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.