Archive for December, 2013


What the impact of the Integrated Transformation Fund (ITF) will be is the question at the forefront of most CCG minds.  It is without question a huge challenge for all local health economies.

There are huge cuts to local government over the next few years.  As a result of this there will be significant cuts to social services, which in turn will impact on health.  Seemingly in response to this it has been agreed that the ITF (now apparently named the ‘Better Care Fund’, but let’s stick with ITF for now) will be established.

The ITF is a £3.8bn fund that seeks to pool existing budgets from April 2015 to enable greater integrated working and the transformation of local services.  According to NHS England and the Local Government Association (LGA) guidance a key criterion for its use is to ‘compensate for social care cuts’.

A critical fact here to keep front of mind is that this is not new money.  It works a bit like a visual trick: social care understand they are receiving an extra £3.8bn and health are under the impression that they still have the same money available.  The NHS, after all, has been ‘protected’ from any funding cuts.

So where then does the money come from?  The expectation set by NHS England is that it comes from the expenditure on acute trusts.    There are two routes identified for this.  One is an expectation that there will be further savings. David Nicholson has talked about the requirement for an ‘additional’ 2-3% productivity gains.  So in 2015/16 there will be a requirement for efficiency savings of 6-7% rather than 4%.  You can make your own judgements about how realistic this is.

The second route is through the benefits that integration realises.  The theory is essentially that if health and social care work together and create new models of care that keep people healthy in the community then admissions will go down and delayed transfers of care will be removed.  But this of course sidesteps the starting point for all of this which was cuts to social care.  The money will at best protect the total current expenditure in community health and social care.

So in reality there will be no new capacity to enable the huge savings required of acute trusts.  Instead the new ways of working through integration will be expected to deliver these benefits with no additional capacity.  Herein lies the key problem that the ITF is creating: it is generating expectations of investment in community services that are not real, and using these expectations to justify the requirement for reduced expenditure in acute hospitals.

So how can CCGs respond?  There are probably two tactics available.  The first is to do everything possible to protect health expenditure.  CCGS can use the absolute minimum possible to be part of the fund, insist wherever possible that the funds used come with clearly badged expenditure, and try to limit the damage that this is inevitably creating.  CCGs could make a judgement that based on the experience of other nationally imposed financial constructs (e.g. MRET) that the incentives will not generate the changes expected, and proceed on that basis.

The second is to recognise that the only actual change proposed within the ITF construct is the integration of health and social care, and so to develop a plan that will maximise the impact of integration.  This then take CCGs into questions of scale, on the basis that the more that is integrated, the bigger the potential benefits (whilst at the same time recognising the bigger the potential risks).  The questions then for CCGs are whether they are prepared to commission all of community health and adult social care with local authorities on a whole system basis?  Are they prepared to create a single commissioning function for this that would incorporate planning, quality and contracting?  Or if not how far are they prepared to go?

Difficult choices ahead.  These choices are compounded by the timescale: the draft ITF plan is due to be submitted on the 14th February.  And we are already well into the contracting round for next year.  Acute trusts are quite rightly going to want to know what the plan is for the ITF ahead of any agreement, particularly any two year agreement.  Unfortunately there are not any straightforward solutions.

Merry Christmas to all, and a big thank you for all of your support and encouragement for this blog throughout the year!

, , ,


Much has been written about maggots this week, but those involved in the maggot business are so concerned with the lack of balance in the reporting that some are thinking about getting out altogether.  So is it time to get out?

At their most basic level, maggots are the larvae of flies, but as you and I know, they are so much more than that.  For a start nearly all fish love maggots, and for them they are a great source of food as well as being effective bait.  Fishermen are even prepared to pay for them: at they go for £2.48 a pint.

Live maggots have been applied as a medical treatment since antiquity, as an effective means of wound treatment.  The late Princess Margaret is possibly the most famous patient to receive ‘larval therapy’ which involves using sterile maggots to clean an infected wound.

And forensic scientists use the presence and development of maggots on a corpse as a way of estimating time elapsed since death.   So called ‘entomological evidence’ was first used to convict a murderer in 1935 when Dr Buck Ruxton was found guilty of the murder of his wife and maid based on maggots dated at 12-14 days old.

But despite their really positive contribution, the business of maggots is getting increasingly bad press.  They are, it seems, becoming something of a problem. 

In August a Worthing woman discovered a maggot in a burger that she bought from McDonalds.  Apparently she wasn’t loving it.

In November cousins Ella Grix and Chloe Appleford were about to take a spoonful of Weetabix, when they were, according to the Worthing Herald, ‘horrified’ to look down on their chocolate-laden biscuits to see maggots crawling in and around them. The girls’ grandmother, Yvonne Read, 45, had bought the box in Gravesend, Kent.  ‘I will never buy or eat Weetabix again. It was disgusting,’ a dismayed Ms Read told the Herald.

Stories like this are just the surface of it.  There are a number of horror stories also doing the rounds.  In July the Independent reported this story, one that the more squeamish amongst you might want to skip.

Derbyshire resident Rochelle Harris had just returned from a holiday in Peru when she began developing shooting pains in her face.

The 27-year-old initially thought little of it, and assumed the problem would quickly disappear, but the following day she  woke to find a strange liquid covering her pillow and began hearing scratching sounds coming from inside her head.

Increasingly concerned by the discomfort, Ms Harris decided to visit the Accident and Emergency department at the Royal Derby Hospital, but was told the problem was likely to be a simple ear infection or mosquito bite.

It was only after she was referred to the local Ear, Nose and Throat clinic for an hour-long examination that was intended to confirm the infection, that the sickening truth of the problem became clear…the doctor said ‘You’ve got maggots in your ear’. I burst into tears instantly… I was very scared – I wondered if they were in my brain. I thought to myself ‘This could be very, very serious’”.

The doctors immediately tried to remove the maggots from Ms Harris’ ear canal, but the deeper they probed the further the maggots went inside her head, eventually disappearing from sight.

A brain scan was swiftly ordered to work out where the maggots were hiding and exactly how many of them there were, as concerns grew that or more of them could reach the brain. …The brain scan revealed the maggots burrowing inside Ms Harris’ head had left much of the area untouched, only chewing a 12mm hole in the ear canal.

Doctors decided the best course of treatment to remove the maggots was to flood the ear with olive oil.

Ms Harris said: “It was longest few hours of my life… I had to wait overnight to see if the treatment worked… I just wanted them out of me and now I knew what was causing the sensations and sounds it made it all the worse.”

Unfortunately the tactic failed, but the following day doctors were able to remove two living maggots that been flushed closer to the entrance of the ear.

Concerned that there may be another maggot they might have missed, doctors sedated Ms Harris and conducted a full re-examination of her ear. 

They were shocked to discover a further eight large larvae – what they dubbed a “writhing mass of maggots” – but with the patient sedated and the creatures easier to reach following the olive oil experiment, the doctors were able to remove them.’

With maggots getting such a hard time in the press, it is doubtless hard sometimes for those in the business to find the motivation to carry on.  It does feel like there is always going to be another story around the corner.  Despite the countless happy fish, one rogue maggot can ruin it for everyone. 

It is probably no consolation, but I think maggots are a force for good, and I hope everyone in the maggot business sticks with it and decides that, at the end of the day, despite the scaremongers, the good that the vast majority of maggots do every day all over the country make it worth carrying on.



The Health Service Journal (HSJ) has this week declared that the ‘Oxfordshire battle will determine the impact of CCGs’ (here).  This is because, as the HSJ puts it, ‘One of the largest and most advanced attempts to bring about integrated, outcomes based commissioning has been delayed following objections from two powerful provider trusts.’

So is the HSJ right? The conclusion seems to have been drawn from what the events in Oxfordshire say about relative ‘power’ of purchasers and providers.  In the private sector different industries have different relative levels of buyer or supplier power.  In some sectors buyers (like supermarkets) wield great power and can drive price down.  In others (like the oil industry) suppliers wield the power and determine the price that buyers must pay.

So the HSJ argument is constructed on the basis that the formation of CCGs was to increase buyer power over providers, and that the amount of power exerted (in this instance the imposition of a specific contract) is the marker of CCG impact.

But there is very little about CCGs that is different from predecessor commissioning organisations that would increase their ‘buyer power’.  Maybe knowledge of services by the GPs and clinicians involved in CCGs, but at best there are only changes at the margins and certainly not enough to effect a significant switch in power.

I would argue that the whole notion of relative power is unhelpful for where we are in the NHS today.  The win/lose mentality between providers and commissioners has not served the NHS well in the past, and is extremely unlikely to help in the future.  It doesn’t help supermarket suppliers or those who buy oil.  And in the highly politically charged environment of the NHS, adversarial relationships inside the NHS will always damage the consistency of public message required to enable change to happen.

CCGs are most likely to be successful not because of an increase in relative power, but because of the ability of their clinicians to create partnerships with other clinicians and drive whole system change to improve outcomes. 

It is effective partnerships that are required, not power games.  According to Wikipedia, a partnership is, ‘an arrangement in which parties agree to cooperate to advance their mutual interests’.  And while it is tough to develop strong commissioner provider partnerships in the current environment, this is what is required. 

It is tough in part because the tight financial state of the NHS means there is limited funding to smooth the transition to any new model.  It is tough in part because each organisation has its own regulator putting pressure on it to take action that may be at the expense of partners.  And it is tough in part because people are not perfect, and in a pressurized environment any misplaced comment or action can quickly undo progress that has taken months to build.

The HSJ is being deliberately provocative in stating the ‘battle of Oxfordshire will determine the impact of CCGs’, but it raises an important challenge as to how we choose to monitor their impact.  Measuring whether or not contracts are imposed is not a good marker.  Any perpetuation of the win/lose mentality of provider commissioner relationships is unhelpful.  A much better marker is the ability of CCGs to form relationships that enable new ways of working that in turn drive improvements in outcomes.  Neither CCGs nor providers can make the changes they need for a sustainable future in isolation; it has to be done in partnership.

, ,


I recently watched a TV debate about smoking and the NHS.  One man was arguing forcefully that it was his right to choose whether he smoked, how much he smoked and what he smoked, and that it was the job of the NHS to provide care for him when he needed it.  In his mind the two were in no way linked and he was irritated by the notion that the NHS might have a role in influencing his behaviour in relation to smoking.

In this country we love the NHS.  In the celebration of Britain at the Olympic opening ceremony the NHS took centre stage.  We are proud of our system because it is available to all, is free at the point of delivery, and is based on clinical need, not ability to pay.  It is our hero, because when we need it, it will do everything it can to save us.

As we consider our future vision for the NHS, the key is not so much understanding what the NHS is, but understanding our relationship with the NHS.  The man in the smoking debate was clear: the NHS for him is something akin to a ‘safety net’, there for him when he needs it.  And this is not an uncommon view.  The current furore over A&E and winter is driven largely by the symbolic importance of A&E as the front line of the safety net that the NHS provides.

Our attachment to the NHS is driven by stories of how the NHS (our hero) saved me/my grandmother/my father/my niece.  These are powerful stories from key moments in our lives.  Regardless of what happens to me or my family I know the NHS will be there for me when I need it, and that is why I will do whatever I can to protect it.  My attachment is built on this metaphor of the safety net, reinforced by powerful, personal stories.

Conversely, prevention does not create the same stories or drive the same level of attachment.  In the same way that a safety engineer that spots an irregularity in an aircraft maintenance check and prevents an accident ever occurring will never be a hero in the same way as the pilot who safely lands a misfiring plane on the Hudson river, so the flu jab will never be a hero in the same way as the hospital that nursed my grandfather back from the brink of death from flu.

And herein lies the problem.  Because our vision for the future of the NHS is one that has prevention as its hero, and that has citizens as active partners with the NHS in improving their own health.

Paul Pholeros has given a great TED talk on ‘Housing for Health’.  You can find the transcript here.  He describes how in 1985 a man called Yami Lester saw that for the aboriginal population of Central Australia 80% of the illnesses walking into clinics were infectious diseases caused by a poor living environment.  They examined the housing conditions of 50,000 Indigenous Australians and found that only 35% had a working shower, only 10% were electrically safe, and only 58% had a working toilet, all primarily due to a lack of routine maintenance.

The Housing for Health project works on toilets, showers and electrical safety, and as a result over 10 years has delivered a 40% reduction in environment related hospital admissions.  I am not doing this story justice here and I would encourage you to read it for yourselves, but the point is that providing great treatment for the infectious diseases was not the answer; rather it was preventing the diseases from occurring.

We are fortunate not to be dealing with the same developing world poverty of the Indigenous Australians in Central Australia.  But if we believe that the role of the NHS is also to improve health in partnership with the population, and not to simply provide a safety net for all, then our work on a 5 year vision for the NHS must start with this as the conversation.

Delivering 5 year plans to improve health will be impossible if we end up fighting a public whose primary goal for the NHS is to defend the safety net and the hero of curative medicine.  We need to create a new hero for the NHS, to build a belief in the power of prevention and partnership, and we need to do this by developing powerful, engaging stories like that given by Paul Pholeros as an antidote to the stories that are shaping our current thinking.

, , ,