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



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’. ( 


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: 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

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

Are we choosing well?

Are we choosing well?

I was recently part of a team of GPs who audited the hospital notes of patients who had been admitted to hospital. The particular group of patients we were looking at were those who had been admitted but then discharged in under 24 hours. The intent of the audit was to look at what was happening to these patients and whether they really needed to be admitted at all, or whether they could just have been sent home without the need for a hospital bed. 

I want to describe a not-untypical scenario I saw happening.

I rremember talking to one of my GP colleagues at the time, asking her how she would have managed a similar presentation in General Practice. The patient was in their 50s (although could have been any age) presenting with a cough and feeling breathless, they have had the cough for several days and they are worried they might have a chest infection, or even pneumonia. On examination they have normal blood pressure, normal pulse rate, normal chest examination (ie no signs on examination of a chest infection), normal pulse oximetry (a measure oxygen levels in your blood), normal temperature, normal breathing rate. I pause at this point and ask my colleague what she would have done. Confidently (because this is exactly the kind of thing GPs see all the time) she replied that she would have reassured the patient and sent them home. In A&E, the patient also had blood tests, a chest X-ray and blood-gases (a sample of blood taken from the artery to determine oxygen levels more accurately). At some point during this process they were admitted to hospital, before then being reassured and sent home.

If the patient had attended their GP, it would have taken a 10 minute consultation. They were in the hospital for several hours. If the patient had attended their GP, it would have cost the NHS around £35, instead it cost the NHS several hundred pounds.

Most people I speak to, including my patients, do not enjoy a trip to A&E. Most people I speak to think we should be using tight NHS resources as efficiently as possible. Despite this, there are many people every day turning up in A&E who don’t need to be there. Last week our local hospital was in the newspapers with this article about increasing numbers of people attending A&E.  I saw it first on FaceBook, and many of the comments suggest that people are attending A&E because they can’t get to see their GP. This is unfortunate, and I suspect largely untrue. I know a lot of GPs in my area and I am pretty confident that all of them would say they would see patients on the same day, where appropriate, if they had an urgent need that could not wait. You may well be asked to wait a couple of weeks for something routine and I don’t think that is unreasonable, but all GP surgeries have provision for emergency patients on the day. Many of the local surgeries in the Central Cheshire area have also been part of the The Prime Minister’s GP Access Fund. This has provided an additional 32,645 GP appointments across the area in the last year, just on weekdays. There have also been an additional 7,691 GP appointments at weekends. On top of that there have been nurse and physio appointments too. 

40,000 extra GP appointments in a year. That’s an average of 3,361 extra appointments per month. (If you read the newspaper article above it mentions that the hospital had an extra 1,600 A&E attendances over a 3 month period. I’m not sure how that is newsworthy, and this isn’t?) 

So, there are more GP appointments, including at weekends, as well as GPs making provision for urgent appointments. There are also Out Of Hours services available if your GP surgery is closed (call 111 to access these), yet still people are choosing to attend A&E for conditions their GP is more that qualified to manage. Do we understand why this is? I’m not sure we completely do. One thing I can be sure of, is that demand appears to be going up. Increased demand to GPs will result in an increase going to A&E. 

I have a few ideas about why demand is going up.

I think as a society we have become less tolerant of ill health. We are no longer prepared to wait it out. I see people attending with coughs, sore throats, sticky eyes and other self-limiting conditions on the day they start. We are unhappy living with the symptoms and want an immediate cure. 

I think as a society we have a greater sense of entitlement. Rather than gratitude for the NHS, and a view that we need to carefully use the precious service which is available for free, we all feel that the NHS is there for us, and that we are entitled to it. This drives increasing use. 

I think as a society we have ever increasing expectations. “You’re telling me that we can put a man on the moon, but you can’t cure my cough?” Well, quite possibly not, and if you’ve only had it for 3 days I’m probably not going to try to unless my examination of you suggests otherwise (or unless you have some other reason why I would need to, like COPD as an underlying condition). 

I think as doctors we can do so much more that we used to. Medicine has moved in. We are actively treating conditions today that a couple of decades ago we were not. Management of chronic, long term conditions has taken over a large chunk of the GPs time. Heart disease, kidney disease, COPD, heart failure, hypertension and more. All being treated and keeping us all living for longer and longer. This is good, but all adds to the ongoing demand. Our local hospital tells us that they are seeing patients with increasing complexity and acuity. In other words, they are sicker, and have multiple medical complaints.

I  think that as a society we are much more litigious. We also tend to think “better safe than sorry”, and seek out advice and reassurance much more than we used to. Schools, nurseries and employers increasingly send people to the GP to check up on things. Gyms stop people from joining until they have a medical certificate saying that it is safe to exercise (it almost always will be) and it has led to a culture requesting that you “Get a note from your doctor”. It also results in doctors behaving more defensively, requesting more tests, and bringing people back more often, none of which are necessarily a good thing. This might account for why in A&E, where you are likely to be seen by a doctor less experienced and confident than your GP, that you are more likely to have more tests (that you might not need), and find yourself unnecessarily in a hospital bed. (There is a side issue here about patients being classed and charged as admissions when they never get as far as a ward, or even a bed, and we need to sort that out too).

You may well be thinking that not all of these things should impact particularly on A&E, but suffice to say that if you increase the work going to GPs, some will spill out and have an impact on A&E. 

We all, collectively need to work out how to tackle this. GPs do sometimes need to look at their access issues and their telephone lines, but I hope you can see from this that GPs are working very hard, offering huge numbers of extra appointments over the last year, and doing what they can to meet the need. I get very frustrated and disappointed when I see them being accused of being the underlying problem behind the A&E crisis. A quick point here – the Prime Minister’s GP Access Fund locally runs out of money within the next 6-8 weeks. We have heard that additional monies are to be made available from the Government, but we have been hearing that for a while and have not seen anything in writing. We are concerned that there will be no money to continue this scheme. The CCG does not have any spare money to fund this. We could only find the money by taking it out of the local hospital. If the money is not forthcoming, those 3,361 extra appointments per month are all going to disappear.

I started my last paragraph says that we all need to tackle this together, and I really do mean all. This is as much a society problem as a GP or hospital one. We all need to do our bit. We need to choose well when we need care, and stop and think if we may initially need to help ourselves before seeking other services. We need a greater tolerance and understanding of risk, and to be less quick to pass all risk onto others. We need to acknowledge that self limiting conditions really are self limiting, and to be patient patients while we wait for them to resolve.

It’s time to rethink how we use and access NHS services. This can be done. Let’s do it together. 

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

Follow Jonathan on Twitter @DrJonGriffiths

Virtually Fractured Clinic

Virtually Fractured Clinic

One of the first blogs I wrote was about the relative of a friend of mine attending fracture clinic. I called the blog “Wait, wait, wait…“. In it I detail the experience of attending the clinic, the inconvenience and wasting of time encountered. Imagine my delight, therefore, when I heard that our local orthopaedic surgeons were keen to introduce a ‘Virtual Fracture Clinic’. Let me tell you about it.

Currently, if you attend A&E and they suspect you have a fracture, then you are treated and sent home with an appointment to attend fracture clinic for follow up. With the Virtual Fracture Clinic, rather than having to return for the follow up, you get a phone call from the orthopaedic doctors, who review your X-rays, ask how you are, provide advice and can often avoid the need for further attendance. Some people will need to be called back for assessment, but many not. Brilliant. This makes things so much better for patients, avoiding unnecessary attendances while maintaining the quality of the service. 

This clinic is a win-win. It’s better for patients, and it’s cheaper for the NHS. As a commissioner of a cash-strapped CCG this is music to my ears. As far as I’m concerned this clinic should be put into place immediately. 

There is a problem though. It might be a win-win, but it’s not a win-win-win. Good for patients, good for the overall NHS budget, but not good for the hospital bank balance. The clinic loses the hospital money as their are fewer out patient attendances. The hospital are the ones who can put this clinic in place, and they have so far not done so. 

This is what happens when you have a system built around individual organisations in their silos all looking out for their own organisational needs rather than the needs of the larger system. The hospital are being instructed to ensure they achieve financial sustainability, and this has become a greater driver than the need for system sustainability. This is what is playing out with our local Virtual Fracture Clinic. It is resulting in fracture lines appearing between the clinicians at the hospital and their management who appear to be blocking the development of the clinic. It is also resulting in fracture lines building between commissioners and hospital managers. 

This is a wholly unsatisfactory and unacceptable. For there to be drivers in the system that prevent the development of something that would improve the long term stability of the local health economy and, many would say even more importantly, be better for patients, then what is going on here? How can this be right? 

We need to take action. We need to push, hard, for clinics and schemes like this to be implemented. Canterbury, New Zealand chose to implement and fund any scheme that saved patient’s time. They recognised that this was a key way in which to improve and integrate their system. Locally, in Central Cheshire we seem to be a way off this.

The system needs to change. The system needs to recognise it is a system. Organisations need to recognise they are just one part of the system, and that we can achieve so much more together, but only by collectively doing the right things for patients, and the system itself. 

We have an opportunity here to do the right thing. Let’s not lose it. Let’s put aside our individual needs and put the patient first.

Fracture clinics are there to ensure healing. Let’s make this project the start of making our local health economy better.

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

Follow Jonathan on Twitter @DrJonGriffiths

Image courtesy of stockdevil at

The Post Boat

The Post Boat

When I was 11 years old my family had the unexpected opportunity to have a holiday of a lifetime. Friends of ours were living in The Bahamas at the time, and we were invited to stay with them. We arranged a 10 day break during the Easter holidays. The trip would be our first and last overseas holiday as a family, and involved our first journeys by aeroplane. You can’t fly direct to Marsh Harbour where our friends lived, so we had flights from Heathrow to Nassau, and a connecting flight onwards. All very exciting.

The outward journey went well, we arrived safely and had a wonderful time. Part way through the 10 days our hosts checked with my parents about our return flight time. My mum explained that she had been rather taken with their descriptions in the past of how people sometimes used the Post Boat to hop from island to island rather than flying. We had therefore got a flight arranged back from Nassau to Heathrow, but thought we would just jump on the Post Boat for the short trip from Abaco Island back to Nassau. 

There was a stunned silence. “The post boat takes at least a week to make that journey,” we were informed. Ah. Our flight back to the UK was in less than a week. There was no way we could use the Post Boat, it was just going to take too long. To make matters worse, it soon became apparent that there were no available commercial flights either. We were stuck on the island, which me and my brother thought was great, but was somewhat stress-inducing for my parents!

It can be pretty stressful when plans fall apart. Sometimes it can be because planning has been poor, sometimes our planning was based on poor or inadequate information, and sometimes the planning might have been fine, but other circumstances beyond our control come into play.

We have known for a while that our local health economy was heading for financial difficulty. I recently blogged about that in a post I called Glass Half Empty. Our plan for some time has been to collaborate and work with local providers to integrate and transform our local system. We have known there wasn’t enough money. We have known we couldn’t carry on with the current levels of activity. We had a plan. It has become apparent that our plan is like the Post Boat – it is going to take time, and our flight is leaving now. The Post Boat still seems like the better way to do it. A better journey, a better or at least the same end point, cheaper and smoother. We’ve run out of time though.

In 1982 my parents had to charter a 6-seater plane to get us back to Nassau. The picture with this blog is of my family standing by the plane (I’m the older child). I dread to think how much that cost. It wasn’t what we wanted. It was stressful and expensive, but it was quick. There were longer-term implications I am sure in terms of our family finances. 

Our CCGs need to find the equivalent of chartering a light aircraft. We have to save money now, and our integration programme is going to take too long. We have developed a Financial Recovery Plan. It has all kinds of things in it, some of which sound really good for  both our CCG bank balance and for patients (I particularly like the idea of the Virtual Fracture Clinic), but many of the schemes are going to be about cutting or reducing services. We will have to look at how many cycles of IVF we can afford to fund. We will have to consider our prescribing, and are looking st promoting self care, and reducing prescriptions for Over The Counter medicines (in other words, please don’t ask for prescriptions for paracetamol or calpol from me, as refusal can often offend). We will have to consider referral thresholds for procedures like hip and knee replacement (so, for example, you might not be able to be referred unless your BMI is below a certain value and only if you are a non-smoker, and you might have to complete a 6 month lifestyle class first). We will have to consider all kinds of things that are unpalatable, unacceptable to some people, and certainly unpopular. 

The Kings Fund recently published a blog from Ruth Robertson about public perceptions of NHS finances. It’s worth a read and gives us an idea of how the public are likely to react to these initiatives. The key message for me is that we need to very quickly present these plans and schemes to the people of the Central Cheshire area. I believe that an informed and engaged public will understand and be tolerant of our actions. What we need to try and avoid at all costs is just cutting services without explaining why. I am disappointed that there is not a higher profile national conversation going on about this, as we are not the only area to be struggling with money. I have said before, and will say again now that I think the government and NHS England have a responsibility to be informing the public of the implications of austerity on the NHS. 

34 years ago, we missed the Post Boat. This year we are realising that the integration boat has already sailed. We still need to do the integration work but it is not going to solve our immediate financial problem. 

This blog is a warning. A warning to fellow commissioners who might still be on the Post Boat – are you sure it’s going to get you there in time? A warning to providers that the money is running out, and that drastic commissioning actions are about to be taken. And most of all, a warning to the public that NHS services as you know them are about to change. You may not like that. You may well blame me for them, and I can understand that, but the most important thing is that you understand why we are taking the actions we are. We want to do this with you, not to you, and the first step in that is letting you know what’s going on.

We’ve missed the boat, let’s make sure we all get on the same plane. 

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

Follow Jonathan on Twitter @DrJonGriffiths