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:

HEALTHY NORWICH

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.

PATIENT OPINION

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...)

NELSON'S JOURNEY AGM

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.

BLOGGING ANNIVERSARY

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:

MONEY

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.

WORKFORCE

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

MONDAY



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?'

WEDNESDAY


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.


THURSDAY-FRIDAY - HSJ COMMISSIONING SUMMIT



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'.

SOLUTIONS?


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.

WEDNESDAY: QUALITY & SAFETY


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.
FRIDAY: MONEY


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.

CEO Diary W/C 2nd September 2013

WEDNESDAY


Operation Domino (our long term transformation project for redesigning Central Norfolk's urgent care system) is moving into its most difficult and most important phase - the partnership honeymoon phase has passed, our short term actions have had important but ultimately limited results, our investments have yet to have a full effect, A&E is full in the middle of summer, winter is coming, and the time for the big long term decisions is upon us. 

At the Urgent Care Board today we achieved an apparent consensus for the concept of an Urgent Care Centre located close to the A&E department of the Norfolk & Norwich Hospital. It would deal with all A&E walk-ins, have access to hospital diagnostics and specialist support, but be staffed by a multi-disciplinary team of health and social care professionals, focused on immediate treatment, but also on delivering or organising packages of care to support people at home rather than on making a hospital admission.

However, there is much work to do in developing a full business case and moving into service procurement: what is the service model, how will it be paid for, how will it fit with existing systems such as 111, and how do we minimise the problem of new capacity generating more presenting demand? The pressure on our current urgent care system is already serious and there is a need for pace; but we are stepping into the relative unknown without proven business and clinical models for the service and if we act with too much haste we risk commissioning a service which could prove clinically ineffective and poor value for money.

On Monday I will be writing to all parties setting out this direction of travel, setting a target for a full clinical and business case to be prepared for the end of November, and asking partners to make space on their board agendas and giving our management lead every support in evidence gathering and analysis. There are hurdles still to jump, but this may be an opportunity for us to leave a lasting positive legacy for the County - a sustainable model for urgent care that is focused on a single journey, high quality appropriate care first time, and which tries to keep our older more frail patients well, independent and at home.


In the afternoon, Norfolk & Waveney CCG Chief Officers met again with Ernst & Young to agree long term options for our commissioning support needs. As reported by David Williams in the HSJ the option of a CCG 'owned' model is an option the BDU is encouraging us to consider, along with a limited procurement exercise next year, and continued support for the existing Anglia CSU model. We were able to agree our core requirements and shortlist of options, and E&Y will now produce a more detailed paper on the merits of each. CSU staff have been through a great deal of upheaval and uncertainty over the past two years, and there is some real talent we need to retain in our local system. I hope that a quick process that protects local jobs and gives a certain future for commissioning professionals will be welcomed by CCGs and the Anglia CSU.

I don't usually name names, but a quick plug for John Farenden of E&Y - we are not the easiest group to herd into a genuine and productive consensus - his work with us to date has been impressive.

THURSDAY


Today was stroke day. In the morning I appeared (alongside the Medical Director and the Director of Emergency Care at the Norfolk and Norwich) before the County Council Health Scrutiny Committee and gave a brief explanation of the challenges facing Norfolk in organising a gold standard hyper-acute stroke service for the county. The work in London was genuinely transformative, but the model is difficult to transfer to an area 70 miles across and served primarily by single carriageway roads; with an ambulance service that struggles to get rural patients to a stroke centre in under an hour; and with a shortage of specialist stroke physicians. We are all in agreement about the nature of the challenge, and our shared commitment to find the right future model. Their decision to form a task and finish group to review services across the county is welcome.

In the afternoon the three Central Norfolk CCGs met with the senior team at the hospital, and the Regional Cardiovascular Network. The meeting was initially very difficult - the medical director of the network set out in forthright and clear terms his concerns about the current hyper-acute service. These were not comfortable messages for either the commissioner or the provider of the service to hear. However, the CCG and the hospital have been discussing the stroke service since March, and the lead physician was able to set out the changes already made and those planned for implementation within the next six weeks:

Recruitment of an additional stroke physician, two specialist registrars and and a fixed term senior grade physician, allowing them to have a full 24/7 specialist rota; joint NNUH/CCG visits to Sheffield and Newcastle to understand and bring back transferable best practice from other parts of the country; additional ring-fenced beds for hyper-acute and acute stroke care; additional nursing posts; dedicated diagnostic slots; better clinical liaison between the stroke service and A&E. 

And for the first six months of the year a standardised mortality rate not only much improved, but now significantly better than the National average.

I left the meeting greatly reassured about the hospital's commitment and their actions to improve the service, but also reflecting on the challenge laid down by the lead physician - 'I can design the very best stroke service, but if there isn't the money to pay for it I'm wasting my time.' (I'm paraphrasing). Is there the money? Norfolk and Waveney has three hyper-acute stroke services. If we had one centre handling over 2,000 suspected strokes every year the London experience suggests the answer to this is 'yes'. But there will have to be leadership, honesty, and hard work from 5 CCGs, 3 Hospitals, the Ambulance Trust, and the Clinical Network to get us there. And then we need to find the money for long term support and re-ablement for those patients surviving and living with the after effects of stroke.


But clinical leaders working in partnership across the commissioner-provider boundary is a powerful force for change, and it continues to be the strongest argument in favour of CCGs. If we can transform urgent care, and the care and health outcomes for victims of stroke - and leave it as a legacy before parliament once again rearranges the deck chairs - I will be very proud to have served.

CEO Diary W/C 12th August 2013

MONDAY



Fantastic news to start the week, and the first major success for the Healthy Norwich project. Back in February we pledged £100k of match funding, and full CCG support to the City Council in their application for a cycling ambition grant from the Department of Transport. Norwich has been awarded £3.7 million as part of a total fund in excess of £5 million to build a cycle lane right through the city. This is not painting a bit of the road a different colour - it is a full transport redesign, that will allow an unaccompanied 12 year old to cycle safely across its entire eight mile route. 

This is a genuine good news story, but I still found myself thinking about a possible media response - is this how health money should be spent? How many pills/operations/nurses would that have paid for? My answer comes from a talk from Dr Thalange - Consultant Paediatrician at the NNUH, and a passionate advocate for lifestyle improvements in the fight against diabetes. He spoke of the obesogenic city, the rise of diabetes in children, and the terrible human and financial cost. CCGs at their best impact on the long term causes of premature illness and death, and in health terms, the return on this investment may make it the single most important thing we have done since we were formed.

On a smaller scale we wrote success letters to 21 bidders for Healthy Norwich micro-funding (maximum £5k) to pay for new projects to advance the Healthy Norwich agenda. There are some great ideas in here, with the voluntary sector the single largest source of bids. Some examples:

- Community Gardening for Homeless Clients
- New local charity to raise awareness and promote self-examination for testicular cancer
- A cycle workshop to help people on low incomes build and maintain bicycles
- Drug, alcohol, and smoking - raising risk awareness in schools
- Support and education for teenage parents

There's a lot of activity and effort here for a very small investment - much of it delivered by volunteers, and I wish every bidder success with their project.

I received an email via our website back in March, from a Norwich resident. She set out in clear, articulate, and dispassionate terms the experiences of her 92 year old father after he fell in the garden and broke his pelvis. It was uncomfortable reading, and highlighted the consequences in very human terms, of how an urgent care system - despite the best intentions of the professionals that deliver it - can fail a patient. I finally met her today, and we spent an hour discussing how her father's health and care had progressed, and how we could use her experiences to improve care going forward.

Her words pre-empted those of the Ombudsman's report - she would not formally complain because the thought of all the bureaucracy, denial, obfuscation that she might experience made it feel like all pain no gain. I don't know if this would have been her experience, but if that is the perception we have a problem. Complaints are vital to service improvement, and patients need to believe that complaints are welcomed, listened to, and acted upon.

However, she is very interested in joining our Urgent Care project, and I hope to persuade colleagues to support her joining our Urgent Care Network as a patient representative. I believe she will add real constructive challenge to our work, the pace of improvements, and the impact of change on patients and their care.

WEDNESDAY/THURSDAY



Met with Ernst & Young - and then the Head of the BDU on Thursday - as we work to develop options for a long term effective and affordable model for commissioning support. We should get an options paper in the next couple  of weeks, amid signs of emerging flexibility in terms of possible models.

I have long been in favour of the concept of commissioning support, because it helps the solve the tension that has been at the heart of so much health system reconfiguration: localism versus scale. In terms of responding to the needs of our population Norwich CCG is about the right size - it serves a city and suburban population of about 200,000 people, people who have homes, jobs, and social lives based in the city. It's a community we can begin to understand in terms of health needs and health inequalities, and we have started to design and purchase services to meet its specific requirements.

However, our main providers cover much wider areas - ranging from the central region of Norfolk (3 CCGs) to the entire East of England (19 CCGs) and much of our contracting and quality assurance work is far less efficient if we do it separately. Reconfiguring services such as pathology or acute stroke care involve multiple CCGs, and there are good arguments that generic technical services such as IT, data warehousing, and invoice processing can achieve huge economies and improved performance from working at scale. And so the NHS commissioning structure (and I have seen this repeated in the private sector as well) - starts small in times of confidence and enthusiasm, and then gradually merging to chase efficiencies, greater control from the centre, and the consolidation of financial risk.

Commissioning support units may therefore offer a way to provide economies of scale, and centres of specialist support, while allowing CCGs to remain small, focussed on local priorities, and able to seek and respond to the needs and views of the community they serve. For true commissioning support (co-design, procurement, contracting, financial and performance management, quality assurance, and business intelligence) an open marketplace is very difficult to foresee - if partner CCGs purchase these from different suppliers it adds rather than reduces complexity and cost. CCGs shopping around also creates significant risk for suppliers, which tends to be reflected in service cost - I know from my time in consultancy that the shorter a contract the higher the daily fee.


So the suggestion that a partnership model may be permitted - based on a long term relationships rather than commercially procured services - is very welcome, and may provide an answer which allows the Anglia CSU to survive and thrive, and enable CCGs to remain small enough to hear and respond to the people they serve.

CEO Diary W/C 22nd July 2013

MONDAY

An encouraging start to the week - our first stakeholder board meeting with Anglia CSU and the Business Development Unit of NHS England. When any provider is struggling you want three key things:

1. They openly recognise the depth and nature of the problem, and accept their responsibility for fixing it.

2. They provide a credible plan, which - if fully implemented - has good prospects to bring performance to the required standard

3. They believe that they can be a high performing organisation, and are determined to succeed.

The CSU leadership team have made significant progress on all three elements, and although the recognition needs to pervade the organisation, the plan needs more detail, and determination needs to translate into results; I have a renewed confidence that our local CSU may yet survive into and beyond the 2014 market testing process. I wish them and all their staff success, and we will do what we can through the fortnightly stakeholder board meetings to support their ongoing improvement.


TUESDAY

A very effective meeting in public with important decisions on quality of care, service design, and finances. The two sections that give me the most satisfaction is our support for the voluntary sector (ring-fencing current levels of investment as a minimum to 2015, and gradually realigning the budget to match our health and wellbeing strategy) and the Co-Production Model.

In the spring of 2012 - during the earliest shadowy days of the CCG - we commissioned the Charity 'Equal Lives' to investigate how we could achieve genuine public involvement in the commissioning of healthcare; to move from 'we design than consult with you' to 'we design it together'. On 5th July we received their report and recommendations (see blog w/c 1st July)

Their central proposal is the establishment of Community Involvement Panels - a group of service users and community representatives to work with us on the redesign and procurement of services. We will be putting their recommendations into immediate effect with a full scale review of community mental health services, leading to a re-procurement planned for April 2015.

The discussion regarding finances was more difficult, with lengthy debate on two important issues. The first is that the Governing Body have reluctantly accepted that we will have to set aside almost three quarters of our 2% transformation fund to meet a legacy debt inherited from the PCT. These are legal claims from patients who believe that they were wrongly denied continuing healthcare between 2003 and 2009, but whose claims were not processed by 31st March this year. This is £2.95 million that should be spent on transforming healthcare, but the books must balance.

Second (and also on the subject of making the books balance) we discussed a more fundamental problem - the simple fact that although we are almost at the end of month 4 we do not actually know what our CCG budget for this year will be. It is officially set at £210 million, but with arguments about the amount deducted for specialised services (commissioned by NHS England) and errors in the 2012 baseline exercise conducted by the PCT, there's a range of about £9 million either way. Our entire QIPP programme for this year is £6.2 million, which gives some idea of the scale of the problem. My Finance Director has planned prudently, but if every decision goes against us we will have a £4 million shortfall, and only 6 months to find the money. The solutions will either be a deficit position, or very unpalatable cuts to services. We will be unlucky indeed to end up in this worst case scenario, but we cannot use a 'cross your fingers' approach to financial planning. The September meeting of the Governing Body may potentially be facing some very difficult choices.

The Governing Body papers and a summary of the meeting can all be found on our website at www.norwichccg.nhs.uk (About Us - Governing Body)

THURSDAY

"You are not a PCT, we are not the SHA, and this is not a performance meeting."

On my experience of them to date, the leadership of the Anglia Area Team are a credit to NHS England. Our three and a half hour checkpoint meeting was professional, well informed, focussed on areas of genuine importance, and saved us hours of box filling by basing the discussion on information already produced for our Governing Body. We were congratulated on having our final authorisation conditions removed, and credited for our approach to urgent care reform and the contract  and relationship management of our local hospital. Where we need to improve they provided us with good practical advice that offered technical and tactical solutions.

The meeting was never cosy, and there was robust challenge on stroke performance (below standard and needing more urgent action), financial planning (we need more contingency planning if the current uncertainty about our allocation all goes against us), and Continuing Healthcare (more pace in the reform of the system). But even at points of disagreement the meeting remained professional, respectful, and good humoured. They recognised that their management of Primary Care had not been good enough in the first quarter, and set out in detail what had been done to put it right for the future.


It's early days in the relationship, and the true test will come when the NHS is under real operational and political pressure. But if we are able to maintain this productive approach I have no doubt that we can develop a culture of transparency, a partnership approach to quality improvement, and slowly rebuild the reputation and public confidence in our local NHS.

CEO Diary W/C 29th July 2013

MONDAY

Meeting with the hospital CEO - this week we just talked stroke for an hour. We agree that stroke services for Norfolk must improve; we're not yet in the same place about money - whether 24/7 specialist stroke care can be delivered at tariff, or whether it needs additional funding. We've agreed to follow the facts, and ask the strategic network to conduct financial and performance analysis on acute providers across the East of England. In the meantime, we will find Trusts with a similarly large stroke service (1,250 admissions per annum) and arrange some joint visits for our clinicians to identify good practice in service management and bring it back to Norfolk.

Stroke is rising to the top of our agenda with the Trust partly because there has been such significant improvement in so many areas - A&E performance (97%), ambulance handover delays (average wait now below 15 minutes, and no more than 1 or 2 60 minute breaches per week), elective waiting list (less than 3% waiting over 18 weeks), MRSA (no cases for over a year), and their level of engagement in whole system improvement. Older and wiser men tell me that our winter planning is the most robust and detailed they have seen in 20 years of NHS management (even as I write this I know they are touching wood, rubbing charms, and cursing me under their breath) and so the quality of stroke care receives a greater and greater focus. 

Like many other people I read the article by Jackie Ashley about caring for her husband Andrew Marr, and recognise that improving stroke care means more than hyper-acute services. The next challenge for our Community Involvement Panel should perhaps be to bring together a group of people living with the effects of stroke to share their experiences, and help us ensure that the support for patients and their carers does not fall away after they have been discharged from hospital.

A plug for Nelsons Journey - a Norfolk Charity that supports bereaved children. They enable children to share their experiences through a series of one to one sessions, and then a residential weekend where they meet other children, share their experiences, and begin to come to terms with the loss of a parent or sibling. The currently receive no statutory funding. The cost of the service is less than £500 per child, and they are hoping the NHS will fund them for the referrals made to them by NHS staff. I am hopeful that our review of voluntary sector funding will release sufficient funds for us to provide them with some support.

WEDNESDAY

There is a guilty pleasure in having two days in the office with almost no meetings in it. The NHS does a lot of its business through meetings - we review information and proposals, keep people informed and on board, make decisions, and take away actions. We agree to meet every 2, 4 or 8 weeks, then go on to the next meeting and do it again. Before we know it the follow up meeting has arrived and we often haven't acted on the decisions or undertaken the actions, because...we were in meetings. On bad weeks it can feel like the Winnie the Pooh quote

'...coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.'

It was nice to stop bumping; clear the inbox, catch up on the reading pile, and have some thinking time.

FRIDAY

Workforce Planning in Norfolk (I don't know about the rest of the Country) seems to have historically been treated by Commissioners as a 'provider issue'. The current shift towards measuring providers on outcomes takes this even further as we become less involved in their methods and more focused on their results.

But I suspect the real reason we haven't got involved is that it's really, really difficult.

If you ask non PbR providers to describe workforce needs they will look at their block contracts, their efficiency plans, perhaps their Foundation Trust business plan, and predict a reduced community workforce of 5-10% less nurses, physios and OTs. 

If you look at the commissioner 'plans on pages' there are ambitious proposals to move care closer to home and we need an increase of 5-10% in community based health professionals. If we don't get this then recommissioning will be futile, because we won't have the workforce to deliver the new service.

If you look at population predictions about how many people will need nursing care - from public health and the RCN - you get an increase of 10-20% over the next five years.

We haven't yet factored in current vacancies, planned retirement, maternity leave, university dropout rates, career changes....

What I didn't realise (forgive me) is that we can't afford to increase university places for nurses, physics, and OTs by 20%, because the NHS fully funds the degree course and pays an annual bursary to many of approximately £9,000 per annum. And at c£60,000 investment for every nurse we train, we need to train the right number, which is somewhere between -10% and +20% of the number we commissioned last year...

I'm too ignorant to comment on this with any confidence (so please explain it to me rather than take offence), but I was surprised that - in an NHS where cash is tight, and the market is our anointed solution to quality and efficiency - we are using such expensive command and control planning processes for workforce. Personally I'd like a little less market in my commissioning (where it seems to add more cost and complexity than efficiency and quality), and a little more market in my workforce.

This was my first briefing as deputy chair of the Norfolk & Suffolk Workforce Partnership, and my head is still spinning slightly, particularly from the comment 'you can only really do effective workforce planning on a continental level'. Perhaps this needs some thinking time the next occasion that I stop bumping...

CEO Diary W/C 5th August 2013

MONDAY-WEDNESDAY

This is not a job you switch off from. This can make it sound like a burden, but it's more that the complexity, challenge, and potential to make a difference is a constant stimulus. I spent 12 years in health management consultancy, and I would struggle to identify examples of real social value in my work. This feels like it matters.

This preamble is to justify (and hopefully normalise!) how pleased I was to be on leave and be able to read the Berwick report in full and at leisure, and watch the response to it through Twitter and email alerts. The report received quite a polarised response - outside of the official 'we welcome this report' messages. I understand that there is a degree of report fatigue, and a cynicism borne of experience that says 'we've heard this talk before, where's the action?' but I would say that Don Berwick has produced a report of clarity, importance, and huge value. 

Some commentators have criticised the report; that it is long on narrative and short on decisive action, that it contains nothing we did not already know. I think this misunderstands what the report is trying to do. This report is a mirror that shows us as we are, and does so in a clear and persuasive voice that can be heard in the heart of government. It is for every NHS leader to read, understand, reflect, and act - if these problems and solutions are already known and understood, why haven't we acted? We cannot sit back and wait for someone to fix it for us.

There's a great deal of substance in its 46 pages, but these are the key points I take from it as a commissioner:

1. Problems with patient safety are endemic to the NHS and all health systems. Behaving as though Mid-Staffs is an anomaly is self-delusion; It is at the extreme end of a continuum of avoidable harm. We must ALL do better, and better means the continual reduction in avoidable harm in every local system.

2. The supremacy of performance and financial targets - and the culture of blame and fear used sometimes to ensure their delivery - is deeply corrosive. Staff want to care and be proud to do it well. Leaders must refocus the agenda back to patient safety, and create the environment, support and training, to foster success.

The two sentences in the report that really struck home are: 

'If the system is unable to be better, the aim becomes above all to look better, even when truth is the casualty.'


[solution: absolute transparency, and the involvement of patients, carers, community leaders at every level of the local NHS system]

'Responsibility is diffused and not clearly owned. When so many are in charge, no one is.'

[solution: while we wait for central government to consider any future rationalisation of commissioners and regulators, locally we can coordinate our patient safety work - sharing information and acting collectively to improve patient safety]

The CCG has always identified quality and safety as its top priority, and regularly reviews and debates these issues, but we can do much more. My Quality Director and I will be taking a summary of Berwick and some specific recommendations to the Governing Body:

1. A CCG safety strategy, that systematically identifies key areas of avoidable harm, sets clear goals for harm reduction, and works to support providers to succeed in harm reduction.

2. Greater involvement of patients and carers in our quality and safety improvement and assurance systems.

3. Training available for all on the modern tools for safety assessment and improvement - our staff, Governing Body, members of visit teams, our member practices

4. Further investment in the promotion and operation of our feedback and complaints systems - Patient Opinion, SickAdvisor, NHS Complaints, Public Meetings.

5. Refocus the patient stories at the beginning of each GB meeting on key areas of avoidable harm, and use them to question the performance of the Norwich system.

These measures - in addition to the systems already in place - will have a significant impact, and are not dependent on national action or changes in policy. Every right thinking leader will have looked at the horrors of Mid Staffs and said something like  'not on my patch, and not on my watch.' Berwick tells us how.

THURSDAY

It was timely that my first day back was at the Quality Surveillance Group - a monthly meeting chaired by the NHSE Area Team, and attended by all those organisations that make up our 'diffuse' system of responsibility: NHSE, CCGs, CQC, Monitor, TDA, Healthwatch, and the local Deanery. We share information about the healthcare providers in our system, identify concerns, and where appropriate conduct greater levels of surveillance, or in more serious cases recommend to the Region that a Risk Summit be initiated. The group has the potential to be an effective local solution to the diffuse regulatory and assurance system, and there is much to commend about the way in which information is shared and analysed.

However, I have asked for the Berwick report to be reviewed at the next meeting because there are things it must do better:

1. The meeting is confidential and FOI exempt. I was never comfortable with this (we promote complete openness from our providers but then have confidential meetings where we talk about them and where they have no voice) but in the light of the Berwick recommendations it seems indefensible. Every document and comment shared in our quality surveillance process should be shared with providers and subject to public scrutiny.

2. The attendees need to be trained in safety assurance and improvement - many of us (me included) are well intentioned amateurs, bringing information, experience, and I hope common sense to the discussions, but we do not yet have the expertise to ensure our actions are fully effective.

3. We need to have more tools beyond the current two (enhanced surveillance, and recommend a Risk Summit), which can feel so limited that we are at times doing little more than hand-wringing. There is further local action we can take to support commissioners and providers

Berwick asks us to rank the elements of quality as defined by the NHS. Patient experience and effectiveness of care are important, but patient safety - avoiding harm from the care that is intended to help - must be the No.1 NHS priority. This I can understand, explain, support, and demand. The Francis report was a long sobering read, the Keogh review a pragmatic and excellent process, but Don Berwick has given me a 'light-bulb' moment of clarity about the fundamental purpose of NHS leadership.

Diary & Blog w/c 26th May 2014

YOUR NORWICH

The hospital contract is agreed, the pain has been shared, and hopefully ink will be on the page early next week. The late stages of contract negotiation have similar rules to those of Fight Club, so I will not touch on the discussions at all. It is enough to say that the deal is done, relationships are largely intact, and we can move forward with our transformation plans for the City.

Operation Domino has been a real success in getting organisations to work together and reduce delays in the urgent care system, but the next big challenge is reducing the number of people who become acutely unwell in the first place. And if we can't reverse the growth in hospital admissions with real pace the whole system is going to run into serious financial and operational problems. So we need to act at whole city scale, getting services mobilised this year, and make significant investment with belief but no certainty of success.

Next week we'll be launching 'YourNorwich' - our five year plan to create joined up community health and social care services - the Eastern Daily Press have very helpfully trailed it for us here.

We hope it will be a transformation triple: first bringing health services together around clusters of GP surgeries; second developing unified health and social care pathways; and third a major step forward in the way in which we design services in partnership with the people they are designed to serve. Health and care designed for you with you.

The formal launch will be at our AGM on 24th June (Open Norwich, London Street, 10am), and if you're a resident of Norwich please do come - we'll do all the statutory bits in 45 minutes and then throw the meeting open to the public - not just to debate the issues, but to set the agenda. Mental Health Services? Residential and Nursing Homes? Access to your GP? Healthcare out of Hours? Patient Transport? You decide and we'll facilitate. Every project will then have a community panel to develop the services in partnership with local clinicians. Your health, your care, your taxes. YourNorwich.

SOCIAL MEDIA PIONEERS

I opened up the HSJ supplement looking for tips on how to use social media to better connect with the public - I have 1,600 twitter followers but only 25% of them are Norwich residents, and having a transparent organisation with an open door approach to engagement is always limited to the number of people who know they're welcome and take the trouble to stop by. It is not false modesty to say that I believed that my tweets and blogs were moderately successful, and fairly standard - particularly as I pinched the whole idea for publishing a diary and a weekly account from Mark Newbold.

So, genuinely surprised, faintly embarrassed, but also very pleased and very grateful to find my name in there, and in such company. Annie Coops is a champion of social media, Teresa Chinn started a movement, James Titcombe has turned tragic and avoidable loss into a determined, balanced, and very dignified campaign to raise safety standards across the NHS.

And where do you start when describing what Dr Kate Granger has accomplished? Me, I tweet a bit, publish my diary, and blog about my week. The important thing for me is that it has validated the effort of waking up on a Saturday and writing even when nothing flows, and given me the encouragement to keep going and raise my game. So thank you to Andrew, Shaun, Emma, and Jenni - it was a lovely surprise and I'm still smiling.

The names are in alphabetical order and so it is entirely luck that I've ended up with the staple through my picture, just behind my right shoulder. This has, however, caused some hilarity in the office - Emma Maier has apparently made me a Health Service Journal Centrefold (I like horse riding, sunsets, and world peace).

Fortunately I'm in Liverpool most of the week for the NHS Confederation Conference, and will not have to bear further teasing. And I hear Kate Granger is speaking. Wonder if she'll autograph my copy?