The NHS – a view from outside a think tank

It’s a new year and the ‘think tanks’ have been busy. So some more of the same – productivity, joining health and social care and leadership – well that didn’t take much thinking then. So we can all put our feet up for another year, do a little research and come up with the same three things next year. After all it is a ten year plan going across at least two terms of government so we would expect some flux and some of the changes are difficult – what a load of tosh!

Contracts – we have far too many of the things and with payment by results – now called the tariff – some of them are too complex to operate properly. We don’t ‘manage’ contracts well and have developed a monster that is inspection. We employ a veritable army to check and verify coding and payments and then inspect and rate. We have to make life simpler.

So how about dumping the tariff, returning to a block contract system. Perhaps we should dump the CQC and invest that money in better contract management. And then work out ways of combining contracts and including increased performance management within the contract to help us manage them better.

Hospitals – we have far too many of these and too many beds. I equally love and fear the Dalton report. But let’s support hospitals to merge, combine services and deliver better care with better management. Balance the drive for this and exert control to prevent Foundation Trust groups becoming too dominant and removing choice. However, I do believe that people want a good quality local hospital rather than the choice, but we must keep some competition in the system to retain commissioning levers.

Let’s transfer elderly care facilities to the Local Authority in the form of ‘Cottage Hospitals’ and see care of the elderly as a natural element of social care – just noting that aging is not an illness. There becomes a natural flow between home, care home and cottage hospital, all under one organisation – the Local Authority.

Primary Care – increasing pressure on primary care has been partially successful in driving change, but the unintended consequences in secondary care have been unfortunate and we haven’t really broken down the siloes – in fact we have made them worse, by separating core contacts from locally enhanced services. We can fudge this with co-commissioning, but we really need to take this to another level.

Perhaps it is time to drive multi-professional provider contracts. We have the emerging federations – so make them a requirement, but they must include all four primary care independent contractors, the community services, mental health and all other local providers. And then we can start linking elements of the contracts together to create the interdependency that we need – where the successful delivery of a contract needs all providers pulling together to be rewarded.

Individuals and Communities – we are all responsible for our own health and we are jointly responsible for the health and wellbeing of our communities. But it is all slipping; people are getting poorer, unhealthier and more isolated. Public Health isn’t working. Something has to start at a more fundamental level. This is about poverty, education, food, crime and safety and it creates an unsustainable impact on the NHS. It is what would make us as individuals care about ourselves and others and the community that we live in. I have seen some superb, astonishing results created by organisations like C2, but I still wouldn’t know how to roll it out nationally. Perhaps it is about accelerating pockets until they coalesce into one nation.

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A new approach to diabetes

Janet was excited today – she came in a taxi with Roy. Roy lives in the same block of flats but below her and has diabetes as well. They chatted in the taxi, shared information and discussed problems.

It would seem that in Janet’s opinion she is doing better than Roy. It was interesting the way that she described ‘better’ a view that is very important for the NHS and those involved in diabetes care to consider:

“Nobody has talked to me about insulin yet – so I must be doing better than Roy”.

How interesting – where I usually think of insulin as just part of the therapy, Janet thinks about it as a sign of failure. And as it happens – so does Roy – he, apparently, is very disturbed by it and she thinks he is worried.

“So what are you planning to do about it Janet”. I don’t really know why I asked the question, but the answer came without any hesitation whatsoever.

“Roy’s coming up for tea later; we are going to have a chat about his control. He lives on his own – I want to see what he eats and see if we can help each other”. Hmmm, I have wanted to know what he eats for years.

I know that this does fill me with some fear. Janet’s control is not too hot and I might be talking to her about some basal insulin soon. But I decided to leave that one out. Concentrate on some dietary advice and leave a final note about getting out a bit more and losing some weight.

Roy’s appointment was less productive. His HbA1c was worse and he had put on weight. It was an interesting discussion where he described everything as a ‘series of failures’. I seriously wanted to talk about disease progression and treatment progression, but I just sat back and listened. Eventually I asked:

“So you met Janet in the taxi today” and at last I seemed to get a positive reaction. Yes she seemed nice, no he didn’t know that she had diabetes and yes she had asked him around for a ‘natter’. He was really interested that her diabetes was better controlled than his (based on the fact that he had a discussion about introducing insulin) and that he was interested to understand how she did it.

It would seem that he would rather learn about diabetes from Janet than from me. I can live with that if both of their control improves. Loneliness and a feeling of continual failure, including the view that insulin is associated with failure rather than success is a learning point for us all. There is no wonder that people don’t always do what the healthcare professional suggests which contributes to significant waste of medicines in the NHS.

The first point is that a taxi sharing service is a great success – but we should make better use of it encouraging more people with the same condition, living in the same area to share the taxi.

The second point is one of reflection; we have many older people with diabetes living near each other in a community. I wonder if they know each other. When you speak to the local community pharmacist he will double the numbers including patients from other practices.

So I might start working on a new plan. We ask all patients to attend a meeting run by the local community pharmacist. We provide patient guided learning material so the pharmacist acts as a facilitator – the CPPE consultation skills for pharmacy practice is a useful and timely resource. And we invite associated healthcare professionals to attend and answer questions and other providers to talk about the services that they offer, lunch clubs, walking and exercise.

Community healing in practice?

NHS Groundhog day

Is it only me that thinks that NHS Groundhog day has arrived. Another meeting, discussing the same problems, with the same people, a different facilitator, but the same sticky pads, the same ideas and the same solutions.

So we now call it transformation, but as a pharmacist, I get the same looks of surprise when I speak and the same response. It is all about doctors and nurses – didn’t you know? We add social care, housing, other primary care contractors just to be politically correct. Although I do notice that the optometrists, dentists, paramedics didn’t turn up. We have to reinvest our money in ‘primary care’ – meaning general practice rather than the other three primary care contractors – perhaps that’s the reason whey they don’t turn up. And the money is going to come from secondary care – fat chance of that when demand for secondary care is riding high.

No patients here either – so much for the patient-centred approach!

The next time I am going to check just who is here and if it represents the equity and diversity of the local providers of health and social care. And if I have time, I will check if it also represents the equity and diversity of the local population around which the services are going to magically transform.

Wait – here comes the summary…….

 

Reworking the NHS

I am going to make this simple. The NHS is not set up right and the current change has not improved much. Everything is still commissioned/contracted in silos; the organisations do not have real cross-commissioning capabilities and as for performance monitoring – still poor.

So we need a different solution that drives integration and supports joint working. Well that is not too difficult really if you think about things slightly differently. And it is not too difficult to divide up existing contracts into parts so that they can be managed and driven in different ways. So her is my thinking:

‘Primary Care’. Primary Care is the delivery of the first element of care. There are several services that provide primary care by this definition. It reflects the continuum that NHS England describes from NHS Choices, through community pharmacy and general practice to out of hours and A&E. Why can’t they be commissioned together? Bring every contract they we hold in which any person rolls up and ask about their health or needs acute care. Include the police, ambulance and paramedic services and others. Fix the total budget and manage it in such a way that co-operation drives profitability and creates a will to manage demand. Look at the capability of each element of the service to one-stop manage as much as possible without unnecessary transfers, signposting and referrals. Build capacity in the most accessible and least expensive elements of the continuum.

‘Continuing Care’. Again there are several services that provide continuing care for patients with medium and long term conditions. General Practice might be considered the backbone, but many patients are admitted to hospital – so called unplanned care – or to care homes. So again, let’s bring all of the contracts together – health and social care. Commission Consultants to work side by side with GPs, community pharmacy, community services, social services, housing with voluntary and charitable organisations. For it to all work people must remain well and in their own homes where possible.

‘Planned and specialist care’. NHS England is already commissioning a range of specialist services to look after people with rare and complex disorders. In this same pot I would commission all planned care from hospitals and the trauma and emergency response services. They should have national standards, national comparisons and controlled providers

‘Public Health’. All services that maintain and improve the health of nation are already commissioned from public health. Is this the one thing that we have right and are they moving in the right direction? Probably yes – they are gathering all of the contracts under their wing, stimulating providers and commissioning across boundaries and silos.

The big question is will it happen? The NHS does not need radical reorganisations and structural change. It just needs a better focus on what it needs to achieve and a better mechanism to drive cross-silo commissioning and inter-service dependency.

Community Pharmacy and patient pathways

I have sat through many meetings discussing patient pathways for many diseases. It has long been a disappointment that the GPs and the consultants focus on their interface and how to make it better. Doctors and nurses become the sound bites, rather than patients, homes and communities. I hear a bit of rapid access here, direct referral there, intermediate service specification, outreach, locally enhanced services and a plethora of others. And of course the solution is so often a specialist nurse, a GPwSI or a new overlaid service.

 

I often ‘cough’ and remind them that community pharmacy manages 70% of the population with that condition with over the counter medicines and advice before they enter the pathway. If it was 75% would that make a difference?

I might add that a simple campaign with screening in community pharmacy would help identify more people and get them to treatment quicker (on a daily basis, community pharmacy sees more people than all other healthcare professions put together).

Or that even some NICE guidance recommends the final disposition of patients with that condition is community pharmacy. And community pharmacy support might prevent another block of expensive NHS care.

 

I sometimes ‘bang on about’ supported self-care and how a 10% improvement in self-care might reduce healthcare costs by 25% (see Charles Allessi and the NAPC for the reference). I might mention access to NHS choices, healthy living advice, smoking cessation, obesity management exercise signposting and simple treatments. In the end, it is all about people looking after themselves and others around them.

 

A pathway isn’t a conveyer belt and we shouldn’t focus all out attention on the middle bit – the interface between general practice and hospitals. There is a front end where community pharmacy and self-care sits and a back end where community pharmacy and self-care sits and a middle section where community pharmacy and self-care sits.  And I haven’t even mentioned the ubiquitousness of medicines throughout – before, during and after.

 

And all the way through is a patient who should be helped to make a choice. A pathway starts with a patient in their own home and should finish there – you realise that this is a big hint! Does anyone think of including housing in the discussion – don’t be too radical – who ever thinks that housing has any contribution to health – just me then. Patients start in their own homes with their own families in their own communities don’t they? And they want to end there as well – well and in control of their condition, gaining confidence all the time.

 

So the next time I sit at a meeting where pathways are discussed – will I see representatives from community pharmacy there? Will I meet my housing colleagues there?

 

Patient pathways – but what should be the tagline – perhaps from community to community or even from home to home. Definitely not from GP to hospital to GP – that is only part of the story!

The Community Pharmacy Challenge

So here is my challenge. A simple challenge given to me at a meeting. A flip chart where someone drew two circles – one general practice and one hospital based care – primary and secondary care they said and smiled. They asked – where does community pharmacy fit – and handed me the pen.

This is simple I said and drew three additional circles on the page:

 

The first circle sat far away from the others. Community pharmacy sits outside the others as a completely separate entity from the traditional NHS. It represents the first port of call for much of the population. It provides a simple contact point for people to get health and well being advice, pharmacy first services for common conditions and a wide range of public health services including simple screening for cancer. It is of vital importance in empowering people to look after themselves without needing to access the ‘NHS’ – an early gatekeeper. There remains a lot to do to make this a reality as it is a bit piecemeal at the moment.

 

The second circle sat next to general practice, but not overlapping. Community pharmacy is an alternative service provider to patients. Some patients may choose to have elements of their care delivered within a pharmacy. It is not difficult to see joint registration and full sharing of medical notes to support this. I have blogged before that I would like to see community pharmacy have a bigger role in managing GI complaints, contraception, asthma, immunisation and skin conditions. We can make this happen and when services are offered to AQP, community pharmacists should be prepared and ready to offer patients choice. It doesn’t usurp General Practice – it sits neatly beside.

 

The third circle overlapped General Practice and I sneaked in a few more – dentists, optometrists, community services, social care, charities, voluntary services and housing. And drew a large circle around all of them. This is the new definition of primary care – where we integrate these and other local services (sorry to the loads that I have missed out) where everything comes together to look after people with complex issues. Of course I mean those who are old, but we must recognise that many conditions are not solvable with a pill and everyone needs to work together.

 

With a gentle smile I put the pen down and fielded questions. So where do we start?

 

That is very simple. I can do the first today and there are some great examples around and a huge need within the whole system for this to happen. We must start to manage demand as a matter of importance. We need to think differently about the profile of community pharmacists and work on patient perception. A simple start would be for all clinicians to ask ‘what did the pharmacist say’.

 

I can do the second next – it will need a little training, but there are examples of contracts and consultant/specialist pharmacists out there. We must plan to expand capacity without creating additional pressure on the system.

 

And the third – the golden ticket might take a little longer. There is a lot to do to redefine primary care and deliver it. Working together takes visionary and charismatic leadership, giving all parts a seat at the table, sharing problems and creating solutions that work. Some of the elements of this jigsaw don’t even recognise the pieces, let alone have an understanding of what can be achieved. But we have to start somewhere – it’s now or never.

 

Simple!

Tony Pulis to manage the NHS

I am not a football fan, but there is a lot that can be learned from Tony Pulis. He arrived at Crystal Palace at a time when they had spent a lot of money to rebuild their team. It was obviously not working as the club was disjointed and languishing in relegation zones.

There is a very simple fact in football that few people really understand. It is not the number of goals that you score that keep you up – it is the number of goals that you let in that get you relegated.

Now, despite Crystal Palace being the 8th club managed over a 21 year period – Tony Pullis has never been relegated. Also despite managing clubs with low budgets, he has taken Stoke to be FA cup runner up and led a spirited campaign in Europe.

So Tony pulls the team together, strengthens the defence and makes the team a very difficult team to break down. He is the bloke in a track suite on the lines and somehow his teams show no shortage of passion – something that supporters love.  And a 46% win rate in the top flight is an impressive performance. In fact he is well known for taking football clubs beyond their means and achieving success on a tight budget.

I know – sometimes his style is not always pleasing on the eye and other clubs can have a rough time. Impressively direct, they say, assertive to the point of aggressive. And with set-piece supremacy! It has to get you thinking…

So I wonder if Simon Stevens understands this. You don’t have to score loads of fancy goals to be a hero – you just have to tighten up the defence and not let many in. You do have to be pragmatic and create passion in your team by walking the touchline.

It is about time the NHS looked at how primary care (General Practice, Community Pharmacy, Optometry and Dentistry) and the other providers of primary care services work together with social care and local communities to improve our defence. Let’s start concentrating on not letting any patients slip past our defence and get admitted needlessly to hospital or care homes. Create care, compassion and passion in the workforce by walking the touchline and being close to the players. The NHS has room to be a little more assertive – to tackle the causes of poor outcomes and to get some results for patients.

Will our hospitals deliver set-piece supremacy – well I hope so – to the delight of the players, the fans and the club owners. Impressively balanced by a great defence.

Outcomes in diabetes

It’s funny when you start a discussion on outcomes in a condition such as diabetes. The usual tripe comes out – HbA1c and then some idiot talks about cost-effectiveness and then those silly QIPP indicators and QoF points. I can even get angry when someone adds medicines safety and adherence. My heart sinks and I really know that the NHS has problems.

So – let’s start from a different place. The person with diabetes wants to feel confident that they can manage their condition over a long period of time. They want to feel that they are in control and they are on top of things. They want to feel well. I even highlighted the key words to make it simple.

Hmmm – the room has now gone totally silent.

I now have to stop the ones that are trying to tell me that they do this, by reading a couple of comments from patients:

‘The diagnosis of diabetes feels like an albatross around my neck’. ‘I seldom feel in control and often feel unwell with my diabetes’. ‘My diabetes makes me feel isolated and alone’. ‘My diabetes makes me feel unwell and unhappy’.

There were also many comments about dependency on the healthcare system and nobody talked about independence – sometimes almost an abdication – my doctor/nurse tells me what to do. And so many that felt that diabetes got in the way of them living their life. A couple were afraid of the complications etc

The comment that really made me stop in my tracks – ‘I sometimes use my wife’s blood for the glucose test because I don’t want to disappoint my doctor’.

Do you want me to go on…..

Well the rest of the day went much better. There might be a plan coming together. One that is patient focussed, that empowers, that connects, that gives hope and delivers confidence and control. Might even help people to feel well.

We agree that when this happens other outcomes will improve and dependency on the healthcare system will reduce. There might even be a VAS for confidence, control and wellness – now that would be innovative.

The cat with diabetes

I have spent a lot of time with the vet – it is a long story, but I was fascinated in the way they managed a cat with diabetes.

Of course diabetes in animals is very similar to humans – it starts with an inability to manage post prandial glucose and leads to insulin resistance and ultimately pancreatic failure. The diagnosis is through a mixture of blood tests, urinalysis (clean dry gravel in the litter tray) and the typical signs – ravenous appetite, weight gain, always thirsty and peeing often. No GGT or HbA1c in the vet. Treatment is also similar with diet manipulation, weight control, exercise stimulation and some medicines.

The fat cat sat on the mat. As it purred gently it had a continuous glucose monitor attached. It hardly noticed as it was fixed in place. Free feeding was replaced with fixed meals and five days later the data was downloaded. The little machine had measured glucose concentrations every five minutes for 5 days – that’s 288 measurements a day and nearly 1,500 measurements over the 5 days. The line appeared showing the peaks and toughs in use.

The baseline glucose level was abnormal and the peaks showing the post-prandial glucose levels were also abnormal. These peaks were then compared to the diet chart and most peaks were explained through the three meals. Well apart from three which were biscuits – your cat eats biscuits? Yes we sometimes sit together in the evening and we share a biscuit – should have guessed really.

I think that we could identify the calorie content of everything that passed that cats lips over the five days – just amazing. Nowhere to hide that little titbit or mouse or latte and muffin.

The owner left with a greater understanding of the influence of diet, a refined diet plan and some medicines. The medicines were initially targeted towards reducing the basal glucose and the vet was sure that this would help to make the cat feel a little better and ‘get out more’.

The owner was told that the cat should come in for another review and that the vet will do another 5 days of glucose monitoring. The vet warned the informed that an improvement in the basal glucose was expected, but the next stage would be adding in another medicine that effected basal glucose or if the post prandial glucose hadn’t improved then a refinement of the diet and a medicine that targeted post prandial glucose. The vet didn’t want to start insulin, but that was firmly on the cards with a twice daily mixture at the two main meals. This all seemed quite rational to me.

I am sure that you want to know about the biscuits. They were changed to either a reduced amount of the high sugar variety or an increased amount of a low sugar variety. The owner understood this and went away with a list of biscuits and their calorie contents printed from the internet. Actually I didn’t know how bad custard creams were – must cut these down myself.

I asked the vet where continual glucose monitoring had come from and why she used it. Well it would seem that it is an adaptation of the equipment used in humans that transferred to vetinary practice about 5 years ago. She felt it was the only way that she could get the information to guide her advice and treatment. The 5 day 5 minute readings linked perfectly to the diet plan and the owner had no doubt what was right or wrong. Obviously, I asked if the vet used blood glucose testing and she almost laughed in my face. Cats don’t like it and the information is hardly very useful in discussion with the owners and agreeing a management strategy. I had to agree with her.

The management of diabetes in cats is particularly important. The complications, particularly peripheral neuropathy can be particularly nasty and hypoglycaemia a real issue, however they aren’t affected by cardiovascular complications to the same degree. If the diabetes is controlled well and the cat loses weight then they may improve to the point that they don’t require treatment – fascinating.

If I should get diabetes, perhaps I will visit my vet first. Well perhaps until the NHS uses continuous glucose monitoring and follows good vetinary practice in targeting treatment appropriately.

Equity and access to treatments – free at the point of delivery

When you read that a third of patients in A&E and over 57,000,000 GP appointments are for people with common conditions / minor ailments that could be managed by a community pharmacist you must wonder why? Why do people choose to visit their GP or go to out of hours or visit A&E?

“I don’t pay for my prescriptions, there is no point going to the pharmacy, I can’t get an appointment at the GP today so I might as well go to A&E or wait until the on-call doctor starts”

“It’s a child – they don’t pay for medicines”

The “free at the point of delivery” is actually an urban myth. When you visit a community pharmacy for a common condition the consultation will be free, but the treatment almost certainly won’t be.

We spend so much time talking about equity and fairness, but if you have money in your pocket to buy medicines then you could go to the community pharmacy and buy some treatment for your common condition. Sometimes we might be talking about a few pennies for a simple pain killer, but £5 or £7 might be much more than many people are willing or able to pay for a medicine. There is also a general feeling that treatments for a child should be free.

So if you are unwilling or unable to pay for a treatment for a simple condition then you need to see your GP and get a prescription. If you can’t get an appointment when you want it, then roll up at A&E, a walk in centre or wait until the on-call service to kick in.

To put it in simple terms, this is ridiculous, inequitable as treatment is based on willingness to pay and in the long run costs the NHS much more per episode of care.

There has been some progress. A number of minor ailment / common condition / ‘Pharmacy First’ services have been introduced. Just 12% of community pharmacies were commissioned to provide this service during 2010-11. Some of these services included the supply of treatments and some included PGDs to enable supply of prescription only medicines. But they were not consistent in their contents and their ability to supply medicines free of charge.

If I was NHS England I would seek to remove this inequity and introduce a single service model throughout England which every Area Team could commission. I would include as many common conditions as possible and PGDs that would allow a wide range of medicines to be supplied to those who are exempt from prescription charges. And I would communicate it to people in such a way to change the flow of people to A&E or other more expensive NHS services. I would engage community pharmacy and double the options for access to simple treatment within the NHS.

Parallel to this I would change the law to introduce independent community pharmacy prescriber (limited) status in which community pharmacists were able to issue prescriptions in place of PGDs and as a stage in qualifying for full independent prescriber status. This would allow acceleration and reduce bureaucracy and paperwork.

If ‘Pharmacy First’ schemes are based on advise, treat, refer – then I would introduce two important links to support the ‘refer’ stage. Firstly community pharmacists would have direct access to emergency appointment slots in local practices. And secondly the community pharmacy should have teleconsultation arrangements out of hours so patients sitting in the community pharmacy consultation room could talk to GPs in an out of hours service.

If we are committed to equity and access to treatment, then why is ‘Pharmacy First’ not a standard across the whole of NHS England?