Tuesday, 18 December 2012


2012 has been quite a year. A year of personal scrutiny. What does that mean? The word apparently originates in Latin: scrutinium; from scrutari, meaning "those who search through piles of rubbish in the hope of finding something of value." A common definition is: 'to look closely (as for mistakes)'. Seems apt.

The start of the year (and the 2 years before that) saw our practice achieve the RCGP Quality Practice Award, a real team achievement and recognition of the focus on patient service, access and meaningful systems by the practice and its attached staff. The visit, following an enormous submission of 'evidence' included patient and staff interviews, observation and a nurse going through every drawer in my room to make sure all was in order and in date. That was a nervous ten minutes. We passed, and it has been a great experience for staff morale and a catalyst for patient engagement in the practice.

As a CCG Chair I then had an assessment to ensure I was able to fulfil the role, at least on paper. Maths and English tests and 360degree leadership surveys were followed by a visit to London where I was interviewed in great detail by the Hay Group and underwent a series of role play and written assessments. A full day later I had a stamp of approval and my first ever migraine. I also discovered that after a certain age writing for 30 mins in examination conditions is almost impossible. If the writer's block doesn't get you, the cramp will.

Next came authorisation. Armed with personal approval to be Chair, was the CCG up to it? We promised ourselves we'd take it as part of the day job, that we were doing the role, that we wouldn't get submerged in 'evidence.' We were wrong. To anyone who thought the process would simply be a formality, the fact that only 8 CCGs have been authorised without conditions (including Bassetlaw) will hopefully provide some assurance. We are a better CCG for having been through the process, but it's good to be focusing on quality and patients rather than process.

Finally, revalidation. My appraisal today was very similar to previous appraisals - a valuable opportunity to reflect on my clinical practice rather than policies and process. So what was different about a 'revalidation appraisal.' Mainly the surveys. Another 360 degree survey, but this time my colleagues in the practice, both clinical and managerial, including my secretary and other reception staff. This was followed by a patient survey. Both were done through an independent company (Edgecumbe) and the process was very smooth with clear reports afterwards. It felt much more personal than previous QOF surveys, and unlike previous 'leadership' surveys this was about my interactions with patients, my consultation skills, how I support staff.

So all my evidence has been submitted now for revalidation. The CCG has been authorised. The practice has the QPA for the next 3 years. A good year, with a focus on quality and assurance. 2013 should be easier. Wait, what's this on everyone's twitter feed? 35 outcomes for CCGs? A new planning framework? More scrutiny by the Local authority?

Better start collecting evidence.

Wednesday, 14 November 2012

The Importance of the Commissioning Assembly: Systems and Assurance

Today was the first meeting of the NHS Commissioning Assembly, bringing together senior figures within the NHSCB and CCGs. Its aim is to ensure that the new commissioning system is effective, accountable and works as a whole. It's important it succeeds. Patients may not care which level or organisation commissions their service, just that it is available, high quality and safe. But by looking at the different organisations potentially commissioning care for patients the challenge for the system is clear.

She was 60 and had terminal lung cancer. She'd had lots of investigations, treatment, the works. She was comforted by an excellent community nursing team, Macmillan nurse and the local hospice, as well as her GP. She assumed her care was well coordinated, that transition between services was seamless.

She wished now she had stopped smoking. She had tried. She had rung the smoking cessation service, but limited access and work commitments prevented her engaging fully.
Commissioned by public health/local authority.

When she had started coughing she was prompted to see her GP by a local lung cancer awareness campaign.
Commissioned by public health/local authority

Her GP, who was unaware of the campaign, saw her in a routine appointment 4 days later.
Commissioned by the NHSCB

A chest X-ray was arranged at the local hospital. This was abnormal and an urgent appointment was made at the local chest clinic.
Commissioned by the CCG

Lung cancer was diagnosed, and a referral made to a tertiary care centre. Chest surgery was performed.
Commissioned by the CCG with input from the regional cancer network

Oncologists recommended radiotherapy and a new form of chemotherapy.
Commissioned by the NHSCB as a specialised service with input from the regional cancer network 

Treatment was eventually unsuccessful and care was provided by the local palliative care and community nursing teams with hospice input.
Commissioned by the CCG with additional voluntary sector funding.

Decisions made at each level have effects throughout the the system. It's vital we work together. Health and Wellbeing Boards will play an important role in linking clinicians and local authorities. Annual assurance of CCGs by the NHSCB will be important. However, true quality and planning oversight will require a systems view, across localities. Quality Surveillance Groups across local area team footprints will be key but must not transfer control or responsibility centrally. We all have responsibility for this patient. I'm optimistic the Commissioning Assembly will facilitate this. The will to work together is definitely there.  Now to make it happen.

Sunday, 7 October 2012

The Site Visit

Despite the fact we had arranged to meet at 8am many of us were there at 7.30.  Having been through the journey towards authorisation together, this was a big day.  As any X-Factor contestant will testify, it 'meant everything,' we'd 'put so much work into it' and we certainly felt like we were about to be judged.  Would we get past the NHS version of Boot Camp?

The site visit, according to the rhetoric, is meant to be supportive, constructive, developmental and a lot of other similar words. All positive.  The training session I'd attended had left me doubtful. Would it just be World Class Commissioning in another form?  Could a team of strangers really learn anything about (judge) our CCG in one day? 

Our anxieties were unfounded.   The tone was set by the panel chair immediately, and was excellent.  At the end of the day I was extremely proud of the CCG team, of their passion in describing patient service improvements and the pragmatism where challenges exist.

My top tips for site visits:

1.     Use the agenda to determine who should attend. Our agenda was very clear, identified which 'Key Lines of Enquiry (KLOEs) would be discussed when, and helped us field a strong team in each breakout session.
2.    Involve other stakeholders where possible. A local authority director of social care attended to describe our joint working and was extremely useful, particularly for the panel local authority representative.
3.    Examine each outstanding KLOE and make sure each is addressed. We prepared an evidence pack for the panel to reference and they found this very helpful.
4.    Use the presentation carefully. It's a short time to focus on the CCG story and subtly deal with as many KLOEs as possible. There's a full day ahead, but many areas that were difficult to get across in a paper submission can be clarified at this point.
5.    Make sure someone in each CCG group is responsible for checking KLOEs are addressed. Our panel were very organised, going through each in turn.  After the training I was worried this wouldn't be the case.  They also stuck to outstanding KLOEs only.
6.    Think what is likely to concern the panel most.  Safeguarding, clinical engagement, financial plans.  We had to emphasise the fact that we'd worked as one organisation with the PCT for over a year, and this was reflected in our policies/plans.
7.    Focus on patients.  All the areas above mean nothing if we don't relate them to patient care, better outcomes.  Identify areas where the CCG has dealt with quality issues, with financial issues, and where patient and clinician input has been effective in producing change.

The site visit was the positive experience it was meant to be.  We are a better CCG for having been through the authorisation journey.  Now to get back to focusing on the actual job, not the process.

Saturday, 6 October 2012

County Hall

It takes me approximately 90 minutes to get to County Hall.  Only 45 miles but traffic, A-roads and the middle of Nottingham have an effect.  Life as a CCG Chair can mean a lot of time on the road, and as I usually do I hoped this meeting would be worth the trip.

Bassetlaw sits between Nottingham and South Yorkshire.  Secondary care flow is north, with 2-tier local authorities, public health, community and mental health services based to the south in Nottinghamshire. It's a complicated arrangement, and is another reason why it's important to have a local commissioning voice for the patients of Bassetlaw.

I reflected as I walked in that I now visit County Hall at least once monthly, often twice. I'd been a student in Nottingham, been to Trent Bridge and Nottingham Forest many times (don't tell my parents, I was studying...) but never noticed the huge building over the road.  It's a world of hushed corridors, paintings of stern looking councillors and, most noticeably, a place where to speak you usually have to press a button on a microphone. If only I could get the children at home to use the same system.

Back to the meeting. Health and Wellbeing Board meets 'Productive Notts', the joint partnership overseeing service change and efficiency within Nottinghamshire.  Was it worth it?  Absolutely.  I often wonder what the term 'clinical commissioner' means.  To me this was what it should mean.  Not about contracts, but working with others to improve services, integrate responsibility and put patients first.  With other CCG leads, we discussed care with chief executives of providers, social care directors and councillors.  The highlight was a presentation by a Professor of Geriatric Medicine.  I was one of his students, but didn't volunteer this as he looked younger than me.

Integration isn't about provision. It's about responsibility.  We shared this in County Hall.  The journey back seemed shorter, with a renewed sense of optimism.

Wednesday, 22 August 2012

Speaking the Same Language

She nodded when I told her what haircut I wanted. It was a nice setting, I had time on holiday that has been all too rare since becoming a CCG Chair, and the fact that the hairdresser could speak only Spanish seemed of little concern. My Spanish vocabulary was limited to a basic knowledge of tapas.

They say there are only two weeks between a good haircut and a bad one. Mine isn’t a bad one, it’s just not the one I wanted, and I have a fortnight to remember the lesson regarding the importance of communication.

This month the NHS Confederation has published resources aimed at developing Health and Wellbeing Boards. The timing is perfect. As we move from the language of establishing Boards to the language of what we are actually going to do together, it is essential that we understand each other. The historic difference in approach between local authorities and GPs needs to be discussed, understood and embraced if joint working is to be successful and the sum is to be greater than the individual parts. We are agreeing plans that will last much longer than two weeks. We need clear outcomes and responsibilities. We can all understand the challenges posed by inequalities, obesity or dementia. We have to be clear about action and delivery. There is no point having a talking shop if we don’t speak the same language.

At the last meeting of the Nottinghamshire Health and Wellbeing Board, there was a presentation from the County Council – an outline of their challenges, their responsibilities and the role they play in improving health outcomes. Speaking as a GP, it was invaluable. A language lesson.

Tuesday, 3 July 2012


Submission. The word meant a lot in Bassetlaw last week. We've had it on calendars, discussed deadlines for completing it and finally achieved it. Our authorisation documents were finally uploaded along with the other 34 CCGs in wave 1.

So how was it? Was submission, as the word suggests, 'an act of yielding oneself to a superior force or to the will of another' ?

We have always aimed to do submission as part of the day job. We had most of the policies and documents already as part of our CCG development. We did have some key tasks: updating the constitution to reflect national guidance and advice, repeating our self-diagnostic and subsequent OD plan, and describing work already done in case studies. And changed our name. Bassetlaw Commissioning Organisation is dead, long live NHS Bassetlaw Clinical Commissioning Group.

The name change posed a challenge. We had built a lot of awareness locally in the name of BCO and reassured patients that there was a future once the PCT vanished. A lot of effort has since gone into reassuring people this recent development is a change in name only.

I have to confess to doing very little once it came to submission. This was partly due to the fact that we had a lot of the documents, but mainly due to an excellent (small) team who put in a huge amount of discretionary effort to signpost evidence and upload 200 documents. The technology worked, thankfully, and we can now get back to actual commissioning. Despite our best efforts authorisation dominated at least a week.

The feeling at Bassetlaw is that this has been a beneficial process. We have reviewed all our documents, challenged ourselves in front of our members and had an excellent 360 degree survey which has made our work on engagement seem worthwhile. We need to build on this.

We have responsibility for a lot of public money and patient services. Authorisation to date has felt proportionate to this. Difficult to get right, but necessary.

We now await feedback regarding gaps in evidence and 'key lines of enquiry' before our site visit on the 12th September. I hope I'm as positive after that.

Wednesday, 13 June 2012

Thinking outside the NHS

Today I spent 2 hours learning. I attended a local event, the Bassetlaw Community and Voluntary Sector Forum. The room was full of people who run or volunteer for local charities, who provide a range of services for others and who look beyond their own lives on a daily basis.

The main speaker was excellent. Enthusiastic about the future, despite funding concerns, and stressing the importance of focusing on the passion behind the charity. 'Don't lose that original passion, focus on what you can deliver within your budget, and remember that when the funding stops, the thinking starts.'

I see a lot of patients who would benefit from a number of the services evident in the room. I found myself asking how often I consider whether I should signpost to the voluntary sector. I'm a GP commissioner, have been in the area for 10 years, and yet the answer is that I rarely look beyond NHS Services unless there is a clear pathway such as the local hospice or teenage drop in services. Why is this? Am I unusual? Probably not. Why would a patient with moderate mental health symptoms benefit more from a medical counselling model rather than contact and support with a local charity? How many elderly isolated patients are in contact with befriending schemes in the area?

I came away with two actions, discussed and agreed with those present. First, we need to increase awareness amongst clinicians. At the moment we have an alphabetical directory of local organisations. But we see patients with problems, with needs. I pledged to work with those present to develop a problem based directory, so that clinicians and patients can easily identify organisations who can help them with their needs or condition.

We also need to harness the innovation in the room. We have a lot of contact with the sector locally, but there were so many ideas in the room, so much awareness of service gaps for patients and opportunities for efficiency, that we must make it easier for charities to approach us.

I hope today has made me a better GP for my patients, and a better commissioner.

Friday, 8 June 2012

Better than a day at work?

It had been a good weekend. In London with my wife to celebrate our
anniversary. Excellent restaurants, minimal shopping (an achievement)
and a much needed break. Assessment Day was on the Monday, round the
corner from the hotel and overlooking the grounds of Buckingham
Palace. This Durham boy still gets excited by London, and I wasn’t
going to let the looming assessment spoil the trip. I’d done the
numeracy and literacy tests, completed the surveys and quite
looked forward to the friendly chat about the Chair role.

I was half an hour early. Completely misjudged the 5 minutes walk
from the hotel (it looked a long way on the map, must get used to
everything being so crowded in London). Couldn’t appear too keen
so I spent a while looking for a coffee shop before giving up and checking
in. Everyone else was already there. Six of us, and I was pleased to
see some friendly faces - GPs and managers applying for Chair or
Accountable Officer roles.

                  ‘This is better than a day at work.’

If I’d assumed this was going to be a relaxing day I was wrong. I
can’t go into the detail of the day (asked not to) but I can reassure
people that it felt like a robust assessment rather than a
developmental day. Both GPs and managers, regardless of future role,
had the same process. By 4pm my hand ached from writing (how often do
we do that now?) and I felt I’d dealt with a year’s worth of CCG
challenges in 7 hours. I’m sure my partners in the practice wouldn’t view
that as a day’s work, but to me it counted.

So what was the point of the day? These are responsible roles, both
in terms of patient safety and finance. It is essential that patients
are assured that there is a process to assess competency, particularly
when CCGs are based on a membership model and local selection.  I wonder
if many will be told they are not likely to be ready for the roles.

The feedback a few days later was unnervingly accurate – more detailed
than the Top Leaders’ feedback. At least my development needs for
this year’s PDP are clear...

Tuesday, 24 April 2012

Patients Not Organisations

He was an elderly chap who wanted to know more about clinical commissioning. He used services regularly, and valued a particular local service which involved social care, community nurses and traditional medical services.

'So,' he asked, 'What does this mean for me? Will I be able to use my local service?'

The answer is that as a practising GP I'm hopefully close to his needs, and that we are working jointly with local authorities and clinicians to not only sustain but to improve this service.

But is it that simple? As CCGs what will our role be in making these decisions? Well we certainly won't be doing it on our own. We are part of a system. The local authority will oversee public health, for example, which will commission some important services in primary care. Educationalists will oversee training and accreditation, which providers rely upon to maintain rotas. Networks will oversee specialised services. The NHSCB will hold primary care contracts. NICE will issue guidance to which we will be expected to adhere. Monitor will regulate providers and commissioners...The list goes on. Try describing it to patients.

So what is the role of CCGs? It is our responsibility to ensure these organisations work together for the benefit of local patients. To make sure there aren't too many cooks, working in isolation. Decisions made at each level will impact on others. Relationships will be key. Immature organisations will need mature relationships. We have to challenge each other to improve services, remove barriers to change and focus on patients.

We are all accountable to our populations, whatever the scale. I am accountable to my patient who needs his service to function and care for his wife. The challenge is to balance, and appreciate, national and local priorities. Patients have to be central to each, and will align the organisations involved. If we ask how our decisions benefit services at each stage then we will be successful in ensuring we maintain our focus on patients and not organisations. That is how we will be judged.

Saturday, 7 April 2012

Question Time

How will we judge the success of Clinical Commissioning?  Well, it depends who's doing the judging.  From a patient's perspective, we will be judged by our level of engagement and actions in areas that matter to the local population.  Engagement is meaningless without actions, and actions are pointless if they do not improve outcomes or matter to patients.

So do we know what local priorities are?  We are likely to know from a financial perspective - we can all name areas of 'risk'.  They are often contractual. We are likely to know from a quality point of view, or waiting time perspective.  These are regularly monitored.  But what matters to patients?  I don't claim to know all the answers - but it is important we find out.

Locally, we have consulted with patients, stakeholder groups and clinicans regarding our commissioning intentions and strategic plan.  It was extremely valuable, but was led by planning timescales and will be much improved next year.  These processes need to be ongoing, not based around deadlines for plans. 

I recently attended a local 'Question Time' panel, organised by Links.  It was a joint event with local councillors, social care leaders and community and secondary care providers.  What did I learn? 

First, the clear priorities were the same as those evident from consultation.  They centred on dementia care, care homes and services for those with learning disabilities.  Increasing problems, led by changes in life expectancy and the need to improve quality for those in need of long term care.  Second, these were questions I couldn't answer on my own.  The issues raised included social care, council services, home provision and healthcare.  The obvious benefit of answering these questions jointly highlights the need to improve the services themselves jointly.  Patients usually don't have one illness,  they don't need just one service, they need joint working around their needs. 

So how will we be judged by patients?  I hope we will repeat the panel next year, and will be able to describe how we engaged with patients to improve these services, what actions were taken together and how outcomes are improving.  Then we will have improved the system.

Tuesday, 3 January 2012

Mental Health

I recently had the privilege and good fortune to spend some time with some very forward thinking Chief Executives of Mental Health Trusts.  It was an enlightening experience - not just for the discussion itself but for the opportunity to reflect beforehand on Mental Health and commissioning.

We all know GPs see a lot of patients with mental health problems - some are well known to us, others are new presentations, and undoubtedly some clues are missed with the focus of treatment being placed elsewhere. 

When we train as doctors, the priority is physical illness.  Hospitals are full of patients who are unwell, who have physical signs, and who fit comfortably with our expectations as doctors.  Comparatively little time is given to education for mental health.  The temptation is to allow commissioning to focus on the same areas, to monitor easily measurable outcomes, and to concentrate efforts on Acute Trusts.

Why?  Because we are most comfortable with these areas.  We understand them, they often fit pathways, and there may be a clearer distinction between primary care and specialist input.  They are 'manager-friendly'.  Diabetes? - lots of measurables.  Clear targets.  Stroke? - time limits for care, clear FAST guidance for patients and national standards for pathways.  Depression? - difficult, multi-factorial, still a stigma for many patients.  Addiction? - historically often associated with blame and service variation.

Contracts are a key factor.  The lack of meaningful PBR for mental health, and a need to manage risk and QIPP, increases the tendency to look elsewhere.  We may not significantly overspend this year on mental health, but can we increase quality, recognise need and explore new ways of working together to promote health?  I was extremely encouraged by the Chief Executives I met.  They worked together, shared ideas and there was a genuine sense of partnership to improve services.  Some had actively worked in acute wards jointly with physicians, others had engaged in partnerships with community services or social housing schemes.  I'm sure similar work is happening nationally. 

Mental and physical health are not inseparable.  The opportunities for joint working are clear, the potential benefits obvious.  This will be a key test for CCGs.  We talk a great deal about integrated care.  Mental Health is an ideal area around which to develop integrated services.  Alcohol and dementia services are key challenges for us, and a priority must be to develop services, with local authorities, that deal with the needs of patients rather than organisations. 

The planning round is underway.  QIPP is important, but Quality comes first.