Tuesday, 23 June 2015

Upsetting.


It made me sad to listen to the interview with Lord Laming on BBC radio 4 Today 23/06/15


He was being asked about the number of young people in the care system who end up in the justice system. He clearly has a kind and wise understanding of the needs of vulnerable children.

He was being asked how do you make Social work a profession people want to do when the stakes are so high, and there is so much blame, and how can you give continuity of care to young people if social workers are dropping out of the profession.

He was asked if he thought that the changes that had come into effect as a result of his recommendations on the Victoria Climbie case  http://www.publications.parliament.uk/pa/cm200405/cmselect/cmeduski/40/40.pdf or the Baby P case http://dera.ioe.ac.uk/8646/1/12_03_09_children.pdf  had contributed to an oppressive target driven culture, and the morale problems within social work

His heartfelt response was “I would find it very upsetting that anything that I had said would lead to a bureaucratic response. to all this”.

It made me think about how we as a country deal with scandals.

The pattern seems to be this:

·         Something happens that grabs the attention of the media, and it dominates the news agenda. Government immediately goes into “something must be done” mode.

·         There is no simple answer so they select a respected person to review and make recommendations.

·         This eminent person makes a sincere attempt to understand the complexity and produces a considered report which has to include recommendations.

·         The recommendations will normally imply the need for greater spending.

·         The government has to be seen to respond positively to the recommendations, It will tend to select those recommendations that do not require extra spending.

·         The government will need to prove that the recommendations are being followed, so it will bring in some kind of system for measuring the actions or outcomes.

·         Boards all over the country will incorporate these measurement systems into their governance systems, and the figures will become a focus for future anxiety.

·         The media may fail to understand the complex picture that the detailed reports have given us, but will focus on the “failings” made visible by the governance systems.




In almost all cases what these reports, brought together by sincere people who have thought deeply about the issues , will recommend that there needs to be joined up thinking, connecting the work of different organisations with the focus on the individual.

In almost all cases these deep recommendations will remain untouched, because no one knows how to make different organisations, each struggling with budgets that will not cover the costs, begin to work together effectively.

Wednesday, 13 May 2015

Is there an alternative to "clipping" care visits?


BBC radio 4 Today’s programme for 13/05/2015 http://www.bbc.co.uk/programmes/b05tllvh picked up on two of the big themes that will be central to concerns in Health and Care for the foreseeable future.

The first is a cry for help from care staff working for a private sector care company. Staff have drawn attention to the fact that they are being expected to “clip” the times on Home visits, to make it possible for them to travel to their next appointment, and have on occasions been told to leave a patient who has fallen, where they are, on the floor, with the door open for the emergency services to come in. I suspect that we will see much more of the same. The interview then went on to talk with Andrea Sutcliffe from the CQC.  John Humphrys from BBC Today characteristically went down the path of blaming the individual care providers and demanding that they should be penalised. I think he is missing the point.  

The second is that the Academy of medical royal colleges is asking GPs and the public to avoid asking for unnecessary interventions. The £22bn cost savings that the NHS has agreed to make, in order to get the £8bn injection of cash from the government (from a source that is not yet specified) will mean that the health service has to stop doing things. The interview with Dame Sue Bailey of Aomrc  shows that Aomrc advocates working closely with patients to help them understand when interventions may be of limited value.

http://www.bbc.co.uk/news/health-32703632


 

Both of these items show the financial pressures on our health and care systems are huge, and show that meeting the growing needs of the next few decades is going to be pretty challenging.

From the view point of Stafford it is clear that the problems in our acute NHS, both at the time of the exhaustively documented local problems in 2006/7 and now, is that there are many people within the hospital system who would be better off being  “somewhere else” if the “somewhere else” exists.

Successive governments (and perhaps also voters) for the last two decades or more have dodged the questions of where should frail elderly be cared for, by whom, and how should we pay for it.  

There is broad acceptance that the only way the NHS can be made to cope is by much closer integration with the social care services. The details of what that should look like are in many cases still to be worked out.

So far it seems that the only people who have fully grasped the implications of the fact that to cope acute hospitals must discourage unnecessary admissions, and must discharge patients more quickly, are the entrepreneurs offering private sector care schemes.  The result of that is that we are seeing the growth of a whole range of social care providers, with care staff, often on minimum wages, being forced to travel some distance between one “customer” and the next. Even if these schemes sincerely wish to provide excellent services, the cards are stacked against them.

We need to understand what integration really means, and we need to think carefully about realistic ways of delivering an integrated service.

Private sector care providers have a simple objective. They need to get into homes for the time specified by the person paying for the care, and deliver the specified service. What an integrated service needs is for the care providers to be a key part of the whole business of monitoring the health of the individual, calling in additional help when required and doing what is necessary to help prevent the individual from having to go into acute care. An integrated service also requires that if an individual is discharged from hospital they can receive the additional help they will need during a period of rehabilitation.

Do the private sector companies that exist now have the necessary skills and motivation to play this role?

To me this seems to be a key moment. The Health service is changing and the care service must change too. Do we know what we want to see? How can it be made to work for both the individual “customers- patients” (I don’t even know what words we should be using) and for the individual carers providing these services.

As care shifts from hospitals into people’s homes, there will be a constant stream of stories about people left after a fall, without food, without company, without access to WCs. We know this will happen. What are our views on this? Is there a better alternative?  

It is a depressing picture, but we have to find our way through this.  For me there are at least some  pioneering projects pointing us in better directions.  I would strongly advise that people should read Atul Gawande Being Mortal  http://atulgawande.com/book/being-mortal/  This matters because it looks at the distressing effects of unnecessary treatments, and looks at different ways of providing the essential social care that we must provide.

I would also advise looking at the Buurtzorg model http://www.kingsfund.org.uk/sites/files/kf/media/jos-de-blok-buurtzorg-home-healthcare-nov13.pdf This very local approach is where I would wish to start in the process of building integrated care that works.

Saturday, 28 March 2015

7 Day working for NHS. So how would that work?



We are into the period when the political parties try to bring out their eye catching policy initiatives.

David Cameron has said that if in government they will bring about 7 day working for the NHS.  http://www.bbc.co.uk/news/32094681
 
This is of course a discussion that has been going on for at least the last 5 years. It is clearly desirable for patients that there should be access to services 7 days a week, but there are also reasons why so far the move towards this is patchy.

The responses to the proposals so far seem to be on the lines:

  • ·         It won’t happen.
  • ·         There is no money to pay for it.
  • ·         Where are you going to get the staff?

Personally I think that it would happen – but at a cost.

It is clear that there is no additional money on the table so how could 7 day working be made to happen?

If we were in a position where hospitals worked in co-operation with each other, one could imagine the creation of networked provision so that there is cover for a range of different conditions provided in different centres during weekends. This would make good use of existing facilities.

But we are in a position where hospitals compete with each other, and there is insufficient funding, especially for acute & emergency services, and there is a finite pool of staff in many areas.  All of this means that only a limited number of hospitals will in the end be able to provide 7 day a week services.

Ability to provide seven day consultant services will in these conditions become a proxy for a hospital’s ability to survive in a situation where there is competition for scarce resources, and media focus on hospitals "failing" to provide a seven day service will drive patient choice.

The reason why I think that this policy will seem attractive to some is because it will drive the centralisation of services. The provision of 7 day services will happen in the big centralised hospitals, and the smaller DGHs will see another step in the downgrading of what they can offer to their communities.

There is also of course the potential for private enterprise to set up or run acute centres to provide the weekend cover.

So yes – expect 7 day consultant services to become a reality, just don’t expect it to be in a hospital near to where you live.

 

Monday, 23 February 2015

What does the future hold for our hospital?


Tomorrow night the Borough Councillors in Stafford will be asked to support a motion for a referendum on the hospital.  I have no way of knowing how that will go.

I have talked to thousands of people over the last few years the frustration and anger at the loss of services has been very apparent. Maybe a referendum will give people a way of expressing this feeling. It might also leave people free to use their election vote to choose the party that they see as offering the right option for them and for Stafford on the many different pressing issues that face us all.

In the years since the Stafford crisis broke there have been many changes in the health service, not least in the way in which hospitals are supported if they hit a tricky patch.  I think that everyone in the Department of Health recognised the harm that was done to Stafford by the years of reports, reviews, inquiries, and the administration process.  Now when it is recognised that hospitals are in trouble, both in financial terms, and in terms of attracting and retaining staff they get placed into “special measures” with the clear intention of turning them around.

In Stafford the reverse of this happened. The Investigation of 2008 isolated the hospital. The turnaround that was attempted in 2009 did not work – in part because of the strongly orchestrated demands for a Public Inquiry.

The first Inquiry gave patients and families a chance to have their voice heard. This was valuable and has certainly had a big effect on thinking within the NHS as a whole. It did also strongly make the point that there are genuine difficulties in managing the care of frail elderly people in our hospitals.
The second Inquiry always seemed to me to be about Andrew Lansley’s desire to demonstrate the structural flaws within the NHS, and to justify his reforms. These reforms were imposed and are now generally accepted to have been a very costly and distracting mistake.

The Inquiries and all that followed  have month by month eroded any possibility for our hospital to recover in its original form.

So if the motion tonight is passed – and if the referendum takes place and is overwhelmingly passed  what then?

Personally I believe it is na├»ve to think that we can return to the way things were.  Staff and teams  are scattered, the hospital and the whole health economy of this part of the country remains in serious financial trouble.  

The health service is changing. Most of us accept that there are some services which are best performed in large hospitals with specialist equipment and consultants on hand 24/7.

Improvements in surgery and other treatments mean that care which in the past may have needed a hospital stay can be done as day case treatment, much of which can and should be done as locally as possible.

The development of monitoring systems means that patients can play a major part in controlling their own conditions and staying well.

It is also recognised that acute hospitals are not the right environment to support and rehabilitate very frail elderly people.  The aspiration is to provide much more care for people in their own homes, to prevent unnecessary admissions, and to help them recover with their families around them.  That raises very serious questions about the availability and cost of social care and community nursing.

When the dust from the Election, and the referendum if it happens, has settled then I believe that there is an important role for all of us in mapping out the right future for our hospital and the wider health services in our area. It is unlikely to be the same as it was – but by working together perhaps we can make it better able to cope with the massive challenges that lie ahead.

 

Friday, 9 January 2015

And Now - Hinchingbrooke


Over the last few weeks we have seen dozens of hospitals declaring major incidents. As Chief executives take to the airways a consensus has emerged. The same words are heard.

Accident and Emergency is coming under “unprecedented demand” and the patient flow through hospitals becomes impossible because of “delayed discharges”.

Coincidentally or not these represent the political explanations of the phenomenon from Conservatives and Labour respectively.

To me the point where the rash of major incidents became predictable came with the resignation of one of the most respected CEOs Dr Mark Newbold, some weeks ago.  He appeared to go because of the pressure applied from above to meet targets that had effectively become impossible to meet, for reasons beyond his control.

I think what we may be seeing with the contagious major incidents is a sign both of the instability within the wider health economy, and the refusal of management to continue to carry the can for problems that lie outside their hospital walls.

Hinchingbrooke was effectively the test bed for a private sector body running an NHS hospital. This presupposes the possibility of being able to do the job and make a profit. Because of the very peculiar structure of the tariff system this is only possible if there is the right balance between elective care and emergency care.  The announcement that Circle is withdrawing from the Hinchingbrooke contract , because of unprecedented demand for A&E and the problem of delayed discharges is about as clear a signal as we need that making a profit from the NHS at the moment, given the structure of the Tariff system and the state of social and community care, is simply not a realistic possibility.

Controlling spending within the NHS is a perfectly legitimate aspiration. Managers have a role to play in ensuring that money is spent well, but if we expect hospital managers to provide answers to the incoherent structures of our health and social care systems then I think that we are likely to be disappointed.  If we want to judge our hospitals on their "financial sustainability", which is what has been happening for the last few years then health service managers need at the very least to have a climate that makes sustainability possible.

The current crisis is a useful wake up call. What we need from our politicians is the courage to ask difficult questions, not least about funding health and social care, and to provide the framework for the different organisations involved to begin to work towards a more coherent system.

There are just a few weeks for politicians to give clear signals that they intend to do so.
 
 
 
Some of the coverage on Hinchingbrooke.

http://www.theguardian.com/society/2015/jan/09/circle-exit-private-contract-hinchingbrooke-nhs


http://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news/franchising-hinchingbrooke-peterborough-stamford-hospitals/

Tuesday, 6 January 2015

Understanding the A&E Crisis in 2015


I usually find myself feeling sympathy with anyone getting the John Humphrys treatment. This extended to Jeremy Hunt working hard to explain why increasing numbers of hospitals are declaring major incidents, because their A&Es reach the point of not being able to cope with demand.

The ground was well prepared by Clifford Mann the spokesman for the College of Emergency medicine, who raised the crucial matter of funding for A&Es, where the tariff does not cover the costs of treatment. This effectively means that hospitals cannot afford to recruit and retain permanent staff and end up with the pernicious and expensive dependence on agency staff. http://www.bbc.co.uk/programmes/p02gcq7d

A manager from one of the hospitals which had declared a major incident also explained the pressures that he was experiencing.  These included: All the bed spaces full, all the overflow beds full, Discharges to community care beds or home difficult, Surrounding hospitals already on ambulance divert and therefore unable to accept a divert from them, the sheer impossibility of getting more staff, as all available agency staff were already spoken for.

Jeremy Hunt of course talked about the extra nurses that they had been employed, and the extra winter funding he had authorised, and he also talked about the growing demand from aging population. He was also gracious about the heroic effort by staff under difficult circumstances.

Jeremy Hunt did not mention the request to Chief execs of Foundation Trusts to see if they have any clever ideas for fixing the problem, but then the results of that plea are not due back to him until later today.

The problems are of course complex, and involve a whole series of organisations trying to find ways to work together to meet the needs of a rapidly aging population. Anyone honestly trying to get to grips with this should have our sympathy, and our support.

The point in the interview where Jeremy Hunt lost my sympathy was when, feeling the pressure, he used the Mid Staffs card. I do understand that in the face of the persistent and growing problems within the NHS the temptation to say “well at least it is not Mid Staffs” is a strong one. What frustrates me is that if we had learned the real lessons from Mid Staffs we might not now be facing a crisis throughout the NHS with so little apparent preparation.

What I think is still escaping Jeremy Hunt, though I think it is understood by growing numbers of health professionals, is that the parallels between the problems that actually existed at Mid Staffs in 2007, and exist in the NHS as a whole now, are very strong.

Staffordshire is a part of the country where people live to be old, and many young people move away for work, so the population here got old a little before it did in other parts of the country.

The “new” element of patient choice led to competition between hospitals for staff and patients. Smaller hospital surrounded by other larger ones found that they were under increasing pressure. More of the profit making elective care drifted away to the bigger neighbouring hospitals, leaving Mid Staffs and other small hospitals increasingly trapped into loss making emergency care.

The fashionable solution of the time, which seems since to have lost its appeal, was for the hospital with the active encouragement of the Department of Health, to become a foundation trust. This was probably the wrong answer. The process of becoming a foundation trust forced the hospital to attempt to balance its books, which it could only do by cutting beds and cutting staff. The application process would certainly not have encouraged the hospital to appeal for help when it needed it.

An additional factor, which was oddly never mentioned in the Mid Staffs inquiry, is that the local authority, faced with the increasing costs of its aging population, took the questionable decision to close most of its loss making care homes, on the basis that public consultation had shown that the majority of people would wish to remain in their own homes. The level of community care needed to support this aspiration did not and probably still does not exist.

With the aging population, cuts to beds, loss of permanent staff, growing dependency on agency staff, and a rapidly escalating “exit block” problem all of the pieces for an A&E crisis were in place. All it took to tip the balance was winter.

If you want to understand what the pressures were like for the staff and patients read this excellent account of what happened when a a neighbouring centre of excellence tipped into a black alert last week. http://t.co/dCR8g4bCuj

There is one substantial difference between the pressures at Mid Staffs in winter 2007 and the pressures on the NHS now. That is the wider awareness of the scale of the problem. In 2007 the staff at Midstaffs were isolated at the centre of a storm. As the hospital beds and the overflow areas filled up and bed blocking became critical they and their managers should have been in a position to call for help, but if they did then no help came.

In Mid Staffs the Emergency staff, and the managers took the blame, for a situation that was entirely beyond their control. I think what we are seeing now, as hospital after hospital declares a major incident, is a refusal to be the fall guys for a hugely complex major problem that is the responsibility of us all.

Mid Staffs is of course a terrifying symbol, largely because of the persistent mis-use of the excess death figures – which never appeared in any report, and do not reflect the facts. I have no doubt at all that there were days in 2007 when the A&E at Mid Staffs, and the emergency wards attached were unpleasant places to be, both for staff and for patients. In part the problems were exacerbated by the pressure to meet waiting time targets, and the unintended consequences of this pressure. The breaches of A&E waiting times, which today’s figures show us http://www.bbc.co.uk/news/health-30679949?ns_mchannel=social&ns_campaign=bbc_breaking&ns_source=twitter&ns_linkname=news_central are now occurring routinely throughout the NHS are just one indication of the huge pressures that staff are experiencing now, which inevitably has an impact on patient experience.

This winter it is much too late for magical solutions. Getting through the pressures is going to take patience and tolerance from everyone. Some of the national papers are requesting stories from people who have experienced A&E and I am sure that stories will be found. It would be great to see papers also exploring some of the potential solutions.  

What I would really like to see, (I am not holding my breath), is the simple recognition that solving these deep problems is difficult, and that we could do better by ending the blame game, trying to understand the complexity, and work towards potential solutions. Understanding the pressures that caused problems at Mid Staffs just a little better would be an excellent place to start.