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.