Last week we announced that following a robust and detailed competitive dialogue we have awarded a contract for our community and urgent care services in Whitby to Virgin Care. The response to this announcement has been fascinating….
We set out to get the best for Whitby. We spent much time developing a joint view with patients and the public and the local health staff about what we wanted….we warmed up the market, encouraging providers both local and national to participate.
We choose competitive dialogue because although we knew it would be a resource intensive thing to do it would give us the best chance to find the right provider for the job. What is competitive dialogue? Well rather than the process being mainly paper driven (providers simply supplying written answers to questions) and then holding a single interview, competitive dialogue is a series of detailed (four hour) face to face conversations with each of the potential providers developing within them the details of our joint ambitions for the services.
By the time we arrived at the decision making phase we had talked to each of the final two providers for 34 hours! We also assessed them through written submissions which included each provider answering a long series of questions marked by pairs of subject matter experts (37 in total) including a patient and public panel. We visited places where the organisations already provide services to talk to staff, patients and commissioners of those services. The visiting team included CCG staff both managerial and clinical, members of staff from the Whitby services, a member of the public and a local councillor. Those visits gave us the chance to triangulate information we had received in both written and verbal interactions with the providers. 70% of the marks were allocated to the assessment of quality of care including patient experience, with the remaining 30% covering financial capability.
How did we deal with conflicts of interest? We were told that our GP Federation had developed links with one of our potential providers therefore the GPs working for the CCG who are all members of a single federation were “conflicted” and couldn’t be part of the process. We held separate Senior Management Teams to cover the Whitby work which excluded them, and we brought in clinical advice from other CCGs where no conflict existed to support decision making. Although I have been a GP in this area for 26 years I no longer work in primary care so I was able to lead without issue.
In the end the process led us clearly and simply to the answer. One provider could offer us the best service for Whitby. They are ambitious. They have a track record which is strong for engaging and involving patients in everything they do and for empowering and developing staff to improve the quality of local services.
Are there challenges? Of course. When you do a job like mine you know what you are taking on. I am a public servant. I follow the rules laid down for my organisation by Parliament. I am also an individual with my own private views and opinions. I vote. As I do my job I am bound to reflect privately on issues that chime with or challenge my personal views. I learned a great deal through this process and yes, it challenged some of my personal views.
Whilst we were visiting the Virgin Care site in Surrey we asked staff what it was like to work for a private company. One of the nurses told me that she sees herself as an NHS nurse offering NHS care to NHS patients, employed by a private company. She commented one of her most challenging encounters had been with a GP. She thought that was a bit much considering that GPs are themselves private providers! It made me think….I see myself as NHS through and through, and yet as a GP partner in a practice for the last 26 years I have been a profit-making partner in a small private business, as all GP partners are and have been since the birth of the NHS. We made decisions week by week which affect how much of our money we invest in staff and services and how much we take home in our pay packet. It is profit/loss at the sharp end.
In conversations with Whitby staff someone said they were sad an NHS organisation wasn’t able to offer something as credible and ambitious as a private organisation. It made me reflect on our process and consider if we had done everything in our gift to stimulate and develop the market both private and NHS, and I am confident we did: we held several open events, made many conversations both formal and informal.
What about the staff? Our NHS staff in Whitby will transfer to the new provider with their terms and conditions of employment intact and will be able to stay in the NHS pension scheme. More importantly as they develop and progress and their roles and pay change and as new staff come they will also be able to choose between NHS terms conditions and pensions and those of Virgin Care. Staff at the site we visited talked enthusiastically about great opportunities to develop and progress they had been given since Virgin took over for all staff groups. A nurse told us that she had been dragged” kicking and screaming” to work for Virgin but she had had to eat her words because they were a good employer who cared about staff and patients.
It is easy, isn’t it; to somehow think NHS providers occupy an ethical high ground. But do they?
The Kings Fund, an respected independent UK Charity that works to improve and develop healthcare wrote recently on this subject they said:
"For-profit, non-profit and NHS providers can provide high-quality care and equally all sectors can fail to do so. Whether a provider (public or private) makes a surplus/profit from its trading with the NHS does not automatically mean that quality of care is compromised. The Fund’s view is that who provides the service is less important than the quality and efficiency of the care that is provided."
In conversations since the announcement people have quoted to me programmes and articles about the shortcomings of private providers. However, they are not alone. How many are there about NHS providers if you look for them? The system we work in isn’t perfect. Sadly there is poor performance in all sectors. We must and do strive to improve the quality of the services we offer our patients and we are committed to continuing to do that.
Will the political landscape and thus our framework change? Possibly. The private sector involvement in the NHS has been sanctioned by both major political parties when in government. Will it change? It may. It isn’t a certainty, but if it does we will manage that. That is our job.
So when people ask me, am I privatising the NHS ? my answer is a simple one. As a public servant my job is to improve the quality of our services and I use the framework given to me by Parliament to do that. I do not make policy. I am not a politician. So no, I am not privatising the NHS. I am doing my job.
We are confident the robust and clear process we have been through will lead to real improvements in services for patients in Whitby. We will to continue to work closely with the patients, public and staff as commissioners of the service to shape and develop services over the next 7 years. The proof of the pudding as they say will be in the eating…
Monday, 23 March 2015
Monday, 2 February 2015
musings whilst swimming...
At a time of challenge and difficulty in the system where should our ambition be? To simply survive day to day? To keep our heads above the flooding torrent’ or do we at the same time as treading water and keeping going aim to do something different to re-route the water, stop it from washing away everything in its path and leave behind a soggy mess? When I was young I went to a college where we provided beach life saving patrols to our local area in the summer. So I learned to swim in the sea. The number one lesson was don’t rush to swim towards the calm bit of water you can see ahead because when you get there it will be just as choppy as the water you are swimming in right now. Learn to swim in choppy water. To make progress when the waters are cold and rough you need to be resilient, skilful and keep your eye on the destination.
There is so much turbulence now…. An election coming that is too close to call and likely who ever takes the helm to mean changes for health.. because somehow there always are…Services under pressure…recruitment right across the system in crisis..
Primary care and the staff who work within it have choices to make…about whether they are architects and builders of something new or simply allow themselves to get washed away ….The response from primary care to my October blog about my Mums care has been fascinating…. Those who felt it was a call to arms to fight to the status quo, build something better.. and those who are simply too tired, too worn down to do anything but reply that my mother’s care was safe at least…safe in the smallest sense.. on that day sending her into hospital was the most risk averse decision…. And that is true if you don’t factor in the risk of hospitalisation for a frail elderly woman.. the risk of infection, falling, a steep worsening of memory…but in the end that is her risk.. not theirs… Is it wrong to want the best rather than accept the average? But it feels like the energy to change is being sucked out of primary care..and a cold hopelessness is creeping in.
It made me sad… I have never accepted the hopelessness argument ( it is all hopeless and I can’t do anything to change it) and have always wanted to make it better. I am a striver.: for every problem there is a solution. Whose job is it then to fight for primary care? The “ Forward View” describes a compelling vision for primary care, who designs the road map to get us all there? Will we in primary care expect this to be done to us? For us? In spite of us? Do we embrace change or abdicate our responsibility and then blame those who make the changes?
Will CCGS DO IT? Co-commissioning primary care. Is that the way forward? Well it seems to be the only option around. CCGS seem keen as do GPs but is that because we will be good at it or because of the lack of capacity in areas teams to do anything? We as a CCG have struggled with the idea and whether it is right. We can talk about conflicts of interests policies to make it safe and I am sure they will help.. but the public don’t understand the NHS Architecture and why should they ? It is absurdly complex… and they see Federations of GPs providing services, CCGs of the same GPs commissioning care, and we can tell them it is all governed and transparent but when I do that I see blank looks and disbelief on peoples faces. I see risks to the clinical leadership in CCGS too because the easiest way to deal with the inherent conflicts are to simply reduce the influence of the GPS within CCGs, but I believe doing that risks a return to PCTS. Our strength and success is built around the real partnership between managers and clinicians and the public working together to change things….
The vanguard initiative ( this is central NHS money being given to "pilot" sites around the country to try out new ideas) will be interesting. To succeed it must allow local areas to work to their own agendas, and resist the temptation to impose structures and timeframes to meet national and political imperatives. The changes envisaged are huge and to be successful it must be clear to everyone participating what the task is.. what the challenge is.. what the future should be before we talk about structures and payment mechanisms… lets get it right for once please…we should know how to do this….function first then form….time to get the buy in from the people who are actually doing the caring first… hurry… won’t help.. people need time to understand and be willing to change..We know this.. Let’s hope that the Vanguard money will be spent to support local development of new ways of working and not a straight jacket of central control as so many of these initiatives have been in the past… a good idea that gets lost in translation….
Most importantly we have to develop a system that safeguards quality and continuity for those who are frail and have complex problems, provide timely and accessible acute care and creates an environment that will attract doctors nurses and other health professionals to choose it as their career into the future…because it is rewarding, challenging but not exhausting and is fun… ambitious enough? I think so!…time to keep swimming…..
There is so much turbulence now…. An election coming that is too close to call and likely who ever takes the helm to mean changes for health.. because somehow there always are…Services under pressure…recruitment right across the system in crisis..
Primary care and the staff who work within it have choices to make…about whether they are architects and builders of something new or simply allow themselves to get washed away ….The response from primary care to my October blog about my Mums care has been fascinating…. Those who felt it was a call to arms to fight to the status quo, build something better.. and those who are simply too tired, too worn down to do anything but reply that my mother’s care was safe at least…safe in the smallest sense.. on that day sending her into hospital was the most risk averse decision…. And that is true if you don’t factor in the risk of hospitalisation for a frail elderly woman.. the risk of infection, falling, a steep worsening of memory…but in the end that is her risk.. not theirs… Is it wrong to want the best rather than accept the average? But it feels like the energy to change is being sucked out of primary care..and a cold hopelessness is creeping in.
It made me sad… I have never accepted the hopelessness argument ( it is all hopeless and I can’t do anything to change it) and have always wanted to make it better. I am a striver.: for every problem there is a solution. Whose job is it then to fight for primary care? The “ Forward View” describes a compelling vision for primary care, who designs the road map to get us all there? Will we in primary care expect this to be done to us? For us? In spite of us? Do we embrace change or abdicate our responsibility and then blame those who make the changes?
Will CCGS DO IT? Co-commissioning primary care. Is that the way forward? Well it seems to be the only option around. CCGS seem keen as do GPs but is that because we will be good at it or because of the lack of capacity in areas teams to do anything? We as a CCG have struggled with the idea and whether it is right. We can talk about conflicts of interests policies to make it safe and I am sure they will help.. but the public don’t understand the NHS Architecture and why should they ? It is absurdly complex… and they see Federations of GPs providing services, CCGs of the same GPs commissioning care, and we can tell them it is all governed and transparent but when I do that I see blank looks and disbelief on peoples faces. I see risks to the clinical leadership in CCGS too because the easiest way to deal with the inherent conflicts are to simply reduce the influence of the GPS within CCGs, but I believe doing that risks a return to PCTS. Our strength and success is built around the real partnership between managers and clinicians and the public working together to change things….
The vanguard initiative ( this is central NHS money being given to "pilot" sites around the country to try out new ideas) will be interesting. To succeed it must allow local areas to work to their own agendas, and resist the temptation to impose structures and timeframes to meet national and political imperatives. The changes envisaged are huge and to be successful it must be clear to everyone participating what the task is.. what the challenge is.. what the future should be before we talk about structures and payment mechanisms… lets get it right for once please…we should know how to do this….function first then form….time to get the buy in from the people who are actually doing the caring first… hurry… won’t help.. people need time to understand and be willing to change..We know this.. Let’s hope that the Vanguard money will be spent to support local development of new ways of working and not a straight jacket of central control as so many of these initiatives have been in the past… a good idea that gets lost in translation….
Most importantly we have to develop a system that safeguards quality and continuity for those who are frail and have complex problems, provide timely and accessible acute care and creates an environment that will attract doctors nurses and other health professionals to choose it as their career into the future…because it is rewarding, challenging but not exhausting and is fun… ambitious enough? I think so!…time to keep swimming…..
Wednesday, 31 December 2014
Farewell
My mother had a stroke early on Tuesday morning. It robbed her of the ability to move her right side, swallow and talk.
She had long been struggling with dementia and had become a small and mostly absent person. Gone was the campaigner for peace, who has survived the London blitz, helped set up the UN after the war, become a passionate educator and a mother of three, who marched against the Iraq war when she was 70 and wore a CND peace badge until she didn’t know what it meant anymore. Many people have written about dementia, but until you watch how the disease slowly and terribly diminishes someone you love day by day it is hard to really understand.
We had found a copy of an advance directive my mother had written and signed in 1997 some weeks previously when going through her papers and bills. It made things easier. It was very clear. Nothing heroic and “if I get dementia definitely no treatment for infections or other significant illness”. So we kept her at home. The staff at the extra care flats where she lived were brilliant. They cared. They kept her comfortable and spoke with tenderness and caring as they washed and turned her.They took care of us too. They stayed beyond their normal shifts and volunteered to sit with her to cover some of the night time so that we could sleep so only people my mother knew would be there if she woke distressed. As my sister said in her euology they truly are "the Angels of Rosemary Court".
We had moved her to a different general practice after problems with the previous practice who had shipped her into hospital unnecessarily and never seemed able to give her any continuity of care over the 10 years she was a patient there. The new practice, despite taking over her care at such a difficult time were fantastic, they listened. They immediately assigned her to one GP (because that is what they do for everyone) who explained to me how to contact her and what to do when she wasn’t there. They visited her before the stroke even though we hadn’t requested a visit, to get to meet her and assess her. They visited her after the stroke and were respectful of my mother’s wishes. They were supportive but unobtrusive. They contacted the nursing teams, out of hours, and the carers in the building. They were in daily contact with us throughout. They were exactly what a general practice should be.
The community nurses were great. They responded quickly always, came regularly and when promised, managed her care with gentle kindness and sensitivity both in hours and out of hours. Their expertise meant she was peaceful and comfortable for all but a few hours when we struggled to control excessive secretions but in the end sorted that too.
My mother died peacefully 6 days after her stroke. She was surrounded by her family, her photos and diaries and memories. We nursed her and when she roused she knew we were there at her side. We told stories about her life, read her diaries, looked at old photos and we became reacquainted with the person she had always been before old age had diminished her: the bright, articulate, opinionated, fiercely loving sometimes difficult woman who was my mother. I don’t think we would have had that if she had died in a hospital bed in the hurly burly of an acute ward. It was a gift to have those days with her.
We were given that gift by those who helped us care for her, the carers, the nurses, the GPs.
Much is written about the NHS and the social care. How it fails, how it needs to do better. I have written about what goes wrong too. I think though it is important to remember that there is so much good that goes unheralded in the press: the care given every day to the most vulnerable and frail. Given generously without expectation of thanks. Individuals who go far beyond what they HAVE to do because they know it is the right thing to do. They are there because they care in a genuinely authentic way as an individual, not just a professional.
So thank you to all the unsung heroes of the caring professions!
I am very grateful to them all and proud of a service that can facilitate such a dignified and gentle end.
She had long been struggling with dementia and had become a small and mostly absent person. Gone was the campaigner for peace, who has survived the London blitz, helped set up the UN after the war, become a passionate educator and a mother of three, who marched against the Iraq war when she was 70 and wore a CND peace badge until she didn’t know what it meant anymore. Many people have written about dementia, but until you watch how the disease slowly and terribly diminishes someone you love day by day it is hard to really understand.
We had found a copy of an advance directive my mother had written and signed in 1997 some weeks previously when going through her papers and bills. It made things easier. It was very clear. Nothing heroic and “if I get dementia definitely no treatment for infections or other significant illness”. So we kept her at home. The staff at the extra care flats where she lived were brilliant. They cared. They kept her comfortable and spoke with tenderness and caring as they washed and turned her.They took care of us too. They stayed beyond their normal shifts and volunteered to sit with her to cover some of the night time so that we could sleep so only people my mother knew would be there if she woke distressed. As my sister said in her euology they truly are "the Angels of Rosemary Court".
We had moved her to a different general practice after problems with the previous practice who had shipped her into hospital unnecessarily and never seemed able to give her any continuity of care over the 10 years she was a patient there. The new practice, despite taking over her care at such a difficult time were fantastic, they listened. They immediately assigned her to one GP (because that is what they do for everyone) who explained to me how to contact her and what to do when she wasn’t there. They visited her before the stroke even though we hadn’t requested a visit, to get to meet her and assess her. They visited her after the stroke and were respectful of my mother’s wishes. They were supportive but unobtrusive. They contacted the nursing teams, out of hours, and the carers in the building. They were in daily contact with us throughout. They were exactly what a general practice should be.
The community nurses were great. They responded quickly always, came regularly and when promised, managed her care with gentle kindness and sensitivity both in hours and out of hours. Their expertise meant she was peaceful and comfortable for all but a few hours when we struggled to control excessive secretions but in the end sorted that too.
My mother died peacefully 6 days after her stroke. She was surrounded by her family, her photos and diaries and memories. We nursed her and when she roused she knew we were there at her side. We told stories about her life, read her diaries, looked at old photos and we became reacquainted with the person she had always been before old age had diminished her: the bright, articulate, opinionated, fiercely loving sometimes difficult woman who was my mother. I don’t think we would have had that if she had died in a hospital bed in the hurly burly of an acute ward. It was a gift to have those days with her.
We were given that gift by those who helped us care for her, the carers, the nurses, the GPs.
Much is written about the NHS and the social care. How it fails, how it needs to do better. I have written about what goes wrong too. I think though it is important to remember that there is so much good that goes unheralded in the press: the care given every day to the most vulnerable and frail. Given generously without expectation of thanks. Individuals who go far beyond what they HAVE to do because they know it is the right thing to do. They are there because they care in a genuinely authentic way as an individual, not just a professional.
So thank you to all the unsung heroes of the caring professions!
I am very grateful to them all and proud of a service that can facilitate such a dignified and gentle end.
Tuesday, 18 November 2014
transformation.. .transformation...transformation....
Have you noticed that everywhere you look in the NHS nowadays everything is “transforming” it is the latest overused buzz word…. What does it really mean? It isn’t some magical process that comes along and changes everything overnight then goes away again… our experience of real redesign and improvement of complex interdependent services is much more about a series small steps leading to an ambitious goal…
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
.
moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
.
moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
Thursday, 2 October 2014
More about Mum...
As I battled through Friday I definitely felt a blog coming on!
I have written about my mum in the past. Yes, she is only one patient with her own story but so often it seems to me to reflect the bigger issues we face as we try to sort out the system and make it better.
On Friday morning my mother fell. Not a big fall but enough to worry the carers who do such a good job day to day and cope with her increasing confusion and distressing incontinence with sensitivity and kindness. They phoned her GP surgery. This is the surgery that tells you on the opening recorded message how busy they are. The same surgery where a receptionist told me a few weeks ago that the letter informing me of my mothers named GP didn't actually mean anything real and was just a "government initiative"
The duty doctor responded to the visit request. She has been in the practice less than a month. She clearly hadn't read my mothers notes: Did not know about her frequent falls, her previous admissions ( all unnecessary) her recent change in medication. more importantly she didn't have any idea about her usual level of confusion What did she do? She summoned an ambulance and sent her into hospital
My mother was no more unwell than she is every day There was no emergency. She tried to call me once, but I was in a meeting and had my phone on silent. By the time I phoned back it was too late. The NHS machine was already in motion. but why? Because she couldn't be bothered to find out more, and wait to see how the day unfolded. It was laziness justified by business. My mothers named doctor was in the practice that day. She has seen her once but because of my persistence and several phone calls could claim to know her. No discussion had taken place between her and the visiting doctor. Clearly the notes were either not detailed or clear enough or not read.
I brought my mother home from hospital on Saturday Of course they found nothing untoward. She was a bit disconcerted by her trip. If it hadn't been me she would still be there this morning because the system would have required assessments and planning to be done.
Primary care is at a cross roads Much is written about its future. It is in crisis. To survive it must clearly define what is its unique contribution to health care. What can it provide that no other part of the system can. Surely that has to be personal continuity of care for those who are most vulnerable and those with multiple complex illness.
What did my mothers gp offer her on Friday that a paramedic or A&E doctor who had never met her before could not have? Nothing. She was bundled into an ambulance in her nightie with no information about her or her problems. to a ward designed to deal with emergencies with staff who knew nothing about her. It was a frightening and completely unnecessary experience for her.
It cost the NHS upwards of a thousand pounds and resulted in no improvement in her care.
If this is all general practice has to offer it will simply become an irrelevance in the system, which will eventually decide it has no value and design something else to fill the void. As a profession GPs need to sort out their own story about their future, their relevance to a changed world and deal with the unacceptable variation in standards of care that mean examples like these are quoted all too readily to denigrate the service I have spent my life developing. It brings me no joy to tell this story today.
What needed to be different?
1. Good GP notes with a clear up to date summary
2. A practice system that flags vulnerable patients ( and if my mum who at 94 has profound dementia and had had 3 unnecessary urgent admissions in the last 18 months, isn't vulnerable who is?)
3. A receptionist on the visit request desk who sees the flag and directs the call to the patients named doctor or their GP buddy if they aren't in.
4. A named GP system that actually means something real, where that person is responsible for delivering on going holistic proactive care.
5. Either the named GP is able to visit that day or if that really isn't possible briefs the visiting gp and is available to discuss with them what they find at the visit BEFORE a decision about next steps is made.
6. Have a proper emergency plan for these patients proactively discussed with relatives in place etc. This could have prevented the alast 4 hospital admission
It is not rocket science is it? Would it be more resource intensive in the long run for the practice, for the system?? Not if it is properly organised
I have worked in primary care for 25 years. I am it biggest fan. Is is all as bad as this? No. but if it doesn't collectively get its act together and sort this stuff out it will not survive.
What will I do next? well I will send the practice my blog. I could complain but am concerned all I will get will be a list of platitudes and justifications rather than a commitment to really overhaul their system. I will think about changing practices but how do I know where to find something good? It isn't as easy as a nice looking building or a fancy website.
CCGs are co-commissioning primary care. Where do we start? Accountable care organisations might be the next step. To put it bluntly If the practice had to pay for that episode of care would they have made the same choices ? I doubt it. But primary care in a million miles way from seeing this future.
In the mean time my Mum is settled back at home until the next time.....
I have written about my mum in the past. Yes, she is only one patient with her own story but so often it seems to me to reflect the bigger issues we face as we try to sort out the system and make it better.
On Friday morning my mother fell. Not a big fall but enough to worry the carers who do such a good job day to day and cope with her increasing confusion and distressing incontinence with sensitivity and kindness. They phoned her GP surgery. This is the surgery that tells you on the opening recorded message how busy they are. The same surgery where a receptionist told me a few weeks ago that the letter informing me of my mothers named GP didn't actually mean anything real and was just a "government initiative"
The duty doctor responded to the visit request. She has been in the practice less than a month. She clearly hadn't read my mothers notes: Did not know about her frequent falls, her previous admissions ( all unnecessary) her recent change in medication. more importantly she didn't have any idea about her usual level of confusion What did she do? She summoned an ambulance and sent her into hospital
My mother was no more unwell than she is every day There was no emergency. She tried to call me once, but I was in a meeting and had my phone on silent. By the time I phoned back it was too late. The NHS machine was already in motion. but why? Because she couldn't be bothered to find out more, and wait to see how the day unfolded. It was laziness justified by business. My mothers named doctor was in the practice that day. She has seen her once but because of my persistence and several phone calls could claim to know her. No discussion had taken place between her and the visiting doctor. Clearly the notes were either not detailed or clear enough or not read.
I brought my mother home from hospital on Saturday Of course they found nothing untoward. She was a bit disconcerted by her trip. If it hadn't been me she would still be there this morning because the system would have required assessments and planning to be done.
Primary care is at a cross roads Much is written about its future. It is in crisis. To survive it must clearly define what is its unique contribution to health care. What can it provide that no other part of the system can. Surely that has to be personal continuity of care for those who are most vulnerable and those with multiple complex illness.
What did my mothers gp offer her on Friday that a paramedic or A&E doctor who had never met her before could not have? Nothing. She was bundled into an ambulance in her nightie with no information about her or her problems. to a ward designed to deal with emergencies with staff who knew nothing about her. It was a frightening and completely unnecessary experience for her.
It cost the NHS upwards of a thousand pounds and resulted in no improvement in her care.
If this is all general practice has to offer it will simply become an irrelevance in the system, which will eventually decide it has no value and design something else to fill the void. As a profession GPs need to sort out their own story about their future, their relevance to a changed world and deal with the unacceptable variation in standards of care that mean examples like these are quoted all too readily to denigrate the service I have spent my life developing. It brings me no joy to tell this story today.
What needed to be different?
1. Good GP notes with a clear up to date summary
2. A practice system that flags vulnerable patients ( and if my mum who at 94 has profound dementia and had had 3 unnecessary urgent admissions in the last 18 months, isn't vulnerable who is?)
3. A receptionist on the visit request desk who sees the flag and directs the call to the patients named doctor or their GP buddy if they aren't in.
4. A named GP system that actually means something real, where that person is responsible for delivering on going holistic proactive care.
5. Either the named GP is able to visit that day or if that really isn't possible briefs the visiting gp and is available to discuss with them what they find at the visit BEFORE a decision about next steps is made.
6. Have a proper emergency plan for these patients proactively discussed with relatives in place etc. This could have prevented the alast 4 hospital admission
It is not rocket science is it? Would it be more resource intensive in the long run for the practice, for the system?? Not if it is properly organised
I have worked in primary care for 25 years. I am it biggest fan. Is is all as bad as this? No. but if it doesn't collectively get its act together and sort this stuff out it will not survive.
What will I do next? well I will send the practice my blog. I could complain but am concerned all I will get will be a list of platitudes and justifications rather than a commitment to really overhaul their system. I will think about changing practices but how do I know where to find something good? It isn't as easy as a nice looking building or a fancy website.
CCGs are co-commissioning primary care. Where do we start? Accountable care organisations might be the next step. To put it bluntly If the practice had to pay for that episode of care would they have made the same choices ? I doubt it. But primary care in a million miles way from seeing this future.
In the mean time my Mum is settled back at home until the next time.....
Monday, 8 September 2014
Inside Out.....
There has been a big and very positive response to my blog about Gemma. That is great and I am glad it has made people think about the issues and talk about things. September 10th is World Suicide Prevention Day. When I came back from leave I found that my team at the CCG, fired up by my blog had decided to have an” inside out” day to highlight suicide prevention on Wednesday. This event is being organised by http://www.ifucareshare.co.uk. The idea is we all wear out clothes inside out and then wear a button that askes people to ask us why and then explain suicide prevention awareness to them… we will have a banner on our emails.
Did you know:
• 1 Million people across the globe die by suicide each year.
• Suicide is now the biggest killer of young males in this country aged 15-35 years
• The North East has the highest suicide rate in this country
• More people die by suicide each year than by murder and war combined.
WE need to talk about these things. Helping people express their feelings, sharing them with others is the first step. We need to understand suicide is the tragic end point of serious mental illness, or a moment of complete despair and isolation where no other option feels possible.
When I was young my cousin committed suicide. She had bipolar disorder. She was 27. She didn’t even have a funeral. It was shameful then. We never talked about it as a family and her parents stoically went on with their lives. To their neighbours and friends they seemed fine, they were members of Rotary and the Conservative Club. Social doers. But I knew the terrible sense of loss and sadness they carried wordlessly, unable to share even with each other, for the rest of their lives. It robbed them of any real joy in life. There were moments when the pain was visible beneath the veneer and they talked in hush voices to their daughter’s friend, me, who had loved her too.
Are we better at it now? I don’t know. It is less shameful maybe. As a health system we examine the case, we assure ourselves there was nothing more anyone could have done. No one to blame. But do we ask ourselves the bigger questions? Do we invest in services which help prevent this- which give young people the tools and the confidence to make a different choice? Do we talk openly to our children about their feelings and their fears? Do we have responsive services for those in our care with significant mental health problems so they can tell us that it is getting too desperate. We know the answers to these questions don’t we?
How many organisations out there are doing anything to mark this World Day? If we are all baking away for the Macmillan coffee morning day and dousing ourselves in icy water for MND, where is the equal publicity for this event that seeks to highlight the terrible tragedy that robs us all of increasing numbers of young and old without warning? I am glad my blog touched people but we all need to do something differently to make things different.
So what will we do? Well we will have the Inside Out Day and we will talk about it to anyone and everyone we come into contact with. We will publicise it on our website. We will work hard with our providers of mental health services to improve our services to young people especially. We will commit to developing mental health services in our area giving an increasing proportion of our budget next year as we did this year, to begin to put right the years of underfunding that went before.
Did you know:
• 1 Million people across the globe die by suicide each year.
• Suicide is now the biggest killer of young males in this country aged 15-35 years
• The North East has the highest suicide rate in this country
• More people die by suicide each year than by murder and war combined.
WE need to talk about these things. Helping people express their feelings, sharing them with others is the first step. We need to understand suicide is the tragic end point of serious mental illness, or a moment of complete despair and isolation where no other option feels possible.
When I was young my cousin committed suicide. She had bipolar disorder. She was 27. She didn’t even have a funeral. It was shameful then. We never talked about it as a family and her parents stoically went on with their lives. To their neighbours and friends they seemed fine, they were members of Rotary and the Conservative Club. Social doers. But I knew the terrible sense of loss and sadness they carried wordlessly, unable to share even with each other, for the rest of their lives. It robbed them of any real joy in life. There were moments when the pain was visible beneath the veneer and they talked in hush voices to their daughter’s friend, me, who had loved her too.
Are we better at it now? I don’t know. It is less shameful maybe. As a health system we examine the case, we assure ourselves there was nothing more anyone could have done. No one to blame. But do we ask ourselves the bigger questions? Do we invest in services which help prevent this- which give young people the tools and the confidence to make a different choice? Do we talk openly to our children about their feelings and their fears? Do we have responsive services for those in our care with significant mental health problems so they can tell us that it is getting too desperate. We know the answers to these questions don’t we?
How many organisations out there are doing anything to mark this World Day? If we are all baking away for the Macmillan coffee morning day and dousing ourselves in icy water for MND, where is the equal publicity for this event that seeks to highlight the terrible tragedy that robs us all of increasing numbers of young and old without warning? I am glad my blog touched people but we all need to do something differently to make things different.
So what will we do? Well we will have the Inside Out Day and we will talk about it to anyone and everyone we come into contact with. We will publicise it on our website. We will work hard with our providers of mental health services to improve our services to young people especially. We will commit to developing mental health services in our area giving an increasing proportion of our budget next year as we did this year, to begin to put right the years of underfunding that went before.
Friday, 15 August 2014
All about Gemma
Parity of esteem. A big phrase. We are all signed up to it. But what does it really mean? I was thinking about this after hearing of Robin Williams’ death. Such a tragedy. Depression is a life threatening illness in its most severe forms. A man who seemingly has so much felt such despair that death was the only deliverance from the pain. WE don’t treat it as such and yet mental illness kills people just like cancer does.
When we talk about illness and pain we still divide our thinking into physical and mental causes. Why? The brain is physical, mental illness is about the brain and chemicals … and yet in our thinking we consider them differently. Someone with a mental health problem is still seen as somehow responsible in some way for their illness. And yet every illness has both physical and psychological components. When as a GP I talk to patients about a psychological component to their symptoms they rush to the view that I am saying it is somehow less valid ,less real, their fault. Our belief system leads us to believe mental health issues are based somehow in weakness, a flaw in our constitution and yet those with mental illness are some of the strongest and bravest people I have ever known.
We talk freely about our family members struck down by cancer but we are less willing to talk about those with depression, psychosis or substance misuse. On some level that remains private, uncomfortable.
There is a strong history of mental illness in my family. So I have watched people I love struggle to survive and witnessed how we as a society respond. Gemma was young when she developed severe depression. Her school was, it seemed, a caring and supportive place. At the same time there was another pupil who developed cancer. The contrast in the way the school handled their response to both pupils was illustrative of the deeply held values that are part of our culture. Both were very ill. Both had life threatening illnesses. Both had long periods in hospitals 50 miles away. Both missed many months of school. One had a computer bought for her, work sent to her, regular visits made to her, cards sent to her, regular updates of her progress in her form and support to her siblings and extended family. The other had nothing. This I believe was not because the school was uncaring or unkind. It just didn’t occur to those in charge. They treated these two poorly girls completely differently, one was “ill” the other “troubled”.
WE as a society raise money for cancer sufferers, run for them, swim for them, build beautiful new shiny buildings full of state of the art equipment for them, but we don’t do the same for those people with mental illness, many of whom still languish in old poorly equipped facilities. They remain on the “edge” of our health services and the “edge” of our generosity as a society. Within the NHS doctors and nurses still draw lines around mental and physical illness rather than seeing people as individuals with complex problems, we as clinicians still perpetuate the belief system that underpins the prejudice.
I read today that more ex-service men have taken their own lives than died in Afghanistan. I am not surprised. But are we outraged as a society about that? WE should be.
Parity of esteem is a grand ambition. WE can do our best as a CCG to make sure we do that. We can write it into our plans, benchmark our investments, include it in our specifications. But for things to change we must all be prepared to do everything differently. To challenge long held beliefs and social norms. Gemma’s family accepted mutely the response of the school, the neighbourhood, the extended family. We must all fight individually to expose the unconscious prejudice that is still as strong now as it was 15 years ago when Gemma was at school. What happened to Gemma? Well finally she found a psychiatrist who cared enough to discover what was important to her, who didn’t tell her as others had that she must have modest ambitions for herself because she was somehow permanently damaged by her illness. He allowed her to believe she could succeed and she has. She went to Cambridge, got 3 degrees and is deputy head of department in a large sixth form college in London after 3 years of teaching and is planning a Phd. More importantly she is well and happy. The health service is a lottery and no more so than in mental health. The struggle to find good care took 8 years.
One day I hope Gemma will write her own story. It will be heart breaking to read. For now she is getting on with her life. The scars are there though, forever in her life, made worse because the journey was so hard, the support so thin. I sent this blog to her to ask her permission to publish it, she commented “ I’ve found it much easier to come out to people about my sexuality than tell them about my depression”. That I think says it all. We, as an NHS and a society, continue to fail so many. We need to start by being honest and open about mental health, to have parity of esteem in every conversation, every interaction with staff, colleagues, friends. We need to challenge every unconsciously unkind thoughtless comment or decision. Small steps yes, but without change in the way we think as a society nothing will really change.... The NHS can lead but it cannot go it alone….
When we talk about illness and pain we still divide our thinking into physical and mental causes. Why? The brain is physical, mental illness is about the brain and chemicals … and yet in our thinking we consider them differently. Someone with a mental health problem is still seen as somehow responsible in some way for their illness. And yet every illness has both physical and psychological components. When as a GP I talk to patients about a psychological component to their symptoms they rush to the view that I am saying it is somehow less valid ,less real, their fault. Our belief system leads us to believe mental health issues are based somehow in weakness, a flaw in our constitution and yet those with mental illness are some of the strongest and bravest people I have ever known.
We talk freely about our family members struck down by cancer but we are less willing to talk about those with depression, psychosis or substance misuse. On some level that remains private, uncomfortable.
There is a strong history of mental illness in my family. So I have watched people I love struggle to survive and witnessed how we as a society respond. Gemma was young when she developed severe depression. Her school was, it seemed, a caring and supportive place. At the same time there was another pupil who developed cancer. The contrast in the way the school handled their response to both pupils was illustrative of the deeply held values that are part of our culture. Both were very ill. Both had life threatening illnesses. Both had long periods in hospitals 50 miles away. Both missed many months of school. One had a computer bought for her, work sent to her, regular visits made to her, cards sent to her, regular updates of her progress in her form and support to her siblings and extended family. The other had nothing. This I believe was not because the school was uncaring or unkind. It just didn’t occur to those in charge. They treated these two poorly girls completely differently, one was “ill” the other “troubled”.
WE as a society raise money for cancer sufferers, run for them, swim for them, build beautiful new shiny buildings full of state of the art equipment for them, but we don’t do the same for those people with mental illness, many of whom still languish in old poorly equipped facilities. They remain on the “edge” of our health services and the “edge” of our generosity as a society. Within the NHS doctors and nurses still draw lines around mental and physical illness rather than seeing people as individuals with complex problems, we as clinicians still perpetuate the belief system that underpins the prejudice.
I read today that more ex-service men have taken their own lives than died in Afghanistan. I am not surprised. But are we outraged as a society about that? WE should be.
Parity of esteem is a grand ambition. WE can do our best as a CCG to make sure we do that. We can write it into our plans, benchmark our investments, include it in our specifications. But for things to change we must all be prepared to do everything differently. To challenge long held beliefs and social norms. Gemma’s family accepted mutely the response of the school, the neighbourhood, the extended family. We must all fight individually to expose the unconscious prejudice that is still as strong now as it was 15 years ago when Gemma was at school. What happened to Gemma? Well finally she found a psychiatrist who cared enough to discover what was important to her, who didn’t tell her as others had that she must have modest ambitions for herself because she was somehow permanently damaged by her illness. He allowed her to believe she could succeed and she has. She went to Cambridge, got 3 degrees and is deputy head of department in a large sixth form college in London after 3 years of teaching and is planning a Phd. More importantly she is well and happy. The health service is a lottery and no more so than in mental health. The struggle to find good care took 8 years.
One day I hope Gemma will write her own story. It will be heart breaking to read. For now she is getting on with her life. The scars are there though, forever in her life, made worse because the journey was so hard, the support so thin. I sent this blog to her to ask her permission to publish it, she commented “ I’ve found it much easier to come out to people about my sexuality than tell them about my depression”. That I think says it all. We, as an NHS and a society, continue to fail so many. We need to start by being honest and open about mental health, to have parity of esteem in every conversation, every interaction with staff, colleagues, friends. We need to challenge every unconsciously unkind thoughtless comment or decision. Small steps yes, but without change in the way we think as a society nothing will really change.... The NHS can lead but it cannot go it alone….
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