Guest blog by Ben Tyler – Reflections on a GP and Commissioning Placement – Week 5

This week I attended the CCG’s Annual General Meeting. It was set up in a ‘market stall’ fashion that gave great opportunity for the public to talk to the staff in a relaxed manner that could prompt lots of discussion. They could also more formally question the commissioners in a Q and A session as well as hearing the Chief Finance Officer discuss the previous year. 

This seemed an excellent opportunity for the public to ask some difficult questions and get some very honest answers! So I was a little surprised at the turnout, expecting many more people to be there. But then I thought about whether I would be interested in attending before I started shadowing Dr Jonathan Griffiths in the CCG, and I came to the conclusion that no, I wouldn’t be. Before this placement I knew little to nothing about how the CCG worked, the decisions it makes or the power it had; and that’s after three years of medical school. 

Do we as a public actually hold as much interest in the NHS as we think?

 This BBC article was one of many published on August 26th discussing some draft sustainability and transformation plans proposing ward closures and changes to GP and A&E care. It was one of the top new stories of the day and attracted a lot of attention. Therefore the public are indeed interested. Is the general population unaware of the connection between the CCGs and these plans, and how many commissioners are helping form these ideas?

In a way this goes slightly against one of my previous blogs, which discussed how involving the public in decisions would aid in the outcome. I still agree that this is the case, but do society want to be involved? Are the majority of people happier to simply leave the decisions to the responsible parties, rather than be part of the solution? I would hope that this is not the case, and simply the NHS, as a whole needs to do more to communicate and engage with the public.

Dr Jonathan has recently been quoted in the Winsford Guardian discussing whether GP’s should continue to prescribe drugs like paracetamol, when they can be bought over the counter at no cost to the NHS. This article engaged well with the public, with three patients the next week mentioning to him that they would like paracetamol removed from their script. This is a good example of the public engaging and taking personal responsibility for saving the NHS money. They became aware of a problem and how they could personally solve it.

Perhaps the problem with the bigger issues for the public is that they don’t feel they are in a position to help. They are very happy to take responsibility of their own person, but don’t know how their opinion can aid in the system. I wonder if more articles were written in local papers about local healthcare plans, would more of the public become engaged? If people realised that local organisations are making decisions for the local patch, would they feel more empowered to help?

Should empowering local people to give their opinions on the local delivery of health, be an important goal for the NHS?

(Post-Script: As the articles above mention, Sustainability and Transformation Plans will be published at the end of October; will there be a huge public outcry? Will people be angry? Where were these people at events like this AGM where their opinion could be noted? Are people happier to simply complain once a solution has been made locally, instead of helping mould that solution?

There are lots of questions I’m asking because I don’t know the answers. If education and communication was improved, I don’t know if people would be become more involved. I would like to think so, but I am not certain.

Educating the public is paramount to the future of the NHS. Difficult plans like these have to be implemented because of government policy, which is in part chosen by the public in general elections.)


This blog has been written by Ben Tyler, 4th Year Medical Student at Sheffield University

Follow Ben on Twitter @BenjaTyler

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Guest Blog by Ben Tyler – Reflections on a GP and Commissioning Placement – Week 4

Last week I discussed how I think consulting the public earlier in the decision process would help the NHS in saving money.

 

This week I’m taking a slightly different tack. In my opinion, some decisions need to be made by those with the relevant training to fully understand the benefits and consequences of them.

 

When practicing for medical school interviews I got posed with a question regarding an ethical scenario similar. It was along the lines of ‘should £X be spent to give one person 50 more years of life, or one thousand people 10 more years of life’. The interviewers weren’t after a right answer, but wanted to see how you thought through the problem and got to the answer.

 

Local commissioning groups are now looking at different conditions they may limit service access to, to save money. How do you decide which conditions to treat? How do you come to that decision? Utilitarianism is an ethical theory that says the best moral action is that which produces the greatest good, for the benefit of the majority. Is this the best way to proceed?

 

A recent discussion at the CCG surrounding access to elective surgery intrigued me. A high BMI and smoking both can effect how successful the intervention is. Therefore should patients be required to lose weight or stop smoking before they are put on the waiting list? If an obese patient has a knee replacement, it will last less time than if a healthy weighted person has one. Therefore should the obese patient be made to lose weight before the operation? But then if their knee is painful how can they exercise to aid weight loss? A similar scenario could be drawn up with smoking.

 

Each case is different and therefore it is hard to use a blanket value. E.g. two people may have a similar BMI but one may be more muscular than another. So then should individual surgeons make the choice whether they operate or not? But then each surgeon may make a slightly different decision. How is this fair?

 

When the NHS is trying to save money, at such a rate, in my opinion it is nearly impossible to do this in a fair way. There are going to be winners and losers. Each individual case can nearly always be argued in either way.

 

It reminds me of a Radiolab podcast I listened to called ‘Playing God’. It spoke about triage and how with a limited resource, how do you decide who receives it first. Essentially, how do you decide which life is worth more. Albeit the current situation isn’t quite that serious, but how do you decide if one person deserves an intervention, and another one doesn’t?

 

There is no right or wrong answer, but perhaps those in the best position to make those decisions are the relevant medical professionals? Those that carry out the interventions and conduct follow up know when it is successful, and how much of a difference it makes. The doctors that see patients with certain conditions are in the best position to understand what will happen if access to interventions for these are limited. It makes sense that these are the people that should shoulder this responsibility.

 

Similar to the conclusion the podcast came to; I think it is unfair for clinicians on the ground to make the decision based solely on their clinical opinion. Emotions can come into play and pressure from patients could sway decisions. Someone in less clinical need but more emotional about the intervention could be awarded it instead of someone in more need.

 

Pathways must be drawn up, acknowledging the local demographic, for clinicians to follow. This means that clinicians are responsible for their decisions collectively.

 

Maybe the general population, with no conflicts of interest, could help work through the more controversial pathways. A group of non-clinicians could debate amongst themselves which interventions or conditions to limit access to, after the pros and cons had been discussed by clinicians.

 

There may be patient backlash about some decisions made, but I think this is the fairest way of coming to conclusions – making decisions with relevant clinical professionals working in tandem with a group of the non-bias public. Although controversial cases may appear in the press and on social media, in my opinion this is the fairest way of limiting treatment to save finance, which unfortunately needs to happen.

 

This blog is by Ben Tyler, 4th year Medical Student at Sheffield University

Title Fight

Title Fight

Roll up, Roll up! Come and watch the event of the year! Ring-side seats still available! Settle down, place your bets, and let’s watch the two contestants enter the ring.

In the blue corner we have the CCG. They don’t look happy to be here, but they nevertheless look confident. They look prepared and ready for the fight.

Facing off against them in the red corner is the local hospital trust. Also not really wanting to be here, but also prepared and ready for this title fight. 

The audience are all ready, and frankly all look a bit confused. It’s not exactly clear why this fight is taking place, and why these two collaborative partners are now fighting. The stakes are high – it’s all about money. Specifically it’s about where some the money for healthcare locally will be spent. The hospital wants more, and the CCG say they haven’t got it. The hospital say that if they don’t get it, they won’t be able to see the patients who attend. The CCG want to invest more in community based services – GPs, community nursing, mental heath – in order to keep more people at home in the first place.

This title-fight will decide what happens. If the hospital win, the CCG will have to continue paying the hospital much as they are now, and will have to just get on with it. If the CCG win, the hospital will have to manage with a lesser amount of money. If the hospital win, the CCG will not have the additional money to pay them with anyway. If the CCG win, the hospital will struggle to remain sustainable. It occurs to some of the audience that neither scenario sounds like a victory for anyone. 

Anyway, no time to contemplate that as the bell rings for round one. Straight away we see some tentative sparring. The CCG have prepared their case well about the levels of non-elective admissions lasting less than 24 hours. The evidence is damning with the hospital admitting significantly more patients than pretty much anywhere else. There is a robust response from the trust though, who cite the inadequate size of their A&E as well as suggesting that the local GPs need to play their part in keeping folks away from the Emergency Department. The CCG press their attack though, this is a major issue for them as the Trust are most certainly an outlier, with most people agreeing their admission rate is unreasonable. It’s hard to see how the Trust is still on it’s feet here, but they are saved by the bell – end of round one. 

The combatants retreat to their corners. Their respective coaches are immediately by their side. NHS England, coaching the CCG, appear to be giving them a bit of a hard time for not having sorted this out sooner. NHS Improvement meanwhile, coaching the Trust, while also pushing them hard on this for victory do seem to be slightly more supportive. The looks they are giving NHS England across the ring are already telling a story of it’s own.

The bell has rung for round two though, so let’s get back to the action. The CCG has a different approach this round. They have clearly been talking to the Trust entourage and have some insider knowledge. Trust clinicians would like to introduce a Virtual Fracture Clinic and the CCG are pursuing this as it would save money (as well as being better for patients). The Trust know this will cause them financial problems, and for the moment the ring side clinicians from the Trust have been politely moved back, and the finance and contracting teams are calling out encouragement from the ropes. The Trust is dancing around here, doing all it can to avoid the blows that are coming. It’s not a pretty sight, but as the bell rings to end the round, the Trust is still on it’s feet.

Both sides are using the break to regroup and consider the implications of this fight. 

As they head back in at the bell they are both using arguments presented to them by their regulators. The CCG are making it clear that NHS England are not accepting of the financial situation being presented, and that the CCG must do all that it can, including ‘thinking the unthinkable’ and doing things that are ‘unpalatable’ in order to make ends meet. The Trust, on the other hand, are explaining how NHS Improvement have made it very clear to them that they must reach their financial control total at the end of the year. NHS England encourage the CCG to insist they will only pay the Trust the value which has been agreed at the start of the year, and not for any additional activity. NHS Improvement encourage the Trust to call breach of contract for not paying on the basis of the national Payment By Results tariff. It’s a mess out there people, and I’m really not sure how it’s all going to go down.

The above narrative might seem a fanciful description of the challenges faced by CCGs and Hospital Trusts, but I assure that this is how it feels at the moment. I first started writing this months ago during our contract negotiations which almost led us to arbitration. It feels just as real now that we are in the midst of financial recovery, trust over-activity and ongoing arguments about emergency admissions. The CCG are meeting with NHS England (NHSE) on a monthly basis to report on our financial situation, which is not improving, and we are being held to account to deliver end of year finances which I don’t believe are achievable. Our local Trust is under the same pressure from NHS Improvement (NHSI). They are doing all they can to end the year at their control total, and so is the CCG. The problem is that the only way the CCG can reduce it’s spend to the level required is by reducing hospital spend. If we achieve this, the hospital will not meet it’s financial control total. If the hospital do manage to meet their financial requirements, then the CCG will not meet theirs. As things stand there is no obvious win-win solution. 

We need to find a third way. We need an innovative, collaborative solution to this wicked problem. Our local health system is only sustainable in it’s current form if we have more money, and there is no sign of that. We have to do things differently. We have agreed that next year we need to move away from the nationally set tariff, and agree our own ‘block’ contract for hospital services. This is a big step in the right direction and will enable us to jointly consider how money is best spent in the health economy. We have a problem right now though. We are fighting right now, and from where I am sitting it feels as though we are being encouraged to fight by NHSE and NHSI. I have recently suggested that the CCG and the trust should meet with both NHSE and NHSI together and essentially ask ‘which of us do you want to fail?’. As things stand, we cannot both succeed. 

I don’t know how much of this our local population will begin to understand. The concept that the NHS has been set up in this way with the conflict in the system is hard to get your head around. What I do know is that we need to be communicating in a more straightforward way, and that the people of our area in Central Cheshire need to know that there is a significant financial problem. The way the system has been set up has driven the money into the hospital at the expense of community, mental health and GP services. We want to change this and believe it will reduce the numbers heading towards the hospital wards, but this means taking the money we need to do that from the hospital. They cannot afford that. Hence the fight.

Ding, ding…round four…

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.

Follow Dr Jonathan on Twitter @DrJonGriffiths


Featured image courtesy of http://www.freepic.com

Guest Blog by Ben Tyler – Reflections on a GP and Commissioning Placement – Week 3

This’ll be my first blog really related to the CCG aspect of my placement. It took me some time to completely get my head around how it works, and I will summarise what I currently think below.

 

NHS England gives each CCG an amount of money per patient in their patch each year. The CCG then chooses what to commission and agrees contracts with hospitals and other providers for different services. Much of this involves the use of tariff rates, usually set nationally. For example a hospital will receive payment from the CCG for an outpatient appointment, or an admission etc.

 

What I didn’t realise is that different services can attract a fee that’s a profit, or a loss to the provider. Therefore the provider is incentivised to provide more of the services that make a profit, and less those that don’t. Regardless of what is best for patients.  How can this be?

 

This is one of many things my naïve self was surprised about, about how the NHS works behind the scenes. With all sorts of attention going into making frontline healthcare more efficient, perhaps some scrutiny should be made into how things work from behind the scenes. Why has any of the NHS been set up in a way that isn’t putting patients at the middle of everything?

 

With the news just starting to hit the press about the planned hospital and ward closures in some parts of the country to cut costs, the public are shocked at such proposals. It surprises me that they haven’t been consulted before. Everyone in England knows that the NHS needs to save money, but no one knows where this is tangibly going to come from.

 

As each patch’s demographic and current services are different, it could’ve been reasonable for each local group to sit down and consult the local population. To explain that to save the money the government need them to save, doing X, Y and Z is the safest and best way for patients to do so, and clarify why they think this and what the alternatives are. Instead the first thing the public know about any real significant cuts is scaremongering headlines in the press. The general public were never going to like the decisions made, so why not make them be a part of the decision making process?

 

I understand that this can be a very ideological way of looking at things, and practically would be very difficult to implement. But if there is significant outcry once different plans are published, wont that lead to even more difficult discussion?

 

In practice we have moved away from paternalistic medicine and now involve the patient in decisions about their care; what’s stopping this change being implemented on a larger scale?

 

This blog written by Ben Tyler, 4th Year Medical Student at Sheffield University

Guest Blog from Ben Tyler – Reflections on a GP and Commissioning Placement – Week 2

A friend posed me a question this week; he had a few marks on his skin and wondered whether he should go and see a doctor. Despite dermatology being notoriously feared among medical students, I was very sure that it was nothing to worry about at all, and I told him this. But as he walked away I suddenly got worried that maybe I was wrong, maybe there was a chance he needed to get better advice. I ran after him and told him if he was still worried or felt a bit ‘iffy’ he should see his GP.

 

This fear of being wrong, and the fear of missing a potential problem, is to me, one of the biggest obstacles in streamlining patient’s access to healthcare. If a medical student more than halfway through his training can’t happily give advice to a friend, how is someone with no medical training supposed to know what to do?

 

A nice solution to people unsure whether to access healthcare should be the 111-advice service. This sounds great! The service is supposed to help channel patients to the correct healthcare provider or give advice on self-care. In theory a competent call handler should know how to deal with a situation much more effectively than an anxious member of the public. In practice I don’t think it has been as successful as hoped.

 

The main issue seems to be that the call-handlers are non-clinically trained and follow an algorithm, instead of using clinical judgement. This can lead to a surprising degree of caution among staff. How can it be that a paramedic ambulance ends up seeing a baby with a simple wasp sting? Clinically trained staff should quickly be able to exclude risk of anaphylaxis and advice on self-care through phone triage?

 

This better safe than sorry theme doesn’t stop with the general population and non-clinical staff, it just changes in appearance. Similarly to a patient presenting with a painful foot since the day before; a doctor might order a scan for a patient where the cause has already been elicited. Just in case. Where a patient might come to the doctors with a headache without trying over the counter pain relief first; a doctor may conduct a full range of blood tests that aren’t clinically relevant. Just in case. I could continue.
This is difficult because you can almost always justify individual actions and decisions. It is also hard for medical professionals to put themselves in the shoes of a patient who does not have the knowledge base. So how can we change this?

 

Surely this is about population education? And about how culturally we are struggling to manage risk and putting this upon the doctors we choose to see?

 

I have heard it said that the GP is the master of diagnosing normality. Perhaps only after all these years of studying and training and practice can someone be completely sure that there is nothing else wrong. In the same way, perhaps only after being clinically trained can you really know if you need to seek healthcare or not.

 

I quickly googled “I have a rash my face, what could it be?” The two top hits related to lupus and meningitis. This is distorting our view of the likelihood of serious illness, and clouding our ability to apply common sense.

 

Perhaps we need to take stock, manage our expectations and address our need for medical intervention.

 

This blog was written by Ben Tyler, 4th year Medical Student at Sheffield University