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.
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.
So the Government have found £500m worth of savings that that they can re-invest in A&E to ensure that targets are hit this winter.
More money can only be good news surely… – but there have to be questions to answer – and some discussion to be had. Below are some of my thoughts and I would be intrigued to hear different opinions on this, especially from people in South Manchester!
My first concern is generally about targets, how they are set and how this drives funding. This funding is all predicated about the fact that A&E departments never met the 95% of patients being seen within 4 hours.
Of course it helps the patient experience if 100% are dealt with inside 4 hours – though I will be reminded that sometimes it is clinically not right to move some people so there needs to be some flex in the breach. There was a point when the target was 98% but the coalition didn’t believe this was clinically justified and moved it to 95%: what I can’t find anywhere is clinical justification for it being 95% either!
Politicians will raise the fact the NHS has ‘failed’ to hit its target if 94.8% of patients are dealt with within 4 hours and claim success if it is 95.1% and of course a breach could be two minutes or eight hours – the data/targets don’t tell us this because they are a blunt instrument. In truth does patient experience and patient outcome change dramatically by the odd % point change? Do we notice the difference?
In the recent Friends & Family test data all of 15 people out of a possible 4,000+ responded for A&E at UHSM (Wythenshawe Hospital)– all of whom said they would recommend the service: it would be great to know why 99.6% never responded – the data does become rather pointless with a .4% return rate.
The other issue about targets that I think the government give very mixed messages: in the light of the Mid Staffs report Jeremy Hunt said that ‘…NHS Managers have been too focused on targets…’ and need to put care first. I for one agree with him – so why now issue £500m with an absolute clear message that this is about focusing on… a target. It would seem to me that by his own admission, too much focus on the target and not enough on care could bring around the tragedy that we saw at Mid Staffs: so how do we know this £500m will improve patient care and not fill funding gaps and lead to more creative ways of ensuring the targets are hit?
My second question is why is the A&E target such a ‘trophy target’? I know that it can be a ‘barometer’ for the way the rest of the system is working: are there enough beds available, are social services able to support patient discharge etc but it is not the be all and end all: you would think that if we hit 95% target in A&E instead of 94.9% then all must be well and good with the system – whilst it is broke if we hit the lower figure. This isn’t true and never will be.
The truth is the system is all interlinked: we could have a focus on the targets related to getting stroke patients into specialist stroke beds: which is probably being missed as we are using the beds for patients we are pushing out of A&E and don’t have other spare beds. If we focused on the specialist stroke beds we might need to stop the flow from A&E and then suddenly hit the A&E target. In my view the A&E target is just the easiest to understand: most of us have had or know of someone who has had, what feels like an unacceptable wait in A&E: so the message fits with some patient experience – though many of those long waits we complain about didn’t last longer than 3 hours 59 mins and 59 seconds – that clearly crucial point in the world of targets.
I see Clare Gerada of the Royal College of GPs says that the investment is a ‘sticking plaster’ and points, at what she claims, is a crisis in primary care. Many patients we hear from complain about access to GPs – this is a problem that manifests itself in people turning up at A&E when they could and should be seen by their GP. However we frame it, most patients seem to believe that accessing their GP is too difficult and would welcome more GPs to help improve access.
My final ‘beef’ is with the way that the NHS is chastised if it misses targets – when in other areas of Government providers are praised for nearly hitting targets: Work Programme providers from the private sector were praised for improvements in performance recently despite massively missing targets: I think NHS Managers would welcome a more nuanced approach to the data rather than it being used to beat them up.
So, in conclusion, I would be interested to hear from people – is the 4 hour target what we should be focusing resources on? Should we be looking at other places to make additional investment? And just how useful are the current targets in improving patient care, experience and outcomes?
At the end of July the Public Patient Advisory Group had an away day – we sacrificed watching the Ashes and the British Open, as well as a beautiful Saturday, to have a look at what our priorities of a group might be (on top of the agenda that comes down via the CCG).
I have spent this evening trying to formulate an action plan out of the priorities we identified. Some aspects need following up to see where we are at and some will be long term issues for us to monitor as a group.
So some of the key priorities that PPAG want to address by working with the CCG are:
- improving communications between consultants and patient and carers
- recognising, and acting on, the health inequalities of the diverse community in South Manchester
- Looking at how nationally set targets serve patients – do they drive the wrong behaviours?
- end of life care – following the Liverpool Care Pathway report
- Accessibility of services
- Integration between professionals to ensure whole person approach
- Transition between children and adult services
- care for carers
- embedding public and patient engagement in every aspect of CCG
This is a long list and there is detail behind each bit, it will certainly add to my workload. I’d be interested to hear if these sound right – and where the gaps are!