I am slightly surprised to be writing this but The Prime Ministers Challenge Fund has done much to stimulate debate in primary care. WE have seen real enthusiasm to change things. To really get stuck into tackling the intransigent issues that face very rural health care. And this is new. WE have great GPs in our CCG, apparently they score the highest in patient satisfaction in primary care of all CCGs in the country. But they haven’t been at the forefront of innovation. What they have been great at is high quality patient centred traditional general practice that values relationship, continuity, commitment. They are mainly although not exclusively small practices dotted amongst the rolling dales and moors of North Yorkshire.
They are worried about the future, for their own services and for the wider health community. The big change is that now our GPs have said they need to stop complaining and start doing. They are planning bigger that just working together as GP practices, they want to look to providing locally based community services and out of hours services, that work closely with mental health and social care services . All joined up and working together. They are prepared to lead that. That includes looking at a different model for the GP contract too. They have a vision, they are developing how to express it and what to call it.
Most of our practices are MPIG practices and stand to lose a lot of investment over the next few years. The cynics may say that that is why they want to do this but I see it as part of a much bigger picture. It may have made them think differently but the prize of working in a system that delivers local care for local people all joined up, supporting each other reducing duplication, stopping endless journeys to distant hospitals for things that could be delivered locally and developing robust health care hubs ( or whatever you want to call them.. there are many names being banded about) would be an exciting and different place to work. Who wouldn’t want to be part of something amazing like that? Was it the fund alone? Or was it a kind of “perfect storm”? I am not sure.. what I do know is that sometimes that is just how stuff changes. Suddenly and for no apparent reason a lot of different things conspire to bring about significant shifts in attitude, in ambition.
We mustn’t lose this. If it is happening all over the country the NHS needs to find a way to harness all this energy and use it. Thee is £50M for ? 9 pilots. If there is £50M would 25 projects with £2M be another way? 2 million is a lot of money.. our CCG management budget to deliver everything is somewhere around £3.5M, do so few pilots really need so much money? I would hate to lose all this and return to the status quo…..
Tuesday 25 February 2014
Thursday 20 February 2014
Decisions...decisions...
Two weeks ago the Council of Members of the CCG came together to make decisions about the Maternity and Childrens services at our local hospital. WE have been considering change for the last two and a half years and talking to the public about the possibilities, culminating in a public consultation which closed at the end of November. I have written about the issues on my blog before. A small hospital, mall numbers of children need admitting to hospital and no middle grade paediatric cover. A maternity unit with 1200 deliveries a year which also struggles to maintain middle grade staff and increasing concerns about safety, quality and sustainability. This was a clinically led issue.: raised by the doctors and nurses who have led this service for the last 25 years who are worried it won’t be safe into the future.
The GPs wanted to make this decision. Many smaller decisions are made by the governing body working with delegated responsibility from the GPS. However this issue felt too important and the GPs wanted to make it themselves as a group. We wanted to develop an open and transparent way to make these decisions, knowing they would be contentious and difficult., wanting to assure the public that the decisions were made thoughtfully and carefully.
As a starter the Governing Body of the CCG developed a priority framework, which was agreed and adopted by the GPs where each option was rated by every practice team in the CCG on a series of aspects: clinical effectiveness, patient experience, cost effectiveness, safety, access, sustainability and affordability. The practices used all the information we had brought together including a review of the evidence, models used around the country and internationally, economic and equality impact assessments impact of travelling , NCAT assessment and most importantly feedback from the patients and public. The practices then came together with one representative from each practice, each with delegated responsibility to speak for their practice at the meeting and feedback collectively the outcomes of the practice discussions. This was then used to develop both the shortlist for consultation and more recently to decide the outcomes of the consultation.. So for the first time the decision was made by all practices in the CCG working together. It was time consuming for us, and for the practices and could only practically be used for BIG decisions but it felt good to have such a robust method of collective decision making.
And some interesting discussions: was each practice voting on what it thought would be best for its own population or for the populations of the CCG as a whole? One of our three localities is largely unaffected by these changes but still has a role as a commissioner of service, so our job is not simply to reflect the issues for our patients in our practices but to have a wider view for all patients across our CCG. What if the discussion develops and new arguments change the overall views of the group?. Does delegated responsibility mean the rep can change their decision based on what they think their practice would do if it was sitting round the table? We agreed they could. Interestingly that was really only as issue when it came to discussing investments around supporting the changes ,not about the need for change itself.
Was it what I expected? Yes and No…It was great to feel part of a process that felt robust and clear.. Some of their recommendations may be challenging to implement but that is my job! I worried that it wasn’t as “smooth” as it might have been, but it was real and unrehearsed and we are learning.
Our constitution stipulates that the GP council meeting is held in private and the Governing Body in public. It is my understanding that this is true for all CCGs up and down the country. If the council of members make “big “ decisions though, we all agree these really should be made in public. This time we videoed the meeting and will release the video with our formal papers so anyone who wants to can watch the debate and how the decisions were reached. The company who recorded it for us joked that it would “ go viral” Somehow I doubt it! But all the way through this process we have tried to be as open and transparent as we can be about what is happening. When we received alternative options from the public we then invited them to our meetings with the clinical teams at the hospital so they could participate in the debate about those new options and whether they would be feasible. There is no national blue print for this, it is about always challenging ourselves and trying to do it better. We need to discuss with the Council that in future we need to go for full public meetings.
When I first worked in the NHS most decisions were made without any real debate, either with clinicians or with the public, based on opinion not evidence. Things are changing. WE need to continue to develop real open ways of talking, explaining, listening..it is a work in progress..
The GPs wanted to make this decision. Many smaller decisions are made by the governing body working with delegated responsibility from the GPS. However this issue felt too important and the GPs wanted to make it themselves as a group. We wanted to develop an open and transparent way to make these decisions, knowing they would be contentious and difficult., wanting to assure the public that the decisions were made thoughtfully and carefully.
As a starter the Governing Body of the CCG developed a priority framework, which was agreed and adopted by the GPs where each option was rated by every practice team in the CCG on a series of aspects: clinical effectiveness, patient experience, cost effectiveness, safety, access, sustainability and affordability. The practices used all the information we had brought together including a review of the evidence, models used around the country and internationally, economic and equality impact assessments impact of travelling , NCAT assessment and most importantly feedback from the patients and public. The practices then came together with one representative from each practice, each with delegated responsibility to speak for their practice at the meeting and feedback collectively the outcomes of the practice discussions. This was then used to develop both the shortlist for consultation and more recently to decide the outcomes of the consultation.. So for the first time the decision was made by all practices in the CCG working together. It was time consuming for us, and for the practices and could only practically be used for BIG decisions but it felt good to have such a robust method of collective decision making.
And some interesting discussions: was each practice voting on what it thought would be best for its own population or for the populations of the CCG as a whole? One of our three localities is largely unaffected by these changes but still has a role as a commissioner of service, so our job is not simply to reflect the issues for our patients in our practices but to have a wider view for all patients across our CCG. What if the discussion develops and new arguments change the overall views of the group?. Does delegated responsibility mean the rep can change their decision based on what they think their practice would do if it was sitting round the table? We agreed they could. Interestingly that was really only as issue when it came to discussing investments around supporting the changes ,not about the need for change itself.
Was it what I expected? Yes and No…It was great to feel part of a process that felt robust and clear.. Some of their recommendations may be challenging to implement but that is my job! I worried that it wasn’t as “smooth” as it might have been, but it was real and unrehearsed and we are learning.
Our constitution stipulates that the GP council meeting is held in private and the Governing Body in public. It is my understanding that this is true for all CCGs up and down the country. If the council of members make “big “ decisions though, we all agree these really should be made in public. This time we videoed the meeting and will release the video with our formal papers so anyone who wants to can watch the debate and how the decisions were reached. The company who recorded it for us joked that it would “ go viral” Somehow I doubt it! But all the way through this process we have tried to be as open and transparent as we can be about what is happening. When we received alternative options from the public we then invited them to our meetings with the clinical teams at the hospital so they could participate in the debate about those new options and whether they would be feasible. There is no national blue print for this, it is about always challenging ourselves and trying to do it better. We need to discuss with the Council that in future we need to go for full public meetings.
When I first worked in the NHS most decisions were made without any real debate, either with clinicians or with the public, based on opinion not evidence. Things are changing. WE need to continue to develop real open ways of talking, explaining, listening..it is a work in progress..
Tuesday 4 February 2014
Snow and high winds ahead!
It is hard….. so much guidance, targets, so many plans. Last year we designed our vision and we have had a year to get that off the ground. I don’t know about other CCGS but we have made a good start…investment in the community system, much improved working by health and social care staff, a real and different conversation with the public about what we all want for our area in the future and here anyway less pressure so far on the A&E front door. Some of those changes have been small I agree. Those who wish to put down CCGS laugh at us and challenge the scale of what we are doing. We have to make changes big and small. This year we have been getting people together, developing a joint sense of purpose and direction, we have been testing this out with small but significant changes, we now need to move at scale. WE have done a lot in a year. We want to hang on to that map, that vision for the future.
Yesterday I was stood on Base Brown in the Lakes. The views down across Borrowdale were spectacular and the light a little menacing but glorious. The winds were gusty and with ice under your feet and a gale that could blow you over at any moment it felt precarious but the reward was magnificent. Sometimes doing this job feels like that. So much turbulence all around. I learned to seek out the snow and avoid the ice..firm feet make you feel much safer. And I wasn’t alone and I knew my companion to be brave but not foolhardy.
I don’t remember a planning round like this one. So much to take on.. As a CCG we need to be brave we need to keep our feet steady ..rooted in the things we know are right and need to be done whilst not getting blown off course by the many targets and trajectories we are required to submit..There is a risk of getting lost in the process itself.. the worst outcome.. a lovely plan that pleases everyone and yet delivers nothing.. What ever happened to bottom up.. light touch…earned autonomy?
This is THE year.. our chance to change as much as we can as quickly as we can, building on last year.. next year we have elections, smaller management allowances, the better care fund… we have to have changed things this year , we have to be making this happen now.. this week,next week, every week…so fewer people end up in our hospitals, by next year. There are no second chances. By next year it will be too late.
Walks in the Lakes are good.. they clear your head… they give you back a sense of clarity and purpose. The physical challenges replace the intellectual ones for a few hours and allow much needed respite. I think I will be walking a lot this year…..
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