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.  

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.