Richard Smith: Dumfries and Galloway NHS 6—developing change locally

richard_smith_2014Richard Smith visited and wrote about the NHS in Dumfries and Galloway in 1980, 1990, and 1999, and this series of blogs describes what he found in 2016. A feature article provides a summary.

Annan is the third biggest town in Dumfries and Galloway, in the East of the Region, and so the least remote. Perhaps because it’s less remote or perhaps because of its entrepreneurial GPs it seems to have fewer problems than towns further West. It has a full complement of GPs, and one of the practices was once a fundholding practice.

Neil Kelly, a local GP and the clinical lead for Annandale and Eskdale, recognises the importance of leadership and is clearly a leader himself. He worries that the command and control system in Scotland stifles innovation, and while bemoaning the plethora of initiatives in Scotland he’s good at capitalising on them. Annan seems to be the California of Dumfries and Galloway, developing innovations that may then be adopted across the region.

Starting from the recognition that the present system is unsustainable, Kelly is interested to explore ways to make it sustainable. These include “recreating self-care,” reducing dependency, supporting lonely and isolated people in the community before they present in crisis, encouraging task sharing, strengthening communities, hastening health and social care integration, concentrating on what matters to patients rather than the professionals, encouraging people to have forward care plans, and promoting the use of information technology. (Bandwidth is a problem in the region: it can take five minutes to download a letter in a branch surgery.)

Kelly believes that these things cannot be made to happen by central dictats but depends on change being made locally. People and relationships are what matter. To that end he’s helped develop a team of people to encourage the developments he thinks necessary in Annandale and Eskdale, and I met many of them.

Developing services in Annandale and Eskdale

Lydia Burnett, a woman with a long experience of change management, is working with practices across Annandale and Eskdale ostensibly to encourage integration of health and social care but more encouraging practices to adapt to the rapidly changing world. You have to, she insists, “sort your own house out first.” She’s working with 10 different practices and all are different with different problems.

I discussed with her and several other people during the week whether rural and remote communities are more resilient or more dependent. She was sure that dependency is “worse in small communities,” but others took the opposite view. The extraordinarily high rates of attendance at Accident and Emergency in Stranraer suggest dependency, but the high rate might be explained simply by the hospital being so close. Perhaps it’s not related to remoteness or size but simply varies among communities.

Julie Robertson and Michelle Wilkie are community link workers who concentrate on identifying isolated people and trying to connect them to the community and any services they might need. Although funded by the health board, they are “women of the people” who don’t have the scariness that tends to infect health and social care workers no matter how friendly they are. They are referred people by social workers, GPs, nurses, the police, and others, and people will refer themselves. They visit about 60 people a month and help them prepare a personal plan.

Evaluating what they do is hard. There seems to be little doubt that they make life better for many people, but are they reducing the burden on the health and social care system, saving money? Are they “core workers,” as we regard GPs, cardiologists, and nurses, or are they “nice to have” extras? They have stories of people who went repeatedly to hospital who now don’t, and they are surely crucial in strengthening communities and encouraging resilience. They are now working across the whole of Annandale and Eskdale.

Forward looking care plans

Donna Wallace is a nurse who has for two years been encouraging people in Annan to develop “forward looking (care) plans.” The word care is in brackets because this is about more than care it’s to “help you focus on what matters to you now, and [it] can help you access support to live well and independently for longer in your own home.” Despite this Wallace has been known as “the death nurse,” but some 230 people in Annan do now have plans. The hope is both that people’s needs will be better met and services used more appropriately. There have been evaluations of the service, and it’s now being expanded to the rest of Annandale and Eskdale.

Local cultural variation

Liz Forsyth works with groups rather than individuals to develop communities. Describing herself as an “Arthur Daly type,” she “makes do and mends,” bringing together resources from the statutory, voluntary, and private sector to strengthen communities. She has lived in Annandale and Eskdale for years and is an acute observer of the differences between the towns: Annan is grateful for all services; Gretna is wary; Langholm is “surveyed to death” and resistant to new services; Moffat thinks of itself as “the jewel in the crown of Dumfries and Galloway” and resilient and doesn’t need help; while Lockerbie is not so resilient and “up for getting involved.” Viewed from London or even Edinburgh, these small towns might seem to be much of a muchness, but they are clearly different, emphasising the importance of local initiatives and the problem of top down management.

Developing primary care

Grecy Bell, a Colombian doctor who is a GP in Annan and deputy medical director for primary care for the whole region, further illustrates the entrepreneurial energy of Annan. She is the lead for patient safety in primary care across Scotland and is also interested in improving services for patients with chronic pain. The Quality and Outcomes Framework (QOF) has been abolished in Scotland, and instead practices are supposed to form quality circles and work together at raising quality and improving safety. One GP, who referred to his practice as “my business,” raised his eyebrows when I mentioned the abolishing of QOF, implying I thought, “We all know this is a way of maintaining our income without asking us to do more.” Self-directed quality circles might well be more effective at raising quality than payments for activity, but will GPs have the time to make them work? And how will they be evaluated? What if GPs decline to join circles or fail to use them effectively?

Recruitment is the top priority for Bell, as it is for almost everybody in Dumfries and Galloway, but she wants as well to help practices across the region improve their efficiency and effectiveness and to improve the coordination with secondary care.

Richard Smith was the editor of The BMJ until 2004.