The Workforce - the sixth priority

In reality the Sustainability & Transformation Plans (STP) are all about reducing costs and in the NHS the cost of the wonderful staff is the biggest part of the overall cost to providing care.  So any good planners will be taking a close look at staffing costs and performance.

Prioity 6 for Buckinghamshires STP is:

"Establish a flexible and collaborative approach to workforce."

Their initiative is:

"A shared workforce plan to support rotation of staff across organisations to increase quality of care and staff retention."

Motherhood and apple pie! The NHS locally has been talking about improving retention of staff for years yet it is still a problem. Staff morale is low. Staff select to wok in some areas and avoid others. Much of the care is provided by locum staff rather than permanent staff.

In Buckinghamshire we have been short of A&E consultants for many years. GPs and Practice nurses, District Nurses and other specialities are also Report vacancies.

So there suggestion is to share staff across different trusts. But as the nurse taking my Blood Pressure on her evening ward round said: "Every trust is in the same situation. Every day I get asked by an agency to work for more money"

We need more permanent staff!

We need to have enough staff to cover illness, holidays, training etc.

There have rumours that across the STP, that is in Bucks, Oxfordshire & West Berks, £34m is to cut from staff budgets. This figure is in the published document but they do not explain how this will be achieved. As I type this on Christmas Eve they are trying to move an experienced nurse from my ward to one that does not a enough staff. This is dangerous. I do not know the outcome of the discussion.

This is the reality of 21st century hospitals across the country.

I do not think that this priority has a viable solution yet.

Improving Mental Health Services - the fifth priority

Mental Health Services have to be specifically included in the Sustainability and Transformation Plan for Buckinghamshire.  These services are already provided across Buckinghamshire by a range of providers, the main Trust covering both Bucks and Oxfordshire already.

The priority for the Clinical Commissioning Groups (CCGs) is:

"Mental Health development to improve the overall value of care provided."

They describe this as :

"Develop a network of providers of specialist mental health care across a larger footprint of STPs coordinating inpatient and community based services."

What do I think this means?

Well this is a guess but I reckon this means they want to increase the number of organisations that provide specific services. They want to do this across a bigger area than they do at present. This might mean that patients have to travel further for their mental health care.

They realise that this means an increase in the number of organisations providing services and that they will be spread across the SE of England. This in turn means that this care needs to joined up and seamless. Good communications are essential as is an improvement in transport for patients across our poor road & transport network.

Do they have the resources to coordinate the fragmented nature of this care? Will they be able to influence the Councils responsible for roads and public transport to improve the roads and buses?

I am not sure!

Collaboration between the three acute trusts - the third priority

The third priority is something to do with supporting the three acute hzospitals in the area to work together.

"Collaboration of the three footprint acute trusts to deliver equality and efficiency".

The CCGs description is:

"Consoloidation of backroom services to ensure high quality and optimise cost effectiveness".

What do I think this means?

To be honest I have no idea but I will try to guess.

Firstly what are the three acute trusts? I assume they mean the hospitals in Oxford , Reading and Buckinghamshire Healthcare (Wycombe & Stoke Mandeville Hospitals). At one time they were meant to be independent and in competition with each other. But things change and now it seems they have to work together to reduce costs.

What do they mean by backroom services? I assume that they mean the services that we, as patients, do not see but are vital for quality care. One service that could be ripe for consolidation (or centralisation or merger) is pathology. These staff in this service do all the diagnostic tests, the blood tests and tissue samples, that help Doctors identify what is wrong with us.

I used to work in pathology and I used to spend hours commuting on the train talking with a colleague about turning pathology into a large industrialised process.  He later went on to work on doing just that and it can work at large scale as long as there is a good courier system and good communications between clinicians and pathologists.

Other services such as personnel (AKA Human resources) and finance could also be consolidated.

What we really want though, is more information and more detail. There are stories that they want to reduce the number of nurses as well as 'backroom' staff.  But that seems crazy as we need more nurses not less for quality care. Of course the real question is can the three trusts work together for our benefit?

So what does this mean for patients. Hopefully it will mean more money for our care but who knows!

Access to high quality care - the Second Priority

The second priority area for the Clinical Commissioning Groups is:

"Access to the highest quality Primary, Community and Urgent Care".

They explain this in their words as:

"Create robust out of hospital services operating from community hubs and coordinated by GPs to maintain independence of elderly and frail patients in their own homes"

What do I think it means:

They do not want so many elderly and frail people in expensive hospital beds. They want to improve the care and support that people receive in the community. There is a widely held opinion that people want 'care closer to their homes' and this is their way of providing that care.

During 2016 there were a number of engagement events run by Buckinghamshire Healthcare NHS Trust called 'Your Community Your Care' where they asked our opinion on what sort of services could be provided outside the hospital. The Trust provides community services as well as acute services.

The different groups of people from different areas of Buckinghamshire provided different thoughts on what they wanted. Most of us thought it was a good idea and should include a wide range of services either based on a building or as a virtual service.

But at the moment there is no clear description of what a community hub would be like, or who would provide it and who would run it.

For a few years before 1999 GPs offered a wide range of services from their surgeries but that came to an end when yet another of the redisorganisations of the NHS took place. District Nurses, Health Visitors, Midwives and other care workers were based around GP surgeries. Now they form teams and don't have the links they used to have with the GP surgeries.  So recreating those teams with lots of different care staff all talking to each other and working together sounds like a good idea.

There are already community hospitals in some parts of the county but not in the big population centres such as Aylesbury and High Wycombe. Will the CCGs be able to fund a base or will the community hub just be a virtual group in the big towns?

Will the Trust be able to employ the right staff given the problems of recruiting healthcare staff in Buckinghamshire. The salaries are higher in London!

This idea could work but it assumes that the GPs are willing to take on the extra role of coordinating the care?

There should also be a big role for the voluntary organisations and charities who already provide a lot of support for the elderly.

The CCGs hope this will reduce the attendance at A&E!  But they have said that many times before and the numbers keep going up.

We need to see the detail of this idea before we can say if it will really achieve the results they want.

Added 21.02.2017

The problem with putting this idea into practice is the need to find the money to set up the new Community Hubs while at the same time keeping the patients in hospital. You cannot stop people going into hospital or transfer them out of hospital until the services are available in the community to look after them.

As I understand it there is no extra funding for Buckinghamshire for this new service

From treatment to prevention - The first Priority

The first of Buckinghamshire's priorities is to "Shift the focus of care from treatment to prevention".

The Clinical Commissioning Group has describes this as:

"Each and every clinical contact to include brief advice, supported by face to face, phone and web based behaviour change support. Build on existing asset based approaches."

What I think it means:

Everytime you see a Doctor, Nurse or other healthcare professional you will be told to eat sensibly (less?), take more exercise, drink less and to stop smoking. You will be encouraged to use an App or website to help us change our behaviour.

Hopefully they will even support patient led groups & community groups to do the same.  I asume these are what they mean by "asset based approaches" i.e using people to reinforce their messages.

This seems a good idea but it will take a long time before any improvements are detected. The Public Health departments in the County Council should be funded properly to support this work. Will the council do that?

I am not sure that busy Doctors and nurses will find the time in our appointments to keep nagging us.

What is STP and what does it mean for Buckinghamshire?

The STP is is short for Sustainability and Transformation Plan. However I guess that doesn't really help does it?

Well it is really the last hope we have to save the NHS because the Government does not want to spend any more of our tax on our healthcare. So instead they want to split England into 44 regions and have told these regions to changes the way services are provided. Our region includes Oxfordshire, West Berkshire as well as Buckinghamshire. But really our plan is a Buckinghamshire plan.

Apparently if we continue to carry out healthcare activity in the way we have been doing it over the last 20 years it will cost £107 million more over the next 5 years than we have money to pay for it. The costs will be much more than our income!

The aims of the plan is to improve outcomes by 2020/21.

The Bucks plan has seven priority areas.

I will try to  explain what they mean - but I cannot promise that my view is the correct one so I suggest you write and ask for the official version.

The Famous seven are:

"Shift the focus of care from treatment to prevention"
"Access to the highest quality primary, community and urgent care"
"Collaboration of the three footprint acute trusts to deliver equality and efficiency"
"Maximise value and patient outcomes from specialised commissioning"
"Mental health development to improve the overall value of care provided"
"Establish a flexible and collaborative approach to workforce"
"Digital interoperability to improve information flow and efficiency"

You can see that the language is a bit 'management speak' and I will try to explain what I think each one means as best I can. I will do a separate blog for each priority.

I write this on a ward in a specialist centre as I wait for my operation tomorrow. I hope that I will be able to complete all seven blogs over the next week as I recover.

How have the public influenced commissioning of healthcare in Aylesbury?

I asked my local Clinical Commissioning Group (Aylesbury Vale CCG) a question about providing examples of how the public has influenced commissioning in advance of their board meeting in public on Thursday April 10th.

Here is the reply from their clinical leads:

My Question: Can you please give examples of where the voice, opinions and experiences of patients and the public has influenced decisions made when commissioning services?

Christine Campling:

We did extensive public consultation on the inter mountain project by focus groups and questionnaires. There was full support for changing the range of options on outpatients to a mixture of face to face, telephone and Skype like consultations. We are currently running questionnaires on pain clinic projects, as we are redesigning the pain pathway.

Stuart Logan:

We have met with Patient Groups in the South Locality for their input into Live Well particularly the Haddenham Patient Participation Group.

We are involving Diabetes UK in the diabetes service redesign. They will have patients at the Stakeholders meeting in May inputting into the redesign process from day 1.

Juliet Sutton:

When they were doing a full review of Occupational Therapy and Speech & Language Therapy services for children, they went out and spoke to a lot of parents of children using the service.  Parents wanted shorter waiting times, a more responsive service, improved technology and access to health professionals in settings closer to them e.g schools and children's centres. All these views were incorporated into the new service design and there have been great improvements in the service since then. The children's physiotherapy service is currently under review and once again the views of parents and carers are being taken into consideration when making recommendations for service improvements.

We are currently undertaking a review of the services provided for children with complex needs/disabilities. Parental feedback is a large part of this process and their comments are being taken very seriously when planning future more integrated care. Single point of access is a recurrent theme from the feedback we have received and this will be one of our main objectives with future recommendations.

Lesley Munro-Faure:

commissioning plans are driven by localities and each locality has members of the public sitting on them who input into all the decisions that are made.

My comments: 

I had hoped that I might get a list of things the patients & public has said or suggested and a another list showing what the CCG had done as result of the comments from patients. 

I had also hoped that I would get examples showing actual changes in how services are commissioned instead I seem to have got examples of consultations & involvement in redesigning services. And there is nothing wrong in seeing examples of patient participation in redesign.

There are examples of good work especially with the work done by the therapy services for children.

The last paragraph of their reply puzzles me.  There are three localities in the CCG and I know that one of them does include members of the public in the group.  But the other two locality groups consist of clinicians only.  Anyway this last paragraph does not give examples of how the public have influenced commissioning.

I will follow up this answer at the board meeting and I will blog about it if anything new is mentioned.

It’s the patient experience, stupid!

I have always thought that the main role of local Healthwatch was to collect the experiences of patient using the health and social care services.

But one of their board members is quoted in the minutes of their November board meeting as saying

 “Healthwatch Bucks could make a business case for the integrated collection, analysis & reporting of patient feedback across health and social service provision in Buckinghamshire”.

http://www.healthwatchbucks.co.uk/sites/default/files/board_minutes_11th_november.pdf

So why does this board member think Healthwatch Bucks needs to make a business case to do what it is contracted to do anyway?  By using the words ‘business case’ he is suggesting, in my opinion, that they should seek funding to do this job. 

They should be doing it now as part of their primary function, not asking for more funds!

I wonder if he has seen what Healthwatch Buckinghamshire says on its own website.

This statement is included as part of their ‘What we do’ section on the Healthwatch Buckinghamshire website

“Collect data and stories about the good and the bad, so we can use evidence based criteria to influence commissioning and policy.”

They expand on this theme in their ‘What will Healthwatch do’ section of the website:

“….seek the views of people about their needs for, and their experiences of, local care services.”

“Examine the quality of local health and social care services.”

“Make the views of local people known, and reports and recommendations about how local care services could or ought to be improved, to people responsible for planning, providing, managing or scrutinising local care services.”

http://www.healthwatchbucks.co.uk/

Even the CCG has something to say on the issue:

In their draft paper on the Review and Development of our (AVCCG) Commissioning Intentions they say:

“(the CCG will) Work closely with Healthwatch to expand the feedback we receive on patient experience from direct observation and feedback from patients, clinicians and the public including those from hard to reach communities. “.

http://www.aylesburyvaleccg.nhs.uk/wp-content/uploads/2013/10/GB-2013-10-4b.pdf

It is high time Healthwatch Buckinghamshire stopped talking and got on with its primary function.

Go out and collect the experiences of patients and carers of health and social care service provision.

My questions at the AGM (Buckinghamshire Healthcare NHS Trust)

In the previous blog I gave my own highlights of the Buckinghamshire Healthcare NHS Trust AGM.

After the Chief Executive gave her presentation and the finance director gave his summary of the financial situation we heard from the leaders of the emergency surgery teams. They described how they had changed the service, what is called reconfiguration, and how the new service was producing better outcomes for patients & reducing mortality rates.  Good news.

At the end of the event there was time set aside for the public to ask questions.  I have no idea how many members of the public were present but I was virtually the only person who asked questions. 

Why is it that people don’t ask questions in formal board meetings?  I reckon most people know the answer to that one.

I asked a couple of questions:

The first was about the campaign to restore an A&E department to the High Wycombe Hospital site. A petition with 16,000 signatures has been organised.

There are 16,000 people in the south of the county who believe that there should be an A & E on the Wycombe Hospital site.

Can I ask that the Communications teams from the Clinical Commissioning Groups and the trust remind us, on a regular basis, about the good clinical, organisational and financial reasons why, in the present circumstances, there can only be one A & E in the county?

This is an on-going issue for those who live in High Wycombe.  The A&E department was closed in 2005 after a public consultation and replace with a minor injuries type of service.

As we know from other examples of such closures the local population is incredibly loyal to their local hospital. MPs too! So the story here is how to sell the difficult and complex reasons, hopefully evidence based, for such closures.

In my opinion the only way to tell the story is to keep it simple and be persistent.

However the audience was asked what else could be done to explain the reasons why there are only resources for one A&E department in the hospital.

My suggestion is that the leaders of the campaign should meet with senior clinicians and managers (and the commissioners) to have an informal, facilitated discussion and look at the evidence. 

As for how to improve the conversation between the hospital executives and the patients is something to explore in another blog.

*****************

The second question I asked was about the way they manage complaints.

Can I ask that the board measures its performance on managing complaints by using the following as outcome measures?

a)    Is the complainant satisfied at the end of the process

b)     has the trust learnt from the complaints  

c)    has the trust acted on the learning.

Normally the first thing that the board reports is that they replied to people within the required time. This is important of course, but I reckon that most people would say the best test of a good complaints service is: was I happy with the result?

  I hope that the trust may consider that a different approach will improve the way people think about the way complaints are managed.

They expressed some interest in this approach and said that they are trying to do something like this.  They have been contacting people by telephone after the complaint has been closed, especially complex complaints. But they have not been recording this activity. It sounds as if they are looking to improve the experience of complaining.

They did say that they get many more accolades than complaints. This is good to hear. 

How can the public hold Clinical Commissioning Groups to account

I think that 'holding to account' means that the public must be confident that the Clinical Commissioning Groups (CCGs) are answerable to the public and patients for the decisions they make on our behalf.

The sorts of decisions they will be making (maybe they have already made them) are:

• What healthcare do we need.
• How much.
• The quality of the care
• Where the care will be delivered and by whom.
• How long will it take to get treated.

There will be over 200 CCGs.  Our is a small one with only 190,00 people and a budget of about £200M.  Others will be much bigger and responsible for very large sums of public money. So it is crucial that they use this money for the benefit of their local population and get value for money.

So how can we hold these organisations to account.  It will not be easy as individuals to do so.  Organisations of this sort can hide behind a number of barriers. They use the Freedom of Information Act to delay answering questions.  They can also use the idea of 'Commercial Confidentiality' to avoid giving answers about the value of contracts, especially with private healthcare providers.  They also use jargon to confuse us.  Lastly one of the ways to ask them questions is at board meetings held in public and that isn't easy for many people. It isn't much fun standing up in from the board and holding them to account.

However there are a number of ways that the public can make sure they spend our money wisely and on healthcare that will benefit us.

Ask questions at meetings

CCG boards will have to hold their meetings in public and publish the board papers online.  Go to meetings and ask questions. CCGs will also hold other so called 'engagement' meetings so please go along and ask awkward question. 

Join your Practice Participation Group (Patient Reference Group)

Each GP surgery should have a group of patients, perhaps as an virtual group, who support the practice in many ways. They can ask questions of the GPs who in turn can ask questions of the CCG.  Our CCG intends to have a Patients Forum with one person from each practice participation group on it. Exact details are current unknown. The patients will need to set the agenda not the CCG.

Service User Groups

If you have a long term condition join the service user group/support group or set one up.  They may be able to ask questions about specific services as they are often considered as 'experts'.  These groups are often used when services are being redesigned or changed. 

Local Healthwatch

These groups will be taking over the role of the Local Involvement Networks on April 1st. They will act as the patients champion  and should be seeking the views of patients and the public about the health and social care services. They will be monitoring the quality of services and holding the CCGs to account if the services are not benefiting patients. These groups will be as new as the CCGs and will take time to become effective. Anyone can join a Local Healthwatch and support their activities.

GPs

Our CCG intends to have an 'accountability forum'.  Each practice will have a GP on the forum and their role is to hold the CCG to account on behalf of the GPs and the practices. Even more reason to get involved in your practice participation group so you can influence the GPs.

Local Health and Wellbeing Boards

This is a joint Council & CCG body that is responsible for strategic thinking and priority setting for health and social care. A lay person from the Local Healthwatch will be a member. CCGs should be answerable to the board to show it is matching commissioning to the health needs of the population. How it will hold the CCGs to account remains to be seen but it could be quite powerful.  

Health Overview and Scrutiny Committees

This is a Council committee that monitors the commissioning and delivery of services and can hold the CCG to account.  The meetings are in public and you can go along and ask questions.

CCG Governance procedures

CCG are required to hold meetings in public, publish their papers online and to publish the methods they use to make decisions.  We should make sure that they actually do use those methods when making decisions about our healthcare. There will be much talk of the use of 'evidence' and we need to make sure they use all the evidence and analyse it in a consistent manner. 

Lay people on the CCG board

Each CCG is required to have two lay people on the board and one of those must act as 'the patient and public involvement' champion.  Find out who it is and make sure they act on our behalf.

NHS Commissioning Board

The new NHS reform act makes sure that the CCGs will be accountable for their performance to this national organisation.  But there is nothing in the act to make the CCGs accountable to us.

Monitor

The CCGs will be accountable to this national organisation for their financial performance.

Conclusion

Those of you who have read my previous blogs about patient involvement might notice some similarity to this one. I feel this is inevitable since the two processes of involvement and accountability are two sides of the same coin.  Both rely on good communication and trust. The same limited number of organisations are going to be active in the involvement process as well as the accountability process. 

Meaningful and effective involvement of patients, at an early stage of decision making, and in a sustained manner throughout the process will enhance the trust that the public have in the CCGs.  The accountability process will follow naturally from the involvement of patients and the public in decision making. 

There seem to be very few ways in which individuals can hold their local CCG to account. So it looks like you will need to join one or more of the organisations mentioned above if you want to make sure the CCG does what it is meant to do and 'make no decision about me, without me'.

The trouble with joining an organisation is that you hope that the person representing you is able to stand up to the CCG board.  Will the CCG take more notice of that person than the opinion of an individual?

Lets hope that the evolving CCGs will be different from the old PCTs. and that they will act in an honest and transparent manner so we can be assured that they are working on our behalf.