Posts Tagged ‘clinical commissioning groups’


Hello all!  Thanks for all the messages of support since my last post at the end of February, where I asked the question as to what next for the website.  Many of you contacted me directly with a number of suggestions, and many gave direct offers of help, and I really appreciate all of your input.

In the end I have decided to continue the blog with support from those with more technical capability than myself!  As a result the blog will now be hosted by The Information Daily ( ), which will provide a much better platform for both hosting and disseminating the content more widely.

Just for the record I still do not receive any form of payment or income for the blog, which is, and always has been, designed to support those working in and with health.

The first of the posts on the new platform is now live, and you can access it by clicking here.  It is entitled, ‘NHS cannot transform healthcare while defending the status quo’, and I argue that radical change may need to come from outside the NHS.

For the next few months I will post a message as a prompt that the new weekly blog is out.  Thank you for your continued support, and do let me know ( if you have any specific questions or topics you would like me to cover.





I set up at the start of 2012.  Since then I have posted every week for over two years about CCGs and all the issues that they have faced in setting up and getting established.  There are now 110 articles on the site, covering issues ranging from making commissioning support effective to the future of general practice. 

The information on the website is provided completely free of charge.  There are hundreds of subscribers to the site receiving the weekly blog.  The most popular articles are (surprisingly) the ones on estates and NHS Property Services! 

The site has offered support to CCGs in the year before they were formally established and in their first year with the new responsibilities.   As we now approach the completion of this first year of CCGs as statutory bodies it is time for a review of the site.  Over the course of the next month I will be considering the following options, and with this I would really value your help.

As I see it there are 6 possible ways forward:

  1. No change.  I could continue to produce a weekly blog as I do now and adapt the content to the changing needs of CCGs as they evolve into the future.
  2. Adapt the existing site.  I could continue with the current site, but adapt the content, format, style so that it better meets your needs.  For this you will need to tell me how you would want it to change.
  3. Start a totally new blog/website.  I could draw a line under the period of the establishment of CCGs, and leave as it is without adding any further content.  I could set up a new blog or website and focus on a new or different area. 
  4. Start a podcast.  As far as I can tell there is no regular podcast within the NHS at present.  As podcasts grow in popularity there must be a place for one within the NHS.  I have no idea how to set one up, but could set about finding out!
  5. Work with others. I have largely produced the content for on my own.  For any of options 2, 3 or 4 above I could work with any interested individuals to make them happen with a wider range of input (let me know if you are interested!).
  6. Stop altogether.  I could of course draw a line under the work to date, recognise the value that it has added so far, but stop and focus on other things.

As I carry out the review over the next month, I would really value your input.  It would really help me if you could let me know what you find valuable about the site, what does not work very well, and what you think of the options outlined above as regards a way forward.  Please email me on to let me know your thoughts. 

Just to be clear this means that there will be no posts for the next month.  Before the end of March once the review is completed I will update on the way forward.  I look forward to hearing from you in the mean time, and thanks in advance for your help!


How do you create trust?  Is it even realistic to think that organisations that are competing with each other for increasingly scarce resources are going to be able to trust each other enough to allow credible whole system plans to be developed?

Joint working is essential, but the barrier to it often boils down to one of trust.  Do the CCG and council trust each other enough to pool budgets? Do the hospital and the CCG trust each other enough to enter a risk sharing agreement?  Do general practice and community services trust each other enough to build a single staffing model across a locality?

This can become a chicken and egg type scenario: we don’t trust each other enough to have a single health economy plan rather than a set of organisation specific plans, and we can’t develop trust because we are not working together closely enough.  So if trust is the secret ingredient, how do we create it?

Well I don’t claim to know the answer, but I was at a session with the previous NHS Confederation chief Mike Farrar recently and asked him this question.  His answer was so good that I thought it only fair that I share it with you!

He said that there are three ways to create trust.  The first is to agree a shared sense of purpose.  He said that many health systems do not put enough effort into this.  A system plan is produced, it goes to a whole system meeting, and is generally agreed.  What doesn’t happen is a stress testing of the purpose or a putting it under the fire of different scenarios.  Organisations don’t take the aims of proposed whole system plan back to base and work through with their Boards as to how the goals of the system can match with the goals they have set for their organisation.  More effort here, according to Mike, is an essential foundation to building trust across the system.

The second is to establish system wide clarity on the approach to competition or collaboration.  There needs to be a shared understanding as to how this will work across the health economy.  What doesn’t work is asking groups of clinicians from all organisations to work together to design a new model of care, and then the CCG springing a procurement on the providers that is not expected.

This does not mean that the CCG has to say that they will not be putting any services out to tender or that they will be procuring everything.  What it means is that a framework is established so that everyone is clear when services will be procured and when they will be developed through collaboration.  The rules of engagement need to be clear and signed up to by all partners.

The third is to establish who the system arbiter will be.  Given the challenges that all health economies face it is inevitable that there will be issues on which organisations do not agree.  It is not good enough to simply say that decisions will be taken that are in the public interest, because this can often be argued both ways. 

There needs to be agreement as to whether deviation from the collective agreement is ever acceptable, and if so in what set of circumstances.  Systems must establish an agreed point of arbitration, which everyone signs up to before such a situation arises, and which everyone agrees to abide by when a decision is made.

Trust is a critical but elusive ingredient of effective whole system working.  The current environment and the challenges that we face dictate that there is not enough time to spend years building it up, but what I think Mike’s answer has provided is a set of actions that systems can take now to make their 5 year strategies much more likely to deliver.

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If we carry on down the same road we have been down every previous year, with providers operating in isolation from other providers and CCGs operating in isolation from all providers, where will we end up?

If each organisation continues to develop its own plans then it plays out something like this.  Providers and CCGs enter the contracting round with the figures they need out of the contract.  They argue about the likely success or otherwise of demand management plans.  With the deadline imminent they agree a figure on paper, but they both take away different assumptions about what will happen during the year.  The CCGs assume demand will be reduced, the providers assume demand will grow. 

The net result is a deficit gets built in to the health economy position, because both build different assumptions into their forecast outturn position.  Someone will be right and so a deficit will inevitably sit somewhere.  The value of the agreed contract figure becomes material only in terms of determining the level of monthly cash payments.  In terms of establishing an agreed end of year position it is virtually meaningless.

In 2014/15 the gap between what CCGs can afford and what providers will require is going to be bigger than ever.  Aside from ever increasing demand and inflationary pressures, the situation is exacerbated by the planning guidance.  Now we have the cost of introducing seven day working, the requirement for CCGs to fund £5 per head for general practice, the need for CCGs to keep 4% out of recurrent expenditure (2.5% non-recurrent, 0.5% contingency, 1.0% surplus), just to name a few.

Once a figure is agreed on paper and the year starts, the cracks will start to appear.  CCGs facing financial challenges will shift down a route of increased contract challenges and reducing elective activity, and providers will try to do the reverse (improve coding and increase elective activity).  Throw in the last winter before a general election and the pressure will ratchet up, and relationships will become extremely fraught.  And if next year does not finish us off the year after will, with the transfer of funds from providers to social care via the Better Care Fund.

But there is an alternative.  We could work as health communities to have a single plan.  We could work together to take the resources that are available (knowing that they are insufficient) and use them collectively to deliver a single plan.  This requires each organisation to relinquish the sovereignty that it feels entitled to; actions would be determined by the greater good, not simply by what is best for any single organisation.

In this model organisations collectively commit to what the health and social care economy must deliver.  There is a single set of assumptions that all sign up to.  Agreement is made as to how the money will be used between the organisations in order to enable delivery of the plan.  The contract negotiations focus on this, rather than simply setting the level of cash flow. 

The alternative is harder to set up.  It requires providers to work with providers and CCGs to work with providers.  It will fail if alongside the one plan organisations have their own (secret? real?) plan.  Each organisation has to commit to the system plan.  Each organisation has to be accountable to each other for delivering their part of the plan. 

Clearly this requires trust between the partners. It introduces an uncomfortable interdependence.  If one organisation does not deliver, all will suffer because delivery of the overall plan will suffer.  And of course the worse the current position, and the longer we continue along the current course, the less trust there will be.  If we wait until we trust each other to do something different, we may never get started!

There is no doubt this alternative is harder to set up, but if we understand where the route we are currently on takes us then maybe we will think it is worth it.  After all, something has to change.

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Clinical leadership sits at the heart of the thinking behind the introduction of CCGs.  But as a result great expectation and great responsibility has been placed on the GPs who have taken on leadership roles in CCGs.

These are not easy jobs.  There are a number of complex elements to them that we have explored in previous posts on this site:

In ‘the importance of localities’ we established the need for those GPs leading localities to build the relationship with member practices,

‘The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.’ 

In ‘8 top tips to drive GP engagement’ we identified that beyond developing the engagement of member practices a key role of GP leaders is to influence individual GPs, and that achieving this is no mean feat. 

Beyond that we determined in ‘CCGs are redefining out of hospital care’ that GP directors in CCGs have a key responsibility in the transformation of these localities around a redesigned general practice.

In ‘Is your CCG really clinically led?’ we established that GP directors have a corporate responsibility for the overall performance of the organisation and how it discharges its responsibilities,

‘An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors.  The distinction is important.  A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate.’

So in summary: build a relationship with practices, create an emotional connection between every member GP and the CCG, lead the transformation of general practice and community services, and take responsibility for the CCG hitting all of its statutory duties.

Can we expect our GP Directors to achieve all of this in 3 or 4 sessions a week?  Have we created undoable jobs?  Are we setting our GP leaders up for failure?  The public debate about GP directors has focussed on the potential for conflict of interests and how these are managed.  But it is missing the real question which is how realistic are the expectations we have placed upon these new GP Directors, many of whom have only been in these roles since April, and how are we supporting them to be successful?

And of course these GPs are primarily elected rather than appointed.  We give them the title of GP director, and then wait for the magic dust to descend and the great leader to emerge.  By and large it is sink or swim.  We are expecting leadership talent to emerge simply because they are GPs, without any structured development programme beyond that provided locally. 

There are examples of fantastic, courageous and highly talented GP leaders who are doing an amazing job and who provide inspirational examples of what is possible.  But how are we helping those for those learning the trade, who have taken on responsibility for leadership in the most testing time the NHS has ever known?  Doesn’t there need to be more: more structured leadership development, more visible support, more investment?  Isn’t this where we need those who are offering to support CCGs to focus their efforts?

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Reading the planning guidance is always a treat(!), so it was very festive of NHS England to release this year’s guidance on Christmas Eve as a seasonal gift for CCGs and organisations across the NHS. 

It is a confusing time to be in the NHS.  We are so used to there being a plan dictated from above, and of taking on the job locally of putting this into place, that it can be quite disconcerting to receive guidance that reinforces that there is no overall plan for the NHS.  In the old days we received the ‘operating framework’, which described what local organisations needed to do to within the overall plan for the NHS.  We now have guidance ‘that sets out the need for bold and ambitious 5 year strategic plans’

It does claim to also ‘describe an approach to deliver transformational change’.  There is (inevitably) a framework (‘5 outcome domains with measurable ambitions, and three further measures of improving health, reducing health inequalities, and moving towards parity of esteem’), and then this strange concoction of ‘characteristics of transformational change’

These characteristics are by and large ambitions (e.g. ‘wider primary care, provided at scale’ and ‘a modern model of integrated care’).  They represent a direction of travel, but they do not of themselves constitute a plan.  In NHS England’s words they are the ‘characteristics’ of a plan. 

Of course NHS England does not claim to have a plan.  It is for local communities to use the guidance to create robust plans. ‘Plans must be owned locally and driven by local needs. Unlike previous years, this document is not prescriptive in how CCGs achieve this ambition.’ (p25).  So we are free to make our own plans locally.

But before we get too excited there are a few caveats.  There are 21 ‘fundamental elements’ that NHS England will use to assess the scale of ambition and plans for implementation, with 47 ‘key features’ to be demonstrated in plans.  These features include:

  • how you will enable primary care to operate at greater scale to improve access and continuity of care and to enable your urgent and emergency care network to function effectively’
  • ‘how you have considered your model of elective care for your local providers to achieve a 20% productivity improvement within 5 years, so that existing activity levels can be delivered with better outcomes and 20% less resource’
  • ‘how your strategic plans address whether your providers are seeing and treating a sufficiently high enough volume of patients to meet specified clinical standards, in line with the need to concentrate specialised services in 15-30 centres of excellence, linked to Academic Health Science Networks’

 The NHS has been trying to make these changes, or ones very similar to them, happen for a number of years.  But rather than tell you how to do it, NHS England is simply stating what must be done.  It is the freedom of how to get there that is the preserve of the CCGs.

But whereas previously funding has been available to smooth the delivery of such grand changes, the fiscal environment now offers no such support.  The NHS must save £30bn by 2021, and CCGs must operate within the financial rules handed to them.  These include a 4% non-recurrent requirement for next year (0.5% contingency, 1% surplus, 2.5% non-recurrent expenditure), rising to just over 6% with the money to be found for the Better Care Fund in 2015/16, with a 10% reduction in running costs in 2015/16 thrown in for good measure.

This financial pressure will hit providers, those that CCGs will be asking to support the delivery of these changes, hard.  Most providers already have very gloomy financial forecasts for next year, and I don’t think this guidance will have helped.

You may be thinking that this is beginning to sound like an impossible task, but help, it turns out, is at hand.  The ‘Any Town health system model’ is to be published in January.  This will show ‘how a typical CCG could achieve financial balance over the strategic period covered’.  Before you become too cynical about this please note that, ‘A number of ‘High Impact Interventions’ have been fully impact assessed and included in the report. Twelve ‘Early Adopter Interventions’ are also included; these have not been impact assessed to the same specification as the ‘High Impact Interventions’, but are innovative, cutting edge ideas which may be promising.’  Help, it seems, is at hand.

The big challenge ahead for CCGs could be working out how to make all of the pieces of the jigsaw laid out by NHS England in this guidance into a coherent local plan.  Or it could be finalising an approach that they believe will have the greatest chance of success.  In the little over 6 weeks that remain until the first submission, the question for CCGs is whether to focus on identifying how they will meet all 47 key features of the fundamental elements of the plan, or whether they should focus on getting local sign up and buy in to their approach to meeting the challenge ahead?  In the absence of a national plan, is stakeholder buy in more important than meeting all the requirements of the guidance? 

So in summary there is no overall plan.  The guidance is designed to help local plans be developed.  Whether it is ultimately a help or a hindrance remains to be seen.  Happy New Year!

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How effective are CCGs?  This is the question that the plentiful reviews of the first six months of CCGs have focussed on.  Reviews have been mixed (CCG reviewers generally more optimistic than non-CCG reviewers, although pretty balanced overall), but very few have focussed on the new context within which CCGs are operating.

What has become clear in the six months since April 1st is that we have entered a new period for the NHS, one that I would characterise as ‘the age of the regulator’.  This year we have seen the system shift from a top down system direct from government, to one where power resides more and more in the hands of the regulators. 

Each month the influence of the TDA grows, as any health economy with a non-foundation trust will testify.  The role of Monitor is expanding (e.g. this month they produced a review of walk-in centres).  The Competition Commission has just blocked plans (which were supported by the local CCG) to merge Royal Bournemouth and Christchurch Hospitals and Poole Hospital Trusts.  Ever since the Francis Report was published the influence of the CQC has risen, and this year they have appointed a Chief Inspector of Hospitals and a Chief Inspector of General Practice with all that that entails.

Even NHS England, with its new post-mandate freedom from political control and directly responsible for expenditure of £25bn, only really seems comfortable in its role as CCG regulator.  Indeed it is with NHS England in this role that all of the talk of CCG authorisation that has dominated many of the 6 month reviews of CCGs has been framed (maybe we could call that section ‘escaping the grasp of the regulators’).

So what does operating within this context mean for CCGs?  Regulation by its very nature (according to Wikipedia, ‘codifying and enforcing rules and regulations and imposing supervision or oversight for the benefit of the public at large’) is not strategic.  Regulators will not create a plan.  There is, it seems, no plan.  And this creates both challenge and opportunity.

It is easy to see the challenges we face: insufficient funding, an aging population and an exponential growth in the demand for health care.  But the frame CCGs must use is that of opportunity: of making the care system sustainable, about integrating around the needs of individuals, and of driving improvements in outcomes.  CCGs have the freedom to create the plan to get there, as there is no national plan that they are expected to implement. 

This means that the most important role for CCGs is that of entrepreneur.  Schumpeter describes an entrepreneur as someone who is, ‘willing and able to convert a new idea or invention into a successful innovation’ (Capitalism, Socialism and Democracy 2012).  The success (or otherwise) of CCGs is likely to be ultimately determined not so much in their ability to evade the grasp of the regulators, but their ability to convert ideas into successful innovations.

So how are CCGs performing in their role as entrepreneurs?  Well if you start with the recently published HSJ list of ‘Health’s top 50 innovators in 2013’ there is not a single CCG entry, so not very well!  But if you look more widely there are promising signs, even within the first six month period.  Bedfordshire CCG has embarked upon an ambitious plan to invest over £120 million over the next 5 years in an integrated MSK system tailored around patient needs.  Cambridgeshire and Peterborough CCG are commissioning a service to provide integrated older people’s services worth up to £800m.  And these are just the high profile examples.  Up and down the country many CCGs are driving the implementation of innovative new models of care.

And while there were no CCG entries in the HSJ list, there were 3 GPs.  Herein lies the opportunity for CCGs, because within the membership of each CCG there are individuals, often clinicians, who are great innovators.  Shortage of ideas is not a problem that many CCGs are facing.  But successful entrepreneurs are not necessarily those with the best ideas.  They are those who can take a good idea and hold the vision clearly in front of them and drive delivery of it, whatever the challenges that emerge along the way.  Effective CCGs will be those that can do the same, who take the best ideas of their members, create a clear vision for the future, and who, in this age of regulation, can navigate a course through to successful implementation.

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As we approach the precipice of the cliff, the pressure is on.  We look at the relentless tide of rising acute activity and everyone is clear, ‘something must be done!’.  In order for our hospitals to be able to restructure and organise services differently, experts and management consultants tell anyone who will listen that what we need is an ‘out of hospital strategy’.

But the NHS is changing. Out of hospital (as opposed to ‘in hospital’) is no longer the distinction that is helpful in framing the changes that clinical commissioning groups (CCGs) are striving to achieve.

Most CCGs are organised around some form of locality structure.  This is where groups of practices from the same area come together and operate as the underpinning infrastructure of the CCG.  In larger CCGs there may be up to 10 localities, and smaller CCGs may be made up of as few as one locality.  The principle however holds that practices are grouped in a rational way that makes meeting and decision making sensible and practical for the relevant practices.

A key question that many CCGs are grappling with is what exactly is the role of the locality in this post-authorisation world?  Initially the importance of localities was based on the engagement of practices in the CCG (which we have discussed on this site, for example here). 

But with the ‘call to action’ and the future of general practice becoming a live issue, the priority that CCGs are giving to the transformation of general practice, the introduction of the integrated transformation fund, and the murmurings about contracting general practice and community services together (here), the importance of localities is growing, and the role of localities is changing. 

Localities are now the focal point of the transformation of community based services around general practice.  The role of the locality is to bring the practices together into some coherent form of general practice provision.  This means a move away from, say, 6 practices operating in splendid isolation, to the 6 practices operating as one unit, and acting actively bringing together community services, social services and the voluntary sector.  There is no piece of NHS infrastructure better placed to support this change than the CCG locality.

This means the locality is no longer an arbitrary grouping of practices with collective responsibility for managing a budget, but is now the practical mechanism by which care for the local community will be organised and, dare I say it, integrated around local needs.  The crude separation of general practice as commissioner and general practice as provider is removed; the advantage of general practice as both is harnessed.

CCGs are redefining ‘out of hospital care’ as ‘locality-based care’.  It starts with the redesign of general practice.  It blends in community services and social care.  It adds any existing community estate.  It is all done in partnership with the local population.  And it can move at the pace of the quickest not the slowest; not all localities have to develop at the same rate.

Herein lies the biggest challenge and opportunity for CCGs.  There is no question this is a hugely difficult task.  But as membership organisations of GP practices CCGs are uniquely placed to make this happen, and if successful have the chance to make more of an impact on the design and delivery of healthcare than any predecessor commissioning organisation in the history of the NHS.

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There is a big gap.  This gap exists between how general practice understands its need to change, and how the wider health system needs it to change.  And at present there is very little that is constructively being done to resolve it.

General practice understands its need to change based on two things: income and workload.  Drawings are down and workload is up.

The two are not entirely unrelated.  As the drawings for each GP partner are calculated based on a split of the total ‘profit’ of the business, as income falls practices tend to go one of two ways.  They either reduce the number of partners or number of staff to keep drawings at the same level, or they accept a reduction in earnings and maintain staffing levels.

As result GPs are either paid less or overworked.  And in many cases it is both.  GPs feel that the current situation cannot continue in the direction that it is currently going.  Some just want to retire and be done with it.  Others are too young and want things to change.

But very few have signed up anywhere in this to evolving the business of general practice.  They want to continue doing the work they do now.  The notion of specialisation is something that most GPs turned their back on when they chose to become a GP in the first place.  But the reimbursement for core general practice is what is being eroded, and is what will continue to be eroded.  The government want more and more for less and less from the core GMS/PMS contract, and that is not going to change any time soon.

At the same time district general hospitals are coming to the realisation that growth is not the answer, that total income is not king, and that a shift of services out of hospital is required if the health system is going to be able to live within its means in years to come.

I was talking recently to an acute trust Chief Executive about this.  He understood the problem really well.  He talked eloquently about how he was working with community services and social care to shift services out of the hospital setting and into local communities.  He gave some great examples of how care was now being delivered in different ways, such as the hospital funding healthcare at home services.

I asked him where general practice was in this in new way of working, and what role it was playing. He looked at me blankly.  I explained the key role that general practice could be playing, with different practices building areas of expertise in different specialties, driving down variation and linking with hospital specialists to enable much more care to be delivered at the first point of contact the NHS has with each patient.  He said no-one in his organisation really understood general practice so they had to get on with making the change happen regardless.

This is the reality.  Those outside of general practice look upon it with bewilderment.  It feels like a magical world of impenetrable acronyms, like GMS, PMS, DES, LES, and (worse) MPIG.  There is no mechanism for engaging general practice as a provider in the conversation about system change.  As a result change is happening regardless of general practice, not because of it.

So this is the gap.  GPs want change for their own survival, but are not particularly interested in models beyond core general practice.  The wider system wants to change but is clear neither on the role of general practice within this change, nor on how to even engage it in the conversation.  There is a very real danger that general practice and the wider system will change in isolation from each other, and not in a way that solves each other’s problems.

CCGs are uniquely placed as organisations that understand the need for system change and understand general practice.  We must step up as organisations and provide the direction the system needs.  General practice in this country, the envy of the rest of the world, presents a huge opportunity to become the platform on which the health and social care system is developed, so that it can tackle the issues of ever increasing demand, a rising, aging population, and an explosion in long term conditions.   And it is up to CCGs to ensure this opportunity is taken.



I recently received a letter from a local man with Parkinson’s Disease.  Hearing from patients, and gaining just a small insight into their lives, is one of the privileges that working in a CCG brings.  I want to share with you the story that he shared with me, and that he is happy that I share with you, directly, and in his words.

‘Whenever I have been asked, ‘How do you feel today?’ there is a simple 3 word answer: ‘Abandoned’, because we have been.  ‘Angry’, not at the condition (that is pointless). I am angry at the way we are treated.  How much use in reality is one 15 minute consultation with your neurologist every 12 months?

The last word is ‘frightened’, not just for me but for my wife, my children and grandchildren. I am in the middle of a ‘bad patch’.  It’s not nice when Parkinson’s Disease rears up and bites. This morning my wife wasn’t speaking to me and to make matters worse I was having a really bad “off” start to the morning. We still were not speaking at lunch time. Paranoid as men are in these circumstances, I pushed to find out what I had done wrong – it flared up for the first time in 4 years of marriage that we had really gone off at each other. 

I got in the car and drove off for 1/2 an hour.  Walking was out.  If I could have managed 100m today it would have been a miracle. When I got back we sat at the dining table, held hands, and I asked, ‘come on, what’s up?’.  ‘I’m scared. I’m scared for you and I’m scared for me’ was her answer, and the only thing I could say was, ‘That makes two of us then’.

There’s nothing I can add to this.  It brings home the responsibility we have to the communities and to the individuals that we serve.  Sometimes commissioning can get reduced to QIPP plans and financial reports.  But really the point is how are we, how am I, making a difference to the lives of the individuals who need us.