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

You’ve got to be in it to win it

You’ve got to be in it to win it

General Practice is under pressure. I have said this before, as have many others. Just within the last couple of weeks there have been news headlines criticising GP receptionists and leaked letters implying that struggling practices might be allowed to ‘wither and die’. On social media I see GPs venting their frustrations, expressing their concern about where they see things heading and clearly articulating their stress about the job they still love, and yet which is driving them to burn out. As a practising GP I see this. I see the long hours, the increased demands upon us, the lack of resource and I feel the stress. It is not difficult to see how this has arisen. General Practice has been underfunded relative to hospital care in recent years, as has Community Services and Mental Health. At the same time there has been a gradual shift of work that was traditionally undertaken in hospitals moving out into General Practice. Much of this is great for patients – closer to home and with the local GP who knows you. Unfortunately the money has not followed the patient, and GPs have added these extra bits of work to existing services, which are now straining and in danger of collapse. In addition it is widely accepted that demand continues to rise. With this as the backdrop, there are currently talks about service reconfiguration led out over larger geographies, under the remit of Sustainability and Transformation Plans. I have seen lots of GPs expressing dissatisfaction with the STP process, commenting in particular that STPs have no statutory status and no political mandate. I wouldn’t disagree.

I think there are two ways you can respond to this situation. You can be either pessimistic or opportunistic. My fear is that it is easy to be pessimistic and angry. I’m not saying that there is nothing to be pessimistic or angry about, but I would like to question if this is the right approach. 

In my experience, shouting about something doesn’t always get you the outcome you are looking for. It might make you feel better for a while, it might get someone to back off for a while, but in the long term you probably haven’t gained much. There is also the danger that you might ‘cut off your nose to spite your face’. When you are angry and pessimistic, it’s hard to lift your head up and see the opportunities. You can find yourself in a place where you can’t see the wood for the STP trees. Where are you on this?

I think we need to ensure we have the right balance. 

Is there a need to express concern and dissatisfaction, to lobby and protest against things we feel are wrong, or are being ‘done to us’? Absolutely. There are various lobby and supportive groups already in existence that I know of – Resilient GP, GP Survival, GP State of Emergency and possibly others that haven’t seen. These groups do this well. They are highlighting the problems being faced. Raising awareness amongst fellow GPs, the wider NHS and Central Government. They can do this because of their large numbers – they can get media air-time in a way an individual will struggle to do. They can also help individuals who are struggling. I see that in Facebook posts on Resilient GP in particular, with GPs asking for advice and support with difficulties they are facing, essentially crowd-sourcing solutions.

My view of these forums then, is that their existence is good, and helpful. I make a point of reading through the social media posts regularly. I have, however, become slightly concerned that they have become a place of increasing negativity. I understand why, and many I am sure would say ‘for good reason’! The problem with this, however, is as I mentioned earlier- we are in danger of missing out. More than this, we are in danger of fuelling disagreements between GPs and the organisations that seek to represent us and our views. In one recent FaceBook post I could read (in a public forum) about disagreements about whether the Royal College of General Practice was appropriate to represent our views, seemingly pitting them against the Local Medical Committees. I can’t see how this is helpful. I would suggest that both would provide excellent input, and would not wish to suggest that one was more qualified that the other – they have different and complimentary roles. 

Whether you like the existence of STPs or not, they are here, and I would suggest you disengage at your peril. A similar thing happened with the Health and Social Care Act. Lots of people were angry about this, and spent a lot of energy protesting against it. It is still here. I wonder what could have been accomplished had that energy been directed to working with the system rather than against it? 

STPs have large geographies, and it can be hard to feel part of something as large as, for example, the whole of Cheshire and Mersey (our ‘local’ STP is the 2nd largest in the country). What is becoming clear though, is that the majority ‘work’ of the STP will be delivered in local areas. For me, this means that our STP is divided into 3 Local Delivery Systems (LDS), and I am in the Cheshire and Wirral LDS which is further subdivided into 4 local integration programmes, mine being the Central Cheshire Connecting Care programme. This I now start to recognise. Within Central Cheshire we have five Care Communities, and I am sat firmly in Team Winsford. I know what’s going on in Winsford, and I know what’s going on in Connecting Care. This means that I do have a connection with the STP, and this is important. 

I have been concerned about the emphasis on acute trusts in STP planning so far. Concerned that GPs have been overlooked and disenfranchised by the process. I still have some concerns, and don’t think GPs have been properly consulted, but once I understood that our local integration programmes would be the STP plans, then I started to feel better. In fact, locally I think I can see a clear line of sight from STP to Team Winsford and our Primary Care Home. 

You have to be in it to win it, and I suspect this will be true of STPs. I suspect that if any more resources are made available to the NHS they will probably come via STPs. If we as GPs are not engaged in this, we might lose out. We can choose to shout and refuse to engage with a non-mandated process, we can be angry and protest, or we can take a moment to breathe and see what opportunities there might be here. Opportunities to do things differently- think physio first, think community matrons doing home visiting for you, think pharmacists doing your med reviews, think about making your local area an attractive place to work, somewhere you can attract GPs to. All of this could and should be part of STP planning. If we can get our community based services right, we can reduce the demand on our hospital services. This is key plank of our STP, and I’m sure will be in others.

Next time you are tempted to shout in protest about something then, my plea would be that you stop and think for a minute first. Your desire to be upset and cross may be entirely justified. What is happening may not seem fair, and may not be something you would have done or that you agree with. Nevertheless, it may be in your best interests to engage with it, and a constructive, appreciative enquiry, in my experience, can pay dividends. Like I said before…

You’ve got to be in it to win it.

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

Follow him on Twitter @DrJonGriffiths

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