Mr Gove and the hidden apology

I am going to avoid the controversial issues such as Healthier Together and Greater Manchester devolution – for today, and instead link to one of the most ironic newspaper stories linked to the recent kerfuffle over a 7 day NHS.

One of the nation’s favourite cabinet ministers was recently inconvenienced and you would think by the reaction of his wife and the Daily Telegraph that this was a result of the lack of willingness of staff to work at weekends.

I see that the paper has now issued an apology – small and hidden away – but an apology none the less. It transpires that Mr Gove does not understand the difference between ‘Minor Injuries Unit’ and a full ‘Accident and Emergency Department’. Does this make our ex Secretary of State for Education stupid or is he a victim of a complicated system many do not understand?

Each year the NHS has to spend millions of pounds on communication but deciding which service is the right service for you at any given moment can be a challenge: last year whilst away from home  I smugly hunted out a Walk-in-Centre for a minor ear problem for my daughter, only to end up in A&E twenty minutes later when told that was more suitable.

We bemoan people turning up at A&E when they need to see a GP, and then we put GP services into A&E. We give confused signals. A friend and I had to stop a young man ringing an ambulance for his dislocated finger recently: in his mind ‘I need A&E + I don’t have a car = I need an ambulance’, it seems to me making decisions about accessing the right services (and in the right way) is growing harder, which inevitably leads to people leaning on the bits they understand, GPs, Ambulances and A&E.

So what does this all tell us?

For me there has to be a message to those re-designing services to ensure the public are involved.  We can design the clearest ‘pathways’ and put services in the most accessible places and create lots of specialities, but if people do not understand how and where to access the services, or their behaviour does not bend to how we want to deliver the service then we will fail.  Designing health services in this country is not a straightforward scientific formula, it has to take account of our previous experiences, of our behaviour patterns and our future needs. It needs to take account of clinical evidence, patient safety and finances, but it must not be about what is politically expedient.

Most of all it must be made straightforward enough such that even Mr Gove can understand it.

The right prescription for south Manchester

Many of my blogs have outlined the financial challenge we face and how we strive to identify savings necessary. Much of the theory behind QIPP (Quality, Innovation, Productivity and Prevention) is that we find ways to invest to save – though at times it becomes save to invest where we don’t hit the targets necessary.

This year we have a huge QIPP challenge and at last we have identified some key areas where in theory we can make some large savings in South Manchester without impacting upon patient care: indeed if we get it spot on we will make things better for patients and have money to invest in further improvements.

Analysis shows that if all our South Manchester GP Practices prescribed at the same level as the average practice nationally, we would spend a staggering £6million less per year: that is massive. We of course realise that shift won’t happen overnight, and that our demographics may mean we can’t get to the average, but it does suggest we can make significant in-roads and save money.  We can save large amounts if our practices prescribed at the Greater Manchester average, and in some cases if they prescribed at the South Manchester average!

To be honest, when this was presented to the Public Patient Advisory Group (PPAG) it didn’t take each member very long to come up with a story about how they had seen waste in the not too distant past, and when you start thinking of services that could be put in: advice services that may help prevent depression and reduce the use of anti-depressants, faster access to physio that could prevent long term use of pain killers, medicine management staff who can review the efficacy of some of the repeat prescriptions; it doesn’t take long to realise we can invest to save quickly.

So this month we have started a process where we can look at investment in our primary care (by which we mean GP Practices) that can help get prescription costs down.  Practices will be offered an investment on the basis they can deliver the savings.  We are looking for them to innovate, to use their knowledge of their patients to maximise the impact of their investment.

PPAG were keen to ensure that practices talk to their patients groups (unfortunately innovative in some areas!) about what the best approach might be and to encourage a dialogue locally with individual patients about making the prescribing more efficient.  We need to act quick but some broader involvement in the investment could help us maximise the savings: then we can make further investments.  Those who have invested in patient groups in the past and maintained them will be best placed to engage – we need to keep encouraging true local participation groups that engage clinicians in dialogue with patients.

The process will have to be quick – we need to realise the savings now – but the potential is huge, if we get our investment in primary care right and if we seek to co-design with our communities and keep the focus on the patients we may just have the right prescription for South Manchester.

Groundhog day & metaphors

There are times where we just feel like we are re-living a day, when exactly the same discussions take place and like we are at a meeting from the BBC series W1A (this week we needed to ‘get our shoulders to the wheel’ think about whether we needed ‘to sweat the small stuff’ all whilst making sure we had a ‘clear line of site’), and two incidents in the last week or so made me feel like this.

Because of the groundhog day element I simply need to direct you to previous blogs and put my head in my hands.

Firstly, my most popular blog was a more personal story about how poorly my father was treated over an appointment.  Unfortunately the same thing recently happened when my sister took him through for a check up: and once again the solution is a phone call or a letter – one minute they insist on attendance at an outpatients appointment, the hospital makes a mess of it, and then they are happy to communicate by phone or letter. If it has happened twice to my dad in a year, how many other people is it happening to? and how much is it costing us? It is unacceptable and shows systems are not working and they are certainly not patient focused.

The second Groundhog day moment was at this weeks Clinical Commissioning Group meeting. Once again we all used our full repertoire of metaphors and looked at the challenge of our budget and our ability to invest in new forms of delivery that are (correctly) being pushed.  The truth is our financial challenge is simply too big. It has to be near on impossible for us to drive the level of efficiency savings in this financial year that are required. Whilst government say they are putting more money in (we may stumble through this year),and whilst the NHS talks about its forward vision, we strive to keep the lights on: I point you back to my previous blog – ‘What do you want us to stop doing?’ as we look at the reality of our future finances.

I truly believe that given the financial challenges ahead, they only way to survive in the current funding environment is to simply stop doing some things. There are of course efficiencies to be made – as my Dad’s story clearly shows, but this will not touch the sides.  The sooner we get on with a good debate about what we can stop doing the better as a collective decision will be better than one imposed from above, the outcomes are not going to be popular – otherwise I fear for the ‘Devo Manc’ team who will have to join us in the challenge, as, to finish on a metaphor, they will truly be receiving a ‘hospital pass’.

Maybe the answer is just a little bit more?

Today I have attended one of our Board seminars. We call them seminars, but in truth they are a meeting where we have Board members and some CCG staff plus invited others, to look in detail at areas of work that need consideration.

Whilst our focus today was to discuss a pilot service related to GPs being based in A&E, the debate naturally spread to other challenges that were all related.  As ever, there is no problem in the NHS that is as simple as it looks and consequently solutions (or attempted solutions) end up being complicated.

UHSM, like many A&Es regularly misses its A&E target. However this is not simply down to a) people turning up when they shouldn’t or b) the department being incapable of managing the numbers coming through. A considerable amount is down to capacity elsewhere in the system: recently as many as 120 patients were considered fit to be discharged from UHSM, but, for a variety of reasons couldn’t be. This creates a hospital wide crisis: patients end up in beds on wards that aren’t the right one for their condition, other patients can’t be admitted, cubicles in A&E get full etc etc. (or so I understand).

Now we traditionally do two things 1) try and decide who is to blame (“it’s social services, it’s the management it’s the…”) and 2) devise solutions through clever thinking, diverting resources, using IT better etc. We then write an action plan, monitor it, watch it fail and go round the circle again.

You could identify lots of issues we could tackle: social services (and it differs by LA) can be slow to get packages in place for people who are ready to be discharged, so the patient stays in hospital too long; nursing/care homes won’t send someone to assess their resident to ensure it is safe for them to return to their home at weekends, so the patient stays in hospital for too long; nurses and hospital staff do not have capacity to keep chasing all of the above, so the patient stays in hospital for too long.

It does make you wonder: if we just had a few more nurses – so they could do their caring job and support discharge. If they could just liaise with that extra social worker (if we had a few more) they could help get the patient home: releasing the bed, helping A&E hit their target because the system is clearer. And perhaps if Care/Nursing homes just had another assessor so we could discharge at weekends then there would be even fewer beds in use and managing A&E becomes even easier and doesn’t need all the millions of pounds we keep pouring in and the special winter monies governments love to announce, there may even need to be fewer beds in hospital – so you could release more nurses for greater capacity on wards – they could then liaise with…

Perhaps we don’t need lots of clever pilots or huge innovation around all of this: perhaps we just need a little more: more nurses, more social workers (and other support in the community) – even more GPs who can help prevent the need for people to turn up at A&E in the first place.  Oddly it may save the system money overall, get people in and out of hospital quicker (less infections!).

Perhaps the system is not as broke as we sometimes think? Perhaps it’s because we are all a little bit broke in terms of resources – a little bit more, in the right place, might just change a lot.

Devo Manc & Health

There has been a mass outbreak of blogging since the BBC leaked the devolution of health budgets to Greater Manchester. As one might expect, a slightly mis-leading headline leads to blogs that are way off the mark but the quality of analysis has improved since more details became public.

Like many of those who have written on the subject I am slightly cynical and have many questions, such as: how does this fit with a National Health Service? As a citizen of Greater Manchester where is the democratic accountability? (the deal does not mention the Mayor at all – not that the Mayor is the answer). Is the timescale too ambitious? How do you join up Local Authorities with a health service that is not currently joined up itself? How do you make a success when so many of the organisations involved are in financial crisis? Where is the capacity to make this happen going to come from given all the organisations are stretched at the moment? Are we simply being used for electioneering? Where is the patient voice in all of this? –  ‘No decision about me without me’ has turned into ‘No decision about GM without GM’: without ‘me’ in a backroom deal.

However despite these questions, which must be answered, I think this is an opportunity we have to grab.

When you look at the health outcomes for Manchester we are constantly at the bottom of all the league tables. Despite investment, committed staff and hard work, we constantly fail to deliver in terms of health outcomes for the people of the City.

At South Manchester CCG Board meetings I have regularly made the point that we could have the best hospitals, the greatest GPs and the best community services, but unless we change other factors such as housing, worklessness and poverty we will only marginally effect the health outcomes of our residents. The devolution agenda is one that acknowledges this quandary – and could allow us to start tackling it effectively.

We can only get tough on poor health outcomes when get tough on the causes of poor health outcomes.  If we have the opportunity in Greater Manchester to join up the thinking and the spending it is probably too good an opportunity to miss.

As I said at the start, there are many, many questions to answer and one of my roles will be to make the case for the patient voice to be heard throughout the process: and that means embedded from this moment on (something you would expect NHS England to insist on). The deal with the Treasury and NHS England has been done in private, but everything from now on needs to be transparent and in the public domain. I am certain the journey will be much slower than the ambitious timescales outlined in the plan and that will be no bad thing if it means getting the openness right: what is important is the ambition.

I am sure I am going to be writing about this a lot more – but for now I am going to be positive about the opportunity given the current health outcomes in the city, after all, doing the same thing year after year and expecting different results would be insanity, wouldn’t it?

Too many dividing lines…

One thing that any lay person who gets involved with the health system suddenly learns is that the system is complex, unbelievably complex.  Successive Governments seem to just add to that complexity – often under the guise of simplification. The trouble is we now end up with a system which essentially operates on a ‘divide and conquer’  basis.  Battles between primary care and secondary care, commissioners and providers, public sector v private sector etc. The system starts to dance around itself: success in one part becomes failure for another, for example a service moved into primary care may save money for the commissioners but have a longer term financial impact on the sustainability of the hospital and commissioners find themselves both complaining that staffing levels are too low but the hospital is spending too much.  All of this makes sense to the system but not to the patients. I don’t believe I have ever heard someone outside the system break it down into primary and secondary care, they understand some of the differences between a GP and a hospital service but the NHS is one beast to the majority. I think we talk too often of the benefits of primary or secondary care and forget the point.  It is truly about the right care, at the right time at the right place.  Understanding this does not just mean thrashing this out around a table of professionals but talking to the very patients this affects. To increase my understanding of local landscapes and meet more patients myself, I have started to be involved in my own GP Practice participation group and came across a new dividing line that I couldn’t believe. As we squashed into one of the GP Consultation rooms for the meeting we discussed how we might expand, what events we may wish to hold and how we could engage others. It was then pointed out that the practice do not own the building. This meant that any additional rooms we used we had to hire: hence the squashed room. Who owns the building? Well, the NHS (well NHS Property Services).  Another part of the system that needs to feed itself and adds to the ‘internal’ movement of money around the NHS family.  (I wonder how much money we spend moving money from NHS organisation to NHS organisation?). I hear a lot of rhetoric around patient voice, I see lots of hard work been undertaken by individuals locally and nationally to turn rhetoric into reality, and then I see barriers. Barriers created by a lack of capacity in parts of the system, by a lack of belief by some still that patient voice is important and now more bureaucratic barriers created by the NHS eating itself rather than putting patients first. There are too many dividing lines in the NHS: perhaps looking at the system from the patient perspective more often may just help rub some of the lines out.

Rearranging deckchairs

I lost momentum with my blogging and I am determined to ensure a minimum of one a month throughout 2015, however difficult it proves!

The year has not got off to the best start for the NHS with so many headlines relating to A&E performance and multiple interpretations as to who or what is to blame – in previous blogs I have discussed delayed discharge: just one of the factors that contribute to the current ‘crisis’.

We may get over the blip with A&E targets – where everyone seems to focus on the government target, not what quality of care patients are getting – but we have further problems down the road and A&E issues are a symptom of wider system issues that we need to address.

In South Manchester we are still looking at a tough financial challenge over the coming years, and we are going to have to work hard to ensure we meet the needs of our community. I have said before, this will need a collaboration between patients, clinicians and the CCG if we are to do it effectively

One constant frustration I have with the system is how funding is constantly complicated – the Government seem to give with one hand and take away with the other: they get the headlines of ‘pumping money in’ when it really feels like we are rearranging deckchairs on the titanic.

The impact of this is that planning is exceptionally difficult, parts of the system are permanently in a cycle of crisis management with little opportunity for people to step back and see where the problems lie – and involving patients and public in the debate about the future and service redesign becomes next to impossible in a system in such constant flux.

The system needs a little breathing space – more money right now would help, but wouldn’t solve all the problems – we need a longer term settlement, less random bidding rounds like ‘The Prime Ministers Challenge Fund’ distracting us and a rethought through relationship between primary and secondary care. We need clinicians from all parts of the system to engage with the public and design solutions that make sense to clinicians and patients alike. Otherwise I worry we will just keep messing about with the deck chairs once again.


What do you want us to stop doing?

Sorry not to have blogged for sometime – bit of writers block!

This week has been one of the busy weeks in ‘CCG Land’ for me with Public Patient Advisory Group (PPAG), CCG Board (private meeting) and Audit Committee on successive days. Also there is reading to do with NHS England launching their five year view.

The common thread of discussion of all of the above is the simple lack of money for the NHS in current Government plans. This is going to be a challenge for South Manchester CCG and all our partners as we face something of a perfect storm: Hospitals struggling, social care facing massive cuts from next year and an increase in demand for services across the whole system.

The mantra of ‘more for less’ can only get us so far, and efficiencies and innovation can help tackle parts of the problem: but looking forward they are not going to provide the savings the whole system needs to balance: anyone telling you otherwise is ‘fibbing’.

The reality for the CCG is if we are going to make our budgets balance in an honest way, we are going to have to stop doing some of the things we are doing now – and that will impact on our local providers, from the hospital to the voluntary and community sector and everything in-between – and on patients.
I suppose we could stop doing some things, do some things slower and/or raise the bar on when certain services kick in – I believe the scale of the challenge is likely to mean it is a combination of all these things.

I have written about this before and I suspect it will continue to be the dominant theme for some time as I think we are going to have to have a big discussion with the public, patients, providers and politicians about how we move forward.

Our challenge is to make the debate an informed one: we can’t have a scenario where those with the loudest voices get what they want: we need to understand the impact of what any changes mean – there is no point finding savings that simply push the cost elsewhere in the system or just a few yards down the road.

I would welcome any contribution to the debate – but as you think about it, just try and think: what do you want us to stop doing?

Anyone got a magic wand? The Challenge of delayed discharge

This week was meeting week again – with the Public Patient Advisory Group (PPAG) on Tuesday night followed by a CCG Board meeting on Wednesday. Both involved excellent discussion and debate and pose a number of interesting questions about how we tackle some of the major challenges we face in the immediate future that will only grow in the long term.

One of the issues PPAG wanted to discuss was Urgent Care and the work undertaken around this. It seems that headlines are set around how an A&E performs around the 4 hr waiting time and that various new action plans and reporting mechanisms are put in place to increase performance but we never quite get there. Then we get different stories from different players – so you may well believe that A&E ‘problems’ at UHSM are caused by the Trafford A&E closure or that everything is the fault of ‘bed-blockers’ (a rather disparaging term for people often still in a hospital bed when they could be elsewhere). Sometimes different parts of the NHS have a different narrative and then the media and politicians will often add further another flavour.

As ever the reasons are always more complex, and no one issue is to blame. When we discussed this on Tuesday night it was great to be joined by the Chief Operating Officer and the Chief Clinical Officer from Trafford CCG as well as our own Deputy Chief Officer and another senior staff member. The discussion covered everything from impact on Walk-in Centres to availability of nursing home beds and patient choice.

The most fascinating challenge which I am still mulling over after discussions on both Tuesday and Wednesday is the challenge created by delayed discharge and how we tackle it: say you are an older person in hospital and are ready and able to be discharged to a nursing home, you are going to have to pay some of the cost of the home, but none you want are available – what do you do? Or what if you can’t make a decision and your family decide they only want you in home X and there isn’t space?

It would appear that on some occasions the patient ends up staying in hospital: not ideal for anyone you would think, but then what do you do? You don’t need large numbers of people in this situation to create problems that then become visible through waiting times in A&E or patients placed on wards not necessarily appropriate for the care they need. The problem belongs to both the hospital and the commissioner and together we need to resolve it.

It feels very easy to say ‘send them to where there is space’ – but we must show compassion for the need of the patient but we must not lose sight of patients who are perhaps prevented from coming in for an operation or treatment who are then delayed due to the lack of bed availability.

I sometimes wonder if the old adage that was often used when someone was in hospital ’Well at least she’s in the best place’ comes back to bite us on the bum? I think for some generations this is still a strongly held belief about hospitals, really what is important is having the right access to the right care at the right time, and quite often that means that hospital is not the right place.

For now greater minds than mine are working on how we resolve issues such as delayed discharge: and we need collaboration across patients, families, clinicians and commissioners – we all have our role to play in joining it all up. Anyone with a magic wand greatly appreciated.

Keep on running…

This is one of those weeks when CCG business seems to dominate my diary. Public Patient Advisory Group Tuesday night, private CCG Board Meeting Wednesday, Audit Committee this morning and then finishing the day with a meeting of the three Manchester PPAGs.

The Board meeting was a closed meeting so was not our full decision making Board with the public and it is often the best meeting for having good in depth discussions of the key challenges and current issues – we get the opportunity to really argue out the key points which we can all be reluctant to do in ‘public’.

As ever financial sustainability was a major discussion: £240m will be taken out of our Manchester Hospitals, the CCG and the City Council over the next few years (that is £30m more than the South Manchester CCG budget!): there seems no way of doing this without an impact on services as far as I can see but we are constantly striving to find initiatives that will reduce costs in the long term whilst also delivering quality services.

I find it ironic therefore that the Health system uses financial penalties for failures to meet targets. The hospitals have penalties placed upon them and the CCG can lose money if we don’t make some of the Governments key targets through the providers we commission.

I fully understand that we need to have levers in the system to ensure organisations remain focused and deliver well, but using money as the stick at a time when the system is precariously balanced just seems madness to me: and increases the likelihood of driving the incorrect behaviours that created problems in Mid Staffs. What is more, if it was a successful strategy surely we wouldn’t be seeing targets like the 4hour wait in A&E missed so regularly would we? Ultimately the system we have is perfectly designed to achieve the outcomes we currently achieve!

The pace that initiatives are thrown out from the centre continues to be a challenge for the CCG. We will soon have feedback from the consultants responsible for looking at the ‘Southern Sector Challenged Health Economy’ (see last blog): this whole process appears to be a totally top down initiative without consideration for engagement of patients, or in reality, CCG Boards, to contribute at all. The model we will have presented to us will take account of other consultations but will ultimately be a financial modelling based on making the system viable. It will be interesting to see how this initiative develops and how much change is proposed: I am sure politicians will find it difficult to support any major changes to services in their area in an election year!

NHS England are also looking at developing the co-commissioning of some GP services with CCGs: it sounds a lot like we are talking about going to PCTs to me – which may lead to some questioning about the whole NHS reform from some quarters. The debate will now start as to whether we end up in a pilot area in South Manchester – more work for the CCG and no sign of more resources.

In my last blog I talked about there always being ‘another thing’ for us to worry about – well it continues and we have no alternative but to keep on running…