Walking up from the station, the Royal Berkshire Foundation Trust has a rather grand frontage. David Oliver, the consultant geriatrician who organised my day, guided me, by phone, round to the modern entrance and bought me a coffee. It was shortly before 8am and, on the hour, we dived into the maelstrom of the clinical decision unit. Over the next two hours I would watch and listen as a team of professionals tackled the problems posed by 17 elderly patients who had been admitted overnight. Only two patients were below the age of 80 and the first person we saw had cancer, heart disease, diabetes, anaemia, falls, and no help at home. more…

Let me tell you a story.

I recently had the opportunity to listen to a woman whose mother developed vascular dementia.  This is what I heard.

A stroke caused expressive and receptive dysphasia along with a change in behaviour so, when stressed, her mother would become aggressive. Despite that, she lived in her own home alone, safely, didn’t wander and her daughter managed to care for her. It wasn’t easy. The mother was on warfarin. They had to get her to the GP surgery for her test which was a struggle, as that stressed her mother, with inevitable problems. The fact she had dementia was not recorded in her notes so staff were unaware. Administering medication was difficult. They got her to the surgery for a flu injection, as requested, and were glad they were in the house when a nurse, not knowing it had already been administered, turned up to give her it for a second time. It all seemed uncoordinated and reactive. It felt like a system they had to work against, not with. more…

I got a new job last week. My daughter was appearing in Annie at the Retford Majestic Theatre. She belongs to the Mini-Operatic Bunch (MOB), the junior branch of the Retford Operatic Society and each year the kids (upper age limit 18) put on a show which the public pay to see. I was recruited to work backstage. It was a new experience for me and I quickly had to learn a new set of skills (like putting up scenery) and learn a new language (I now know what a dead drop is and it has nothing to do with premature mortality!). more…

Sometimes, it becomes apparent that what we have been talking about for so long is actually beginning to happen.

Over the last few weeks we have been preparing for our Annual Accountability Review with the SHA. We have had our monthly cluster board meeting. We also had a meeting with the acute trust, looking at mortality. Then there was the NHS Confederation conference. Meanwhile the commissioning support services were re-launching a new and improved CCG dashboard to track activity and variation. more…

One aspect of my job that I have enjoyed over the last few years has been engaging with the public. It has never been dull. When I first arrived in Lincolnshire we did a lot of work, talking with the public and professionals about the principles we should use for commissioning services. This became a consultation called Shaping Health for Lincolnshire. It helped, I believe, set a new tone for the way commissioning was regarded and a new way of working with people to make change happen. more…

In the last week, I have managed to catch up with two old friends who are the sort of GPs who I would be delighted to look after me or my family. As I listened to them both, I empathised with the pressures general practitioners face. On top of the burden of more and more patients with co-morbidities for whom more and more is expected from general practice, GPs are expected to find time to get deeply involved in commissioning. The pressures on GPs and practices are growing and they are under strain. more…

Ch,ch,changes. The next couple of months are going to see a sea change in the management of commissioning across England. The appointments to the NHS Commissioning Board (NHSCB) sectors are being made. Appointing to these four posts will allow the wave of appointments to the local offices, to be renamed as local area teams, to be made. The commissioning support services are passing through “checkpoint two” and being set up to receive large numbers of staff from PCT clusters. more…

We are working through trying to understand exactly how commissioning support (CSS) will work with Clinical Commissioning Groups (CCGs). At a recent time out the lead manager for the CSS presented on the progress being made with Greater East Midlands CSS (GEM). They highlighted the scale of work that is required with the 277 tasks in the development plan. One of the Chief Operating Officers presented the programme of work required to see through the transition from a CCG. As they pointed out, this was a transition plan—for which the work required for authorisation is a component, not the be all and end all. There is as much to do to develop the CCGs as there is to develop the CSS—and they are mutually dependent. more…

Over the last few weeks my reading and listening has made me consider whether we are at a crossroads in understanding and agreeing the purpose and nature of healthcare. Let me start with this quote from the evaluation of the 16 integrated care pilots that were supported by the Department of Health:

“Over the past 50 years healthcare systems have been focusing on strengthening acute care sectors to respond to the needs of patients suffering from life-threatening conditions such as heart attacks. Thus, healthcare systems may not be well equipped to respond to the needs of increasingly older patients suffering from multiple chronic conditions and who require a combination of regular primary care support with both predictable and unpredictable specialist care. The goals of care for those with chronic and/or disabling conditions are not to cure (as is the case for acute conditions), but to enhance functional status, minimise distressing symptoms, and prolong and enhance quality of life through secondary prevention. It is clear that these goals are less likely to be achieved through traditional approaches to care that focus on individual diseases and are based on a relationship between an individual health/social care service-user and a single health/social care professional.” more…

The political ambiguity is, mostly, resolved. Very shortly, appointments will be made to Clinical Commissioning Groups (CCGs). At the same time appointments will be made to the local arm of the NHS Commissioning Board (now to be known as the “Area”), the NHS Commissioning Board Sectors (formally known as SHA Clusters), and Commissioning Support services. What was theoretical is becoming something very tangible. more…