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Alternative Canary

Friday 31 March 2017

I'm just back from a week trekking around La Gomera, the smaller and lusher Canary island nestling safely to the west of the lobstered hordes on the beaches of Tenerife. It's a dramatically beautiful place, but lush implies moisture, and the first few days of the trip were characterised by horizontal permadrizzle- delivered on a brisk wind, and refreshing enough to drop the apparent temperature to just above freezing. Thankfully the sun appeared in time to unmask the precipitous drops on/off the later tracks across the volcanic barrancos in their full and terrifying glory. The extraordinary geography has meant communication and internet access has been as fleeting as the sunshine, and although sporadic emails got through, the ethereal sludge was too viscous to open any attachments, particularly those with NHS logos and straplines. Still, it allowed me an opportunity to get some perspective from afar, to stretch out my thumb on the medicopolitical pencil, and have a squint at the horizon.

In days of yore I'd trudge off on holiday and all my worries related to the patients. I found all manner of things to fret about: patients I knew were sick, the things I thought I'd missed, and anything I'd inadvertently left for my colleagues to clear up. I envisaged returning to hear about a whole ward at Musgrove filled entirely with the results of my incompetence, and it was a relief to return and find that (usually) there had been no disasters.

Now that I'm older and wiser, I worry about much, much more. I'm still concerned about the patients, but in a different way- I'm more confident in my ability to know what's wrong with them, but alas less confident in the system that's looking after them. I worry more these days about the practice: How are they managing? Has anybody gone off sick? Is the roof still on? This week, though, I've mainly had my LMC thinking-cap on, wondering where "this" is all leading, and when and if we're ever going to get there.

At the March Primary Care Joint Commissioning Board meeting, there was a finance paper from NHS England which for the first time (to my knowledge) outlined a specific Primary Care budget for Somerset, and detailed the projected growth over the coming years. It was in Part A of the meeting and so the papers are in the public domain. Primary Care in Somerset has apparently been relatively over-funded in recently years (yes, really) and we hear the "distance from target" was 14.2% in 2016-7. I'm sorry but we need some more figures here.

We know that the whole NHS budget was pre-loaded, and the £8 billion (or £4.5b as it actually worked out) bung of last year across the NHS meant that the coming years do not look rosy. For 2016-7, the CCG budget rose by 3.0%, and then for the following years it will rise by 2.1%, 2.0%, 2.1% and then 3.9% in 2020-1. The Primary Care budget however, rose by 2.9% in 2016-7, and is due to rise by 1.0%, 1.0%, 1.6% and 3.3% over the same period, with the aim of reducing that "distance to target" figure to 7% by 2020-1. At a time when the emphasis is on collaboration and moving services into communities, it seems a complete nonsense to isolate the Primary Care budget in this way, and damning that the growth is significantly less than that of the CCG's overall budget. What sort of message do they think this sends out? Even more concerning was the fact that virtually all of the Primary Care budget is non-discretionary- the core payments, MPIG, seniority, premises costs etc are fixed. I challenged the NHS England Financial Planning Lead who presented the paper and he admitted that the one area where there would be scope for flexibility (and only in one direction) was the Enhanced Services budget. I have written to the CCG outlining my concerns, especially about the sort of message this sends out to the troops.

In some recent bloggage, I mentioned how we are finding it increasingly taxing to spread ourselves around all the meetings with the vast plethora of groups that seem to be springing up, and it's obvious that it's not just the LMC who are struggling to keep up. I've seen charts outlining the governance structure and relationships between the workstreams, but new groups seem to appear all the time, and the responsible officers also chop and change. I collected three new meetings to attend whilst in the departure lounge at Exeter airport just before we left, and it was only eight hours after we hit the tarmac (worryingly hard) back at Exeter that I found myself at a meeting in Bridgwater, having first popped into the practice to check the roof was still on (it was). This was the first meeting of the "Primary Care Same Day Access Group", which has replaced 3 previous groups (enhanced primary care, complex care, and same day access), and has representatives from all the usual NHS groups and providers, as well as Social Care and Public Health. As often happens with large groups like this, the chances of getting everybody who needs to be there in the room, given the often brief period of notice, is slim, and the first part of every meeting is inevitably taken up with introductions, trying to clarify how the group fits into the wider picture (this one is meant to align with A and E Delivery Board, and the Urgent and Emergency Care Network, just so you know), what all our roles are, and what the remit of the group is. One of the topics for discussion was the requirement by NHS England to have "GP streaming" in every Emergency Department by September- correlating to the £100 million pledge from the Chancellor in the budget. They had circulated a model from Luton and Dunstable, which was labelled as "best practice" (who says?), and on paper at least, it appeared very prescriptive, and to my eye was written by somebody with little clue about the reality of the workforce. There was a quaint notion that if the single GP was getting slightly worn down late in the evening, another could be summoned to help out. As our esteemed Medical Director puts it, if you've managed to get your own locally designed system up and running and purring like a purring thing, to force another complicating service into the mix would be akin to lobbing a brick into the gearing. We are hoping, and there are some encouraging signs, that local flexibility and common sense will prevail.

I've just heard Simon Stevens on R4 getting quite a grilling on this and the rest of the NHS from Sarah Montague. It followed from his announcement that effectively something has to give, with prioritisation for cancer, and A and E services, and he was pretty candid about the overall situation. It was also refreshing to hear him say that homeopathy was a waste of resources and shouldn't be prescribed.

Yesterday, we held a meeting with one of the Federations to discuss some local political unease, and then I was off to Yeovil for a meeting with Rosie Benneyworth and representatives from Somerset Primary Health to discuss how we can get the best possible representation for Primary Care in forthcoming discussions about the Accountable Provider Organisation. Given that most of us going to the meetings need constant briefings and updates on how everything is meant to fit together (and if we're honest would probably still struggle to explain it succinctly to a colleague over a quiet pint), it's going to be a huge task to get everybody in a position where they have the best shot at knowing what the future holds. It's vital that we try, though, and at our meeting yesterday we agreed that we will aim to put on some sort of joint communication event with the LMC and SPH, possibly at the SPH AGM. Bet you can't wait.

Today I'm sitting down to look at the latest set of FAQs and the service spec for the PCIS. They arrived yesterday at midday, and we have to comment by close of play today. Good job I'm still on holiday. Meanwhile, our brilliant and esteemed vice-chair has kindly agreed to have a look at a colossal generic contract document from the Local Authority that somewhere mentions smoking cessation, which we also saw for the first time yesterday, but we agreed that she can finish her Prosecco first. That's probably best.

I've got just enough space left to offer some advice for anybody arriving at the check-in counter at Tenerife (Dante's Inferno International Airport) prior to their flight home, and who is surprised to find themselves fully 8kg over their luggage allowance. Before deciding to lighten the case by wearing every possible item of clothing, it just might be worth checking that somebody in your party hasn't tried to sneak some decorative volcanic rocks into the luggage.

Just saying.

Nick Bray

(T + 70)

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