Odd Socks

I have a strategy for dealing with odd socks as they come out of the wash. I put them into my sock drawer, and wait for the other sock to arrive in due course. I am of the view that things will generally work themselves out eventually.

It became apparent recently that my wife also has a strategy for dealing with odd socks. She puts them into a little bag by the washing basket, and waits for the other sock to arrive. Essentially, she takes the odd socks out of circulation until they are paired up. 

You will realise the implications of this on my own strategy. I could be waiting some time before my socks get paired, with one in my sock drawer and one in the little bag.

I would maintain that both strategies have merit. You may prefer one method over the other, but on their own they both should work. It becomes a problem with both strategies are employed together.

We were recently thinking about the various strategies and work streams we have in motion at the CCG. In particular we were thinking about the development of new clinical pathways. It became apparent that we were approaching this in a number of ways simultaneously. None of the approaches was ‘wrong’, in fact they all have merit. Until recently we have had a Clinical Pathways Action Group led by a secondary care consultant with input from other consultants and GPs. We have developed an Expert Patient Reference Group and an Expert Professionals Expert Group (just now being merged into one Expert Reference Group). We have asked our GP practices to form into clusters and asked the clusters to use Right Care to consider new pathways to increase value locally. We have a CCG-driven Sustainability Action Group looking to see what we could put in place to make our local health economy sustainable long term. All of these groups are thinking about how to change pathways – to improve the patient experience, to ensure value for money, to reduce duplication and waste and to make our system run smoothly.

Individually, they are all a good idea.

Together, we have a problem. Some lack of coordination. Some lack of communication. Some lack of oversight. There is a risk that we run out of capacity to run all the projects. There is a risk of duplication. There is a risk that some projects get completed but never actually enacted (nothing more frustrating than asking how to refer into the pathway you helped create last year that now doesn’t seem to exist).

We realised that we needed to take some action. In simple terms, just communicating and overseeing the work is probably all that is required. In the same way that we are trying to join up care for invidious patients, we need to join up the work of commissioning new pathways. 

It’s time to streamline and get this sorted. 

Realisation of this brought with it a big sigh of relief. Things suddenly became clearer and more achievable. 

Just as I have greater confidence in being able to wear matching socks, I have greater confidence that our pathways work will not look mismatched.
Dr Jonathan is a GP and Clinical Commissioning Group Chair.

Follow Jonathan on Twitter @DrJonGriffiths

Dirty Hands

Dirty Hands

I was recently the guest at a birthday party. It was a great night, with excellent live music from The Rubber Wellies. If you like folk music, then I suggest you check them out. Favourite songs for me include “Ban The Bomb!” and “The Beard Snood”, but I want to talk about “Dirty Hands”.

For me this song is about doing the right thing, and sometimes doing the right thing means getting your hands dirty. You can read the lyrics here, but this is the chorus:


“Well, there’s only one thing I want, when my time on this Earth ends, a pair of dirty hands, O Lord, and a clean conscience.”


Sounds easy? I think not. This song is about integrity, speaking out, and not turning a blind eye. This is hard stuff. A pair of dirty hands implies hard work, of getting down to the business at hand and seeing it through. I’m sure we can think of examples where this just does not happen.

I could choose to talk about Mid Staffs. I could chose to talk about equality, diversity, racism, sexism and homophobia in society and within the NHS. I could talk about the failure to maintain duty of candour when things go wrong, of cover-ups and re-writing of history. I have my own personal examples, and you will have yours.

Sometimes our Governing Body conversations seek to tackle difficult issues. I am so glad that I do not chair a Governing Body that sits quietly, unquestioning and letting the executives get on with it. I see challenge, concern and a desire to understand. I also have seen our Governing Body make decisions which have put our executives in difficult situations, where they have then come into conflict with colleagues from partner organisations. Sometimes it feels as though the CCG is being asked to do or report things in a particular way that we do not agree with. Deciding to put ourselves in a position of conflict in this way is an example of getting your hands dirty. We have a duty to the people of Central Cheshire. We have for a long time felt uncomfortable about how we are asked to report our financial situation. I encourage you to check out some finance papers from CCG Governing Body meetings. I suspect you will find phrases like (example only) “forecasting to meet our control total”, but quite possibly in the same paper “we have £2 million uncovered risk”. Let me interpret this – it means they are forecasting to end the year £2m below their control total. (The control total is an artificial zero that CCGs all have to work towards, it is intended to provide a buffer so that you don’t go into the red. If your control total is £1m, and you have £2m uncovered risk, you are essentially forecasting a £1m deficit.) If you speak NHS Finance, you understand this. If you don’t, you won’t. Governing Body members are supported and trained to understand this language, but our public are not. We do not think this is transparent. We think this is potentially deceiving our public, which we do not want to do. It is, however, how we are asked to report. Our Governing Body do not like it. We want the people of Central Cheshire to understand our financial situation.

Moving away from finance, CCGs have a responsibility for quality of the services they commission. The Governing Body of the CCG will have its eye on quality, safety and effectiveness of services. Holding providers to account for the quality of their services is not always easy. People and organisations get defensive when challenged. People and organisations may look to discredit the data, to explain it away, and to reassure you that all is well. Being able to hold the line and pursue your agenda can be hard work. Turning a blind eye can feel like the path of least resistance, but is not the right thing to do. Let’s not be complicit. Let’s speak out and challenge until we are assured.

You never know when you might be required to get your hands dirty. Doing so is likely to require hard work and personal resistance. We hear stories of the challenges faced by ‘whistle-blowers’ – criticised, ostracised and intimidated. Surely in the NHS we need to develop a culture of transparency, integrity, honesty and support.

In this blog I would call upon you to consider how this might apply to you. Where are you being called to get your hands dirty? Where do you need to stand up and hold the line? Or perhaps you need to support others who are putting themselves in the firing line in this way.

My personal hope is that when required, I will have the integrity and resilience to do the right thing, and that you might be there to support me.


“Well, there’s only one thing I want, when my time on this Earth ends, a pair of dirty hands, O Lord, and a clean conscience.”



Dr Jonathan is a GP and Clinical Commissioning Group Chair

 Follow Jonathan on Twitter @DrJonGriffiths

Glass Half Empty

Glass Half Empty


Are you a glass half-full or a glass half-empty person? Do you see doom and gloom or success and blue-skies? I tend to be an optimist. I like to see the best in people, to expect that things will all turn out ok, and be positive. I think how I behave at home, at work and with friends tends to reflect that. I think how I write and blog tends to reflect that. This blog is not the same.


Things are going wrong in my part of the NHS left, right and centre.


We cannot agree a contract with our local hospital. In a financial situation where we as a CCG cannot afford any more growth, our local trust requires £10m more than last year in order to survive.


We cannot agree our plans with NHS England. We are forecasting that we will end this current financial year with a significant financial deficit. NHS England find this unacceptable. So do I, as a matter of fact, but I cannot see where the money can sensibly be taken out other than from the local hospital (see my first point above).


General Practice locally is struggling. I have practices threatening to stop taking out stitches following operations, or stopping syringing ears. I have practices unable to recruit to vacant GP posts, and looking at closing their list to new registrations. These actions are a response to the unbearable strain many GPs feel they are facing. It appears our local issues are reflected nationally if you read the King’s Fund publication Understanding Pressures in General Practice (which I strongly suggest you do!).


We are being asked by NHS England to ‘think the unthinkable’ and make ‘unpalatable decisions’ in order to make our books balance. This means cuts. Cuts means going after the areas you think you can easily cut, which is not the same as going after the areas you would prefer to cut. In reality this means potentially reducing spend in Primary Care, Community Care and Mental Health. It’s very hard to cut the hospital care elements because of the way the payment systems work. Cutting Primary, Community and Mental Health Care just leads to more problems for GPs, and in the medium term an even worse financial situation. In other words, the cuts we can make to achieve savings this year will just lead to greater money problems in future years – we are nevertheless being asked to look at this.


The wider NHS system at the moment appears to be all about providing stability for hospitals while not at all recognising the issues in General Practice and community care. While the NHS England GP Forward View does recognise this and lays out plans to help, I cannot see anything on the ground for right here and right now. Right here and right now the message seems clearly to be that we should protect our local hospital. No one appears to be looking to protect GPs, community staff or Mental Health workers.


So why is this happening? What’s gone wrong? Is this due to our mis-management of the system as Commissioners? I’m going to say that I don’t think so, although some may think exactly that, and that is exactly how this will end up playing out if we fail to deliver our finances. Is this due to our hospitals behaving badly? I don’t think so, although some may disagree with me. Is this due to local NHS England making inappropriate demands of us? It feels that way, but actually all they are asking us to do is live within our means and use the money we are allocated to provide health care for the people of Central Cheshire – we are asking for more than we can afford.


I have to say I think the problem is, as ever, multi-factorial, but starts with there not being enough money. I would argue we are not getting our ‘fair share’ allocation, but even more fundamentally there doesn’t appear to be enough money in the NHS coffers. So, is this the fault of the government? It is certainly their responsibility to appropriately allocate public money. Are they doing that? If they were to give the NHS more money, where would they get it from? Should we take it from Education, Defence, Foreign Aid? They have already taken it from Local Authorities, hence the pressure in social care which is impacting on health. Perhaps the government don’t have enough money? So who’s fault is that? Perhaps we should start pointing our fingers at the banks?


Or perhaps we shouldn’t point fingers anywhere, and just deal with what we have to deal with. And by that could I suggest that we don’t start pointing fingers at the CCGs? I can see where this is heading. I can see how things are lining up to accuse CCGs when they run out of money. How it will be CCGs fault when things start going wrong, that the Accountable Officers will start to be removed as they fail to meet their financial responsibilities, and the Clinical Chairs (like me) will either resign or be removed when clinical quality starts to fail because of financial constraints.


This makes me angry. If the government and NHS England are responsible for anything here, they are at least responsible for not being open and honest with the public. Where is it being said that the ask of a number of CCGs this year is unachievable? Where is it being said that financial constraints will mean cuts in service? Why is there no national rhetoric around this? Why instead will local organisations be held to account for budgets they cannot possibly balance and then criticised for this, when in fact it is a national problem?


I am unsure how this is going to end. Locally if things carry on as they are then our local hospital will continue to grow while the rest of the local health service shrinks and the CCG runs out of money. General Practice will collapse, community care will fail, mental health services will disintegrate and more patients will find themselves at the door of the hospital, reinforcing the view that the money needs to follow them to meet the demand. A viscous cycle will ensue…


I am struggling to see the solutions that will make a difference. I have no call to arms or suggestion to make.


But I wanted you to know. I want you to begin to understand what’s going on here.


Doom and gloom.


Glass half-empty.


Dr Jonathan is a GP Clinical Commissioning Group Chair

Follow Jonathan on Twitter @DrJonGriffiths