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