do we really mean by leadership anyway…



My mother was admitted to hospital three times in the last three weeks. She is 93 years old and has dementia. Up to this point she has lived quite successfully in a small flat with a day time warden and a life line service but clearly things are getting more difficult. As a family we experienced the wonders that are the fragmented, patchy, variable services for older people. I am sure our experiences will not be that different from everyone else’s across the country. Where my mother lives is an average sort of place with an average sort of trust and an average GP. Nothing extraordinary but okay. As we navigated through out of hours services, acute medical wards, wards for older people, community hospitals, social service teams , care homes, what became obvious to me is the huge variability of attitude, approach and energy within one small location. The worst experience by far was trying to get help initially and the tortuous map of repeat questioning( does the system have dementia?) and changing personnel that is NHS111….. 50 minutes to get to speak to someone who could maybe do something… To the best… a small community hospital with the attitude that it will make the right thing happen and that each person is important and valuable..



What made the difference? Dare I use the word? Leadership…. visible leadership… in the community hospital the matron is brilliant, she leads by example. She cares, she bothers, nothing is too much trouble… and everyone in that hospital is infected with a sense of purpose and achievement. It feels good to be there. The staff smile, they stop and greet you when you walk in. They don’t rush by with their eyes to the floor.. looking busy and hassled….My Mum was happy there, I was relieved and happy she was there. She made progress. But why the variation? It cant be right can it that each little building block of the NHS is so dependent on the individual in charge. It makes it far too fragile… So within a huge organisation made up of so many tiny parts how do we drive up quality everywhere? It feels like an impossible task. How do we get 100% excellent CCGS doing great commissioning and all trusts and All GPS caring for patients to the highest of standards? Because that is what we want for our mothers, our children, ourselves.. what is acceptable variation? We know that 50% of anything is below average, just by the definition of the word , but we have to reduce the distance from worst to best so that the variation isn’t big enough to feel from a patient perspective. The only answer I can come up with is something about the leadership of the whole system, not of each hospital or CCG but of the whole NHS. It needs to be different, palpable, with core values that are lived by everyone in the work they do every day.. Where leading can be kind. Not soft or sloppy, but intelligent, and caring. So each part of the NHS, each layer each organisation can look up and se those values everywhere. No bullying, no intimidation, no weasel words to avoid answers. AS NHS staff, managers, clinicians, support - senior or junior we have to treat each other with the same values we expect and value as patients. WE must never forget that we are all potential patients in the system we design…. my guiding principle as a GP has always been ..would this be good enough for me.. my family… if not then it isn’t acceptable for anyone….



The new NHS is an experiment… it allows a whole garden of flowers to bloom…it is a risky plan especially in such a cold and cloudy time…as a new flower ourselves I applaud that but it relies on a gardener who understands how to get the best from each variety, and how the species interact with each other. She needs to be present, visible, dealing decisively with the weeds and with those bits that overgrow, or aren’t healthy… watering, feeding, nurturing, and providing the environment that will support healthy development whilst being clear about the overall direction and shape… gardening a system requires patience , vision, permissive bravery and the wisdom to act decisively but kindly when necessary.



My mother was bewildered by the labyrinth of services she encountered….. do we have the collective will and the imagination between us and together to work with the system we have and make it work for her?

What a difference a day makes

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It hasn’t been a particularly good couple of weeks in the land of CCGS.. nothing big really but lots of hassle that makes doing the job difficult and  increases stress… no amount of zumba can take away the stresses of not being able to get on with the job because we don’t have phones or emails  and it is amazing how much time you can lose trying to retrieve lost diaries…

But.. then we had Tuesday and an “open  space” event… about care for older people.. I have never been to one of these before and  it was new to most of us and a bit daunting… no sitting  quietly in the back of the meeting planning quietly what you are going to cook for tea.. no this was all about full on participation .. listening and contributing…It was part of a piece of public engagement we are running called “fit 4 the future” and  involved all our local stakeholders.. public.. private ..voluntary… it was great . 70 people came and there was so much energy and  positivity in the room. And I thought that I wish our  public could see this.. see how passionate the people  who work in our many services are. How much they want to make things better, that despite cut backs  and staff shortages and  so much negative coverage in the media about older peoples services these people really care.

People had lots of ideas…some new…some a little off the wall…So much  of what we talked about was about how we work together  across the organisational boundaries that divide us to do the right things and make it better…accepting that there will always been boundaries somewhere and  it is easy to use these as excuses to do nothing…

And we talked about how many times we have all been here before.. said the same things before… can it really be different this time?

Well.. yes I hope so.. and I told my  story about the patient who came to see me for help giving up smoking.. they said sheepishly… well I have tried 4 times before and FAILED… and my reply was as it always is.. they were not failures they were rehearsals…. So lets hope that just like the smoker desperate to give up… we desperate to get it right this time can learn from all those many rehearsals we have all participated in before. .learn from why they didn’t work and  get it right ( or at least most of  it) this time…

So I went away from that day feeling tired but so much more positive.. buoyed by the commitment of so many people who just want to get it right and who despite everything care so much…

All Change!

So here we are… finally the real thing. Lots of people have asked  me “How does it feel?”…. Well the answer is for me personally .. not very different really in that we have been doing the job for the last 18 months or so.. but now I guess the buck stops here….with me, and that feels big!

What has been interesting though has been to watch the architecture of the commissioning ( buying services) part of  NHS  be taken apart and  rebuilt  gradually over the  last few  months picking up speed towards the deadline….and  how complex and difficult that has been. Now we have gone past the date when it all had to be rebuilt and ready for habitation… we have discovered  we need bits we cant find and  bits that we have that aren’t ours but don’t seem to fit anywhere else.... like one of those old jigsaw puzzles you find in a dusty cupboard … some pieces missing and some pieces that just don’t seem to fit anywhere…

Just to make life even more interesting many organisations have recently moved home ( we have moved from old PCT building to share  with our local authority) and along with that comes phone and IT chaos lasting weeks ( no landlines for 2 weeks, slow or absent internet access) …. And then .. just to top it all for some reason someone decided that Aprils Fools day would be a great day to migrate  all staff from one email system to a new one… with new addresses.. less functionality… marvellous!

And the day job has to go on.. despite lack of computers of telephones contracts must be signed, plans made, savings made.. the clock is ticking..

It has not just been us that have been confused… We  received a letter from a patient who was appealing against a decision made early this year by our PCT individual case funding panel and ,because of  reorganisations, her case is now being dealt with by a new and much more remote part of NHS England, involving a whole new set of people. And she is confused and I don’t blame her.

And I ask myself… surely we could have done this better…such big organisational change  means new jobs, new  roles, new colleagues, new challenges feels difficult.. painful.. confusing…uncertain… Surely the NHS -which does this so regularly-should be getting better at learning the lessons and at least do the structural bits efficiently and swiftly, which might lessen the pain.  Maybe the problem  is we lose so many good  people each  time we shake everything in the snow globe up again , and there are few  people left with the memory of the past and  those who are left worry about being seen to be  overly  negative..

It will get better, and in a whole this will seem like a distant memory we can laugh about…Lets hope there are enough of us left next time ……

A cultural revolution?

Much has happened in the past few weeks. Firstly and probably least importantly CCGs have been authorised as new organisations. We are now the real thing. I am no longer an interim, shadow or designate. I am in charge and that is both exciting and frightening. More importantly the Francis Report has thrown a public spot light on the cultural issues within the NHS was all know are there and have talked about in hushed conversations between friends. A bullying culture…top down pressure to make the money work.. jobs on the line..




How could we ever have thought that it was okay to accept that at the top of the NHS somehow believing it didn’t affect anything important, only mattered to those in receipt of the pressure, when of course we all knew somewhere inside ourselves that it affected everything..



And I wonder how to change it. I am now a senior leader. It is my job to play my part in making the NHS a better place to work and a better care giver for patients.



So much of it is SO good. There are so many who work really hard to give a fantastic service to patients, often unsung, unthanked they just get on with it because it is the right thing to do. In all of this soul searching it is important we remember that. It is about growing a culture that supports the good and challenges the less than good to be better, to aspire to the best rather than accepting poor standards.



Leadership is key. WE need compassionate leaders, who lead by example. It isn’t possible to have one culture of leadership at the top of the NHS and expect that not to filter right down to the front line. If we want compassion and caring for patients then we need a leadership style throughout the NHS that delivers that at every level. WE need to understand that being caring doesn’t mean being soft. It doesn’t mean tolerating poor performance, laziness and lack of progress. It means we manage people as we would like to be managed with clarity, sensitivity, openness. WE need to be clear about our expectations of each other and we need to remember to praise people for the effort they put in and the successes they achieve.



AS a GP I have always tried to deliver the standard of care to patients that I would want for myself and my family. I am intolerant of poor care and I say so. I am sure that there have been times in my career when I have delivered less than best care. I am human after all. There are times when it feels so busy that I am concerned I cant give the person on front of me everything they need. I reflect on those moments, worry about them, and do my best to make changes to stop them happening again in the future. As a leader I try to do that same. I don’t get in right all the time but I am learning fast.



Collectively we have to have a strong shared belief that we can make a difference. That the culture in the NHS, even though it ia a huge organisation, can change. Bringing clinicians into management helps I think ( well I am bound to say that aren’t I?) Brining patients and the public into decision making in a real way is also vital. Developing an openness where we share our plans , our successes and failures is also key. And that isn’t about just having board meetings in public it is about talking at those meetings openly about the issues and challenges we face rather than just going through the motions ,and it is about getting out there and sharing with our public the really big and difficult issues we face and for which there are no simple answers. Should we fund IVF? If so where does the money come from? How do we decide between the many competing priorities for investment we receive, when there is no new money?



In the end rather than try to fix the big picture I will focus on trying to get it right here, in our little locality. That is a big enough challenge. If we are all doing that, all over the country there is hope that it will feed up into the centre from all the roots of the NHS…So it is about doing stuff differently and challenging the old ways… interesting that when I started writing this I wondered if it might been seen as critical by people above me in the NHS tree and then I wondered why that would matter if we truly are an open organisation happy to question ourselves and admit our faults….

So is this the begining of a quiet revolution?

Caring.. how do we put the caring back into health care?

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With the imminent publication of the Francis Report I guess we are all reflecting on what  “care” really means. There has also been much debate about the Liverpool Care Pathway and the potential for its misuse. Over the Christmas break I experienced health care as a relative. Not as a doctor or a manager but at the sharp end of care, and perhaps in the most challenging environment: the elderly care ward of a district general hospital. Perhaps the place where you can really judge an institution’s commitment to patient centred care. It isn’t fast paced or exciting. It  is all about individual patients who are frail and vulnerable and often cant speak up for themselves. Get it right here and surely the rest is easy.

 My uncle, who was 94 was sent into hospital from the care home where he lived because he was increasingly poorly. He had widespread prostate cancer and no one expected him to live very long. I don’t know why he ended up in hospital in the first place. I hope if he had been my patient I would have managed his last few days where he was used to being, as close to being in his own home as possible. He was admitted with dehydration and a chest infection to his local hospital, not to a hospice but to a general ward for elderly people.

We went to visit him on the Saturday between Christmas and New Year, a 6 hour round trip, across the other side of the country. When we got there he was in a twin bedded ward. It was noisy, crammed  but clean. It was visiting time and three nurses were huddled around the nursing station. We were told it was impossible to speak to a doctor at the weekend as there was only one on duty for the whole hospital and the nurse could only tell us  “ nursing” information. We asked if there was a care plan? A Liverpool care pathway in place ?? No one seemed to know much but there didn’t seem to be a pathway in place. We could talk to the consultant on Monday. A conversation  in the corridor. We felt unimportant. A bit of a nuisance and yet we were his next of kin.. his closest family. Were they too busy to take us to a quiet place to talk? Was it too much to expect to be spoken to like it mattered?

My uncle held my hand and asked me if he would be alive tomorrow. He looked and sounded scared. He had been a fighter pilot in the war. The only one of his squadron to make it through to the end. He was a husband and a successful business man who worked in his family’s business when he came back from the war. A father who had buried  his 3 children .To me  he had always been brave and dignified, funny and charming, invincible. Now he was dying and he was frightened. Did anyone here care? As I looked at him I could see what they would see…. another old bloke on his way. Yet to me he was so much more.

On the Monday.. and several increasingly irate phone calls later and we got to talk to the consultant. No, he wasn’t ill enough to be on the Liverpool care pathway but wasn’t on antibiotics and was just having fluids into his body through a needle in his tummy.. He had wondered if he would die of his chest infection over the weekend but seemed to be picking up. So I am thinking "how can he be both not ill enough to be on the pathway and yet might have slipped away over the previous weekend?"  He wasn’t giving him anything for his anxiety because it might suppress his appetite. And I am thinking.. "This man is dying.. today/ tomorrow /next week… does it matter if his appetite is suppressed.? . surely it matters more if he is lying there feeling scared"
Isn’t that what the Liverpool care pathway is all about? Allowing someone to die with dignity, as free from pain and fear as possible? But perhaps I am mistaken…. There has been much in the papers recently about the Liverpool Care Pathway but my experience of it is that used correctly it is brilliant. It is about building an agreed was forward for someone who will die soon between those who are giving care and the person and their family. Managed care…. Care that acknowledges that the persons feelings are what is most important.. There is so much written about this.. so many plans and strategies “patient centred care”  “the six Cs”.. I have read these throughout my career as a GP. What I know is that Peter didn’t want to die in pain or in fear.

Early the next morning, the first of the new year my uncle died.

 His care was not terrible. He was clean,  tended to every couple of hours by trained nursing staff who took care of his pressure areas and kept him hydrated. So he wasn’t thirsty or in pain.. But it could have been so much better. It wouldn’t have taken much to move his care from  adequate to fantastic.. It wouldn’t have cost anything. It is all about attitude and culture. He could have died at his care home where he as surrounded by his own things and where he felt at home. It was peaceful there. He could have been given medication to reduce his fears. He might have told them there how he felt. He didn’t say anything to the staff in the ward because he didn’t know them and he as strictly old school.. stiff upper lip and all that. He could have been seen for the person he was brave and  funny but tired.

Why do we as an NHS keep failing.? Why is benign neglect still more prevalent than caring.. that real connection between people which acknowledges our common humanity and is a giving of respect, understanding and empathy from one to another. See this old frail man as if it was you in his skin, lying in that bed, feeling scared and lonely after 94 years, not just some old bloke without his teeth.

funding fairness, what does it all mean?

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Before Christmas I read with some dismay the news about NHS funding for next year.  Flat growth for all CCGS and a further review of the new funding formula.  Let me say right up front that I completely agree that deprived areas need money to be spent on improving health. But  am I alone in thinking there is a big difference between improving health and funding health care? To influence the determinants of health we need as a society to invest in education, housing, job creation. Absolutely.  We need also to fund public health so they can invest in programmes that improve health: smoking cessation,   promotion of healthy life styles, sexual health initiatives. Completely agree. So we need to target that money to places where the evidence shows us it will have the most impact. Investing in health treatment services in deprived areas has less impact on improving health than investing in education, housing etc. Most health care spending treats illness once it has happened . It doesn’t stop people getting sick.

When it comes to health CARE spend though we also need to go back to the evidence. This shows us that the biggest determinant for spend on health care is age. The older you are the more illness you have, the more money is spent on your care. Therefore it follows that areas of the country that have very elderly populations spend more on health care that areas with younger populations.  The difficult bit is that in areas of the greatest social deprivation people die early so have fewer elderly people. We need to change that. So in some ways it feels uncomfortable for all of us to invest more in seemingly “affluent areas” but that is only measuring one variable. We could say we are investing more in areas with the oldest populations where health care spend is the greatest. To  go back to the previous point, to help people live longer we need to improve their overall health. As they become healthier they will live longer and will then need more investment in their health care. So they can live long healthier lives.

No formula works absolutely and there are always winners and losers. I have a personal  interest in all of this of course. As a CCG in a relatively affluent area with high levels of elderly we have a low funding per capita compared with the national average and have a long term problem with living within our allocations. We are a health economy in long term financial deficit. We get £1474 per person per year compared with Barnsley, a much more deprived area,  who get £1900 per year. A small change of £50 per person per year would sort out or long term funding issues. So we don’t need to formula to turn things up side down , just one to be slightly more in our favour. On top of this we read and hear every week about health economies with lots of money desperately trying to find  ways to spend the money they have in year, who try all sort of new and untried schemes whilst we are asked to consider draconian measures  like short term closures of community hospital beds to meet our financial targets .A very small shift in the formula towards a more age related model would significantly improve our situation. We are told that our problems are of our making: bad management, lack of will to change. But the evidence doesn’t support that. Countless changes in management have failed to sort out the issues. We, as a health community, put in many of the measures to improve efficiency in the system years ago that most areas are just beginning to consider now.. We don’t moan about it we just got on with it. Running an efficient health system is the right thing to do. But being efficient isn’t enough!

An eminent group of people were tasked to look at the formula and come up with a new one that more closely modelled health care spend. They have taken years to come up with this and my understanding was that is increased the weighting for age. Changed slightly the balance between deprivation and age. It didn’t turn it upside down but it did change things a bit and it did move money into health econmies with very high percentages of older people. So I hope any review undertaken now doesn’t fundamentally undo all that work. I have talked to our public in Hambleton Richmondshire and Whitby very openly about the funding challenges we face. To maintain a safe health system in a rural area is expensive . There is no weighting in any formula for rurality.. I believe our public  will understand the reasons for any changes if we can explain them openly and honestly.