Oh for the good old days of payment by results. In yet another unexpected twist I have found myself over the last weeks, stuck between a rock and a hard place. We have a brilliant team who have developed pathways and led research in a niche area of medicine. Pre-COVID they were slowly becoming the place to send these patients for the whole country. Growth was about 75-125 patients a year. As a complex long term condition management service, the team was made of clinicians of all types – Advanced Health Practitioners, psychologists, nurses and doctors. Since COVID this has meant at least 150 new patients to a case load and no new money. So to prevent the service being overstretched and existing patients suffering we have had to make complicated decisions. Firstly we cannot simply scoop up the whole country’s patients without more resources. To manage this the team could start saying no to patients from outside our region and raising the clinical risk that this creates to NHS England. It is then their call on whether to embed the service in a nationally commissioned specialist service thereby overcoming the block contract and allowing additional monies to flow. This solution allows the service to evolve, i.e. funding the growth of required staff. If the answer is not a nationalist service then the no to patients has to hold and patients will have to be managed locally by non-specialists, provoking anxiety in families, specialists and local staff, not to mention real clinical risk.

The additional problem this generates is that part of what is driving the patients to come to our center is that we are developing a research base alongside the clinical growth. The access to so many patients is hugely useful for pure research but also for commercial studies. If we turn off the flow we hold back both of these. Clearly an alternative would be that the commercial studies support the out of area patients who are contributing to their studies by funding the additional staff,…more negotiations required for this.

Furthermore the benefit of a growing unit is that fellows can come and spend time in the service learning skills that can be moved to other areas of the country over time. There is even the possibility of exporting these skills to support an even broader population base. If unit size is restricted this pipeline is slowed down. Training takes time so this slowdown puts future growth at risk as there then won’t be staff who are ready to support their niche service.

Turning off the new patient tap may not be enough though, as with this condition the complexity increases with age. So more input is needed later in the course of the disease. So here too the solution is reducing the demand on the specialist service. Discharging patients back to local care with clear instructions on how to manage and when to re-refer. For clinicians, saying no to patients is distressing. They worry about them and their families. It feels so out of keeping with the NHS ethos to turn away patients who could be helped, especially if there are almost no other places for the patients to go that have the acumen and expertise needed, never mind the access to research trials. With the lack of electronic health records covering the whole country (yet), maintaining a distant watchful eye remotely is not currently possible. One day this will be, and a population health approach with disseminated delivery but national oversight will manage out some of these expertise deserts without the patients losing out.

Driving a postcode lottery seems fundamentally wrong. Putting existing patients at risk due to spreading the clinical skills set too thin is wrong too. The answer is probably as always a bit of everything: NHSE designate the service a national service, commercial studies contribute more and perhaps foreign fellows pay towards their education.

Magical Meander

Magical meander is an anonymous blog series written by a medical manager working in the NHS and published on BMJ Leader Blog.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.