What He Doesn't Know

She is 85, frightened and confused in her increasingly rare lucid moments.  Her husband struggles to care for her, his days a constant battle of negotiating, reminding, coercing.  They both have an overwhelming sense of frustration.  And guilt.

Their daughter has done well, with a successful career, a family and a large house.  150 miles away.  They've thought of moving but they have always lived in this village, and neither can face a new environment.

The carer comes twice a day, mainly to help with bathing and dressing.  The visits are short, but most days this is the only conversation he can look forward to. Lately the carers change more.  They seem to be quicker, often talking about where they need to be next.  They come at 9am, when his wife is often asleep after her increasingly disturbed nights.  They've been told they can ask for their needs to be reassessed, but they seem so busy and he doesn't like to trouble anyone.

The district nurse used to visit when he had a leg ulcer.  3 times a week.  They asked a lot of questions, seemed genuinely interested in his nutrition and mobility. His wife wasn't 'on their books' but she enjoyed their visits.  His leg ulcer healed 3 months ago, and he 'isn't housebound' so he's been 'discharged.' He is mobile but wishes he could leave the house, but she gets distressed whenever he leaves.  Tesco delivers their shopping now.  The chemist delivers their medication.

The last time he saw his GP was when his wife had her dementia review.  Her blood pressure was fine, she had normal blood tests and showed no signs of depression.  There seemed to be a fixed set of questions to run through.  He had asked about carers and the GP had requested a social care assessment. That was when the carers started coming.  Things were worse now, and he felt less well himself but he'd probably wait and bring it up at the next review.  He wasn't sure when that would be.  He had received a letter offering a flu jab appointment.  He might ask then if he was able to get someone to look after his wife.

Anyway, if there was anything else anyone could do they'd probably have done it.  The carer would have mentioned it, wouldn't they?  Or the district nurse might have expressed her concerns to the GP.  The GP might have called in on his 'rounds'.  Dr Robins would have done, but he retired 10 years ago and he's not sure who the new GPs are now.  When his wife had a water infection recently they'd sorted a prescription over the phone.  There is a practice leaflet but so much seems to be on a practice website nowadays.  Not really much use without a computer.

What he doesn't know is that the carer doesn't know who his GP is either, or which
 practice he is registered with. The district nurse doesn't have access to his full GP record, and hasn't had a face to face conversation about anyone with his GP for 8 months.  The district nurses moved out of the practice into a new 'hub' then, and their new contract means they have a limited number of visits and only to those who are medically housebound.  They aren't on the GP 'radar' because their medications aren't up for review yet, and their QOF reviews aren't due for 4 months.

He's married yet lonely.  They have carers yet aren't truly cared for.  And their story will be familiar to many.

This blog was written to raise awareness and to reflect discussions in the CCG members' meeting where GPs discussed the importance of the primary care team, communication and the lack of engagement with community teams.  This is a key challenge to the CCG and emphasises the importance of the members and the role of the practice/practice team.

The survey. A new way of working?

Yesterday I joined a teleconference finalising the survey which will be used to assess the relationship between CCGs and NHS England, focusing the behaviours experienced.

The survey, organised by NHS Clinical Commissioners, will be available in October and will be completed by CCG chairs, chief officers and chief financial officers.  It comes at a key time.  The first round of 'assurance' reviews and feedback will have taken place, and planning for 2014/15 will be underway.  Has the system moved towards focusing on patients, joint responsibility and the integrated working needed in the new commissioning system?  Have CCGs been given (or felt) the freedom needed to succeed? Have they been given the support to develop beyond authorisation?

It's clear that the survey is welcomed by NHS England and this is key.  Learning Organisations need feedback, and the fact that NHS England and CCGs will undergo assessments moving forward is important.  

As the role of CCGs develops it's increasingly clear that NHS England is just one of the organisations with whom CCGs have a vital partnership, and where a mature relationship is essential.  Health and Wellbeing Boards are becoming increasingly important, and with the implications of the spending review still uncertain CCGs are developing key relationships with local authorities.  

Behaviours and relationships will be crucial if we are all to keep our focus on population health and joint working.  The survey is an important starting point.  A collective CCG voice and feedback is key to this. 

A&E and GP Access

Another week of headlines.

Millions 'wrongly attending' A&E.  GP access needs to improve.  GPs could do more to ease the burden on hospitals. 

'Winter is coming.'

So what would happen if a practice opened the doors and allowed walk in access to its patients for urgent conditions? No triage. No need to ring.  Partners and nurse practitioners  working as a team, average wait 30 minutes.  The ability to phone if you want to speak to someone.

This is my practice.  The model has been described in another blog: http://clinicalcommissioning.blogspot.co.uk/2013/01/opening-doors.html?m=1

The practice

We have a large practice, across 4 sites, looking after over 27,000 patients.  14 partners, 3 nurse practitioners.  Separate entrances and waiting rooms for the urgent care service, based at the main site with 15,500 patients.  We have just started a walk in service at one of the branch surgeries this summer.  We have tried most systems over the years including telephone triage and traditional on call models.  There is no additional contract for the service, it’s simply our model for our patients.

The main site is a few hundred yards from A&E.  There are areas of significant deprivation and high levels of chronic disease, obesity and substance misuse including alcohol.

We have partners with a high level of training and experience in a number of areas including dermatology, orthopaedics, palliative care, substance misuse, diabetes, ophthalmology and ENT.

The effect on the practice staff

The service (known as LUCS – Larwood Urgent Care Service) has been extremely popular. Routine surgeries are no longer overbooked and receptionists now have no frustration finding appointments for patients wanting to be seen urgently. 

Staff work extremely hard, and are proud of the service they help deliver.

Attendance levels

We opened the service in November 2010 - at the start of a flu epidemic.  We coped well with up to 140 contacts per session that winter.  As the service has become established we have more stable numbers attending, less inappropriate use and numbers have dropped slightly from 24,000 per year in 2010/11 and 11/12.

We are able to predict attendance numbers and adjust staffing levels with higher numbers attending on Monday, Tuesday and Fridays.

Patient satisfaction levels are high, and we have seen and diagnosed a significant amount of serious illnesses in the walk in service.  Patients are asked their main problem as they attend to ensure they do not have symptoms of a myocardial infarction or a stroke.

A&E attendances

The practice is situated next to A&E and has a high level of morbidity and deprivation.  A&E attendance is therefore higher than most other practices in the CCG with more rural locations.  A&E attendance overall has reduced slightly, but less than we expected with a difference of 2-3%.  We have seen an increase in complex conditions in A&E and a reduction in minor illness attendances requiring no investigations.

2012 Attendances By Day (in-hours)

2012 Attendances by Month (in-hours)

Add caption

Pressure on appointments

Routine surgeries now have no extras, and visits seem to have reduced due to the ability to be seen quickly at the surgery.  There is still a pressure on appointments and we continue to work on this.  We see a lot of patients, do extended hours and have a large team of highly trained nursing staff.  The service has improved the efficiency of the practice and for a large urban practice the ability to separate acute and planned care has undoubtedly been beneficial.

Wasted appointments

Despite enabling online booking and texting reminders to patients before appointments we had just under 10,000 appointments wasted last year due to DNAs.  We are working with the patient group and local media in an attempt to reduce this.

Conclusions

There are many reasons why the walk-in service is better for the staff and our patients.  Reducing A&E attendance was not a key driver in an area where inequalities are significant and comorbidities common.  Reducing inappropriate A&E attendance was a driver, and we have had some success with this.

Patients attend A&E ‘inappropriately’ for many reasons.  Primary care access may be one, but deprivation, family culture, free prescriptions and distance from A&E are key factors.  We know that the ‘frequent attenders’ at A&E have mainly alcohol or mental health problems, and it is essential that practices and CCGs ensure services are commissioned to deal with these problems in an appropriate setting. 

There is little evidence that we can prevent inappropriate A&E attendance through education.  We should focus on making A&E safe, focus on staffing and pathways, and look to integrate services (including primary care) where possible. 

Blaming GPs for not doing enough, or patients for attending, is not the answer. 

Transparency

Two recent events have persuaded me to write this blog.

1.  A patient recently asked me which doctor at the hospital she should see.  I replied they were all fine, that hers was a routine operation.

But which one, she asked, would listen.  How would she know?  She'd had a bad experience with a consultation in outpatients the year before, and didn't want to repeat it.  What did patients and colleagues think of the consultants in that department?

2.  We discussed the role of the CCG in improving primary care quality recently.  We agreed that the CCG had a unique opportunity, as a membership organisation, to promote transparency, increased peer review, open discussion regarding local services.  

So, on a personal level, I've decided to publish my scores from my revalidation survey.  Thousands of doctors have been revalidated so far.  Would it help patients if results were public?  At least discussed within practices or departments. No doubt there will be those who argue for and against.  Popularity isn't the same as quality.  It is by no means a perfect system.  But there's an opportunity to increase transparency, to publish both peer and patient feedback, and it's at least a debate worth having.

https://www.dropbox.com/s/dxxzrjg17ldd8bd/SKEdgecumbecolleaguesA.pdf

https://www.dropbox.com/s/2ymq7t1pf8t1npw/SKedgecumbepatient.pdf

Running Costs

As well as a £3.8bn transfer of commissioning money to local authorities, the Spending Review has brought with it a c10% reduction in NHS administration costs.  This is significant for CCGs, providers and patients.

CCG life is getting busier.  We have an ever increasing need for quality assurance, are completing new pathways and leading urgent and integrated care boards with partners.

We have significant public engagement and are active members of Health and Wellbeing boards.  We meet regularly with providers, local clinicians and (of course) report regularly to NHS England area teams.

We are responsible for commissioning budgets which effectively reduce over time with a need to make significant efficiencies - and we are expected to improve quality across primary, secondary and community care. 

I remain optimistic.  Clinical involvement in commissioning is delivering. 

But we need to be realistic about resources.  The £25 running cost is already too blunt a tool, not taking into account size of organisation or local health needs.  The commissioning system has already lost a significant number of experienced staff and is more fragmented.  CCGs are already incredibly lean.  Discretionary effort is part of the job description.  There’s a point where a lean organization becomes an ineffective one.  Patients, and the NHS, needs CCGs to succeed.  

A cut to running costs will make some unsustainable.

CCGs are part of the front line, developing new services, walking the wards and reviewing vulnerable patients in nursing homes.  Their strength is their level of clinical engagement and local knowledge.  Some suggest mergers as the answer. Their size is determined by local patient flows, by local authority boundaries, by consultation with members and patients.  Did large PCTs perform better than smaller ones after their reorganisation? 

Commissioning needs to be local, proactive and patient focused.  Primary care is already feeling the effect of a more fragmented, transactional approach to its own commissioning.  Regulation is important but is not the answer to many of the problems facing the NHS. 

Let’s get commissioners and providers talking, resource them both to do so, and deliver the rewards in efficiency and service quality.

Holding Course

2 months after major reforms, and the official birth date of clinical commissioning, there's a debate about the role of CCGs.  Whilst not unexpected, it does seem premature.

A Foundation Trust Chief Executive told me last week that clinical commissioning was the best thing to happen during his time in the NHS.  The increased level of clinical conversations, the focus on patients had helped his organisation and was a welcome change.  

So is now really the time for a change in direction?  Is the agenda different?  Undoubtedly there is a need for integration, for joint working with social care.  But this isn't new.  There is a need to understand the impact of conflicts of interest, but it's difficult to think of any organisation with no conflict whether political or as a provider of services.  

The goal of integration does not need a mandatory change of commissioning responsibility or NHS budgets, but a change in working and behaviour.

CCGs across the country are working to achieve integration and are working in partnership with local authorities.  Health and Wellbeing Boards are now established, but are not tested by an authorisation process and vary in membership and readiness to govern.  Some have had significant turnover in membership and political ideology following local elections.  

The NHS needed to change.  Now is the time to give clinical commissioning some time, the space it needs to succeed.  I'm confident it can, but we need to retain the sense of clinical responsibility for our patients, to continuously improve outcomes.  This won't come from advisory roles.  We have a real opportunity to change the way clinicians and managers view the NHS and its outcomes for patients.  Responsibility is key.

Apparently less than a third of people are aware there has been a major NHS reform.  Their focus is on provision, on their local services.  Satisfaction in the NHS remains high.  Changing commissioning roles too early may weaken the NHS and is unlikely to be of significant political benefit.

We are very much aware of the importance of time as clinicians, of giving treatments the opportunity to work.  Let's do the same with the NHS.  

Hospital Walls

There are some things we can change, and some we can’t.  According to the serenity prayer, the key is knowing the difference.  With limited management and clinical capacity, this is crucial for CCGs and the NHS.

Unplanned care is one of the main challenges facing the NHS.  Rising demand, admissions and a reducing social care budget create a perfect storm for hospitals and practices struggling to meet A&E targets, improve access and quality.  It can be difficult to look up, to examine the system, when we are running on a treadmill that seems to relentlessly increase in pace.

Locally, we have commissioned an annual review of hospital admissions for each of the last 3 years, using a validated external tool.  Over a defined period, how appropriate are admissions, what is the situation on the wards, where are the gaps in services outside hospital?  Many areas do similar studies.  The challenge for the new commissioning system will be to make a difference, but it will take a partnership approach, involving providers and social care.

What were the main findings?  The majority of patients are admitted appropriately.  11% were thought to be medically inappropriate (17% in 2011).  Approximately half of these inappropriate admissions were unavoidable because local services didn't exist that might have cared for them.  Inappropriate admissions were not related to patient age.

42% of patients admitted had a mobility problem.  25% had cognitive problems.  Respiratory illness was the most common cause of inappropriate admission.  

67% of admissions were from A&E, 28% via GPs, consistent with previous years.  GP admissions were more likely to be inappropriate (15%) compared to those from A&E (8%), where investigations were possible beforehand.  

70% of patients who were in beds could have been discharged from acute beds earlier, with variation between wards and specialities.  Increasing age was related to delayed discharge.  

We are currently reviewing the results and discussing the findings with social care and healthcare providers.  Discovering what we can change.  There are clear messages already.  When discussing increasing admissions and increased pressure within hospitals, we need to know our population, know our local services and look beyond the hospital walls.

April's here. Why be involved in a CCG?

As we reach April 1st the debate on what the reforms means for the NHS has increased in intensity. With this debate comes, perhaps understandably, challenge to those involved in CCGs - why are we involved, what's in it for us, are we being naive, why not walk away, are we part of the plan to privatise the NHS?

This is my personal perspective.

I believe clinicians should be involved in planning patient services

Clinicians can drive improvements in services by working closely with managers, patients and partners such as local authorities. By focusing on patients and quality we engage others, including local GPs. We are passionate about local services, about improving patient outcomes.

CCG leads know what the challenges are.

I don't feel naive, don't feel used in some master plan. I feel a sense of responsibility to patients, to members and to the local community. I spend a lot of time with other CCG leads - all work extremely hard for patients and any suggestions of naivety does them a disservice.

Commissioning helps me as a doctor.

I'm a stronger patient advocate as a result of commissioning. I'm more aware of pathways, understand local services better. I, and my GP colleagues locally, know much more about local providers and their quality.

The system is more fragmented

From April there are more organisations responsible for commissioning. Patient outcomes and safety must remain the focus. GPs are ideally placed to work with others, to listen to patients, to be powerful patient advocates across the system. CCGs have a crucial role in ensuring the system works.

Walking away would not benefit patients

This is a crucial time for the NHS. Clinical commissioning is an opportunity. Clinicians, from the whole system, should be responsible for planning, as well as delivering, care. My duties as a doctor don't end at my consulting room door.

External roles can be beneficial

There are many external roles, such as working with the BMA or RCGP. All are valid, and can enhance knowledge and job satisfaction. Doctors should not be criticised if they are not consulting full-time. There are many reasons to be part-time, and focusing on population health can deliver significant benefits for patients.

I'm not here to privatise the NHS

There may be occasions when competition is beneficial, or where existing EU law will mean we have to tender for services. However, CCGs are focused on increasing integration to improve quality, as shown in a HSJ survey in 2012. I'm determined to help improve NHS services, to strengthen them.

CCGs deserve professional support

It is important for the profession to support clinical commissioners, to understand their motivations and help build a successful commissioning system with clinicians and patients at the centre. It's an opportunity for General Practice.

Make It Simple.

At the Bassetlaw Dementia Summit in February, one of the carers delivered a plea from the carers' group.

'Our lives are hard enough. Your jobs are to make them simple.'

She went on to describe difficulties with diagnosis, difficulties with inconsistent carers, and most of all difficulties with social care, particularly the finance department. The challenges were clear. Sometimes we place obstacles for patients and carers, make their lives harder.

This week I've learned from experience. I'm a GP. I know the system. I'm confident on the phone. I understand which forms are which. And yet it's been a struggle, taken a lot of time and made me realise how hard the system must be for vulnerable patients, particularly the elderly or those with dementia.

The task? Sounds simple. A close relative has terminal cancer, is elderly and has dementia. He's struggling to get to hospice appointments, is starting to fall. He needs a blue badge or will become housebound. I offered to help. The forms were complex, quite medical. No mention of terminal illness though. I completed them, took a passport photo for him and rang the council a few days later to ask how long it would take to process. I was told 3 months. He doesn't have that long. They could expedite it if I could get a copy of his DS1500 (a form confirming terminal illness). This was completed a month ago. He hasn't got a copy, gets upset when I ask him for paperwork.

Nowhere on the blue badge form did it mention a DS1500. I couldn't get a copy from his GP, Macmillan nurse or consultant. The lady on the phone said they couldn't accept anything but the form, not even a letter from his GP. He'd probably have to come in for a medical. Where would he park? Would they ask him questions despite his dementia? Nothing they could do. I was given the complaints number. They were 'just following the rules.'

Anyone who knows me would say I'm a determined advocate for patients. After 6 phone calls I was eventually told I could get a copy from the Department of Work and Pensions. They're apparently happy to issue copies. I rang them. They denied ever doing that, until after another 3 calls a kind lady agreed to send one to the patient, for me to send to the council. I'm currently waiting for the post.

I've learnt a lot. Patients describe similar experiences regularly. This is just one example. Their lives are complicated enough. Where we can, we should make it simple.

Dementia - Beyond Planning

We have just submitted our draft commissioning plans for 13/14. Pages of trajectories, targets, pledges and aspirations. The team have put a huge amount of effort into the document, translated guidance and the new system, and we are now currently consulting with partners and patients.

One of our local and national priorities will be dementia. We have a national target to increase the number of patients diagnosed with dementia, as have all CCGs. Putting the issue of screening aside, is early diagnosis a good thing? Does it matter if treatments aren't effective for all, if a delay in progression is likely to be the best outcome? We are also aiming to reduce antipsychotic prescribing in patients with dementia. It's important to look behind the targets, to talk to patients, to see if what we are doing is likely to make a difference.

So I recently met a group of carers, all with relatives with dementia. They were an inspirational group of people, and it was one of my highlights as a CCG Chair to spend some time with them, realising how they provided mutual support for each other. It was also clear that they shared their frustrations, their anger with the condition and with the care system. There were plenty of tears during the meeting. This was the reason behind the plans.

Clear themes emerged from the discussion.

Diagnosis

All used a common word to describe the process of diagnosis. It was a 'battle'. In some cases it took years. The younger the patient, the harder it seemed. Stories were relayed of stressful trips to tertiary centres, to see specialist neurologists, only to be told their loved one's memory was not as good as it used to be. 'I'd told them that, I'd known him for years.' Nearly all had been diagnosed with depression first. 'If he was depressed, it was because he knew what was happening. No one took into account his family history of dementia.'

All agreed that early diagnosis would have been beneficial. But it wasn't just about treatment. It was clear that they valued the mutual support available, the benefit of talking to other carers abut how to cope with difficult behaviour, how to reassure an anxious husband or wife, avoid unnecessary medication. A recognition that their husband wasn't himself, that they were right and that they could explain the diagnosis to people.

Continuity

After diagnosis what was the most valuable aspect of care? Continuity. There was significant anger at changes to carers, to services that had been changed. Trusting a carer was so important, establishing a routine crucial. Changing times of service offered, the carers involved and worst of all insisting on a move to a different care home had significant effects on patients and their families.

Understanding

Carers weren't embarrassed by their loved one's behaviour or condition. But they did want understanding and compassion. This included health professionals, carers and the public. There were positive stories about the police, about officers going above and beyond to make sure patients were safe. What would happen if someone forgot to pay and walked out of a shop? This was a cause of some anxiety for some of the carers and patients.

Most said it would have been easier if the diagnosis had been cancer. There would have been a clearer path to diagnosis, more certainty regarding progression, more understanding.

Back to planning

This was the story behind the plans. We have already significantly improved the community memory service and commissioned an excellent outreach team. But we can do more - improving diagnosis accuracy, access to local scans and specialists. But its what we do afterwards that matters most. Focus on continuity, avoiding unnecessary antipsychotics. And listen to carers.


Bassetlaw Dementia Summit is on 5th February, bringing together more than 100 carers, professionals and partners including surgeries, hospitals, voluntary services and emergency services.

Opening the Doors

In November 2010 we took an important step as a practice. We opened our doors. We said, 'If you feel you need to see us, come down. If you feel you'd like a telephone call, ring us and we'll ring you back.'

Prior to November 2010 we had a GP on call, with patients phoning for urgent appointments. We would ring them back, usually ask them to come down depending on which GP was on call, and try to manage our workload and their problems. Phone calls and attendances would start at 3pm and finish at 6.30 at the earliest, often with visits in between, and there were extras in each routine clinic. Staff had the difficult job of managing demand amongst doctors, and we could see have up to 60-70 contacts in an afternoon for one GP.

To set some context, we are a large practice with 4 sites and over 27,000 patients. We have over 15,500 patients at our largest site, next to A&E but with high demand and high levels of social and medical morbidities. Over the last decade we had tried models such as nurse practitioner triage, GP telephone triage, minor illness clinics. We had recruited more doctors, more nurses, more reception staff due to a sustained rise in list size. How could we improve access for our patients?

So back to November 2010. The doors opened. Our Urgent Care Service was opened. We are very tight on space but we dedicated 3 clinical rooms to the service, built a separate entrance and allocated a separate waiting room and reception desk for registered patients with urgent, on the day, problems. No phone call needed. We employed nurse practitioners and an additional GP. We opened more routine appointments (no need for extras). We established a GP rota and ensured the Nurses and GPs worked as a team, with reception trained to ensure urgent problems such as chest pain or strokes were screened at the desk. Urgent and elective care was separated and access increased without contractual change or additional payment.

How do we judge if it has been successful? Patients think it is, and satisfaction surveys have been extremely positive. One patient judged the service as 8/10 because they'd 'had to wait 8 minutes', but the service has been extremely popular. We coped with a flu epidemic when we would have struggled, we can adapt the number of GPs and nurses per session as we can predict demand and routine surgeries now start and finish on time. Generally, patients are seen with 20 minutes, sometimes immediately, although at peak times it can be longer. Patients are learning when is best to attend. The doors open from 8.30 to 11.30 and 2.30 to 5.30. If there is a surge in demand GPs can help by seeing additional patients, but it is relatively rare. The 5.30-6.30 period is now relatively quiet.

In the last 12 months we have seen over 24,000 patients in our urgent care service. Most have been appropriate, and we have seen a small but significant reduction in A&E use during the day. Staff are not spending hours on the phone trying to get an urgent appointment for a patient, and visits seem to have reduced. Personally, I feel more confident having 'eyeballed' patients, and telephone calls are now genuinely for problems that can be dealt with on the phone. There are still some teething problems, some inappropriate attendances or days with longer waits, but we are getting there. We may have increased demand, but we provide a better service and we can't ask patients not to go to A&E if we don't provide an alternative.