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.'
'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.