Six Cs

As I was driving into work today I was listening to the Today programme and our Chief Nurse Jane Cummings talking about the new  nursing strategy which focuses on the 6 Cs :

care, compassion, competence, communication, courage and commitment.

I have never really liked catchy headlines and feel sometimes we spend too much time thinking them up rather than doing anything about them but these words struck a chord.

I found myself thinking that these should be true for everyone working in the NHS not just nurses, but doctors, managers, porters, receptionists everyone. It needs to be the culture of the NHS not just for nursing.

Sadly there are many many stories where care got lost in “management”. We all have our own stories. I do. My Mum, My daughter. Contacts with the NHS at time of acute personal stress and vulnerability when nothing terribly bad happened but that vital human acknowledgement of the needs concerns and values of person inside the medical problem are ignored, brushed aside. Working in the NHS myself hearing these stories makes me feel embarrassed and apologetic. And there are worse of course. WE await the Francis Report which we know will be as hard to read and the previous reports have been.

Those 6 Cs seem so obvious don’t they? The blindingly obvious. Why do we need to spell them out?  

To many outside the NHS it may seem strange to have “courage” in there but to those of us who work within it…we understand. It is the courage to stand for what is right, to always keep the patient at the centre of everything we do even when the pressure is on. . It is wrong though to focus on individual alone. Yes everyone who works in health care has a responsibility to do their best but It is about growing systems that support people to work to do just that.  And pressures come from many different places.

 Organisational cultures can sap personal strength make staff feel powerless and even bullied  Front line  staff working with patients every day need to work in supportive environments. In fact the environments need to have those same 6Cs as their guiding principles. We all work best when we are treated with care, and compassion, by a competent management team who communicate well and lead with courage and commitment.

I hope things can change. There mustn’t be  about a tick box approach to implementation of change. We have lived through “named nurses” who were never there, lip service to individual care plans. This needs to be deep fundamental cultural change through the NHS from top to bottom and side to side… where everyone believes this is more important than short term financial issues and process targets.What could be more important than this?

Logs and Bricks

It is too long since I last blogged… my excuse well time and pressure. Lots going on and it is so easy to get drawn into the day to day and lose sight of the bigger picture. We have been busy of course and all of it is important. Busy doing what? Well… getting the CCG authorised ( a national process that measures us against a set of criteria laid down to test that we can do the job we need to do once PCTs finally go in April next year.. so they cover everything from how we talk to our public and patients to how we are managing our finances and whether we  have robust processes for safeguarding)…  continuing with our on going work around the paediatric and maternity services at the Friarage, trying to get a handle on the finances for our locality and developing and implementing new pathways of care to make our health system work better… and then sometimes I find myself wondering if we are making a difference.

 As a GP at the end of each day I can look back and measure what I have achieved that day….. number of patients seen, referral written, path results actioned, hospital letters read, patients phoned, prescriptions signed. A pile of neatly chopped wood, evidence of decision making and action. More importantly I can go home thinking that  somewhere in that list of jobs I have made a difference to someone.. Helped someone.

 At the CCG it isn’t so easy. Days are full of a mix of meetings big and small, phone calls and emails. Some of it is about fire fighting situations that just come our way out of the blue, much is about developing a new organisation.. working on culture , values… supporting staff…but at the end of each day it is harder to measure change. I still find I measure success in  terms of people: individual interactions, a good conversation, finding common ground when none seemed possible,  sorting out an issue about a service that was reported to us by a GP or patient, but I am learning that the other more architectural stuff is important too…it is more like building a house brick by brick than chopping wood, each brick laid doesn’t seem to amount to much and at the end of each day it doesn’t always look much different to the day before… and until you get the roof on it is pretty useless really…but together as long as each follows the blueprint we have all agreed upon we can build something and once we have got our “authorisation roof “on we can begin to take shape …. Sometimes we make mistakes and have to take a few bricks out and put them back differently. We are still an apprentice team although we each bring skills to the job in hand and we learn from each other day by day. Why do I like doing this? Because it is fun to work with such a great team of people who care passionately about what we do and I sincerely believe we can make a difference to those same people I worked with as a GP. WE can make the services we all use here better, higher quality, more efficient and effective.

Safety and the vintage car

During the time I was going round the area talking with people about the Friarage and the issues we face there, lots of people asked me about what “safety” really means. We use the term a lot as doctors. But how come services that were once seen as safe now aren’t? and it is a good question.




When I was chatting to one of my patients about this he said “ so its like old cars” I looked blank… he continued “ well in the past we all thought the cars we had were safe and we drove around in them happily. Then over the years there were seat belts air bags, ABS brakes, crumple zones.. the list goes on… now no one in their right minds would drive their toddler up the M1 in a vintage car without seat belts or air bags..” And he is right.. In medicine too lots has changed.. better drugs, better investigations, better technologies… And just like seat belts we don’t need them most of the time.. for 99.9% of the journeys we make it doesn’t matter if we have seat belts or not but when we do need them we are really grateful they are there. If I or one of my family was to be really unwell I would want them to be where everything they might need is there, just on case.



When I was fist a GP in Catterick I worked as a GP in the accident and emergency department of the Duchess of Kent Military Hospital. At the time it was a fully functioning hospital.. It was very quiet at night and when I worked there I was the only doctor in the hospital. I covered the accident and emergency dealing with road traffic accidents, injuries etc , paediatrics with children with fevers ,pneumonias etc, the high dependency unit, coronary care where people who had had heart attacks were monitored , and general medical and surgical wards where patients who had just had major surgery were recovering. I am a GP, not a bad one I hope, but I am not a hospital doctor. Specialist doctors were “available from home” usually 20-30 minutes away. At that point in time that was considered “safe” now it would be seen as completely unacceptable on the grounds of clinical safety. I suppose there was less we could do then ,but when I broke my leg last year I was comforted to be in a large trauma centre where I had the best and most modern care. Life moves on.

Another step along a very long road

Oh dear.. It has been a while since I last wrote my blog….. life has been particularly hectic and everything else gets in the way of this.. but I guess that is real life taking precedence over a virtual one.. which is a good thing!




Having finished the conversations with the public around the possible reconfiguration of services around the Friarage hospital we have been completing the report and going through the various assurance processes necessary for the next phase a “gateway 0” review( which looks at the process) and a. NCAT review (which looks at the case for change etc). Both were very supportive and helpful. On of the things about the whole process that has surprised me is that so much of this we have had to learn as we go along. There doesn’t seem to be a blue print that guides you through, even though it has been done so many times before. Perhaps we will write one!



As a newly formed CCG, we struggled with the how do you get a really “clinically led” decision. There is the governing body of the group that has been given authority by the GPs to make some decisions in their behalf but this seemed like a really big recommendation so we wanted every fmaily doctor to have a voice.



So we decided to ask each practice to look at the three short listed options and score them according to various criteria ( these had been chosen previously by the governing body) and then each practice sent one of its members to a meeting of the GP council and all the scores were put together to come up with an overall score. There was a great deal of agreement between practices around the scoring of each option and we came to a decision everyone there felt comfortable with. We then went back and phoned the few practices who couldn’t come, and checked out the results with them..



It is now my job to talk to our partners about the recommendations the GPS have made, in the end it just another step along a very long road…. From here we go to the PCT board then through an assurance process by the strategic Health authority (management tier above the PCT and below the National Commissioning Board) and then probably out to formal consultation with the public….



We have had a few people telling us they are concerned about everything being aired so publically. I think it is absolutely how we should do things. We have made some “rookie” mistakes along the way because we are learning and there are polished operators out there who love to trip us up every time we falter. My only response is that we are trying to do the right thing and we will go on doing that. Hopefully we wont make the same mistake more than once.



I am learning fast…It feels like a long and challenging process but then it should be. It is a big change and will affect people so it is important that it is rigorous, open and challenging.

Gone off her legs

This week somehow my blog got into Pulse ( a national GP medical magazine )and got some comments… I wondered if I should reply there but decide to here instead….

It is true that to say closing beds in acute hospitals and moving people into the community isn’t the whole answer. Of course it isn’t. The problems in the NHS are complex. As I have discussed before: if there were easy fixes we would have found them, done them by now. The problems for North Yorkshire are complex too and we are trying to do the right things to begin to fix them, not believing there is a magic answer.

I know two things though. Most people would like to stay at home if they could, when they get ill. In our area a recent bed audit showed us that on average 30% of people were in beds they didn’t need to be in and 90% of the patients in one of our community hospitals could have been cared for at home if the care was available.

Hospitals are changing. The pressures put on them like changes in doctors’ hours, training, working life aspirations and safety standards mean that you need larger hospitals to sustain services. For a rural area that means people travelling further for their care. But does everyone have to travel further?

We call it “gone off their legs” when a (usually) elderly person who has been managing at home okay suddenly doesn’t. It is often caused by something relatively small happening, medically speaking: a urine infection, a minor fall, and suddenly someone who was doing okay isn’t anymore. Off their legs that can’t go to the bathroom, get themselves food, change their clothes. Not able to cope, they end up in hospital Going into hospital can make things worse, It is unfamiliar, and confusing and that person who has “ gone off their legs” then becomes “confused” as well, and it can take weeks to get them home. We should try and keep them at home in the first place but we can’t, because we don’t have enough staff in the community to take care of them.

Over the years staffing levels in community services in our area have been reduced because of the financial situation, whilst spending in acute hospitals continued to increase. Why? Well it was simple really. The community services and those services were paid by “block” which means they were given a lump of money and had to manage within it to do everything asked of them. By contrast Acute trusts (providing hospital based services) are paid for each bit of work they do.

It is like taking two people: one being paid a salary for the job they do and a second being paid by the number of things they make each day. When demand is increasing and there isn’t any more money it is easier not increase the salaried person wage because they will just go on doing the job anyway, doing more for the same money whilst the person paid per thing will simply be paid more as the number of things they do each day increases. Add to that the fact that there is no restriction on the number of things that person is allowed to do in a day, so no control over what they can earn. Who would you rather be in difficult times? So community services got left behind.

No one is saying hospital care is bad and community care is good. What I am saying is people shouldn’t be in hospitals if they don’t need to be.

Will it sort out our costs? Probably not. Maybe it is a small step on the way. In a large rural area with people having to travel long distances to hospital anyway it is surely a good thing to do as long as it provides high quality care and doesn’t cost any more money.

I am a GP and I am a practical problem-solver by trade. Give me a problem - I will try to sort it out. There are lots of bits of the system I can’t change. I can’t change the funding formula. I can’t change the system which pays for care. I can, however, look at a small bit of our system that looks broken and try to mend it. No one knows what the outcome of that fix might be, or what the unintended consequences might be; we can only try and then move on, then fix the next bit.

Will that fundamentally mend the system? I am not naive enough to think so. But, if I can make things a little better for some of the people who live in this area, then that is something worth doing. If someone goes off their legs can be managed at home and helped to get better in their own place with their usual food and clothes and surroundings and they get better, then it was worth doing.. And it is better than spending endless hours arguing about how we make things better on a grade scale and changing nothing.

A wicked problem?

This week North Yorkshire and York PCT (made up of 4 clinical commissioning groups including ours) announced a financial deficit. It has been there for years and years but in the past it has been temporarily sorted with loans from the strategic health authority ( the next tier up) and made up of money from other PCTs who have under spent. This year there is no “bail out” and so we will probably finish the year in deficit too.

There is no easy solution to this financial problem . No Willy Wonka Golden Ticket, no matter how hard we look for it. The reasons North Yorkshire is in deficit are complex. I have written about them before but it basically about three things: our rural geography, the way hospitals are configured and the way we are funded. We have tried to sort this out each year but got nowhere because of the complexity of the issues.

I went on a leadership course years ago. I learned many things that I have used since: lots of leadership theory, some more helpful than others. One of the sessions that really stayed with me was the concept of “wicked issues”. These are complex problems with no easy solution, lots of interconnecting issues, each one challenging and complicated. These are the problems people talk about often but put in the too difficult pile because even considering them gives you a feeling of doom and helplessness. We can all think of examples of these in our personal and working lives I am sure.

We need to change our health care system. We need to live within our means financially. We might all think the funding is unfair (and I believe it is) but I don’t think it will change much over the next 5 years and spending lots of time and energy fighting about the funding formula is just a distraction.

We need to re-engineer our system. We need to keep patients out of expensive hospitals and improve and strengthen care in the community- more district nurses, occupational therapists, physiotherapists who can, if required, provide a service in a patient’s home.  So that when I see an frail elderly person in the middle of the night as an out of hours GP and that person is not seriously ill but not well enough to stay on their own at home I can get them support and care they need in their own home rather than send them to a hospital miles away. That means fewer beds in hospital and the money that used to pay for those beds can be used to employ community staff. To do this we need the courage to make changes that may initially make our communities anxious and worried.

We need to find a way to explain the reasons behind the need for these changes so that they understand we can improve care for patients and save money. But it won’t necessarily look like the care we have had in the past.  Less time in hospital, more care at home. We have lots of “evidence” that this is the right thing to do and it is what individual patients want. Every time I send people into hospital they say to me “do I really have to go Doctor? Couldn’t I stay here?” We need our politicians to listen and to understand the problems and the solutions and help us explain these to our communities.

Maybe that all sounds straightforward to you.  I know it isn’t.  It requires courage, trust, stamina, commitment, tenacity. Easier to focus on the simple stuff.but that won’t fix the problem.

Wicked or what?

Different hats

I am on holiday. My daughter is getting married at the end of this week and my family and friends are be congregating in Richmond. This evening, as I write this there is a hen party in Harrogate and a stag do in Edinburgh…. I have been cooking: curry, meat loaf, apple pies and cheese cakes. It is lovely to relax doing something practical and simple.

Then I realised I hadn’t written my blog for a while and felt I should write something before I shut down my lap top and turn off my blackberry for the week. I cant believe it is 4 weeks since my last blog. Where does the time go? And I got to thinking about the different hats we all have… I have many…some professional: GP, CCG leader, out of hours doctor, appraiser.. .then lots of other ones: Mum, daughter, sister, friend…

 For the last few weeks I have been wearing one hat more than any of the others: I have been preoccupied with the work about the Friarage. So much to do: meetings, radio interviews, TV even, press quotes, visits around the country. Sometimes it is pretty tough. We have so much to do as a new CCG. We are the only CCG in the north trying to set itself up, make important efficiency savings AND manage a major public engagement around an issue as sensitive as the paediatric and maternity services at the Friarage


We didn’t choose to do this, and we are trying to do it right. We knew it would be a challenge. Interestingly there seems to be no national guideline about how to do it right. You have to make it up as you go along. We have tried to be open and honest. We have tried to listen and to respond. We have tried to reach out to everyone and follow up every suggestion and contact. Why is it tough? Well whilst so many people have been open and interested and keen to listen and to question, others seem so quick to criticise, to question our motives, to assume we are trying to mislead, to interpret occasional mistakes ( well we all make them!) as conspiracy. That gets tough. I am open to any discussion around the issues. They are difficult, complex. There are no easy answers. They are no hidden agendas. We all have feelings though, and we ALL care deeply about all of this. I am not moaning. I have a job to do and I have to do it as best I can. And I am learning so much very quickly. We need to respect each others’ views and feelings, and remember we are all people and we all wear many hats.

So, I am ready for my holiday. Ready to focus on my family to put down my professional ‘hats’ for a little while. To have time to enjoy cooking, and having long chatty meals with my kids and friends sat round the table, and watch my daughter and her great man get married! I will enjoy being Mother of the bride this week!

And I have a great hat!