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?

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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…

Just another thing…

Another month passes by and life as a Lay Member continues to be challenging, at times frustrating but overall enjoyable. Though my blogs seem to becoming repetitive…

During the last month I have attended the full round of meetings as well as assist in an interview process for new engagement workers and bring together some GPs, CCG and Council commissioners plus a representative from the voluntary sector to explore how the voluntary sector gets more involved in the integration agenda.

The last of those meetings mentioned was very positive. But like much of the work of the CCG, feels difficult to nail down as there is always something else to do that is important – and we struggle for the resource to do it.

At the Board meeting this month, the phrase ‘negative growth’ was used on several occasions until one of the GPs said ‘can’t we just call it cuts’. He was right – but so typically in the NHS he is wrong. I have described before how the CCG gets a budget (the headline is there is growth) but we then get told how to spend it and in some cases we don’t have control of it.

There always appears to be ‘just another thing…’ – we are given our budget and asked to ensure we have a 2% surplus: why? Why not give us 98% and say that is our budget? They then top slice for various programmes ranging from Better Care Fund to Continuing Health Care cases that may have to be essentially refunded: now we have done our work on this and made provision but nationally they will top slice. It is just another thing.

The latest thing to add to our work is that ‘we’ as part of the ‘South Sector’ (a geography that covers South Manchester, East Cheshire , Tameside and Stockport) are part of a ‘Challenged Health Economy’ – which I believe to mean is our hospitals are struggling for cash (I may be wrong but I think that is it!).

Now we have a whole set up looking at re-configuration of services in Greater Manchester – Healthier Together – and our staff and some Board members already spend significant time on this agenda, now we have a second area to add to our woes. This is a top down initiative with a small window (about 12 weeks I believe) and I am glad that when highlighted at Board there was support for engaging the public in the debate: the problem is this whole piece of work is ‘just another thing’ to add to the increasing pressure on everyone in the system that seems to keep getting passed down.

Whether it is ‘develop a five year plan’; another top slice on the budget or another initiative such as ‘Challenged Health Economy’, it starts to become irrelevant how ‘right’ the powers that be are and how worthy the work might be – it all feels like ‘just another thing’: and I am concerned at some point the system might crack under the weight of too many things.

A Problem of Capacity

It seems I am struggling through lack of capacity as I never seem to find the time I need to even write a small blog!

The last week of March was a busy one for me in Lay member terms, I spent half a day at a NW network meeting, had PPAG Tuesday evening, CCG Board on Wednesday and Thursday morning was taken up with Audit Committee.

That’s about 15 hours of meetings and events without considering the 400+ pages of documentation to read to ensure you are up to speed and can ask the right question.

The PPAG meeting turned out to be one of the most insightful we have had, with an added reality check at the end. First up was a presentation from Stephen Tomkinson, Chair of the South Manchester GP Federation.

Stephen outlined the rationale behind the Federation that is made up of the GP Practices across south Manchester and is starting to look at how primary care is delivered and improved. With the changing world of primary care and a desire to shift more of the work out of hospitals and into this arena it is a rapidly changing environment. New developments such as seven-day working will require more than every single surgery repeating what it does five-days a week at the weekend: (how would our smaller practices do it?) it will require collaboration across our practices and new models of delivery to be created.

Following on from Stephen we heard from Dr Attila Vegh, the Chief Executive of UHSM (what most of us think of as Wythenshawe Hospital). Attila had a very open dialogue about the challenges they face at UHSM: they need to deliver £50m of savings over the next few years which seems a huge challenge however you look at it.

The challenge from our first two speakers was an interesting contrast: in the first instance we are trying to move more care into community settings and out of hospitals, and with the hospital, one of the ways to tackle the looming deficit would be to do more work there: a real conundrum for the health sector.

Plans are afoot at UHSM though and there does seem opportunity to generate income in some real innovative ways. The challenge for the commissioner (the CCG) is how we ensure the right quality care is delivered whilst these changes happen and for patients, we want the right services, delivered in the right way at the right time.

Our third speaker was Claudette Elliott, the Deputy Chief Officer of the CCG. Claudette was outlining some of the proposed projects for investment in over the next twelve months. In current plans the CCG is looking to make around £4m of investments: that requires us to make the same amount in savings over the next year. PPAG will be putting forward their priorities for these investments which need to be made quickly if we are to reap savings by April 2015.

After the speakers we had chance to hold our usual meeting – with feedback from the wide array of voluntary activity undertaken by our members. But crucially we were reminded of some of the realities by a colleague who told a patient story that is not going so well: a reminder that whilst we discuss the big picture and the strategy for the future, some people are suffering right here right now and long term promises will mean nothing to them.

It brings us back full circle to the point about capacity at the beginning, how do we ensure we have the right capacity to deliver now and ensure excellent services, alongside the right capacity to look into the future and help redesign services to improve the service and ultimately the outcomes we need: a challenge Stephen, Attila and Claudette will be constantly mulling over.

A Healthier South Manchester and other updates…

This week was both the Public Patient Advisory Group and the private Board meeting.  I think I have mentioned before that I feel private meetings actually lead to greater debate amongst Board members: there is just something easier about challenging one another when you are not in a public situation – nothing sinister.

The Advisory group received a presentation about ‘A healthier South Manchester’ highlighting the challenges we face in the area – to summarise quickly:

  • There is a 10% greater chance of dying if you are admitted for emergency treatment at a weekend
  • Women from Manchester die younger than anywhere else in the Country

This is in the context that there will be a £440m gap by 2017/18 if we do nothing.  This means significant changes are necessary – and I have discussed the financial challenges a lot in previous blogs.  The major response to the challenge will be through the integration work.

The good news from the Board is that the early evaluation from the integration pilot has been positive.  One of the main concerns about integration has been about delivering savings: there is little doubt it makes sense in terms of providing the right healthcare and support for individuals, but nobody knew for sure that savings could be made.  The final figures will be released in due course, but integration does have the potential to deliver better service and cost less – a true win win. Whether it will deliver the level of savings we all need to make is another question altogether!

Other issues we have picked up included following up on a ‘Mystery Shopper’ exercise undertaken by PPAG members with the Communications and Engagement Team which has raised a number of minor issues about primary care patient access, we will receive feedback from what action has been taken in due course.

Also during the last month we have had a City wide meeting of the three PPAGs to look at the work currently being undertaken to look at the recommissioning of Mental Health Services.  Thus far the engagement process has been far reaching with many voluntary organisations hosting engagement events facilitated through Macc and other events hosted by the CCG.  Reports on the results of this feedback and how it has impacted on the final commission will eventually be published.  It will be good to see how effective the patient engagement is.

Finally just to report that PPAG members have also been included in doing walkabouts at Wythenshawe Hopsital: these walkabouts are useful for the CCG in seeing the delivery of the services we buy and supporting Wythenshawe in continuous improvement. As these visits do not form part of an official inspection process we are able to feedback to the hospital and follow up to see what action has been taken.

This week I will be attending Health Expo in Manchester and will feedback from that event shortly.

Are they cutting the NHS? (yes)

It’s been ‘meetings week’ with Public Patient Advisory Group (PPAG)on Tuesday evening and the CCG meeting Wednesday.

 As ever PPAG was informative and helpful.  We looked at the early work on the CCG strategic priorities – there is plenty of work to do – members are concerned that the integration plans are viable within South Manchester but can see the positive aspects of the joined up working between health and social care. One of the big challenges is how other services are brought into the integrated agenda: voluntary organisations, for example, potentially have a huge role to play too if we can truly integrate services.

 We also met with commissioners responsible for looking at end of life care and discussed how services are to be developed.  A major part of the Living Longer Living Better strategy will involve ensuring that people receive the care they want, where they want as we approach end of life.  Again PPAG was able to question developments and feed into commissioner thinking, as ever members were able to draw on personal experience to identify how we can make improvements.

 The CCG Board was swamped with papers: a sign of the challenges facing the staff team to keep on top of everything.  In order to keep this blog brief I shall focus only on the finances as I understand them.

 Firstly there was some ‘good’ news: back in September I wrote a blog which expressed concern about changes to the NHS funding formula: fortunately, NHS England wisely decided to add a ‘poverty premium’ onto these figures such that the target funding for Manchester would now be an uplift not a cut.

 The good news stops there.  Have a look at the finance plans amongst our board papers and a story starts to unfold: South Manchester CCG had funding of £201m in 2013/14 and we will have ‘growth’ of 2.14% to £205m for 14/15.  Then there is some smoke and mirrors that goes on with the Better Care Fund – a fund agreed nationally for investment in integrated care: some of which is performance related, which means our budget in 15/16 will be £201m again. 

 Inflation may be low, but inflation in the health sector always seems to be higher and a budget which is virtually static in 2015/16 is undoubtedly a cut.

 The next page shows there will be a 10% (in cash terms) cut in running costs of the CCG in 2015/16 (figures set centrally) which is always a popular move ‘cutting bureaucracy’, but there is only so much you can cut the system that needs to drive the change and transformation we require and this could have dire consequences.  I already think we are driving some of our staff into the ground: this looks like a trend that will continue.

 Finally, the next page has our QIPP targets on.  Now QIPP is about quality and innovation: but the target is a financial saving.  It is no longer acceptable to improve services to patients and improve outcomes at the same cost – you have to do that and reduce costs.  Our 2014/15 target is £2m – which might seem reasonable if we hadn’t taken about £6m out in the last two years but I am sure we will make a good fist of it.  The 2015/16 target, the amount we need to make our budget make sense is nearly £5.5m.  Right here right now that sounds impossible but ho hum.

The truth is, however often a politician says it, the NHS is facing cuts over the coming years. Whilst we have an ageing population, want to move to 7 day working and have the usual developments in drugs and technology, the NHS is going to have to be leaner and smarter to survive, and it must do this whilst taking significant cuts.

 Such is the scale of the transformation required this cannot be done in the Board rooms of the CCGs or the hospitals alone.  We need to engage the public more than ever in the debate: redesign of services must be a joint venture, the public must have a say: I am sure we can improve many services and reduce costs by working together – just not sure we can save as much as the Government expects us to!