Cardio and Strength Training : Loser2Ripped

In cross training anaerobic efforts are used to develop aerobic conditioning for weight loss superfoods. Because you are doing cardio and strength training simultaneously, you’re working out at a higher intensity for a shorter period of time—with greater results. In each workout, you’ll get a high level of aerobic fitness without the muscle loss that is associated with high levels of aerobic exercise.

Cross training also incorporates core, functional and metabolic conditioning into each workout to improve endurance, stamina, strength and flexibility, key factors in maximizing athletic performance as well as losing weight.

At Cross Training San Marco, we bring a unique approach to fitness by incorporating a variety of methods such as core, functional, athletic and strength training to improve endurance, stamina, strength, flexibility, and aerobic and anerobic capacity. Components of our workouts include:

  • personalized workouts with a certified trainer
  • improve endurance, stamina, strength, flexibility, and aerobic ability
  • work all your muscles, not just the ones you use regularly
  • cardio and strength training combined to increase athletic ability

Intense and Effective

High-intensity training, such as cross training, has been proven to trigger significant weight loss and promote rapid increases in physical fitness. For example, if you exercise at moderate intensity on a treadmill, elliptical trainer or stationary bike, you’ll burn about 5 to 7 calories per minute. But if you exercise at 80 to 100 percent of your maximum effort, you will double your caloric expenditure. Additionally, you’ll build muscle and amp up your metabolism which will burn more calories for the rest of the day.

Researchers at Laval University in Canada found that exercising intensely helps you lose fat and build fitness faster than ANY OTHER WEIGHT LOSS PLAN. These results which were supported by studies at the University of Virginia showed that people exercising more intensely lost much more body fat, even though they exercised for less time than people training at moderate intensities.

High-intensity exercise also decreases appetite more than moderate or low-intensity exercises.

My Dental Braces Journey Starts Now

Last week I decided to get my first dental braces, and now I am steady getting used to it. Since this is my first time, I did have some toothache so I took paracetamol since there were so many essential appointments I couldn't miss.

Now I feel a bit more relaxed, and headaches are gone, but still, my regular food and fat-free chips causing big trouble because eating them are nearly impossible. Atm, I have changed my meal according to this article I read on "What not to eat with braces." Breaking up the food is easy, but chewing motion causes considerable discomfort but hopefully will fix itself soon.

Another weird thing which happened was nobody mentioned the braces at my practice only some my interns who were wearing braces asked more about it. Particularly one intern told that speech has changed a bit and also I loved uncomfortable when explaining.

At the end of the day I felt my lips dry but also another problem was the discoloration of the band. I was so careful not to stain them throughout the day, but it caused "yellowish stain" so at the moment I am brushing my teeth and brace six times a day.

Overall a very challenging experience hopefully it will change soon, and I will start looking some excellent results.

Diary & Blog w/c 19th May 2014

 A packed and very stimulating week - Peter Fuda's insights on transformative leadership are a powerful mix - based on strong field research but also intuitively right - the way the best new ideas change your thinking, but then feel so self-evident you wonder in hindsight why they didn't occur to you. Sadly, I had to miss the Kings Fund event on leadership, as some complex service and financial arrangements with a provider had to be finalised.

Our first Integrated Care Programme Board set the right tone by having commissioners, providers, and stakeholders round the table from the outset, and we have our six most urgent projects initiated as we start to eat a very large elephant in a series of bitesize chunks (focus on these six, get them done, and don't think too much about the other 50 in the queue). First up:

  • Identifying those patients at highest risk of becoming acutely unwell (risk stratification)
  • Developing a secure cloud based system for uploading care plans so patients & HPs can access 24/7
  • Developing a community rapid response service for health and social care
  • Enhancing Primary Care support for nursing homes 
  • Increasing number of patients able to remain at home at end of life
  • Urgent review of intermediate care services to enable smooth discharge and best possible recovery after a stay in hospital

But the pick of the week was Friday - an excellent forum from NHS England & Macmillan on 'Commissioning for a Better Patient Experience'. The session used actors to explore patient stories in rich detail, and made good use of IT to share the thinking from the workshop tables in real time. I was part of the 'Stress Test' Table - senior people from NHS England across patient experience, commissioning, and contracting, plus the PE Director from a Provider Trust in the North East that has been doing some really impressive work on using patient experience to systematically improve the quality of care. Our job was to gather in the ideas from the five main tables and provide challenge, feedback, and try to develop concepts into something that commissioners could act upon.

Patient Experience is an underused resource in the NHS, partly I think because its importance is consistently misunderstood. Too often it is perceived as the equivalent of a comment card at the end of a meal; useful to check people are happy with the service, but an optional extra when compared to whether the food is hot and fresh, bookings are coming in, and the till is making all the right noises. I would argue that PE is actually one of the big three measures for the success of our health system, alongside the health outcomes of care, and value for the taxpayer, especially if we think much bigger than the Friends and Family Test.

Beyond the obvious and most serious example of Mid-Staffs - where patients had serious safety concerns but were not listened to - there is huge scope for using patient experience as a safety monitoring and alert system. Patients and their families may not be familiar with detailed safety standards, but they know when somewhere isn't clean, or when basic needs for food, water, pain control, and comfort aren't being met. If tools like 'Patient Opinion' were in widespread use by patients we would quickly identify areas of concern.

And in addition to what patients report, are there behaviours that might warrant attention - 'red flags' that warn of a possible problem? There might be good reasons why a patient discharges themselves against medical advice; or accesses Primary Care, Walk-In Centre, and A&E all in a 24 hour period; but it might also highlight a lack of confidence in care. If we invested more time and resource in asking systematically about the experience of care - what happened as much as how satisfied there with what happened - every patient becomes an inspector, safety and quality are enhanced, and the QA responsibilities of commissioners and regulators may start to feel achievable.

Beyond assurance, the intelligence can be used to drive improvement. I have never met a health professional that doesn't want to provide the best care they can, and I have never met an NHS or Social Care Manager who doesn't want to change services for the better. The debate with commissioners is almost always about the constraints - money, workforce, rules - but never about the desire to improve.  There's a real and very rational nervousness for individuals and provider organisations about the idea of having a public running commentary on the care provided, but once embraced as an improvement tool it can be incredibly powerful. Some providers are already using patient experience feedback to inform staff appraisals, provide quick feedback to care teams, and to direct and measure system improvement.

For commissioners there are further opportunities beyond assurance and improvement - patient experience information could inform the 'wrong care delivered well' problem. A high satisfaction score for an urgent care episode won't identify gaps in community services that created the emergency, but patient stories can inform every stage of the commissioning cycle. We can use this intelligence to plan, design, and mobilise new pathways and services by working in partnership with the patients who use services now, and use this same intelligence source to measure change as new services come on line.

The session on Friday will be part of a longer conversation that will produce national policy and potentially guidance or service frameworks for commissioners to implement. In the meantime commissioners can act now, by including Patient Experience as a key part of provider quality schemes and quality incentives. In Norwich we are working to embed 'Patient Opinion' into all Provider contracts, asking them to promote its use, respond to stories, and use the feedback as a quality improvement tool. Here's the Norwich feed - most of the stories are reports of great care, and I check in every day to read and tweet them.

Final word from Peter Fuda. There was a timely contrast between leadership based on fear and building a sense of crisis - the 'Burning Platform'; and that based on mobilising people's internal drive to excel - the 'Burning Ambition'. Inviting many more patients to share their experience of care might initially be a little frightening, but it ultimately taps in to the burning ambition of every NHS professional out there. We all want to do the best we can for patients; we just need to ask more patients for help.

Diary & Blog w/c 12th May

It has been a packed week, the kind where your in-tray just grows day by day and then you pile it into your case and bring it home for the weekend. But it has also been a week of real highlights, with a theme of the wider elements of health and wellbeing:


Tuesday began with a Healthy Norwich Fair in the Forum, centred around the launch of WalkNorwich - part of the Healthy Norwich initiative with the City Council and Public Health. For 'Beat The Streets' part of the City has been turned into a giant walking game, with residents walking between card readers fixed to lampposts and other street furniture, and clocking up their own and the total mileage for their team. In only four school days Heartsease Primary School already has 5390 points (539 card reader swipes).

The health summary at the launch from Dr William Bird was quite powerful - inactivity is the 4th leading cause worldwide of premature death, and is a more significant risk factor than smoking or hypertension; but also that regular exercise has a big positive impact on hidden visceral fat, even without any overall weight loss. Norwich is a beautiful city, but cities can be traffic choked obesogenic public health disasters, and it's important that the CCG continues to think beyond just A&E targets and annual budgets, and works in partnership to make it healthy as well as picturesque.

Full details of the walking schemes are on the CCG and the Norwich City Council Website.


Straight from the Forum back to City Hall for 10am for the Norwich Patient Opinion Workshop. We've been promoting its use through our hospital contract since last April, and it was an important development to have the PO team come to Norwich and talk to other providers and commissioners across the County.

Patient stories about their experience of care - good or bad - can be powerful drivers of reflective practice and service improvement. Since launch last year Patient Opinion has delivered to the Norwich Health system over 200 patient stories. Most get a response from the provider; many lead to change which is then shared on the website.

The patient voice - if heard - is the most important quality assurance and improvement tool  the NHS can access. We're still learning how to take full advantage of it, and still persuading some to take the plunge, but a health service that listens to patients is a safe service and an improving service, and I am determined to grow the number of providers registered with the service, and the number of patients using it.

 And finally, the PO team brought cake. They didn't buy cake, they made cake - rock buns and welsh cakes baked just for us. And I'm hoping they come back very soon (James - flapjacks next time? Or chocolate brownies a little gooey still in the middle...)


If you want to break the resolve of a grizzled old commissioner with a heart of flint and a fist clenched tightly around the public purse, take them to some charity AGMs. Nelson's Journey is a Norfolk charity that supports children suffering a family bereavement - workshops, counselling, and weekends away for group therapy. It survives - and is thriving - on donations and legacies, but receives little from the statutory sector despite most of its referrals coming from education and health. We've been able to help this year as part of our commitment to grow voluntary sector investment in line with our key community themes: older people, carers, mental health, and end of life and bereavement.

I had expected the AGM to be worthy but a little dry - a few spreadsheets, a review of the year, and heartfelt thank you's to patrons and volunteers. It had all that, but it also had two young people talking about the loss they had suffered and the difference Nelson's Journey had made. They were incredibly brave to talk to a room mostly full of strangers about how they had felt after losing a mother and a sister, and how the charity had helped them and brought them together with children their own age who had experienced similar loss. They looked about ready for GCSEs, and it really brought home how much a bereavement - if not properly supported - could impact on education, employment, mental health, and life chances of young people.

I just about escaped dry eyed, but was caught out at the end by them giving everyone a plant pot, inviting us to write down someone we remember, and then (if we remember to water it) think of them as we watch it grow. It's one of the ceremonies they use as part of the therapy process, and few of the attendees escaped unmoved. This one's mine, and the name tucked in the back is Kathryn Laura.


I published my first blog on 18th May 2013. It was short and a little dull, but fortunately almost nobody read it. I've managed 41 posts  and had almost 30,000 blog hits since then, and although sometimes I wake on a Saturday morning and wish I'd never started doing it, overall it's been a great experience. It has helped me to reflect on my responsibilities, and think more about how I spend my time; I've met new people and had a lot of very helpful feedback through Twitter; and it has created opportunities for me to engage with local people, health professionals, and colleagues across the country.

I've never been trolled, but people have on occasion  violently disagreed with what I've written. Last week's epistle on money and workforce got an angry response from a local trade union office, and some tweets suggesting that I should be fighting for more NHS resources rather than talking about efficiency savings. I understand the argument but I don't agree - I'm an unelected public servant with a duty to do the best I can for Norwich with the resources we're given; whatever my private views, I don't have the right to use my position to take a political stance on issues.

This time last year I watched the Canaries beat West Brom to secure another year in the Premiership; this week I got to the top of the season ticket waiting list just in time for relegation. I hope I'm still blogging another year from now, that I'm be cheering on the terraces of Carrow Road as we bounce straight back, and that I'm still doing this job in this great City.

Diary & Blog w/c 5th May 2014

If winter is the season of pressures, Spring is the season of workshops. I've attended four this week covering collaborative commissioning, 5 year plans, integrated care for Norwich, and Strategic Workforce Planning.

Regular attenders of these might sometimes substitute 'talk' for 'work' when they describe them, and for an outsider we must look at times like the Committee of the People's Front of Judea, but system workshops endure because we have not yet found a better way to bring everybody together to tackle the problems none of us can solve on our own. The workshop season has been particularly febrile this year; in part because of the very complex and ambitious planning guidance that requires us to plan five years ahead and pool health money with social care; but also because as problems go, we are having to face up to some big ones. Amongst them stride two colossi:


This financial challenge is expressed in a variety of ways - the cash, the demographics, the growing burden of disease, even the 24 hour society - but it all relates to the last six years of budget growth below wage growth and inflation, combined with increasing levels of demand for healthcare. Each year it gets harder for commissioners to balance the overall budget for their system, and providers have to find efficiency savings of 4-5%. They've all done the easy stuff, and now have to find ways of cutting into the wage bill without reducing the quality of care.

Our mental health and community providers  got less than a 1% uplift this year, but they have to treat more people, pay a small wage increase of 1-2%, and face higher costs on equipment and consumables. Our mental health provider produced a five year plan that added these 4% challenges all together and described a 20% cost pressure over 5 years. It has been unhelpfully translated by the newspapers into a '20% budget cut for mental health'.

These headlines are technically wrong - Norwich CCG for example has increased  its spend on Mental Health in 2014/15, and ring fenced at least that level of spend in 15/16 - but there is a truth at their heart. We cannot pay any of our providers enough to continue with their existing models of care, there is little slack in the system to fund change, and so it becomes increasingly difficult for them to balance the books, and for us to get signatures on contracts.

We have a plan for Norwich that we hope will meet this challenge, and are excited about working with the Kings Fund for the next three years. We will create a whole system model of integrated health and social care for the City - improving  outcomes, reducing costs, and keeping people well, independent, and at home for as long as possible. I believe this is represents our best chance of emerging from this period of austerity with the quality of care protected and our health system intact and solvent, but it will not be easy and we will need to work together to make it happen. And if an occasional workshop brings us together, reminds us of the mission, and creates a space for us to iron out the tensions, then I will happily sit cabaret style with a mug of coffee and some flip chart paper and give it my undivided attention.


The workforce challenge has had less coverage than the money, and yet in some ways it is of greater concern.

In Norfolk and Suffolk 17% of the health workforce are over the age of 55, and are expected to retire within the next five years. I am told by the Local Medical Committee that almost half of all surgeries in Norfolk have at least one GP vacancy. We expect to be 2,000 nurses short of requirements in Norfolk and Suffolk by 2019. We already need 400 more paramedics for the East of England. And many hospital departments - especially A&E, Stroke, Medicine for the Elderly - report increasing difficulty in recruiting consultants.

Unlike the money problem, government cannot simply turn the tap back on. It takes between two and ten years to train people into these various careers; double the number of nursing commissions at Universities tomorrow and they will begin to join the wards, surgeries, and patients' homes in the summer of 2018. Do the same for doctors and it will be later than 2020. The paradox is that although we are training fewer than we need, we are training as many as we can afford.

Health Education England are responding to this challenge -  looking for efficiency savings that will enable them to increase the number of commissions they can afford. Even more importantly they are investing in the training, support, qualifications, and greater recognition for the health support workforce, known internally as 'Bands 1-4'. If we can standardise the training and produce a nationally recognised qualification we could quickly create a large skilled and transferable workforce able to perform a variety of health support tasks, and freeing up the time of doctors and nurses.

I have taught on HCA courses in the past (from new to ready to go can take as little as three months), watched them provide care, and talked to both doctors and nurses about the opportunities for sharing their workload with trained assistants. I believe there is huge scope for reducing the costs of care without reducing quality, and this initiative should be a major part of the puzzle to the workforce challenge we face.

I asked a senior clinician that worked on our Urgent Care Unit trial this winter about what had made it so successful. He talked about the developing relationship between community and hospital staff, the proximity of the unit to A&E, and the speed of treatment and discharge. But top of the list was the Healthcare Assistant that drove frail patients home, settled them in, and made sure they were comfortable and safe. Each journey almost certainly prevented a patient being admitted. This wasn't nursing on the cheap; it was professional and appropriate assistance that made nursing care on a ward unnecessary.

So, money tight and workforce ageing? All hail Bands 1-4!

Diary & Blog W/C 16th September 2013

This week's diary brought to you in iOS7


Very useful briefing from Broadland District Council on the North East growth triangle - ten thousand new homes planned for the northern urban fringe of Norwich. They want to engage with health commissioners to ensure we build this focused population growth into our health service planning. There's always a temptation in these circumstances to define CCG responsibilities, and the new commissioning system (Primary Care isn't us - NHSE are based in Cambridge - that bits Public Health - they're now with the County Council) but I don't do this anymore. I can't explain it or make it sound credible, I can't justify the way it's set up, and it just sounds like I'm ducking responsibility. So rather than show them the excellent Kings Fund video, I just say this:
  • The commissioning system for the NHS has become quite complex, and there are a number of different organisations with a range of responsibilities.
  • CCGs are the local commissioners and we have an overall interest in the health and wellbeing of this population. 
  • We would be happy to a) act as your point of contact and facilitate your engagement with the rest of the system, or b) give you the contact details for the organisations with whom you would need to engage.
Option a) has a 100% hit rate and saves me that feeling of embarrassment when I finish explaining how the system works, they look at me through deepening brow furrows, and ask 'who thought that was a good idea?'


Visit with my Chair to a member practice. Chris is still an active GP Partner but it's really valuable for me to get an informed viewpoint from the front line - the GP workload, the impact of recent changes to community nursing and therapy, access to mental health services, and thoughts on the Call to Action for Primary Care. We will make every effort to visit every practice before 31st March - not with any agenda other than trying to make Clinical Commissioning relevant and interesting to our members. The two things genuinely different about CCGs are clinical leadership and the membership structure. The impact of these differences will only be optimised if all our member practices feel that they are part of the CCG, and that they can work with the Governing Body to improve services and maximise the value of the local health budget.


Two days of discussion on the need for change, and the role of commissioners in designing the new system and driving it through. Chatham House rules were in effect throughout, so I will not name speakers or institutions, but we were able to speak with the most senior leaders from commissioning, regulation, politics, and strategy. CCG leaders were the largest group, and this inevitably affects the subject matter and tone, but the areas of greatest importance and discussion in the sessions I attended were:

The Financial Challenge - the gap between growth in NHS funding and growth in demand for health services (if current trends continue) is in the region of £15-50 billion. Some think it can be done, some think services will decline, some think health spending as a proportion of GDP (and probably taxation) will rise. Nobody - at least out loud - suggested that we could continue to operate the NHS in the way it is currently configured.

Primary Care - Needs a fundamental overhaul, is the key to effective out of hospital care, and CCGs rather than NHS England are far better placed to lead the change. Until GPs can call quickly on resources to support people in their own homes we will continue to bring our frail older patients in ambulances to our hospitals. Nobody wins from this - least of all the patient.

System Reconfiguration - Necessary in some areas - centralising specialist acute care where the evidence on health outcomes supports it, and in some cases closing hospitals where an area has an over-supply, but real concern that politicians and competition regulators will act as a barrier to necessary change.

The Transformation/Integration Fund - The health people were clear - the £3.8 billion is not a transfer to social care, but a ring fenced budget for out of hospital care with joint health and social care governance. Local Government were not in the room to offer an alternative opinion (but some are already using the money in their forward planning to plug gaps in social care provision.). It was also described as petrol poured on the burning platform of NHS finances.

The Quality and Safety of Care - Can the quality and safety of care really be maintained through a period of gradual financial decline?

Competition and Choice - regardless of politics, the original intent of bringing the market to the NHS was to use competition to driving quality and value for patients. Instead 'we have become subject to the perversities of competition law'.


Value as a Currency - in the NEJM in 2009 Michael Porter argued persuasively that commissioners/customers should focus on value (outcomes for patients) rather than inputs or units of activity. He has focused on the US Health System, but anybody involved in NHS Management at the commissioner-provider interface will find this familiar:

'Our system rewards those who shift costs, bargain away or capture someone else's revenues, and bill for more services, not those who deliver the most value.'

Now imagine the transformative effect if our system lifted away the activity payments and process bureaucracy and focussed purely on incentivising and rewarding:

1. Reduced Mortality
2. Improved Quality of Life
3. Faster recovery
4. Reduced incidence of harm
5. Patient Experience

We might do less, spend less, and achieve significantly more. Interestingly we may not need National Policy change - just a willingness from providers and commissioners to agree outcome based funding systems.

Redesigning Out of Hospital Services Around Primary Care - a strong majority view that CCGs should be working with NHS England as co-commissioners to develop a coherent model of out of hospital care based around redesigned General Practice. Some Area Teams have already agreed a 3 year funding guarantee for General Practice - enabling them to step away from QOF, DES and LES payment systems, and have the space to redesign their systems to meet the needs of patients. Invest in a seven day service with community and social care services built around Primary Care and we may be able to develop a model that intervenes earlier, keeps people at home, and reduces the incidence of acute illness that can cost so much in human and financial terms.

There is a huge amount of interesting work going on across the country - as usual I left feeling we should be doing more, but with a phone full of new contacts willing to share their ideas, data, service descriptions, and knowledge.

CEO Diary W/C 9th September 2013

A CCG Accountable Officer has a range of statutory duties, which - if he/she fails to perform - can lead to loss of office and potentially prosecution. Of this long and intimidating list, there are two that are key - which the NHS system rightly expects to be consistently and competently performed:

1. Make sure that the services you commission are high quality and safe.

2. Don't overspend your budget.


The NHS England Area Team chair a monthly quality surveillance group (QSG), which feeds into a Midlands and East Regional group every quarter. I attend personally whenever I can -  it has the potential to add great value to the mission to improve patient safety across local systems. It brings together CCGs, NHSE, CQC, Monitor, TDA, Healthwatch, County Councils, and the Deanery to share information about the provision of care, and - where patterns emerge - consider how best to respond to concerns. Its work is vital to manage the very complex regulatory environment, and - if properly developed - could go a long way to ensure that those recent high profile failures in NHS care are not repeated.

I am very much in the reform camp of the QSG - it needs to develop as a system, and to develop its ambition further. I used the publication of the Berwick Report to set out my thoughts at the meeting this week.

1. It needs to have an explicit and clearly stated purpose - more than any other body of which I am a member, these groups can deliver and should adopt the Berwick Challenge.

'The goal is the continual reduction in harm'
2. It must be more transparent. The QSGs are currently FOI exempt, private, and confidential. I know the reasons for this will have been advanced in good faith (people must be able to speak candidly without fear of sensational coverage or complaints of libel), but in the context of the Berwick Report it seems outdated and ill-judged. It engenders fear by excluding providers from the discussion or the outputs, removes accountability from those raising concerns, damages our credibility when we ask providers to be completely open with us, and limits our ability to engage with providers about early indications of problems.

'transparency is essential - expect and insist on it at all levels'

3. It must empower itself to act. We need a range of measured and proportionate responses to safety concerns, where it escalates beyond the powers of the individual commissioning CCG. Berwick is right that responsibilities for these safety and improvement functions need to be more clearly vested, but we have all the players round the table, and the opportunity to act collectively and with impact.

'All NHS Leaders should place patient safety at the top of their priorities'

The discussion was productive and real progress was made - both in terms of proposals for informing each provider of any discussions or concerns raised, and for providing local supportive intervention before we trigger a Risk Summit from the Region. I hope we are able to implement these for the next meeting, and use them as a starting point to drive forward the patient safety agenda.

The advantages of having a Finance Director with 'system memory' (knowledge of the how the Norfolk PCT managed its books) coupled with real technical competence (detailed understanding of the intricacies of hospital tariffs and contract finance schedules) cannot be overestimated. As we prepare for the next meeting of our Governing Body I am struck by how little time we have had to spend discussing finance, and how much it has enabled us to focus on the interests of patients, the care they receive, and our work to improve the health of the population. To steal a line from McCoy to Spock (and thus reveal myself as an occasional trekker) I have come to trust her guesses more than most people's facts.

She has been away from the office for a few weeks - conducting a detailed exercise on budget adequacy - and we met to discuss the results and her forecasts for the rest of the financial year. I tried to stay with her as we sank into the detail, but the complexity is all but overwhelming. More on this in a moment, but first a little context...

The NHS reforms have generated huge amounts of work for finance teams, particularly where CCGs have different geographies than their predecessor PCTs. In Norfolk the ledger had to split vertically to four CCGs, and every budget line potentially required different methodologies - some generated by actual patient activity, some by weighted population, some by geographical responsibilities, and some by service usage. This is in addition to the horizontal splits that all systems have to complete, to separate the PCT ledger into CCG responsibilities, Public Health, Primary Care, and Specialised Commissioning. And all must be done in an environment where money is tight, everyone has some degree of efficiency challenge, and no part of the system can afford to be out of pocket on the splits. What surprises me is not that our budget is wrong, but that it is not far from being right. (I will leave funding formulas for another time...)

Regular readers of the HSJ and other journals will be aware of two current financial headaches for CCGs - legacy debt and the size of the specialised deduction. The legacy debt derives from legal restitution claims - patients who believe they were wrongly denied Continuing Healthcare Funding during a ten year period up to 2008. If the PCT couldn't fully assess the size of these liabilities it could not make provision for them in its accounts and these debts fall on CCGs. Cases are still being processed (at CCG expense) and we expect the final bill for Norwich to be in the region of £3 million. 

The specialised deduction is more complex. PCTs commissioned some specialised services  which are now commissioned by NHS England. CCGs no longer get the bills for these services, and so the corresponding budget has been deducted and transferred to NHS England. It was a very difficult set of calculations without a great deal of time to put into effect, and it is of little surprise that it is not completely right. We think we have been overcharged by approximately 6.5million - approximately 3% of our budget. NHS England are aware and are conducting their own analysis. I am optimistic that we will get most if not all of this returned, but at the same time we have to make plans to cover this potential shortfall. Although there are going to be difficult conversations behind closed doors there are no villains here - just a lot of people trying to cope with a great deal of complex system change while making sure the right amount of budget ends up in each part of the system.

So Norwich CCG has a potential shortfall (in addition to our 6.5million QIPP plan for this year) of £9.5 million from a budget of 215 million - a little under 5%. Savings of this scale were routine during my time in the private sector, but create a real headache for NHS Commissioners. Simply put, none of the options available to me in previous roles offer much of a solution:

1. I can't change input prices because most are set nationally through the National Tariff
2. I can't generate cost efficiencies in service delivery because I'm the purchaser rather than the producer.
3. I can't cut overheads to a meaningful degree because commissioning is not a particularly expensive activity - the total spend on Governing Body, Management, Staff,  premises, auditors etc. is just over 2% of the budget.
4. I can't reduce programme expenditure - even if I wanted to, I can't stop people visiting their GP, hospital, mental health Trust etc. (and I don't want to - I have no interest in leading an organisation that denies care to those that need it)

The answer is of course to modernise, to transform, to change the pathways of care so that patients get the care they need first time, and in an efficient coordinated way. My team and Governing Body clinicians have no shortage of ideas. The constraining factor is that transformation costs money, and the clinical and financial benefits rarely accrue in the same year as the money was spent. The NHS know this and sensibly ring-fenced 2% of the budget to fund transformation activities. But of course this transformation fund becomes a contingency fund when holes begin to appear in the budget. The majority of this year's transformation fund (£3million of it) has been held back to cover the CHC restitution claims.

CCGs have a real appetite for improving local health services, and for investing for the long term to improve health and wellbeing. We will find ways of doing this while balancing the books. But the next time you read a commentator call for scale and pace it is worth reflecting that the financial reality is that unless there is a good evidence base, we must test innovation smaller and slower than we would wish.

I have been invited to speak at the Commissioning Summit next week in Nottingham - a panel discussion on the £20billion challenge facing the NHS. The numbers are bigger but the principles will be the same - I will share our solutions on Thursday, and hope to bring back with me the solutions of others.