Risk

Risk

The sound of running feet followed by a twang, a thump and then a crying child. These were the noises that grabbed my attention while I stoked the fires of our portable pizza oven at our Cornish campsite. Not the noises you want to hear while trying to relax on the last night of your holiday. First check – is it my child? No. Not good news though as it is my nephew, 7 years old, and he is not a happy chap. Dad (my brother-in-law) is quickly there, and we determine that he’s hurt his arm. Then I hear the inevitable, “Don’t worry, Uncle Jon is here, he can have a look at it.”

 

I think these scenarios present an interesting challenge for the GP. They are, on the one hand really difficult to manage, and on the other, really easy. They are difficult because it is really hard to give a confident diagnosis in this acute phase. As a GP you NEVER see someone with an injury which is only a few seconds old. We all know that children will cry when they fall over, whether there is a serious injury or not, and it is impossible to know in those first few minutes whether this is likely to be anything more serious than a bruise. In some respects the person most able to determine whether there is a problem or not is the parent, who does know how likely their child is to be crying like this with a minor injury. I suspect, however, that there is an expectation that you should know. That you should be able to instantly say whether something is broken or not, just by looking at it. It happens in the movies all the time after all. So, you feel immense pressure to be able to get this right, even though you know you probably can’t really tell.

 

In contrast, the scenario is easy to manage because what to do next is really simple – you watch and wait. If he calms down and starts moving his arm, you’re probably ok. If he doesn’t, then he needs an X-Ray.

 

He didn’t settle down.

 

He had spent a week participating in reasonably high risk activities. Body-boarding in reasonably rough seas, hard-core coasteering, climbing over rocks on the beach and cycling at high speed around the campsite. He broke his arm tripping over a guy rope. Isn’t that a lesson for life? We worry about the obvious, risky things, but fail to notice the simple ones. How often have you heard the same story about how people get injured? Occasionally it is from the high impact road traffic accident, but more frequently it is a simple trip or slip. I have been physically present 4 times when someone has had a fracture. Only on one of those occasions would I have predicted a fracture based on the level of injury.

 

So what is the lesson here? A couple of things I think. The first is that we need to be aware that it isn’t always the obvious, high risk items that will bring us crashing down, but often it is the less obvious issue that slips under the radar. As a CCG Clinical Chair I have spent more time dealing with things relating to issues like removal of sutures or irrigation for ear wax than you would imagine, yet I bet you would never have predicted this would be a major problem. When we run our risk assessments we rightly focus on the things that we can see looking ahead, but you don’t know what you don’t know (I’m sure you all remember Donald Rumsfeld’s famous quote on this[1]). I’m not suggesting we need to put everything onto our risk registers, but that we need to keep alert, keep our eyes open, and watch for any warning signs of problems we were not expecting. Game of Thrones fans might relate to this recent quote from the ever-sneaky Petyr Baelish, “Don’t fight in the North or the South. Fight every battle everywhere, always, in your mind. Everyone is your enemy, everyone is your friend. Every possible series of events is happening all at once. Live that way and nothing will surprise you. Everything that happens will be something that you’ve seen before.”

 

The second point I wish to make is related – we are poor judges of risk. We see risks in things that are relatively safe, and ignore risks where they are present. Participating in ‘high risk’ activities is often much safer than you imagine, because you take precautions and are alert to the danger. Meanwhile we are blind to the risks of everyday activities like driving or crossing the road. We also have a distorted view of the likelihood of disastrous events occurring. The media has heightened our sense of risk for terrorist events[2], plane crashes, murder, child abductions and other high profile scenarios, all of which remain, thankfully, relatively infrequent compared with car crashes[3] (for example). Not many people spend their lives worrying about having a car crash, however, but I suspect a good number are worrying about terrorism and considering avoiding places like London and Barcelona at the moment.

 

Our failure to properly understand and respond to risks also factors into our approach to medicine. Conversations between clinicians and patients too infrequently explore the risk-benefit ratios in question for treatment options, and we often perceive greater risks in our actions (whether this be starting or stopping therapy) as opposed to our inactions. There is also an increasing culture of ‘better safe than sorry’ and of wanting to investigate to eliminate all risk, without consideration that increasing investigation can increase medicalisation, ‘over-diagnosis’[4] and carry its own risks.

 

These are complex issues and far too overlooked.

 

So what do we need to do?

  1. Consider, inquire about and understand the risks that you face.
  2. Be aware that there are many unexpected things that could suddenly arise and cause you a problem.
  3. Try to keep your view of risks proportional to reality.
  4. Explore the risks of treatment options with your doctor, including the risk of not doing anything!

 

My nephew needed 3 hours in surgery and 4 wires to fix his fracture. He’s doing ok now though!

[1] https://en.wikipedia.org/wiki/There_are_known_knowns

[2] http://www.telegraph.co.uk/news/0/many-people-killed-terrorist-attacks-uk/

[3] https://www.gov.uk/government/publications/annual-road-fatalities

[4] http://www.preventingoverdiagnosis.net/?page_id=1176

 

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group
Follow Jonathan on Twitter @DrJonGriffiths

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The Fell Race

The Fell Race

The hardest running race I think I have ever done was the Langdale Horseshoe Fell Race. At 21.1km long and with 1450m of total ascent it was a killer (that’s 12.5 miles and 4600 feet in old money). The route starts and finishes at The Old Dungeon Ghyll Hotel  and takes in Thunacar Knott, Bowfell, Crinkle Crags and Pike O’Blisco. The worst part of it was that they have set times at which they close the checkpoints. This means that you have to get there before the checkpoint closes, or you are disqualified. The first checkpoint with a closing time is Esk Hause Shelter and I remember struggling to approach this with time running out. I was pushing hard, back of the field, with my brother encouraging me, although it looked as though he was floating effortlessly across the fells beside me. I was convinced I would not make it, but I did, with probably only a minute or two to spare. There was a moment of relief, then the crushing realisation that I was able to carry on! Only 40 mins to get to the top of Bowfell… The problem with just meeting the target was that meeting the next target was harder, and so it went on. I got round, I was nearly last, but I finished making it past each checkpoint just before they closed. After the event I remember an ‘encouraging’ friend saying “Why were you so rubbish?” I forget my response…

There are a couple of tenuous analogies I want to draw out here. The first relates to NHS finances. If you fail to get across the line at the end of the financial year, and post a deficit, then you don’t get sent down the mountain for an early shower. Instead you carry on the next year, but with the previous year’s deficit taken off at the start. This means that if you are already struggling with the money, then next year is harder. You have to keep running, but the checkpoints become harder and harder to reach as you go on. Getting out of this downward spiral is tricky. We (my CCG) have just found ourselves in this difficulty. Posting a deficit last year means we start with less this year. This is one of the reasons we find ourselves in the Capped Expenditure Process (CEP). I have recently mentioned this in a couple of blogs (No Stone Unturned and Coalition). We are at the point now of taking our provisional plans to our next Governing Body – you can read the papers here. We are looking for the Governing Body to approve our approach and take things forwards. There is much work still to do, and nothing will be enacted before the public have been engaged in developing proposals and quality impact assessments have been undertaken.  Final plans will in some cases be brought back to Governing Body for final sign-off. When speaking to colleagues about the need to achieve financial stability, people use a couple of words which always draw attention, namely ‘rationing’ and ‘cuts’. I can see why, although I think if we get this right there is less cause for alarm, and more of an opportunity to get things right for our area.

This is about living within our means. It’s about ensuring that we only spend the money allocated to us to spend (this was the main point of discussion in my last blog, No Stone Unturned). We have a ‘gap’ of about £30m locally. Our plans look to bridge this gap in a number of ways, and I want to use the blog as an opportunity to explore the possible scenarios we may develop to do this.

One of the areas we are looking at is referrals from Primary Care. There are currently many patients who get referred on to hospital by their GP who actually could be managed better in a different way. Reviewing our approaches to referrals should not affect quality, so long as we have alternatives in place, and are able to disseminate best GP practice. There are various ways we could look to do this. We already use a company called Medefer to help provide advice and guidance to GPs to avoid unnecessary referral. We are also considering peer review and ongoing education to ensure patients receive the care they need in the most appropriate place (which is not necessarily with a consultant!)

Thinking back to my fell race, it would have been nice to have arrived at Esk Hause Shelter will plenty of time to spare. I could have pressed on happy in the knowledge that even if I needed a brief rest, or to slow down, that I could do so without worrying about hitting the next checkpoint in time. The NHS has a variety of targets, and it is always nice to exceed them with a comfortable margin. One of the targets that our local hospital is currently exceeding is the Referral to Treatment (waiting time) target (RTT). This target essentially states that 92% of people referred by their GP will wait no longer than 18 weeks from referral to treatment (if required). The hospital currently meets this standard for 97% of patients. By changing referral practice, we can bring ourselves in line with other areas so that the national standard is met.  Urgent cases, particularly patients presenting with symptoms that would turn out to be cancer, would not be affected by this change in referral practice.

If you need to save money but want to continue to meet your constitutional targets, then this is an obvious place to look – we think we can still meet the standard for 92% of patients (which is what we are required to do) by slipping our performance down from 97%. This, may mean longer waiting times for some patients (please note that for urgent cases, particularly patients presenting with symptoms that could turn out to be cancer, there are other targets and we are NOT talking about them.).

The obvious problem is that if you aim to just achieve the target then there is a greater chance that you will miss it. This is a risk that we will be running and we are, in fact, likely to fail this target at times during the year, although we are planning to be delivering again before the year is out.

This is an example of something we are doing to help with costs while balancing patient need. We need to spend some time thinking through the implications and running the quality impact assessment on this and other ideas, but it gives you an idea of where we are at.

I am keen to hear views on this and on other elements of the CEP. I suggest you keep an eye on this blog and future blogs as well as other communications from the CCGs.

Featured image is of me on the slopes of Bowfell, but not taken during the Fell Race mentioned!

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

 Follow him on Twitter @DrJonGriffiths

Drug Switch

Drug Switch

I had a dream last night. In it I was trying to persuade a mother that we should change her son’s prescription so that we could issue tablets (which we had established he was able to swallow) rather than the liquid suspension. The issue was that the main reason for wanting to make this switch was for cost. The drug was the same and no harm would come to the child, yet the mother was concerned that a cheaper drug might not be as good for him.

The dream is remarkable in that it is very close to the reality of what I often find myself doing. General Practice has, for many years, taken on responsibility for being cost effective as well as clinically effective. Prescribing has been a key area where we have seen this. As a patient you may notice the brand of drug you are prescribed may change from time to time. An old example would be when we consciously made an effort to change people from prescriptions for Ventolin to prescriptions for salbutamol. For those who don’t know, salbutamol is an inhaler used by people with asthma and other respiratory conditions and Ventolin is a brand of salbutamol. In other words, Ventolin IS salbutamol, and if you look on the packaging of Ventolin inhalers, it will say so. Prescribing salbutamol was cheaper for the NHS than prescribing Ventolin. As far as I am concerned they are the same drug. As far as I am concerned we should stop prescribing the more expensive brand and always go with the cheaper, but equally effective one. This does not stop patient’s complaining that salbutamol doesn’t work as well as Ventolin. There are numerous other examples. Before I continue there is a point worth drawing out here. People frequently make the mistake of thinking that ‘you get what you pay for’ applies to medicines. It does not. Costs of drugs do not vary according to quality, but according to what the manufacturer believes they can charge. A more expensive drug does not necessarily mean a better drug, and vice versa. Please do not make this mistake yourself, and please spread the word about this!

As we all know, the NHS is struggling financially at the moment. We are therefore continually looking for ways to be more efficient so that we can provide the best healthcare possible within the resources we have available. Cost efficient prescribing is one way to do this, and is appealing because changing drugs from one brand to another, or encouraging patients to buy their own paracetamol should not result in any adverse clinical scenarios, yet should save money. This feels like a no-brainer. It nevertheless feels like hard work.

In my experience most patients accept changes to their medication without question. I should point that that we do not change prescriptions without a corresponding letter of explanation. There will always be a few individuals, however, who are unhappy, and a disproportionate amount of time tends to be spent on these few. It seems to me that we have not done a very good job of changing the culture of our society to be more responsible. Instead we seem to have a society which is quick to offload responsibility to others with a backdrop of litigation and blame when things do not go according to people’s wishes. This leaves me with the awkward conversations tying to persuade people that is it ok to change their prescription, rather than one where everyone recognises the need to prescribe appropriately and cost effectively and to do their part. We need to move from a sense of entitlement to one of joint acceptance of the responsibilities. Clinical Commissioning Groups up and down the country are encouraging GPs to encourage patients to take some responsibility and buy what they can from the pharmacy. There is push back from other doctors about how this is being done, and while I recognise that the language and ‘mandate’ need to be correct I do think it is unfortunate that CCGs are being criticised and referred to the Advertising Standards Authority rather than helped to get this right http://www.pulsetoday.co.uk/clinical/prescribing/ccg-reported-to-advertising-watchdog-for-misleading-patients-on-otc-prescribing/20034946.article.

While this level of collective responsibility remains lacking we will continue to get push back from GPs about their willingness or otherwise to have these conversations. Doctors and other health care professionals will say that their responsibility is to the person in front of them, and that cost should not be a consideration. I disagree with this, and would quote General Medical Council duties to them which make it clear that we need to make appropriate use of the resources we have available to us . I was once at a public meeting where we asked if we could provide assurance that doctors would not be making decisions thinking about cost and resources. The response, provided by one of my fellow GPs on our Governing Body, was that of course doctors should be considering financial resources. It would be completely irresponsible to do otherwise.

I have long thought that we should just let all our patients know that they should expect their medications to change from time to time. We should reassure that any change is not expected to result in any detriment to their condition, but make it clear that we all need to collectively accept some responsibility for managing the NHS budget, and for appropriately spending money from the public purse. Every GP is aware, I am sure, that every time they sign a prescription, they are essentially signing a cheque and committing resource. I want to be clear in saying that I don’t think we should stop prescribing appropriately, but that we should continue to prescribe cost effectively, and that our patients and public have a role to play in facilitating this.

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



Follow Jonathan on Twitter @DrJonGriffiths

 

Featured image from https://pixabay.com/

Cheshire?

Cheshire?

Cheshire  no longer exists. A few years ago the multitude of Town, City and Borough Councils across Cheshire were all brought together into two unitary authorities, Cheshire West and Chester  and Cheshire East. From that moment Cheshire as an individual entity disappeared, although clearly the word still describes a geographical area for many people, and when I am asked where I live and work, I will always say ‘Cheshire’ rather than ‘Cheshire West and Chester’. (I actually live in Cheshire East and work in Cheshire West and Chester…from now on I will use the acronyms of CWAC for Cheshire West and Chester and CEC for Cheshire East Council).

 

The local authority boundaries have caused a problem for NHS commissioning because our Clinical Commissioning Group (CCG) areas are not coterminous with them. Our local hospital, Mid Cheshire Hospitals NHS Trust is based in Crewe (in Cheshire East), but patients from many parts of the Vale Royal area of CWAC also use it as their local hospital (as an aside Vale Royal was a previous Borough Council and no longer exists either, but was recognizable enough by local people for us to provide the name of our CCG). In contrast our two neighbouring CCGs tend to have their patients flowing to either the Countess of Chester NHS Foundation Trust (in Chester, unsurprisingly), or East Cheshire NHS Trust (in Macclesfield), each of which is entirely within the footprint of either CEC or CWAC.

 

Why am I telling you all of this? Partly to express a little of complexity we have grown up with and dealt with over the years of our CCGs existence, and partly to help explain some plans the four Cheshire CCGs have moving forwards.

 

As you may have already realised, there is a reasonable amount of duplication occurring across the 4 CCGs. Our mental health provider, for example, provides mental health services across the entire Cheshire area and beyond (into Wirral). We have also recently had cause to look at some procedures of limited clinical priority which we have done again over a Cheshire wide footprint to reduce the potential for a post-code lottery. It would make sense f we could do some of this together, and only once, without having to go to gain approval and agreement from four separate Governing Bodies, each of which might make a slightly different decision, bringing about the very post code lottery we were trying to avoid in the first place.

 

There is also an issue of capacity. In these times of limited financial resource the CCGs are running light. Capacity to commission effectively is stretched, and just when we wish to be working on transformation of local health and social care, and moving towards the development of Accountable Care Systems, we are in danger of not having the workforce to press ahead.

 

We are hoping that we can solve some of these problems by creating a Joint Commissioning Committee across the four CCGs. (For clarity I am talking about NHS Vale Royal CCG, NHS South Cheshire CCG, NHS West Cheshire CCG and NHS Eastern Cheshire CCG). The idea behind the joint committee is that we can delegate authority for some decision making up to a joint committee, ensuring that things that only need doing once, are only done once, and then freeing up capacity in the CCGs to focus on the work that really does need to happen locally. The key part of the local work will be in the continuing development of Accountable Care. We currently have three strong, local integration systems based around the footprints of the three local hospitals (Connecting Care in Central Cheshire, the West Cheshire Way in West Cheshire and Caring Together in Eastern Cheshire). It is possible that these will form into three Accountable Care Systems. Over time these may take on the bulk of the functions currently undertaken by the CCGs, while a merged Cheshire Commissioning Organisation could provide a strategic commissioning function across the whole – but we are a way off that yet!

 

The Joint Committee is the first step, and regardless of possible future directions of travel seems to be an important one that I would endorse. We need to be doing all that we can to be lean and effective. We do not want to be spending time on things that are being duplicated, and we do want to be able to spend the time on the things that matter locally. I believe that the joint committee will help us to do this.

 

So, what have we done so far, and how are things progressing? The four Governing Bodies have met individually and together to discuss and have approved the direction of travel. This has included executives, lay members and clinicians all working on the Terms of reference for the Joint Committee that are now in draft form and about to be approved. The Accountable Officers and Chairs from the four CCGs have been working together to bring this to this point, with numerous formal and informal conversations and email exchanges.

 

The next step is for the Memberships of the four CCGs to consider these proposals. Clinical Commissioning Groups are membership organisations, and the GP practices are the members. They are the ones who will ultimately need to approve any changes, and need opportunity to consider, discuss and decide. We neglect our local GPs at our peril. The Health and Social Care act that created CCGs in 2013 put clinicians at the heart of the commissioning process and GPs in the driving seat. We need to reassure our GP colleagues that any changes will maintain this ethos of clinically led decision making and ongoing clinical engagement. I would hope to be able to provide some of this reassurance. Clinicians have already been involved in this work (not just the Clinical Chairs, but also the GPs on the Governing Body), and we have ensured that clinical representation on the joint committee is enshrined into the Terms of Reference. The important point will be in deciding the work plan – i.e. deciding what the Joint Committee is actually going to do. This is not yet agreed, and I would suggest that the Memberships need to be kept fully informed of this process, along with the Governing Bodies.

 

The bottom line, in my view, is that we need to develop space to breathe, act and develop our plans at a CCG level. Without this, we are going to struggle with our plans for integration and movement towards Accountable Care. The Joint Committee should provide some if this.

 

If you want to follow how it all goes, then watch this space!

 

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

 

Follow Jonathan on Twitter @DrJonGriffiths