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

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Coalition?

As I write this it has been less than two weeks since the UK General Election. I’m still trying to work out who ‘won’. Without being overly political, this has got me thinking. It seemed to me that the result of the election, with no one having a clear majority, presented our political leaders with an opportunity. It was an opportunity to be bold. An opportunity for each leader to say to the other  “We can’t do this on our own, and you can’t do it your own. What say we work together?” 

 

The alliance between the Conservative Party and the DUP is exactly this, but I think missed an opportunity for the larger, main parties to work together for the good of the country as a whole. We are left with a country divide by two-party politics. Parliament is instead set up for confrontational ‘us and them’ debate and the risk of arguments rather than agreements about how to work jointly for the betterment of the people of the UK.

 

This led me to reflect upon the unhelpful ‘us and them’ dynamic that has arisen in some places between commissioners and providers in the NHS. The wider system has pitted us against each other, with our respective regulators insisting upon financial controls totals being met that result in winners and losers. I blogged about this last year when I compared our negotiating to a ‘Title Fight’. (https://drjongriffiths.wordpress.com/2016/09/16/title-fight/) 

 

For some time I have been saying that this is not a helpful approach. It is clear that neither of us can fix the NHS system wide problems on our own. We have to work together. 

 

Our local system is one of a few across the country that is part of the Capped Expenditure Process (CEP). You can read a news report about the CEP here: http://www.bbc.co.uk/news/health-40190597. There is much I could say about the CEP, and hope to be doing so over the coming weeks and months. Not everything is positive. There are, however, some things about the CEP which have resulted in better conversations. One of the fundamental principles underlying the CEP is that we have to all ‘own’ the problem. We collectively need to acknowledge that the amount of money we have to provide care for our population is all that we have, and then together determine how we live within that fixed resource. It is no longer good enough for the hospital to be content if they have balanced their books while the CCG runs into deficit. Instead we are all responsible for achieving financial balance across the system.  

 

What we need locally is a coalition. We need to come together, work together, plan together. We need to put aside our differences and together ensure we are providing the best possible care for the people of the area. This cannot be about organisations looking after themselves, it has to be about organisations looking after the patients. There is no place for one-upmanship. There is no place for individual or organisation protectionism. We simply cannot afford that. If we are to continue to provide the services that the people of our area deserve then we have to put all of this aside and together work out what we need to do.  

 

In Westminster we now appear be led by a coming together of two political parties. Locally in Central Cheshire our health care leadership now needs to consist of a coming together of commissioners and providers across the system. These ideas are not new. I have been blogging about them for a long time. The CEP does seem to have changed things though. It has changed the approach of the regulators, who are now speaking with one voice and giving a consistent message to all parts of the system, and I hope it is beginning to bring about a greater understanding and acceptance between individuals and organisations that their own part of the system is not the only part to be looking out for.

 

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

Follow Jonathan on Twitter @DrJonGriffiths