Holding Course

2 months after major reforms, and the official birth date of clinical commissioning, there's a debate about the role of CCGs.  Whilst not unexpected, it does seem premature.

A Foundation Trust Chief Executive told me last week that clinical commissioning was the best thing to happen during his time in the NHS.  The increased level of clinical conversations, the focus on patients had helped his organisation and was a welcome change.  

So is now really the time for a change in direction?  Is the agenda different?  Undoubtedly there is a need for integration, for joint working with social care.  But this isn't new.  There is a need to understand the impact of conflicts of interest, but it's difficult to think of any organisation with no conflict whether political or as a provider of services.  

The goal of integration does not need a mandatory change of commissioning responsibility or NHS budgets, but a change in working and behaviour.

CCGs across the country are working to achieve integration and are working in partnership with local authorities.  Health and Wellbeing Boards are now established, but are not tested by an authorisation process and vary in membership and readiness to govern.  Some have had significant turnover in membership and political ideology following local elections.  

The NHS needed to change.  Now is the time to give clinical commissioning some time, the space it needs to succeed.  I'm confident it can, but we need to retain the sense of clinical responsibility for our patients, to continuously improve outcomes.  This won't come from advisory roles.  We have a real opportunity to change the way clinicians and managers view the NHS and its outcomes for patients.  Responsibility is key.

Apparently less than a third of people are aware there has been a major NHS reform.  Their focus is on provision, on their local services.  Satisfaction in the NHS remains high.  Changing commissioning roles too early may weaken the NHS and is unlikely to be of significant political benefit.

We are very much aware of the importance of time as clinicians, of giving treatments the opportunity to work.  Let's do the same with the NHS.  

Hospital Walls

There are some things we can change, and some we can’t.  According to the serenity prayer, the key is knowing the difference.  With limited management and clinical capacity, this is crucial for CCGs and the NHS.

Unplanned care is one of the main challenges facing the NHS.  Rising demand, admissions and a reducing social care budget create a perfect storm for hospitals and practices struggling to meet A&E targets, improve access and quality.  It can be difficult to look up, to examine the system, when we are running on a treadmill that seems to relentlessly increase in pace.

Locally, we have commissioned an annual review of hospital admissions for each of the last 3 years, using a validated external tool.  Over a defined period, how appropriate are admissions, what is the situation on the wards, where are the gaps in services outside hospital?  Many areas do similar studies.  The challenge for the new commissioning system will be to make a difference, but it will take a partnership approach, involving providers and social care.

What were the main findings?  The majority of patients are admitted appropriately.  11% were thought to be medically inappropriate (17% in 2011).  Approximately half of these inappropriate admissions were unavoidable because local services didn't exist that might have cared for them.  Inappropriate admissions were not related to patient age.

42% of patients admitted had a mobility problem.  25% had cognitive problems.  Respiratory illness was the most common cause of inappropriate admission.  

67% of admissions were from A&E, 28% via GPs, consistent with previous years.  GP admissions were more likely to be inappropriate (15%) compared to those from A&E (8%), where investigations were possible beforehand.  

70% of patients who were in beds could have been discharged from acute beds earlier, with variation between wards and specialities.  Increasing age was related to delayed discharge.  

We are currently reviewing the results and discussing the findings with social care and healthcare providers.  Discovering what we can change.  There are clear messages already.  When discussing increasing admissions and increased pressure within hospitals, we need to know our population, know our local services and look beyond the hospital walls.

April's here. Why be involved in a CCG?

As we reach April 1st the debate on what the reforms means for the NHS has increased in intensity. With this debate comes, perhaps understandably, challenge to those involved in CCGs - why are we involved, what's in it for us, are we being naive, why not walk away, are we part of the plan to privatise the NHS?

This is my personal perspective.

I believe clinicians should be involved in planning patient services

Clinicians can drive improvements in services by working closely with managers, patients and partners such as local authorities. By focusing on patients and quality we engage others, including local GPs. We are passionate about local services, about improving patient outcomes.

CCG leads know what the challenges are.

I don't feel naive, don't feel used in some master plan. I feel a sense of responsibility to patients, to members and to the local community. I spend a lot of time with other CCG leads - all work extremely hard for patients and any suggestions of naivety does them a disservice.

Commissioning helps me as a doctor.

I'm a stronger patient advocate as a result of commissioning. I'm more aware of pathways, understand local services better. I, and my GP colleagues locally, know much more about local providers and their quality.

The system is more fragmented

From April there are more organisations responsible for commissioning. Patient outcomes and safety must remain the focus. GPs are ideally placed to work with others, to listen to patients, to be powerful patient advocates across the system. CCGs have a crucial role in ensuring the system works.

Walking away would not benefit patients

This is a crucial time for the NHS. Clinical commissioning is an opportunity. Clinicians, from the whole system, should be responsible for planning, as well as delivering, care. My duties as a doctor don't end at my consulting room door.

External roles can be beneficial

There are many external roles, such as working with the BMA or RCGP. All are valid, and can enhance knowledge and job satisfaction. Doctors should not be criticised if they are not consulting full-time. There are many reasons to be part-time, and focusing on population health can deliver significant benefits for patients.

I'm not here to privatise the NHS

There may be occasions when competition is beneficial, or where existing EU law will mean we have to tender for services. However, CCGs are focused on increasing integration to improve quality, as shown in a HSJ survey in 2012. I'm determined to help improve NHS services, to strengthen them.

CCGs deserve professional support

It is important for the profession to support clinical commissioners, to understand their motivations and help build a successful commissioning system with clinicians and patients at the centre. It's an opportunity for General Practice.

Make It Simple.

At the Bassetlaw Dementia Summit in February, one of the carers delivered a plea from the carers' group.

'Our lives are hard enough. Your jobs are to make them simple.'

She went on to describe difficulties with diagnosis, difficulties with inconsistent carers, and most of all difficulties with social care, particularly the finance department. The challenges were clear. Sometimes we place obstacles for patients and carers, make their lives harder.

This week I've learned from experience. I'm a GP. I know the system. I'm confident on the phone. I understand which forms are which. And yet it's been a struggle, taken a lot of time and made me realise how hard the system must be for vulnerable patients, particularly the elderly or those with dementia.

The task? Sounds simple. A close relative has terminal cancer, is elderly and has dementia. He's struggling to get to hospice appointments, is starting to fall. He needs a blue badge or will become housebound. I offered to help. The forms were complex, quite medical. No mention of terminal illness though. I completed them, took a passport photo for him and rang the council a few days later to ask how long it would take to process. I was told 3 months. He doesn't have that long. They could expedite it if I could get a copy of his DS1500 (a form confirming terminal illness). This was completed a month ago. He hasn't got a copy, gets upset when I ask him for paperwork.

Nowhere on the blue badge form did it mention a DS1500. I couldn't get a copy from his GP, Macmillan nurse or consultant. The lady on the phone said they couldn't accept anything but the form, not even a letter from his GP. He'd probably have to come in for a medical. Where would he park? Would they ask him questions despite his dementia? Nothing they could do. I was given the complaints number. They were 'just following the rules.'

Anyone who knows me would say I'm a determined advocate for patients. After 6 phone calls I was eventually told I could get a copy from the Department of Work and Pensions. They're apparently happy to issue copies. I rang them. They denied ever doing that, until after another 3 calls a kind lady agreed to send one to the patient, for me to send to the council. I'm currently waiting for the post.

I've learnt a lot. Patients describe similar experiences regularly. This is just one example. Their lives are complicated enough. Where we can, we should make it simple.

Dementia - Beyond Planning

We have just submitted our draft commissioning plans for 13/14. Pages of trajectories, targets, pledges and aspirations. The team have put a huge amount of effort into the document, translated guidance and the new system, and we are now currently consulting with partners and patients.

One of our local and national priorities will be dementia. We have a national target to increase the number of patients diagnosed with dementia, as have all CCGs. Putting the issue of screening aside, is early diagnosis a good thing? Does it matter if treatments aren't effective for all, if a delay in progression is likely to be the best outcome? We are also aiming to reduce antipsychotic prescribing in patients with dementia. It's important to look behind the targets, to talk to patients, to see if what we are doing is likely to make a difference.

So I recently met a group of carers, all with relatives with dementia. They were an inspirational group of people, and it was one of my highlights as a CCG Chair to spend some time with them, realising how they provided mutual support for each other. It was also clear that they shared their frustrations, their anger with the condition and with the care system. There were plenty of tears during the meeting. This was the reason behind the plans.

Clear themes emerged from the discussion.

Diagnosis

All used a common word to describe the process of diagnosis. It was a 'battle'. In some cases it took years. The younger the patient, the harder it seemed. Stories were relayed of stressful trips to tertiary centres, to see specialist neurologists, only to be told their loved one's memory was not as good as it used to be. 'I'd told them that, I'd known him for years.' Nearly all had been diagnosed with depression first. 'If he was depressed, it was because he knew what was happening. No one took into account his family history of dementia.'

All agreed that early diagnosis would have been beneficial. But it wasn't just about treatment. It was clear that they valued the mutual support available, the benefit of talking to other carers abut how to cope with difficult behaviour, how to reassure an anxious husband or wife, avoid unnecessary medication. A recognition that their husband wasn't himself, that they were right and that they could explain the diagnosis to people.

Continuity

After diagnosis what was the most valuable aspect of care? Continuity. There was significant anger at changes to carers, to services that had been changed. Trusting a carer was so important, establishing a routine crucial. Changing times of service offered, the carers involved and worst of all insisting on a move to a different care home had significant effects on patients and their families.

Understanding

Carers weren't embarrassed by their loved one's behaviour or condition. But they did want understanding and compassion. This included health professionals, carers and the public. There were positive stories about the police, about officers going above and beyond to make sure patients were safe. What would happen if someone forgot to pay and walked out of a shop? This was a cause of some anxiety for some of the carers and patients.

Most said it would have been easier if the diagnosis had been cancer. There would have been a clearer path to diagnosis, more certainty regarding progression, more understanding.

Back to planning

This was the story behind the plans. We have already significantly improved the community memory service and commissioned an excellent outreach team. But we can do more - improving diagnosis accuracy, access to local scans and specialists. But its what we do afterwards that matters most. Focus on continuity, avoiding unnecessary antipsychotics. And listen to carers.


Bassetlaw Dementia Summit is on 5th February, bringing together more than 100 carers, professionals and partners including surgeries, hospitals, voluntary services and emergency services.

Opening the Doors

In November 2010 we took an important step as a practice. We opened our doors. We said, 'If you feel you need to see us, come down. If you feel you'd like a telephone call, ring us and we'll ring you back.'

Prior to November 2010 we had a GP on call, with patients phoning for urgent appointments. We would ring them back, usually ask them to come down depending on which GP was on call, and try to manage our workload and their problems. Phone calls and attendances would start at 3pm and finish at 6.30 at the earliest, often with visits in between, and there were extras in each routine clinic. Staff had the difficult job of managing demand amongst doctors, and we could see have up to 60-70 contacts in an afternoon for one GP.

To set some context, we are a large practice with 4 sites and over 27,000 patients. We have over 15,500 patients at our largest site, next to A&E but with high demand and high levels of social and medical morbidities. Over the last decade we had tried models such as nurse practitioner triage, GP telephone triage, minor illness clinics. We had recruited more doctors, more nurses, more reception staff due to a sustained rise in list size. How could we improve access for our patients?

So back to November 2010. The doors opened. Our Urgent Care Service was opened. We are very tight on space but we dedicated 3 clinical rooms to the service, built a separate entrance and allocated a separate waiting room and reception desk for registered patients with urgent, on the day, problems. No phone call needed. We employed nurse practitioners and an additional GP. We opened more routine appointments (no need for extras). We established a GP rota and ensured the Nurses and GPs worked as a team, with reception trained to ensure urgent problems such as chest pain or strokes were screened at the desk. Urgent and elective care was separated and access increased without contractual change or additional payment.

How do we judge if it has been successful? Patients think it is, and satisfaction surveys have been extremely positive. One patient judged the service as 8/10 because they'd 'had to wait 8 minutes', but the service has been extremely popular. We coped with a flu epidemic when we would have struggled, we can adapt the number of GPs and nurses per session as we can predict demand and routine surgeries now start and finish on time. Generally, patients are seen with 20 minutes, sometimes immediately, although at peak times it can be longer. Patients are learning when is best to attend. The doors open from 8.30 to 11.30 and 2.30 to 5.30. If there is a surge in demand GPs can help by seeing additional patients, but it is relatively rare. The 5.30-6.30 period is now relatively quiet.

In the last 12 months we have seen over 24,000 patients in our urgent care service. Most have been appropriate, and we have seen a small but significant reduction in A&E use during the day. Staff are not spending hours on the phone trying to get an urgent appointment for a patient, and visits seem to have reduced. Personally, I feel more confident having 'eyeballed' patients, and telephone calls are now genuinely for problems that can be dealt with on the phone. There are still some teething problems, some inappropriate attendances or days with longer waits, but we are getting there. We may have increased demand, but we provide a better service and we can't ask patients not to go to A&E if we don't provide an alternative.

Scrutiny

2012 has been quite a year. A year of personal scrutiny. What does that mean? The word apparently originates in Latin: scrutinium; from scrutari, meaning "those who search through piles of rubbish in the hope of finding something of value." A common definition is: 'to look closely (as for mistakes)'. Seems apt.

The start of the year (and the 2 years before that) saw our practice achieve the RCGP Quality Practice Award, a real team achievement and recognition of the focus on patient service, access and meaningful systems by the practice and its attached staff. The visit, following an enormous submission of 'evidence' included patient and staff interviews, observation and a nurse going through every drawer in my room to make sure all was in order and in date. That was a nervous ten minutes. We passed, and it has been a great experience for staff morale and a catalyst for patient engagement in the practice.

As a CCG Chair I then had an assessment to ensure I was able to fulfil the role, at least on paper. Maths and English tests and 360degree leadership surveys were followed by a visit to London where I was interviewed in great detail by the Hay Group and underwent a series of role play and written assessments. A full day later I had a stamp of approval and my first ever migraine. I also discovered that after a certain age writing for 30 mins in examination conditions is almost impossible. If the writer's block doesn't get you, the cramp will.

Next came authorisation. Armed with personal approval to be Chair, was the CCG up to it? We promised ourselves we'd take it as part of the day job, that we were doing the role, that we wouldn't get submerged in 'evidence.' We were wrong. To anyone who thought the process would simply be a formality, the fact that only 8 CCGs have been authorised without conditions (including Bassetlaw) will hopefully provide some assurance. We are a better CCG for having been through the process, but it's good to be focusing on quality and patients rather than process.

Finally, revalidation. My appraisal today was very similar to previous appraisals - a valuable opportunity to reflect on my clinical practice rather than policies and process. So what was different about a 'revalidation appraisal.' Mainly the surveys. Another 360 degree survey, but this time my colleagues in the practice, both clinical and managerial, including my secretary and other reception staff. This was followed by a patient survey. Both were done through an independent company (Edgecumbe) and the process was very smooth with clear reports afterwards. It felt much more personal than previous QOF surveys, and unlike previous 'leadership' surveys this was about my interactions with patients, my consultation skills, how I support staff.

So all my evidence has been submitted now for revalidation. The CCG has been authorised. The practice has the QPA for the next 3 years. A good year, with a focus on quality and assurance. 2013 should be easier. Wait, what's this on everyone's twitter feed? 35 outcomes for CCGs? A new planning framework? More scrutiny by the Local authority?

Better start collecting evidence.