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.

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

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.

Better Care Fund - Mission Impossible?

The government having just made the biggest re-organisation of the NHS is now insisting that local health and social care economies now embark on another! 

Health and Wellbeing Board which only came into existence 12 months ago are now developing plans to use the Better Care Fund.   This fund is drawn from existing funds from health and social care commissioners. The total could be around £4 billion for England and in Buckinghamshire the fund will be nearly £100 million. This is three times the size of the fund that other areas are implementing!  Are they being too ambitious?

What will this fund do?

The Better Care Fund is to be used to integrate health and social care services, especially for older people.  It is hoped that this integration will reduce costs and improve the quality of care (in that order).

Many of us have asked for a closer integration of health and social care and so we should be welcoming this new work.  But should the timer scale for developing the project be longer than 12 months?  Can these new organisations, barely out of nappies, successfully implement such a big change in the way services are commissioned?

 Patients, especially those with long term conditions  & the elderly need care and support and they get that support from many different agencies – the NHS, Social services, the voluntary sector, the private sector, families and friends to name a few. Currently some care is called health care and some is called social care. But patients don’t really care what it is called. Or who commissions & funds it.  What they want is for it to be provided without any gaps, when and where they need it.  

They don’t want to have to go to one lot of people for one sort of care and then go through another assessment for more support! They just want to go to one point to ask for help.

So this Better Care Fund sounds as if it a good idea. But some say it will not save money and will not improve services.  They say there is no evidence that it will achieve these objectives.

I am also concerned that locally the public and patients have not been involved in the design of this new service.   As usual we will be involved and consulted with in the middle of the process rather than at the beginning.   Who is to carry out that involvement?  It is Healthwatch Buckinghamshire who are virtually unknown to the population of Buckinghamshire.   Will they be able to carry out a meaningful engagement with the public, let alone real involvement in the design of the new service?

Finally who is going to manage this fund, who will monitor the quality (and quantity) of the care? Who will be accountable?

It’s a mystery!

You can see the latest update on Buckinghamshire Health and Wellbeing Board's plans here

Here is a review of the evidence recently published by the University of York which suggests that these schemes should be rolled out cautiously and may increase overall costs.

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.

A&E issues in Buckinghamshire

There are a lot of unhappy people in the south of Buckinghamshire, especially in the High Wycombe area.  They want their A&E and other hospital services back! The sad truth is that this is unlikely to happen.

As I have written about previously (What is happening to my hospital)  the A&E service closed down in 2005 and first there was the Emergency Medical Centre then in 2012 there was the Minor injuries and Illness Unit (MIIU). This must have felt like a downgrading of services each time there was a change.

The authorities did not do a good job in explaining the reasons for these changes to the residents of High Wycombe and the surrounding area.

As part of their inquiry into the actions being taken as a result of the Keogh inquiry into Buckinghamshire Healthcare NHS Trust the county Council health and social care select committee is going to examine the provision of A & E services.

I am predicting that they will say something along these lines:

• Better facilities for A & E should be provided at Stoke Mandeville Hospital.
• More permanent  Consultants, junior doctors and nurses in A&E are needed at Stoke Mandeville Hospital.
• Better parking is needed  at Stoke Mandeville Hospital.
• Better transport links (roads and public transport) between High Wycombe and Aylesbury are needed.
• An effective and regular publicity campaign about the appropriate service to use (A&E, MIIU, Pharmacies, GP surgeries etc.) is needed.

They may use a few more words though.

See press articles

http://www.bucksfreepress.co.uk/news/healthnews/10718683.Campaigner_calls_hospital_crash_response__a_joke_/

See Steve Baker MP for High Wycombe Blog

http://www.stevebaker.info/2013/10/farce-at-wycombe-hospital/

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. 

Buckinghamshire Healthcare NHS Trust AGM 2012/13

I realise that I have not written anything for my blog for a long time.  It has been a good summer so I have been otherwise engaged on holiday and working on my allotment.

I have just come back from our local hospital trust AGM.   This is a trust under special measures and heavily involved in the Jimmy Savile inquiry. Yet all is not lost –there is good news as well.

There was not a single case of MRSA during the year 2012/2013.  They recorded their lowest number of C Diff infections ever. – down by 50%.

The Hyper-acute Stroke Unit is the best in the region according to the Royal College of Physicians.

The hospital and the spinal injuries centre were at the centre of the Paralympics opening ceremony. A statue of Sir Ludwig Guttmann has been installed in front of the Spinal Injuries Centre

Three members of staff received national awards during the year.

In the first quarter of 2013/2014 even the HSMR has dropped below 100, it is now 97!

As the Chief Executive, Anne Eden, said “It was the best of times and the worst of time”.

The hospital had over a million contacts with patients and 5770 babies were born.

There have been service development and a £5M capital investment in A&E is being undertaken.

As part of their response to the Keogh report they have started  an “Every Patient Counts” action plan designed to improve services.

But the future is challenging as the health and social care economy has been under stress for many years and will be even tougher in future years. The CCG which is a major contributor to the income of the hospital is looking at a shortfall in its budget next year. There are difficult decision to be made in this year’s commissioning round which starts now.

The cost of the staff in the hospital accounts for 59% of the total expenditure of the trust.

There was a presentation by the emergency surgery team on how they have been redesigning the way in which they manage things.  They admit 3800 patients a year of whom 500 are over 80 years of age.  They see three times that number altogether.

I found it a bit confusing when they talked about emergency surgery that does not need to be done that day and the fact that their patient could be reasonably well.  Some patients can even stay at home.   This is obviously a version of ‘emergency’ that is new to me.

It was amusing to hear surgeons talking about holistic care!

The CE presented some internal awards to staff who had “Gone the extra mile” for patients.   These were people nominated by their colleagues and patients and from the hundreds of nominations a small number were selected.  They were both clinical and non-clinical staff and it was a nice way to end the formal part of the event.  Congratulations to those who received an award.

There was a final event when the statue of ‘Poppa’ Ludwig Guttmann was formally donated to Stoke Mandeville Hospital by the charity that had raised the money for it and other projects. http://www.poppaguttmanncelebration.org/

At the end of the meeting there was time reserved for the audience to ask questions.  I will discuss what happened then in the next blog. 

A story of a hospital - high mortality rates

It has not been an easy time for hospitals in Buckinghamshire.  Not that it has been easy for any hospital recently.

In 2005 two previously independent hospital merged to become the Buckinghamshire Hospitals NHS Trust.  One was Stoke Mandeville Hospital in Aylesbury and the other was Wycombe General Hospital in High Wycombe, 18 miles away on the other side of the Chiltern Hills.  Suddenly the management team had to look after three sites, three PFIs and work with a Primary Care Trust that was struggling to keep within budget. The budget was one of the lowest per head in England.

In 2005 the trust closed down the A&E in Wycombe and created a minor injuries unit, much to the disgust of the local population.  Trauma services were also moved while earlier the consultant led maternity unit and children's services had also been moved.

In 2010 the trust took over the management of community services, previously managed by the PCT.

In 2012 there was a big reconfiguration of services with some moving to one hospital and others being centralised at the other. So Wycombe Hospital now has a very good Hyper Acute Stroke Unit and a cardiology department while inpatient care for emergency medicine, respiratory, gastroenterology and medicine for older people have all moved to Stoke Mandeville Hospital.

Two mergers and a major reconfiguration within 5 years must have an effect on the effectiveness of a hospital. 

At the same time as all this merging and shifting of services, not forgetting the scandals & investigations, the trust has been trying to become a Foundation Trust. 

There is more!

 Now it is one of the hospital trusts being investigated for high mortality rates.

According to the data from Prof Brain Jarman's website http://brianjarman.com  trust has been reporting higher than expected death rates in 9 out of the last 11 years. The last four years have been higher than 110. So now they will be investigated by the Department of Health.

The trust, now called the Buckinghamshire Healthcare NHS Trust, has said that it has been examining the deaths of patients for the last 2 years in an effort to understand why the rates are so high. See their press release here. 

The trust  has in the past been quite successful in improving the quality of care it provides. Following the hospital acquired infection outbreaks the board saw the Infection Control reports at every board meeting. Now the trust is one of the better performing trust in this area.

Yet after two years of an in-house investigation the mortality rates are still high. Why?

What could be the causes for the high death rates. The Francis report on the Mid Staffs high death rates found that there were many causes but meeting targets, keeping to budget and getting foundation status were some of the primary causes.

In Buckinghamshire the health and social care economy has been under stress for many years. There have been the merger of the two hospitals and then the integration of the hospital and community services. There has been the Foundation Trust application. 

Is the fact that the PCT has been managing referrals and diverting patients to alternative providers before referring to the hospital meant that patients are sicker when they do get into the hospital?

Is it that they have been poor at coding patients in the correct way?  They have had two years at least to sort that one out. 

Is the reporting and analysis of the data flawed. Not so, says Prof Jarman and Dr Foster.

So is it that the hospitals are providing poor quality care?The patients are not reporting great concern, as far as I know, to the Trust, their GPs or the Local Involvement Network, or even Patients Opinion.

So what is happening  here? Why are the mortality rates still so high?

When will the investigation start and who will be on the team representing local people?

We need a swift and effective investigation so that the patients and the public can be re-assured that the trust is providing good quality care and is a safe place for us to go to when we need to use the hospitals

A story of Stoke Mandeville Hospital

This is a story about my local hospital. Well, its more of a history than a story.

It is quite well known.  Famous almost.  The original hospital, built in 1940 for casualties from the war, consisted of two long corridors of pre-fabricated wooden huts. It was not meant to last long.  My father-in-law tells the story of coming out to the site as a quantity surveyor to cost a tender for building it. (They did not get the tender.) It was green field site then, outside the small market town of Aylesbury. 

Those original wooden wards stayed with us until the new PFI funded hospital was built recently.  There were miles of corridors and there had to be two 'crash teams' as it took so long to get to the wards in an emergency.

I can see the hospital from my house.  I have been a patient there and I even worked there for a while.   I was a patient on the famous wooden wards.  When I was on the local Community Health Council we campaigned for years for a new hospital.  We were pleased when the new one was built.  Little did we know of the consequences of the way it was funded.

So this is our hospital and we are proud of it.  It is Stoke Mandeville Hospital. 

You have probably heard of it. 

In 1944 Ludwig Gutttman came to work here and created a new way of treating patients with spinal injuries. An amazing man!

In 948 the first Stoke Mandeville Games were held and in 1952 they became the international games. Thus was born the Paralympic movement.

The National Spinal injuries Centre (NSIC) moved into a purpose built building in 1983.  One of the chief fundraisers for this great facility was Jimmy Savile.  This is another reason the hospital is famous as it is currently in the middle of an investigation into his activities while associated with the hospital.

The hospital has had more than its fair share of scandals. 

In 2001 the Chief Executive and Chairman resigned because the Waiting Lists were fiddled. 

In 2003 and again in 2005 it was at the centre of the hospital acquired infection outbreaks when over 30 people died in two C. Diff outbreaks.

Now, in 2013, it is one of the nine hospitals being investigated by the Department of health for high mortality rates.

Is it an unsafe hospital?  In the next blog I will write about the recent history of this famous hospital.