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.