I have a rare disease - Angiosarcoma

I have a rare disease

That should be I ‘had’ a rare disease as I finished my treatment three years ago and I am still clear of the rare cancer called Angiosarcoma that was found on my back.

I am lucky in that my wife, family and friends were here to support me. But I was also used to life in a hospital as I had worked as a biomedical scientist in a London teaching hospital and as part of my job I used to go to the wards and operating theatres.  I was used to the language & terminology of medicine.

This background of working in healthcare meant that I was not really anxious about the new situation I found myself in in autumn 2016 when I found out that I had cancer.  Yes, I was a bit worried but I was positive that I would be back to doing the things I did before cancer as soon as I could.

I can understand how people get very emotional about getting a diagnosis of cancer and going into this rather alien environment that is a hospital. I spent about ten days on the ward and I used to chat to my fellow patients and some of them were very anxious.  It is scary being on your own, away from family & friends, especially if you were in a specialist centre a long way from your own home as we were.

This sense of isolation that someone with a rare disease feels is one of the important lessons I learnt from my experience. Even on the ward of this specialist hospital we were all in different situations and different stages of our life with disease. Some had been in and out of hospital over several years with complications. All of us had had life changing experiences. (I almost forgot that I was in the same situation as them and typed ‘them’ instead of ‘us’!). 

I found myself observing the activity within the ward, watching the interaction of staff & patients.  I had spent some time working in change management in the NHS & in quality improvement. Here was my opportunity to experience it first-hand. It was an interesting experience being a patient and then as I recovered, an observer.

The thing that made the biggest impression on me was the need for good communications about what was going to happen to us and also the need for emotional & psychological support for both patients & relatives’/carers while we are in hospital & on our return to our home. 

It is a shock being told you have cancer. It is a shock going into hospital. It is a shock going home.  When you have a rare disease, it is an even bigger shock as there isn’t any local knowledge about your condition. Clinicians may only see one example in their working lives and that is you!  You probably know more about it than they do.

By the way I discovered that a friend of 45 years also had the same cancer as I did so perhaps my statement is a bit of a generalisation.

So, these are my thoughts on Rare Disease Day Feb 29^th 2020.

Please provide more emotional & psychological support for rare diseases.

What is the Buckinghamshire Integrated Care System?

I attended the Buckinghamshire Health and Social Care Integration Summit in November 2017 when the new Integrated Care System was discussed by representatives from the local authorities, health care system, local charities & the voluntary sector and some members of the public (me included). 

Sadly the presentations went over time so there was no time for questions (not good!) but I did send my questions into the organisers.  I have now received the response to those questions.

Of course the name of the new system has been changed in the meantime.  However the purpose of the new system remains the same.  So for Accountable Care System (ACS) please read Integrated Care System (ICS).

Q1. Is there any extra funding for Buckinghamshire ACS to invest in Public Health & community services?

Answer: NHS England is offering Accountable Care System (ACS) transformation money to support us to meet our priorities and go further, faster. Opportunities to bid for further funds do often arise.

In addition to monies that may be made available through the ACS, we are investing £1 million in community services, bringing together nurses, therapists, social workers, GPs and other relevant organisations to provide 24/7 cover for people who need the greatest health and care support and give them better, more coordinated care in their homes. 

Q2. ‘Accountable’ to whom? How can the public hold this new organisation, which most know nothing & were not consulted on, to account?

Answer: The ACS is not a new organisation, it’s about further developing our system way of working, which supports:

•       Joined up working between health and social care services to provide better care and help people to stay healthier

•       Staff to work together easier across our provider and commissioner organisations

•       More local control and freedom to make decisions

•       Extra support to go further and faster in improving services

It will allow us to have stronger local relationships and partnership work based on common understanding of local priorities, challenges and next steps.

Q3. How will the public know that the ACS has achieved its purpose, indeed what is its purpose?  What baseline measures do you have for outcomes, organisational, financial and patient outcomes, so we can compare the improved public health & other outcomes in the future?

Answer: The purpose of our system working is to achieve our vision for “One Buckinghamshire, one integrated health and care system”, by further developing our community-focused approach to integrating services and collaborative working across the county. 

We have a track record of success on working collaboratively to improve quality, transform service models and build financial sustainability. Some of our successful working to date includes:

A system wide Primary Care Strategy,  agreed in 2015 and with strong clinical leadership across primary care that has seen the development of a nationally recognised innovative alternative, the Quality and Outcomes Framework, with outcomes that build a ‘fit for purpose’ future primary care service. This has established a care and support planning approach in primary care resulting in Buckinghamshire being the best for diabetic glucose control in the country.

A Buckinghamshire Provider Alliance agreed between FedBucks, Oxford Health NHS Foundation Trust and Buckinghamshire Healthcare NHS Trust, with a commitment to integrate seamless services for patients;

Care Closer to Home – Integrated Adult Community Healthcare teams have provided 24/7 services since 2012. Locality led initiatives include the introduction of the Airedale model remotely supporting care homes and enhanced primary care teams supporting frail elderly people developed from our system work on Multi Agency Groups;

We are piloting the development of Community Hubs including increased community based services, short term packages and a new frailty assessment service, reducing the use of overnight community beds;

A collective approach to engagement – with a single communications and engagement team across Buckinghamshire County Council and the Clinical Commissioning Groups working closely with colleagues in provider trusts.

Q4. One example of an ACS in Canterbury in New Zealand. This has taken ten years to achieve its aims and required extra funding for public health, community services & social care.  We do not have the luxury of time not it seems any investment.  We need improvements now to maintain the quality of care services & to improve outcomes. Can this ACS do in a short time what took Canterbury 10 years to achieve & without extra funding?

Answer: We do recognise that like Canterbury, we are not going to be able to achieve what we want overnight. Some work streams will take longer than others. However in the meantime we are equipping ourselves with the lessons learnt from the Canterbury project, as we have been able to meet with them and apply this where appropriate to our work.   We have also set ourselves some priorities to deliver for 2017/18, which include:

•       Providing more joined-up care closer to home, through community hubs and integrated teams working with groups of GPs, tailoring care to the needs of their local communities.

•       Making it easier for people to get urgent care when they need it, including out of hours.

•       Improving and simplifying care for diabetes and musculoskeletal problems.

•       Improving and increasing access to mental health services, including for children and young people.

•       Improving the prevention, diagnosis and treatment of cancer.

Q5. How will the Bucks ACS improve retention and recruitment of staff? What is the effect of the ACS on the working conditions of staff, on their Terms and Conditions, GP surgery & Pharmacy contracts etc.?

Answer: Staff will continue to be employed by the organisation they currently work for and as such there will be no changes to their terms and conditions or contracts as a result of Buckinghamshire becoming an ACS.

We hope that being an ACS will help to improve retention and recruitment of staff in a number of ways.  By working closer together across the system it will make it easier to make sure we’ve got the right people in the right place at the right time. Job satisfaction will increase as together we will be able to provide better care in the community, at home or in hospital, helping people to stay healthier.  There will also be greater career development opportunities for our people, as they will have the opportunity to work in integrated teams or rotate across different health and care settings. As one of the first ACS we believe the opportunity to get involved in something that is exciting and innovative will also be an attractive prospect for some.

Q6. What will be done to improve access to Primary Care Services & GP services, especially in places like High Wycombe and the rural parts of Buckinghamshire?

Answer: Improving access to primary care services and GP services is central to NHS England’s Five Year Forward View (FYFV) and General Practice Forward View (GPFV) and so is a key part of much of the work at Aylesbury Vale and Chiltern CCGs.  We also have a number of work streams in place specifically designed to ensure the population of Buckinghamshire have timely access to appropriate primary medical services. This work is being done in the context of the development of an ACS for Buckinghamshire which encourages partnership working across the whole health and social care system and whose benefits are already positively impacting on improved access for primary care services.

NHS England launched the General Practice Resilience Programme (GPRP) as part of the GPFV, which is designed to secure sustainability of GP surgeries by tackling many of the issues that are creating pressures on general practice and threatening the viability of practices. A key part of the GPRP in Buckinghamshire is to encourage practices to work together in clusters on a range of projects which improve access to primary care services, for example, developing integrated teams with a focus on integration with other primary care professionals (nurses, pharmacists) or improved working with the voluntary sector, addressing the needs of high intensity users of primary care, out of hours services and A&E by better working with social services. We now have thirteen such clusters beginning to form local plans across Bucks.

In addition, GPRP funding is being used to train care navigators in general practice. Care navigators provide front of house signposting of patients to ensure they receive the right care from the right healthcare professional, or alternatively are able to access social care or services from the voluntary sector.

Many practices are also using or developing alternative methods for patients to access primary medical services such as on-line booking of appointments, Skype and telephone consultations.

So that access to primary care services in and out of hours is seamless for patients, we are also in the process of commissioning extended access into primary care services whereby patients will be able to book an appointment with a healthcare professional 8am to 8pm Monday to Friday.  We will also be looking at whether we need to commission this type of service at the weekend (although experience from elsewhere suggests that routine appointments for primary care services at the weekend are poorly utilised).  We anticipate that 100% of the Buckinghamshire population will be covered by this new service by March 2019.

The extent of the work means that all residents of Buckinghamshire should see an improvement in access to primary care services whether they live in a town or rural area. A key part of cluster working is for practices to understand and plan for the needs of their local area, including how different groups access services. As the CCGs develop working as part of the ACS this locality focus will widen out to other health and social care providers to create an integrated care system with timely and appropriate access at its heart.

Q7. Buckinghamshire has already squeezed the local health economy and has, just about managed its finances but there are now signs of stress in that a deficit is forecast for this year.  Is the ACS really just a means to balance the books rather than improve quality of care? Buckinghamshire has already made many changes to remain within the financial targets so what other changes can be made in the way that hospitals deliver acute care more efficiently?

Answer: Becoming an ACS is certainly not just a means to balance the books although we are hoping that by working better together we can find ways of delivering higher standards of care more cost efficiently.  For Buckinghamshire Healthcare NHS Trust, being part of an ACS is about how we can work with our partners in the system to ensure the residents of Buckinghamshire stay healthier for longer - now and in the future. Research shows that it is in the best interests of patients to stay at home and receive treatment locally. We are working as a system to achieve this, ensuring that acute care is there for those that really need it and that all patients are seen at the right time, in the right place, first time.   We believe greater transparency and openness between organisations – working towards a common goal – means that we would reduce duplication and stop moving money around the system, instead focussing on where the greatest support and investment is required.

Q8. There is a mismatch between what senior managers/civil servants NHSE say and the views of those providing and reviewing care on the wards, in outpatients & GP surgeries!  We need to bridge that gap – what is being done to do so?

Answer: We take the views of our staff extremely seriously and hold regular informal and formal feedback sessions to understand any issues or to hear suggestions for how we can improve things.

We know that our staff have the solutions and so an important principle for our ACS is for there to be strong clinical and staff leadership, and that we actively involve and engage our patients and communities to co-design future services.

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!

A recap on Buckinghamshire's STP - my thoughts

Ten days ago I wrote a number of blogs before I went for the operation to remove the subcutaneous lump on my shoulder. I am just about over the GA and the couple of big bleeds post-op and somewhere close to normality. Well .... there is a short period each day when I can concentrate for more then 5 mins.  Will that do for normal?

Anyway I am now a cancer survivor.

Hopefully, beds providing, I will heading to another hospital for a skin graft over the Christmas festivities.  Such fun!

Anyway....the blogs were about the Sustainability & Transformation Plan for Buckinghamshire (STP).  I have tried to put in my terms an explanation of a summary document that our CCGs circulated at their recent set of public engagement events.  They have tried to explain why they needed to develop the plan in association with local hospitals and the county council. They were very honest and said that it is because the increasing activity they will have to fund over the next five years will not be covered by the budget given to them by the Government.

Can't be clearer than that.

But sadly people still don't get it. Some people still believe the Government will throw money at the hospitals again. It didn't work in the past and it won't work this time.

Tonight and tomorrow I will try to finish what I started last week. I have their final three priorities to finish.

Specialist services Maximising value - the fourth priority

This one is a horror story!

"Maximising value and patient outcomes from specialised commissioning"

In CCG speak:

"Identify opportunities for modifying pathways, standardising thresholds and increasing prevention to reduce spend and increase value"

Well that is a mouthful! Lots of jargon and management speak in that statement.

What do I think?  I think it is all about reducing the cost of providing specialist care. This is the sort of care that is not done in our local hospitals. The sort of specialist treatment I am getting as I write this.  I have to declare an interest here!

There is always opportunities to improve the path us patients take through the system. We need to reduce the number of times we move between different parts of the system. This is a good thing. But it is not new and has been going on for years. But this must be done in partnership with the patients.

The interesting phrase is 'standardising thresholds'. What do they mean? I think it means they want to make it more difficult for GPs to refer us to the specialist centres. At  the moment many treatments are provided after the patient has ticked the boxes. The condition has to be severe enough for the CCG to fund it. Patients have to apply to the CCG for an 'individual funding review' when the CCG will look at each case before making a decision. This could be extended.

I am not sure what they mean by increasing prevention and I assume this is linked to priority 1.

As I said earlier it seems that the emphasis for this priority is on reducing cost.

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.

Deja Vu - Moving care closer to the patient

Our local hospital, Buckinghamshire Healthcare NHS Trust (also the community health provider for the county) is holding a series of public meetings about developing care closer to the patient. I guess the need for this event comes from the publication last year of the ‘Five Year Forward View’ that describes the strategy for the NHS over the next five or more years.

 It is called ‘Your Community, Your Care – developing community hubs’.

The first meeting was held on Thursday evening in Thame. Thame is a lovely market town on the Oxfordshire/Buckinghamshire border. There were quite a few people there and the groups were buzzing with ideas on what services should be provided in their community. 

A few common themes emerged.

• The services should be truly multi-disciplinary and joined up.
• There should be rapid access.
• It could support the promotion of good health & signposting for solutions.
• The ‘hub’ could act as a true community facility. 

At the end of the meeting I was chatting to one of the facilitators about the results of the meeting.  I said that the things that people said were not a surprise. Indeed I said that we have known that this is what people want for many years and went on to add that what we should be doing is getting on with developing these community based services instead of having more public engagement meetings.

********

Now I am a sad person and I keep lots of documents and stuff about health care, usually filed in heaps on the floor of the spare room. I knew we had had similar meetings in the past so I went through the piles of papers and found the feedback from a previous meeting (August 2010) on: wait for it!

‘Developing community healthcare services’

The views of the public then are the same as the views expressed at the meeting on Thursday. In fact the hospital could save itself the trouble of writing a report on the meeting and just recycle the old one from 6 years ago.

Amazing!

Not!

*******

They are holding another five of these meeting in the next few weeks.  What a waste of time.

The question is why have they not developed these community hubs?

Now I am guessing here but perhaps the reason that they failed to do this six years ago and a distinct risk to doing it now, is the fact that the various providers of services cannot agree to share the scarce resources i.e. staff and budgets.

They talk about joined up working and integrated care but still won’t take the risk with the money.

All the talk at the meeting was about care.  Not ‘health’ care or ‘social’ care but ‘care’.  As we get older, and I am a pensioner now so in the next few years that will be me, we need care and support. It becomes harder to distinguish between health care and social care as we become frailer and less able to cope on our own.

So until we get the Directors of Finance and the CEOs to come to these meetings and tell us that they will share the resources we need to have our community hubs I cannot see these ideas being implemented.

I wonder how many more times I have had these Deja Vu moments?

NHS MSCP Vanguard funding

The NHS has to work differently in order to provide good quality services for all within the current funding limits.

In different parts of England there are lots of different models being tried out to see which works best.  These are called Vanguards and are receiving extra funds to transform the health care systems locally.

I thought I would try to find out how much extra funding they were receiving.  It was a harder job than I thought.  In the end I used the Freedom of Information Act to obtain the information from 14 Vanguard who were piloting one type of model.  The Multispecialty Community Provider (MSCP) model of care.

https://www.england.nhs.uk/ourwork/futurenhs/new-care-models/community-sites/

It was difficult finding out who to approach for the financial information, sometimes I got it right first time but for others I had to go through several organisations before getting to the right person.

Vanguard	Population	Funding £ (2015/2016)
Calderdale Health & Social Care Economy	200,000	150,000
Erewash MSCP		No reply
Fylde Coast Local Health Economy	330,000	4,300,000
Modality (was Vitality)  (Birmingham)		No reply
West Wakefield Health & Wellbeing	153,000	2,829,000
Better Health & Care for Sunderland	284,000	2,305,000
Dudley MSCP	315,000	2,700,000
Whitstable Medical Practice	169,806	1,850,000
Stockport Together	300,000	3,900,000
Tower Hamlets Integrated Provider Partnership	284,000	2,990,000
Better Local Care (Hampshire)	220,000	6,960,000
West Cheshire Way	255,000	4,900,000
Lakeside Surgeries		No reply
Principia Partners in Health (Nottinghamshire)		Not received

There were 14 Vanguards and I received 11 responses.  

One Vanguard had only received a small initial payment and one had not received any funding at the time they responded and I excluded them from my analysis..

So for the remaining 9 Vanguards the funding varied from £31 a head to £8 a head.

General Practice - Appointments, Capacity and Choice

Talk to anyone about the thing that irritates them about General Practice and the first thing they mention is appointments. It’s not just the patients! The staff also feel the pressure on appointments.

How can we increase capacity in General Practice so that there are enough appointments when there are a falling number of GPs?  What is ‘enough’ appointments anyway?

There are those who say we should also increase choice for patients in where they go for primary care – “more surgeries” is the cry.

The digital solution

There are several websites or Apps, such as http://askmygp.uk/ that allow people to enter their symptoms and answering some questions allows the GP to work out the best way to help.  These may advise the patient as to who is best p[laced to help them. This may create some spare capacity so that those who need to see a GP, such as people with complex needs, can do so.

The ‘do it on the phone’ solution

Instead of seeing a GP or other healthcare professional the patients the consultation will take place on the telephone or via Skype or some form of webcam interaction or by email. There are a number of solutions available to manage phone calls such as http://gpaccess.uk/ & http://www.digitallifesciences.co.uk/

Both of the above solutions could also be considered the ‘managing the demand side’ solutions.

The Changing traditional General Practice or more GP surgeries solution

(‘more of the same’)

This solution is about increasing the number of GP surgeries so increasing the number of appointments and increasing choice for patients.

So how do you go about developing a new surgery? You need to raise the cash to buy or rent a suitable building. You need to recruit the relevant staff. That means a full multi-disciplinary team to provide a 21^st century service. The cost of a building for 6000 patients could be around £1.5 million but could be more if an extended team is required.

 This investment has to come from somewhere.  There is the Prime Minister Innovation Fund (now with a smart new name) that was for existing practices if they developed 7 day working. There has not been any funding for new builds from central government for the last 25 years or so. If there is a new housing development and if the local planning authority is up to the mark such a new building could come from ‘planning gain’ and built into the cost of the development. However the developers would only build the bare minimum – based on 1990’s requirements.

However there is still the problem of revenue costs which has to currently come from the NHS. Unless, of course, there is a change in the views of the public on private healthcare or health insurance.

Finally there is the problem of recruiting the staff. GPs and nurses are hard to recruit or retain at the moment.

The nuclear solution

One way of increasing appointments with a GP is to do the reverse.  Patients will only see a GP after they have been seen by another health care professional, (a nurse, a pharmacist or an emergency care professional).  They would refer patients onto a GP as appropriate in the same way as a GP refers to a consultant.  Thus the GPs would see fewer patients.

Other solutions

• Reduce unmanageable & unsafe workload
• Improve perception of General Practice as a career option for junior doctors & nurses.
• Reduce administrative & regulatory burden.
• Return to self-management of minor illness.

There is a final solution 

There could be real and meaningful investment to restore the percentage of the NHS budget spent on General Practice back to the 10% it used to be.

So how will these solutions increase choice and capacity?

Really the only solutions to do that are ‘the more of the same’ solution of increasing traditional general practice by increasing the number of practices.

This is highly unlikely given that there is no investment in new building and real problems in recruiting new GPs.  If the government does not invest will private investors take that role?  Again, in my opinion, I think that is unlikely as there is no profit to be made from general practice at present.

Would a community enterprise or other not for profit organisations invest in general practice?  That is an interesting question.

So sadly I can see no way to increase choice for patients.

Similarly the only way for general practice to survive is to manage demand rather than increase supply.

#GPincrisis

Urgent prescription for general practice

Impact of a shortage of GPs

In many parts of the country GP surgeries are having trouble recruiting Doctors and Practice Nurses. 

What impact is this having on patients and the care they receive?

My guess:

·        There will be a shortage of appointments, so patients will have to wait longer to see a GP.

·        Telephone lines will be even busier so it will be harder to contact the surgery.

·        Patients will be asked (forced) to see someone other than a GP.  This may be a Practice Nurse or a pharmacist.

·        More locum staff may be employed.

·        Practices may close completely.

·        Surgeries will close their lists to new patients.

·        Branch surgeries will be closed.

New patients will have to join another practice which may be some distance away from their home.

This will put pressure on these other practices as they get more patients joining the practice and the cycle continues.

Don't just talk - do something.

Have you ever talked about your GP surgery over dinner, sitting in a café, standing in the checkout at the supermarket….?

Well you are not alone!

A Million people a day use their GP surgery and most of those will have something to say about the experience.

Most of those experiences are good.

However sometimes us patients have ideas about how to make the experience of talking with a GP or practice nurse better.

There can be problems with the phone service, making appointments isn’t always easy, seeing your own GP can mean waiting weeks, no privacy at the reception desk, access can be difficult for those with disabilities and as for car parking…!

So instead of talking about things on your own – join your Practice Patient Participation Group (PPG) and do something about them.

A patient participation group is a bunch of volunteers who want to make a difference.  They work with the practice to gather information from patients and to make suggestions about improvements.

They look at the surgery and ask:

What works well?

What works less well?

Are there services that are not provided but would benefit patients?

They also run an annual patient survey, hopefully the questions are set by the patients not the surgery.

Sadly General Practice is going to have to change. Being part of your PPG is one way you can help to make sure we keep the best bits of General Practice

Your voice on its own is very quiet.

But the voice of the many people in the PPG is much louder and will be listened to.

Please join your Practice Patient Participation Group.

Ask at reception or look on the practice website.  Maybe there is a social media page?

Has General Practice passed the tipping point?

Is this the future?

Unless something dramatic or revolutionary happens at the Department of Health after the election have we seen the end of General Practice as we know it?

Here are three possible scenarios.

Scenario 1.

GPs become consultants in the management of patients with complex and unsorted symptoms. Everything else i.e. minor illnesses, uncomplicated long term conditions, social issues, work related problems, etc. will be managed by other members of the Primary Care Team: Pharmacists, advanced nurse practitioners and physician assistants.

The GP will assess, investigate and sort out patients presenting with undifferentiated symptoms and look after patients with multiple co-morbidities and complex needs.

Patients will no longer have direct access to a GP.

Scenario 2

GPs will become disease specific consultants working in the community.  All acute patients will be managed by pharmacists, NHS 11, nurse clinics & physician assistants.

 Patients will no longer have direct access to a GP.

Scenario 3

Co-payments. Patients will pay for their primary care, perhaps with government paying for a set number of  consultations per year.

Personally I do not think that civil servants and politicians do ‘revolutionary’!

I am sure there are others scenarios.  Please suggest some.