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!

More money........

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

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

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

          Where do we take the money from?

          Who makes that choice?

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

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

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

Going back to talking about the overall NHS funding issues:

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

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

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

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

Money money money

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

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

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

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

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

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

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

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

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

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

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

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