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.
Wednesday, 13 June 2012
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.
'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.
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.
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.
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.
Wednesday, 7 December 2011
Power (What's in a word?)
One word has stood out to me over the past few weeks. It was said at the excellent NHS Alliance Conference, on stage, and struck me as an interesting concept.
The word was 'power'. A small word but significant, and one which, in the context of NHS reform, has usually been used with reference to GPs recently. I think it's unhelpful.
The word 'power' may apply in some ways. GPs and other clinicians do have some power to influence commissioning decisions, to determine strategy and to spend real budgets. However this may have caused some dissatisfaction as 2013 approaches and the reality of commissioning complexities become apparent. GPs and other CCG clinicians have had power given to them, but now (before 2013) we need to accept and learn how to share power, let go of some roles and ensure that the system works in the best way for the patients.
What does letting go mean? As an example, it is clear the NHSCB will have a significant role in commissioning, including specialised services and primary care. Health and Wellbeing Boards will have a role in overseeing strategy and commissioning intentions for communities. Commissioning Support Organisations will provide intelligence, manpower and support. Local Authorities will increasingly expect an input into decisions which would be better taken jointly and affect social care. Secondary care services will hope for integrated working and planning of services. Managers are vital and key if we are to succeed.
What then, is the role of the CCG in this? Are we, as some suggest, really commissioning nothing? I'd argue we have a key role in ensuring this system works, in representing our patients and striving for improvements. We are used to working with consultants and other agencies when we care for patients, are often strong patient advocates, and coordinate complex care pathways for individual patients daily.
So are there better words than power? I prefer 'responsibility' and 'influence'. We have a real responsibility to commission effectively for our patients, to ensure they get the best services and in the right location. We have a responsibility to ensure we use resources appropriately, so that we protect patient care and have the ability to be flexible and improve services in the future.
The key is 'influence'. We must allow patients and the public to influence the way we commission and define our responsibilities. The contract planning underway is a current challenge for us - can we meaningfully engage to ensure we contract for outcomes that matter to patients? Can we plan for next year and include priorities that affect our populations? Can we deliver the better outcomes, working jointly with providers to plan better services? This will be the test for CCGs in the future.
So let's try to move away from 'power', and towards responsibility and shared influence. Build relationships that deliver, let go where appropriate and ensure the system works for patients.
To quote Thomas Jefferson:
I hope our wisdom will grow with our power, and teach us, that the less we use our power the greater it will be.
The word was 'power'. A small word but significant, and one which, in the context of NHS reform, has usually been used with reference to GPs recently. I think it's unhelpful.
The word 'power' may apply in some ways. GPs and other clinicians do have some power to influence commissioning decisions, to determine strategy and to spend real budgets. However this may have caused some dissatisfaction as 2013 approaches and the reality of commissioning complexities become apparent. GPs and other CCG clinicians have had power given to them, but now (before 2013) we need to accept and learn how to share power, let go of some roles and ensure that the system works in the best way for the patients.
What does letting go mean? As an example, it is clear the NHSCB will have a significant role in commissioning, including specialised services and primary care. Health and Wellbeing Boards will have a role in overseeing strategy and commissioning intentions for communities. Commissioning Support Organisations will provide intelligence, manpower and support. Local Authorities will increasingly expect an input into decisions which would be better taken jointly and affect social care. Secondary care services will hope for integrated working and planning of services. Managers are vital and key if we are to succeed.
What then, is the role of the CCG in this? Are we, as some suggest, really commissioning nothing? I'd argue we have a key role in ensuring this system works, in representing our patients and striving for improvements. We are used to working with consultants and other agencies when we care for patients, are often strong patient advocates, and coordinate complex care pathways for individual patients daily.
So are there better words than power? I prefer 'responsibility' and 'influence'. We have a real responsibility to commission effectively for our patients, to ensure they get the best services and in the right location. We have a responsibility to ensure we use resources appropriately, so that we protect patient care and have the ability to be flexible and improve services in the future.
The key is 'influence'. We must allow patients and the public to influence the way we commission and define our responsibilities. The contract planning underway is a current challenge for us - can we meaningfully engage to ensure we contract for outcomes that matter to patients? Can we plan for next year and include priorities that affect our populations? Can we deliver the better outcomes, working jointly with providers to plan better services? This will be the test for CCGs in the future.
So let's try to move away from 'power', and towards responsibility and shared influence. Build relationships that deliver, let go where appropriate and ensure the system works for patients.
To quote Thomas Jefferson:
I hope our wisdom will grow with our power, and teach us, that the less we use our power the greater it will be.
Friday, 11 November 2011
Sleeps
Mick Jagger may have felt that time was on his side, but many of us don't. April 2013 looms large, with only 507 sleeps (it is nearly Christmas...) until CCGs must be authorised in full or partial form. There remains significant variability in CCG progress and, whatever one feels about the reforms, this variability is unlikely to benefit patients. So what are the main issues facing CCGs at the moment? After a lengthy brainstorming session (alone) these are my thoughts, focusing on authorisation: No doubt there are many more and they will vary - please let me know what I've missed.
Having a clear vision
The need for clarity increases, and having a clear vision to drive progress is vital. Whilst we can't always wait for detail there is an increasing need as authorisation approaches, as the focus needs to be on patient care and services rather than structures.
Developing real and meaningful patient engagement
There is a definite desire to improve this, and many ideas re: doing so. Avoiding token representation on committees, enabling genuine challenge from patients, ensuring a cross section of views - this will be a key test for clinical commissioning in the future and one we should be judged by.
Working together with clear roles
We must ensure we work together constructively and have clear roles. CCGs should be clinically led, but with support and challenge from managers. Relationships are vital, and the culture and behaviour of CCGs will determine success or failure.
Governance structures
CCGs have significant responsibility, and with that a duty to have strong Governance systems and support. It's there to challenge and protect. Separating governance and management is difficult, and will need much input from lay members. Setting up audit committees, establishing clear lines of delegation - all important but time-consuming and must not detract us from the vision we set and the need to focus on patients. Work with others to agree structures, taking advice from existing non executive directors and Chairs. We have many of the responsibilities of PCTs but need to have a different feel and culture.
Understanding and developing partnerships
Identify what the potential benefits are for collaborative work, and accept the need to 'let go' of some roles which may be better done jointly with a Commissioning Support Organisation or Local Authority. Getting these arrangements right will be vital if we are to encourage wider views, better integration and efficiency with commissioning resources. There are many competing interests but none should override what is best for the services or patients. Provider partnerships are essential if we are to achieve integration and enable transparent governance mechanisms.
Establishing an effective Health and Wellbeing Board
These have tremendous potential, but will be judged on outcomes not words. We have reviewed key issues in Nottinghamshire such as dementia, alcohol and substance misuse and childhood interventions. We need to ensure the time given and potential for change is not wasted, and that there is a clear strategy and benefit from these boards.
Running Costs
There is still significant debate regarding size and running costs. April 2013 is a deadline which does not allow for a lot of further reconfigurations.
Setting Priorities
There seems to be an endless stream of improvement opportunities. Establish which are most important to patients and for large scale benefit. Some issues may be quality related, and having a firm understanding of these issues will be crucial. QIPP is important if we are to have resources to improve services, but if we achieve financial balance at the expense of patient care we will have failed.
Transition arrangements
Establishing CCGs, PCT capacity reduction, newly clustered PCTs and SHAs and a new NHSCB represent significant challenges to the system. We need to ensure quality and safety are the main focus during this period, and that we ensure there are robust systems to manage this. Clusters will, rightly, want to have confidence in the arrangements set up and they will undoubtedly evolve over time. We might resemble PCTs during the transition, but for a reason.
Valuing Clinical time
Balancing the roles of clinician and commissioner is difficult both in terms of time and duty. Good governance and challenge will protect against this, but the interests of patients must be paramount. Many GPs will be working harder to maintain patient continuity and fulfil their CCG role. Organisational and personal development needs will be significant. Working together with managers and as a GP community is vital if we are to succeed.
(For those of you who are curious, it's 43 sleeps until Christmas.)
Having a clear vision
The need for clarity increases, and having a clear vision to drive progress is vital. Whilst we can't always wait for detail there is an increasing need as authorisation approaches, as the focus needs to be on patient care and services rather than structures.
Developing real and meaningful patient engagement
There is a definite desire to improve this, and many ideas re: doing so. Avoiding token representation on committees, enabling genuine challenge from patients, ensuring a cross section of views - this will be a key test for clinical commissioning in the future and one we should be judged by.
Working together with clear roles
We must ensure we work together constructively and have clear roles. CCGs should be clinically led, but with support and challenge from managers. Relationships are vital, and the culture and behaviour of CCGs will determine success or failure.
Governance structures
CCGs have significant responsibility, and with that a duty to have strong Governance systems and support. It's there to challenge and protect. Separating governance and management is difficult, and will need much input from lay members. Setting up audit committees, establishing clear lines of delegation - all important but time-consuming and must not detract us from the vision we set and the need to focus on patients. Work with others to agree structures, taking advice from existing non executive directors and Chairs. We have many of the responsibilities of PCTs but need to have a different feel and culture.
Understanding and developing partnerships
Identify what the potential benefits are for collaborative work, and accept the need to 'let go' of some roles which may be better done jointly with a Commissioning Support Organisation or Local Authority. Getting these arrangements right will be vital if we are to encourage wider views, better integration and efficiency with commissioning resources. There are many competing interests but none should override what is best for the services or patients. Provider partnerships are essential if we are to achieve integration and enable transparent governance mechanisms.
Establishing an effective Health and Wellbeing Board
These have tremendous potential, but will be judged on outcomes not words. We have reviewed key issues in Nottinghamshire such as dementia, alcohol and substance misuse and childhood interventions. We need to ensure the time given and potential for change is not wasted, and that there is a clear strategy and benefit from these boards.
Running Costs
There is still significant debate regarding size and running costs. April 2013 is a deadline which does not allow for a lot of further reconfigurations.
Setting Priorities
There seems to be an endless stream of improvement opportunities. Establish which are most important to patients and for large scale benefit. Some issues may be quality related, and having a firm understanding of these issues will be crucial. QIPP is important if we are to have resources to improve services, but if we achieve financial balance at the expense of patient care we will have failed.
Transition arrangements
Establishing CCGs, PCT capacity reduction, newly clustered PCTs and SHAs and a new NHSCB represent significant challenges to the system. We need to ensure quality and safety are the main focus during this period, and that we ensure there are robust systems to manage this. Clusters will, rightly, want to have confidence in the arrangements set up and they will undoubtedly evolve over time. We might resemble PCTs during the transition, but for a reason.
Valuing Clinical time
Balancing the roles of clinician and commissioner is difficult both in terms of time and duty. Good governance and challenge will protect against this, but the interests of patients must be paramount. Many GPs will be working harder to maintain patient continuity and fulfil their CCG role. Organisational and personal development needs will be significant. Working together with managers and as a GP community is vital if we are to succeed.
(For those of you who are curious, it's 43 sleeps until Christmas.)
Subscribe to:
Posts (Atom)