All CCGs are considering co-commissioning primary care and some are keen to do it all.. budgets and all… We are more cautious. Co commissioning has 2 major flaws it seems to me, conflicts and capacity. We are living the issues that will inevitably arise when people start to do these things in earnest. We are re-procuring our community and out of hours services through a competitive dialogue. We want something new, innovative, joined up. Something that will bring together services and reduce duplication and waste. Our GP federation is probably going to bid. All the practices bar one single hander are in our federation therefore every GP on the governing body is conflicted.
Not everyone gets the problem. Many of my GP colleagues who manage confidentiality and potential conflicts of loyalty, information, role every day think it should be easy to sort and what is the fuss all about? But these issues are important.
We are a very open organisation we don’t really do secrets and huddles. From now on we will have to be careful who is in what conversation, who overhears what, what conversations are okay at lunch. WE eat lunch together each day.. or at least anyone who is in the building congregates in the kitchen. It is fun, social. We learn about each other as people with lives, families, interests. The chat is about all sorts but sometimes strays back to work. WE will just need to be careful we don’t talk about “some things” within the earshot of our GPs. It is important we can’t compromise them. Our weekly Strategic Management Team meeting is now divided into 2 with separate notes and minutes. The big stuff- Governing Body meetings etc. are easy enough it is the day to day that presents the challenge. AS we assess the PQQs we can’t use our usual clinical resource so will bus some GPS in who have very kindly agreed to help, from the north…This is a single project… when we commission primary care as a CCG which no doubt in the fullness of time we will all be doing it will be harder still.
Yet it is important. The public are rightly concerned about GPs making decisions about their own work and pay. Practices are concerned about in- crowds and outsiders…Everyone is concerned about fairness. Yes, CCGS understand primary care the best probably but are they best placed to make tough decisions about the services that are delivered by their friends and colleagues?
The second issue is do we have the skills and the time to do this well?...IT is a massive job. WE are doing good things but I worry that there comes a tipping point where if you take on too much you stop being able to be creative, productive and proactive and simply do nothing but fight the fires that have ignited when you were too busy to notice. And you end up running from one fire to another- exhausted, directionless. I have been there before.
Is this the right direction for primary care commissioning? I think the issues the services faces are huge and very complex. I am normally fairly good at coming up with solutions to problems…. But I struggle to even begin to find a model that will develop and invigorate primary care whilst safeguarding the pivotal role it delivers in the NHS within the structures we have today. National contracts, privately own premises, independent contractor status, financial pressures, scary workforce predictions around both recruitment and retirement, lack of leadership capability… all these conspire together to create an impending catastrophe for primary care and yet we are all sitting around watching feeling powerless to change things. Will co-commissioning be the answer? Definitely not in my view… but what will be?
Tuesday, 12 August 2014
Thursday, 17 July 2014
Everyone is talking about change in primary care....
Our GPs came first nationally for overall patient satisfaction this week in the most recent national survey. That is a fantastic achievement. 93% of patients rated the service as good. Does that mean that things are easy in general practice here? No. Talking to the practices I know they are working really hard and struggling to meet the demand they face. They need though to be congratulated for the effort they put in to maintain such good services despite the pressures. It is an even greater achievement at a time of such pressure in the system.
General practice is under pressure as never before. A perfect storm seems imminent. The age profile of GPs in our area (and reflected nationally) points to a mass exodus over the next 5 years, exacerbated by pension changes, revalidation demands and general change and workload fatigue. At the same time applications for vocational training are at an all-time low. Our local VTS which normally has no problems recruiting has less than 25% of its usual numbers this year. They can survive one year like that but another year would mean serious problems for the area and the hospitals the training posts support. Practices are struggling to recruit. I am reliably informed the average age for a female GP to leave the services is 36! Mainly because they leave to have children and then don’t return, choosing other specialities over general practice. WE have to do something urgently to make general practice a more attractive place to work. At the same time demand is spirally upwards.
We will also have a real deficit in GP leadership. CCGs are predicated on clinical leadership from the GP community but we also now need leaders to develop and change general practice as a provider of health care, leading federations of primary care, looking to new models that both secure what is best about primary care whilst responding to the challenges of a changing work force and service demand.
And there really is some urgency about finding solutions. Poor primary care will lead inevitably to increased demand on hospital services.
I have been out of clinical practice for just over a year. I returned recently to my old practice for a meeting. AS I walked across the threshold I was struck by the return of what I can only describe as “ a tension in my gut” and I recognised that feeling as something was there every day at work but had never consciously felt it. I only was able to recognise it in retrospect. Looking back I can see it was all about managing the unpredictability of the day and making decisions big and small.. all day.. managing risk… all day every day… I did it for 25 years and loved it but it is a tough job. And it is getting tougher. The role of the gatekeeper to the service is underplayed but it is a vital part of our system.
As a profession though, we must resist the impulse to push patients away as a response to overwork and the pressure. I phoned my Mums GP practice this week and asked for someone to visit her. No panic. Not urgent but she is too confused now to visit the practice. It would be too frightening for her. We had received a letter telling us who her “named GP” was. I was relieved. At 94 and having been at the practice for 10 years she is still only ever seen in one off episodes. When I requested that the named GP visit her… I was told promptly that the service “doesn’t work like that” and anyway “it was just a government paper exercise”. If we are going to campaign about poor funding and workload pressure surely GPs must still occupy the moral high ground and do our best for our most vulnerable patients. We must remain the advocate for patients . When I told my story many people responded they too had found themselves “fighting” to get in through the primary care front door. This wasn’t good enough for me, for my Mum. I made a fuss and in the end she was visited but it shouldn’t be because of who I am. It should be there as a right for everyone.
What can CCGs do? Well we have commissioning an “out of hospital scheme” this year… rolling up our local enhanced services monies and adding some more to move services AND the funding out of hospital and into practices. We supported our GPs to successfully bid for the Prime Ministers Challenge fund, and we are working with our local VTS to develop services in our local DGH that will make coming to our area as a trainee more attractive, and develop roles for trainees within the CCG. WE are also doing our best to develop and support any GPs who demonstrate interest in leadership, by offering bespoke roles and leadership skills training. We have expressed an interest in gently becoming involved in co-commissioning but we anticipate the issues will be complex and are concerned about a general lack of capacity either within area teams or at CCG level. It is a complex agenda and needs good people to invest time and energy into getting it right.
It isn’t enough. Some of the solutions need national action…the first step is for everyone to acknowledge the size of the issue we face and to understand what is driving people away from primary care and into other career choices. Of course waning interest in primary care as a career has happened before and the profession has survived but the issues around retirement weren’t there then, GPs were staying on into their 60s.. they aren’t now so unless we address the issues we will fall down a hole and such high levels of user satisfaction in primary care everywhere, but particularly in our area will be a fading memory….
General practice is under pressure as never before. A perfect storm seems imminent. The age profile of GPs in our area (and reflected nationally) points to a mass exodus over the next 5 years, exacerbated by pension changes, revalidation demands and general change and workload fatigue. At the same time applications for vocational training are at an all-time low. Our local VTS which normally has no problems recruiting has less than 25% of its usual numbers this year. They can survive one year like that but another year would mean serious problems for the area and the hospitals the training posts support. Practices are struggling to recruit. I am reliably informed the average age for a female GP to leave the services is 36! Mainly because they leave to have children and then don’t return, choosing other specialities over general practice. WE have to do something urgently to make general practice a more attractive place to work. At the same time demand is spirally upwards.
We will also have a real deficit in GP leadership. CCGs are predicated on clinical leadership from the GP community but we also now need leaders to develop and change general practice as a provider of health care, leading federations of primary care, looking to new models that both secure what is best about primary care whilst responding to the challenges of a changing work force and service demand.
And there really is some urgency about finding solutions. Poor primary care will lead inevitably to increased demand on hospital services.
I have been out of clinical practice for just over a year. I returned recently to my old practice for a meeting. AS I walked across the threshold I was struck by the return of what I can only describe as “ a tension in my gut” and I recognised that feeling as something was there every day at work but had never consciously felt it. I only was able to recognise it in retrospect. Looking back I can see it was all about managing the unpredictability of the day and making decisions big and small.. all day.. managing risk… all day every day… I did it for 25 years and loved it but it is a tough job. And it is getting tougher. The role of the gatekeeper to the service is underplayed but it is a vital part of our system.
As a profession though, we must resist the impulse to push patients away as a response to overwork and the pressure. I phoned my Mums GP practice this week and asked for someone to visit her. No panic. Not urgent but she is too confused now to visit the practice. It would be too frightening for her. We had received a letter telling us who her “named GP” was. I was relieved. At 94 and having been at the practice for 10 years she is still only ever seen in one off episodes. When I requested that the named GP visit her… I was told promptly that the service “doesn’t work like that” and anyway “it was just a government paper exercise”. If we are going to campaign about poor funding and workload pressure surely GPs must still occupy the moral high ground and do our best for our most vulnerable patients. We must remain the advocate for patients . When I told my story many people responded they too had found themselves “fighting” to get in through the primary care front door. This wasn’t good enough for me, for my Mum. I made a fuss and in the end she was visited but it shouldn’t be because of who I am. It should be there as a right for everyone.
What can CCGs do? Well we have commissioning an “out of hospital scheme” this year… rolling up our local enhanced services monies and adding some more to move services AND the funding out of hospital and into practices. We supported our GPs to successfully bid for the Prime Ministers Challenge fund, and we are working with our local VTS to develop services in our local DGH that will make coming to our area as a trainee more attractive, and develop roles for trainees within the CCG. WE are also doing our best to develop and support any GPs who demonstrate interest in leadership, by offering bespoke roles and leadership skills training. We have expressed an interest in gently becoming involved in co-commissioning but we anticipate the issues will be complex and are concerned about a general lack of capacity either within area teams or at CCG level. It is a complex agenda and needs good people to invest time and energy into getting it right.
It isn’t enough. Some of the solutions need national action…the first step is for everyone to acknowledge the size of the issue we face and to understand what is driving people away from primary care and into other career choices. Of course waning interest in primary care as a career has happened before and the profession has survived but the issues around retirement weren’t there then, GPs were staying on into their 60s.. they aren’t now so unless we address the issues we will fall down a hole and such high levels of user satisfaction in primary care everywhere, but particularly in our area will be a fading memory….
Tuesday, 8 July 2014
Hard work should be fun!
It is a while since I have written my blog…. I guess life got in the way.. two of my daughter had babies so I have been juggling work with grandparent fun stuff and some things have to slip… anyway.. as I have driven round the country I had had many potential blogs running around my brain..
Every day as I listen to Radio 4 Today programme on my way to work I hear the endless drip of negative NHS stories, we seem as a nation intent on always believing the worst. It makes me sad. For those of us working in the service working really hard to make it better but believing we already deliver a service that is good for most, excellent for some but we know it is poor for some too .. and no room for complacency and so many challenges ahead. But all the negative makes it hard to feel good about what we do every day when we come to work. It weighs you down. My daughters had a patchwork of experiences.. some good.. some excellent some only average.. mostly dependant on the individuals they came across. So much of what influences patient experience is the attitude of the individuals who deliver the service..and what mattered to them was being involved in decisions, treated like a person not a walking womb, given time, looked at and acknowledged. Simple stuff. But that simple stuff happens when the organisation allows individuals who work there to flourish and enjoy their work. To feel valued and important. When you feel valued it is easy to help others to feel like that too. It is infectious!
At a time of such threat and challenge in the system it is more important than it ever has been that those who work in the NHS feels valued and can feel good about coming to work. WE talk about fun. Is it fun to be at work? If I hear laughter in my organisation I feel we are on track. Yes we are busy and we do a lot every day.. but we can also be relaxed enough with each other to laugh at lunch times, which we have together in the kitchen and even at the meetings where important work is done too.
We have developed a game to play with our stakeholders and the public called “Strictly Come Commissioning”. It is a board game played by a group of people playing at being commissioners for a day We piloted it our recent Health Watch conference and it went really well. It stimulated lots of conversation and debate about all sorts of issues. There was a real buzz in the room. Should we commission services for people who smoke/are overweight/ subfertile? How do those services stack up against services for people with cancer or autism? What do you do when urgent admissions spiral out of control? We did get a letter for someone who got the invite but didn’t attend saying we shouldn’t be playing a game about serious things.. but we learn through play and it was fun. Is that wrong? When did work become something that had to be serious all the time? Surely that isn’t a natural way to be? We are now thinking we could use the game to explain commissioning to all sorts of groups: GP trainee doctors, A level students, patient groups, surely better than me standing there with a powerpoint?
So whilst we are all working so hard changing so much, working under such pressure, lets remember also to have moments of lightness and fun too. It helps teams to value each other and work better together and it doesn’t reflect any lack of commitment to the job. I read somewhere that adults laugh an average of 9 times a day compared to children who laugh 40-50 times a day. So here’s to hard work and laughter.
Every day as I listen to Radio 4 Today programme on my way to work I hear the endless drip of negative NHS stories, we seem as a nation intent on always believing the worst. It makes me sad. For those of us working in the service working really hard to make it better but believing we already deliver a service that is good for most, excellent for some but we know it is poor for some too .. and no room for complacency and so many challenges ahead. But all the negative makes it hard to feel good about what we do every day when we come to work. It weighs you down. My daughters had a patchwork of experiences.. some good.. some excellent some only average.. mostly dependant on the individuals they came across. So much of what influences patient experience is the attitude of the individuals who deliver the service..and what mattered to them was being involved in decisions, treated like a person not a walking womb, given time, looked at and acknowledged. Simple stuff. But that simple stuff happens when the organisation allows individuals who work there to flourish and enjoy their work. To feel valued and important. When you feel valued it is easy to help others to feel like that too. It is infectious!
At a time of such threat and challenge in the system it is more important than it ever has been that those who work in the NHS feels valued and can feel good about coming to work. WE talk about fun. Is it fun to be at work? If I hear laughter in my organisation I feel we are on track. Yes we are busy and we do a lot every day.. but we can also be relaxed enough with each other to laugh at lunch times, which we have together in the kitchen and even at the meetings where important work is done too.
We have developed a game to play with our stakeholders and the public called “Strictly Come Commissioning”. It is a board game played by a group of people playing at being commissioners for a day We piloted it our recent Health Watch conference and it went really well. It stimulated lots of conversation and debate about all sorts of issues. There was a real buzz in the room. Should we commission services for people who smoke/are overweight/ subfertile? How do those services stack up against services for people with cancer or autism? What do you do when urgent admissions spiral out of control? We did get a letter for someone who got the invite but didn’t attend saying we shouldn’t be playing a game about serious things.. but we learn through play and it was fun. Is that wrong? When did work become something that had to be serious all the time? Surely that isn’t a natural way to be? We are now thinking we could use the game to explain commissioning to all sorts of groups: GP trainee doctors, A level students, patient groups, surely better than me standing there with a powerpoint?
So whilst we are all working so hard changing so much, working under such pressure, lets remember also to have moments of lightness and fun too. It helps teams to value each other and work better together and it doesn’t reflect any lack of commitment to the job. I read somewhere that adults laugh an average of 9 times a day compared to children who laugh 40-50 times a day. So here’s to hard work and laughter.
Tuesday, 29 April 2014
More Good news!
I think I am on a roll about good news. Since writing my previous blog I have had many conversations with people who are fed up with all the gloom. So today I am also writing about good things happening in the NHS.
I will start with an update about my Mum. Those of you who have read my blog in the past will know about my Mum and the problems she faced last year. She is 94 next week and has escalating problems with dementia. Last year she had the classic story of a series of falls, increasing anxiety and 3 unnecessary urgent admissions at a hospital because there was nowhere else for her to go and in the end was placed in a nursing home as a place of safety because being home was no longer manageable. Having visits for 21 different carers a week and then probably 15 other people popping in with meals, medication, monitoring her falls risks and her mental state etc etc was just too much for someone already confused and frightened by her confusion. It could so easily have ended there… but we were lucky. She lives in an area where there is “extra care”. Having read Roy Lilleys’s blog I now realise this isn’t universal so we as a family have been lucky.
We as a CCG are also lucky that our local authority are developing extra care at pace across the county.
So what is extra care?.. ... My Mum still has her own flat, her own front door. She is still home. A team of carers work in the building and Mum has got to know them and to trust them. Although that did take time. At first she wouldn’t shower or wash, but then why should it be easier for her to get naked with a stranger just because she is old? She showers now. At first she was rude and difficult with the carers lecturing them about their educational achievements and that they should try harder. She was a teacher. It was excruciating to witness but the carers managed her with kindness and tolerance and gradually as it all became more familiar she became calmer. She has meals with all the other residents at midday and her other meals prepared by the carers in her flat. A team of people do her shopping, washing and cleaning. When she falls ,night or day she calls them and they are there on the premises, they assess her and then pop her back in her chair or into bed. No 999, no A&E. AS long as her behaviour remains manageable she should be able to stay there as her memory shrinks further. She is content. Her aggression is very much linked to anxiety so hopefully now everything is familiar it won’t be a problems although of course you never know. Many extra care facilities keep people even when they are very demented. Technology allows monitoring of wandering , falling etc. My Mum is also no longer lonely. The carers and other residents have become part of her world rather than strangers and although she doesn’t talk to them much they give her a sense of community and belonging.
I was at a public meeting locally when someone in the audience said they would hate to live in a place like that “ a rabbit hutch for old people” and yes I can see why when you look in from the outside it might seem like that but what I have learned from watching my Mum is that her needs and aspirations have changed as she has aged and whatever I may think about it ,she is content and that is what matters.
As a CCG we are working with our Local Authority to develop integrated health and extra care models to jointly commission facilities where frail older people can be supported to be independent but access the care and the companionship they need. Maybe a community hospital co-located with an extra care building with shared staff and more importantly shared ethos. We could also add housing for younger people living with serious chronic illness or disability, who need nursing and care support but are keen to live independently. These new developments will take time and will need our public to be along side us. For now we are working with the local authority to get the best out the ones already built so that we maximise joined up input to keep residents as healthy as they can be for a long as possible .
This morning I was discussing with one of our local physicians from our local acute trust the recent experience of his pilot in our local A&E where he and a colleague work two shifts a week to trial consultant assessment at the front of house. Yesterday evening he saw 8 patients, sent 6 home with the much improved community and social care support that we have been developing over the last year including night caring, integrated neighbourhood health and social care teams, better resourced social care assessment and fast response etc. One of the two who were admitted clearly could have been managed at home with the right more enhanced home care so we will work to provide that. So that is 6 patients who would have found their way into an acute bed able to go home and have their treatment and care there. Last year our urgent admissions reduced by 3%. He is convinced that because we have good primary and community care we can manage more of the people at present on his wards at home. With investments we are making this year we can do it better and for more people. We just need the collective will and the confidence to do it. We are developing a “hot clinic” in our community hospital run by physicians, therapists, social care and community nursing to urgently address the needs of older people who are becoming frail before they hit a crisis.
It is all good stuff. Is it big enough? Well, you could look at each initiative and accuse CCGs of playing at the edges, not being strategic or ambitious enough. Or you could see each scheme as part of a much bigger picture and acknowledge that CCGs are making changes on the ground; changes that mean better services for individual patients and their families; changes led by local doctors, nurses ,social workers and therapists; changes that are there to address the difficult issues no one in the past has had the will to sort out, changes that will add up to a better system, a system that is better than the sum of its parts.
I will start with an update about my Mum. Those of you who have read my blog in the past will know about my Mum and the problems she faced last year. She is 94 next week and has escalating problems with dementia. Last year she had the classic story of a series of falls, increasing anxiety and 3 unnecessary urgent admissions at a hospital because there was nowhere else for her to go and in the end was placed in a nursing home as a place of safety because being home was no longer manageable. Having visits for 21 different carers a week and then probably 15 other people popping in with meals, medication, monitoring her falls risks and her mental state etc etc was just too much for someone already confused and frightened by her confusion. It could so easily have ended there… but we were lucky. She lives in an area where there is “extra care”. Having read Roy Lilleys’s blog I now realise this isn’t universal so we as a family have been lucky.
We as a CCG are also lucky that our local authority are developing extra care at pace across the county.
So what is extra care?.. ... My Mum still has her own flat, her own front door. She is still home. A team of carers work in the building and Mum has got to know them and to trust them. Although that did take time. At first she wouldn’t shower or wash, but then why should it be easier for her to get naked with a stranger just because she is old? She showers now. At first she was rude and difficult with the carers lecturing them about their educational achievements and that they should try harder. She was a teacher. It was excruciating to witness but the carers managed her with kindness and tolerance and gradually as it all became more familiar she became calmer. She has meals with all the other residents at midday and her other meals prepared by the carers in her flat. A team of people do her shopping, washing and cleaning. When she falls ,night or day she calls them and they are there on the premises, they assess her and then pop her back in her chair or into bed. No 999, no A&E. AS long as her behaviour remains manageable she should be able to stay there as her memory shrinks further. She is content. Her aggression is very much linked to anxiety so hopefully now everything is familiar it won’t be a problems although of course you never know. Many extra care facilities keep people even when they are very demented. Technology allows monitoring of wandering , falling etc. My Mum is also no longer lonely. The carers and other residents have become part of her world rather than strangers and although she doesn’t talk to them much they give her a sense of community and belonging.
I was at a public meeting locally when someone in the audience said they would hate to live in a place like that “ a rabbit hutch for old people” and yes I can see why when you look in from the outside it might seem like that but what I have learned from watching my Mum is that her needs and aspirations have changed as she has aged and whatever I may think about it ,she is content and that is what matters.
As a CCG we are working with our Local Authority to develop integrated health and extra care models to jointly commission facilities where frail older people can be supported to be independent but access the care and the companionship they need. Maybe a community hospital co-located with an extra care building with shared staff and more importantly shared ethos. We could also add housing for younger people living with serious chronic illness or disability, who need nursing and care support but are keen to live independently. These new developments will take time and will need our public to be along side us. For now we are working with the local authority to get the best out the ones already built so that we maximise joined up input to keep residents as healthy as they can be for a long as possible .
This morning I was discussing with one of our local physicians from our local acute trust the recent experience of his pilot in our local A&E where he and a colleague work two shifts a week to trial consultant assessment at the front of house. Yesterday evening he saw 8 patients, sent 6 home with the much improved community and social care support that we have been developing over the last year including night caring, integrated neighbourhood health and social care teams, better resourced social care assessment and fast response etc. One of the two who were admitted clearly could have been managed at home with the right more enhanced home care so we will work to provide that. So that is 6 patients who would have found their way into an acute bed able to go home and have their treatment and care there. Last year our urgent admissions reduced by 3%. He is convinced that because we have good primary and community care we can manage more of the people at present on his wards at home. With investments we are making this year we can do it better and for more people. We just need the collective will and the confidence to do it. We are developing a “hot clinic” in our community hospital run by physicians, therapists, social care and community nursing to urgently address the needs of older people who are becoming frail before they hit a crisis.
It is all good stuff. Is it big enough? Well, you could look at each initiative and accuse CCGs of playing at the edges, not being strategic or ambitious enough. Or you could see each scheme as part of a much bigger picture and acknowledge that CCGs are making changes on the ground; changes that mean better services for individual patients and their families; changes led by local doctors, nurses ,social workers and therapists; changes that are there to address the difficult issues no one in the past has had the will to sort out, changes that will add up to a better system, a system that is better than the sum of its parts.
Thursday, 17 April 2014
Getting better?
We read a lot about how bad things are in the NHS… how tough life is for staff how terrible for patients… but it is never universally true..and there are good news stories too. WE don’t often hear them because somehow they aren’t as news worthy… it is sad to me that a good news story comes and goes , little is said about it whilst bad news is the stuff we discuss in coffee shops across the land…..what does it say about us all that we would rather dissect all the bad things that happen rather than celebrate the good.?
Our GPs were successful in getting the challenge fund bid. An injection of cash which allows them to really work on how to improve primary care into the future and the time and space to do it right: A rare opportunity, a fantastic thing. It was covered my our local paper on the front page but we hardly received a call from the media who are normally all over us when something is difficult or contentious. One of my colleagues said to me yesterday they were surprised by the lack of interest. Many members of the public stop me in the street and ask me why they don’t heard more about the good things we are doing. Well we try, but putting out press releases it not the same thing as getting things into the press!
We have lots of good news! As a health economy we have balanced our books for the first time in many many years.. having paid back debt inherited from our PCT. We are investing in community services to build a robust and coordinated community system, mental health services especially services for people with dementia. We are putting back things our PCT had stripped out in an ever increasingly desperate attempt to balance.. like IVF. .investment in weight management services, autism services, counselling services etc..etc… Staff who came with us from the PCT are excited and energised because we are actually getting to do the right things..rather than endlessly talking about taking reducing services… we are building our communities, strengthening local services, working in collaboration with our GPs to make things better, brining care closer to home. We have wrapped up our local enhanced service monies into one basket scheme and added some to it, so it is now an “out of hospital scheme” and includes the monitoring of stable prostate cancer patients, acute catheterisation, taking patients from the ambulance service who called 999 but are assessed as being suitable for GP services, DVT assessment et etc and is now delivered by all our practices to all our patients. Fantastic.. and we will add more.. .we are now looking at preoperative assessment etc. It is actually taking care out of distant hospitals and bringing it home. It is a small but important change and by doing it for every patient we can actually decommission the service from the acute hospital. It is one small example of something good. Many have written that CCGS haven’t delivered. My response is give us a chance! We have only been here for a year. Show me the PCT that made significant change in a year! And we all know that transformational change is actually a series of small changes that build a new system.. a pointillist painting…
It almost feels now that saying positive things isnt allowed... we are all supposed just to say how difficult and awful everything is. I remember years ahgo I went to a conference where a "motivational speaker" was first on the agenda. AS we waited for her my heart sank..this is going to be a waste of time/embarrasing etc but it was amazing. She challenged us all about our positivity.She asked us to stand up and tell the audience something great we had done over the previous weekend. We all loooked to the floor avoiding eye contact. She then posed the question " why do children go into school on Mondays bursting to tell the class about the wonderful things they did at the weekend whilst when I asked you you all stared at the floor? When does that happen?
WE have fun at work. WE laugh. We DO. We are proud of what we are doing. IT feels good.
We know there are clouds looming. WE aren’t immune from the threats we all face but can we please please sometimes celebrate the good?
Our GPs were successful in getting the challenge fund bid. An injection of cash which allows them to really work on how to improve primary care into the future and the time and space to do it right: A rare opportunity, a fantastic thing. It was covered my our local paper on the front page but we hardly received a call from the media who are normally all over us when something is difficult or contentious. One of my colleagues said to me yesterday they were surprised by the lack of interest. Many members of the public stop me in the street and ask me why they don’t heard more about the good things we are doing. Well we try, but putting out press releases it not the same thing as getting things into the press!
We have lots of good news! As a health economy we have balanced our books for the first time in many many years.. having paid back debt inherited from our PCT. We are investing in community services to build a robust and coordinated community system, mental health services especially services for people with dementia. We are putting back things our PCT had stripped out in an ever increasingly desperate attempt to balance.. like IVF. .investment in weight management services, autism services, counselling services etc..etc… Staff who came with us from the PCT are excited and energised because we are actually getting to do the right things..rather than endlessly talking about taking reducing services… we are building our communities, strengthening local services, working in collaboration with our GPs to make things better, brining care closer to home. We have wrapped up our local enhanced service monies into one basket scheme and added some to it, so it is now an “out of hospital scheme” and includes the monitoring of stable prostate cancer patients, acute catheterisation, taking patients from the ambulance service who called 999 but are assessed as being suitable for GP services, DVT assessment et etc and is now delivered by all our practices to all our patients. Fantastic.. and we will add more.. .we are now looking at preoperative assessment etc. It is actually taking care out of distant hospitals and bringing it home. It is a small but important change and by doing it for every patient we can actually decommission the service from the acute hospital. It is one small example of something good. Many have written that CCGS haven’t delivered. My response is give us a chance! We have only been here for a year. Show me the PCT that made significant change in a year! And we all know that transformational change is actually a series of small changes that build a new system.. a pointillist painting…
It almost feels now that saying positive things isnt allowed... we are all supposed just to say how difficult and awful everything is. I remember years ahgo I went to a conference where a "motivational speaker" was first on the agenda. AS we waited for her my heart sank..this is going to be a waste of time/embarrasing etc but it was amazing. She challenged us all about our positivity.She asked us to stand up and tell the audience something great we had done over the previous weekend. We all loooked to the floor avoiding eye contact. She then posed the question " why do children go into school on Mondays bursting to tell the class about the wonderful things they did at the weekend whilst when I asked you you all stared at the floor? When does that happen?
WE have fun at work. WE laugh. We DO. We are proud of what we are doing. IT feels good.
We know there are clouds looming. WE aren’t immune from the threats we all face but can we please please sometimes celebrate the good?
Tuesday, 25 February 2014
Challenging Times
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…..
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…..
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..
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