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Hearts and Minds

Friday 14 September 2018

Well- that’s certainly going to stir things up a bit. The announcement last week of drastic cuts to the local authority spending threatens to significantly affect the provision of adult social care and children’s services in the county, just at the time when the health and care systems need to be working closer together than they’ve ever managed before. It also throws into stark contrast the different cultures and rules governing the two main commissioners of health and social care, the CCG and Somerset County Council.

The financial struggles of the health system in Somerset (and indeed nationally if you peer behind the smoke and mirrors) are well documented and used by our regulators, NHS England and NHS Improvement, to harangue our local senior health service managers at regular intervals. The harsh reality is that there is not enough money coming into the local health economy to pay for the current activity levels, and certainly not enough to cope with the anticipated annual growth. The emperor has no clothes, and no amount of creative accountancy is going knock up even the snuggest garment to cover his modesty on an ongoing basis. Nevertheless, if the ‘system’ as a whole comes up with, and then is seen to collectively support, a coherent plan to recover the deficit over a number of years, the regulators are more likely to take at least one foot off the providers’ throats.

Compare and contrast this with the situation of the local authority, where there is no provision for running a deficit budget, and hence the dramatic cuts recently announced. David Fothergill, the council leader, told us at a leadership meeting a few weeks ago that they were very much at the ‘pointy’ end of austerity, having lost £73million from their budget over the last six years, mainly due to a 40% reduction in their funding from central government. There is no bail-out available, they can’t raise council tax, and the early-announced plans to shut the Taunton park-and-rides were seen as being the easier decisions. The cuts proposed and discussed at the council this week will take nearly £4 million out of adult social care and a smaller figure out of children’s care (though I understand the decision on this was delayed on Wednesday).

The emerging proposals as part of the Health and Care Strategy Review make much of the need for health and social care to work much more closely together. The scale of savings needed to make even a modest dent in the deficit have to come from closing hospital wards, and it’s blindingly obvious that to look after more people in the community is going to need a significant boost to our community services and to social care provision, both in terms of funding and workforce, when there is precious little availability of either. Slashing the social care budget clearly isn’t going to help, and there are impact assessments being initiated to quantify what impact the cuts will have on health provision more widely. The health sector has expressed considerable sympathy and moral support for our local authority colleagues, but they are going to need something more tangible than ‘thoughts and prayers’ to fill the hole in their budget if they are to avoid losing the services and making significant redundancies.

Having attended more (no, far more) than my fair share of grim meetings recently, it was a real pleasure to meet up at the racecourse yesterday afternoon for our latest LMC county meeting. The executive spends long hours honing and pruning the agenda so that we can use our afternoon meeting, that now happens every two months, to maximum advantage. We always have informed and impassioned discourse, and yesterday devoted a significant chunk to the debate on how much information should be visible to other clinicians in the NHS to view via EMIS viewer, for example. When last considered two years ago, there was a consensus that only coded entries, and not free text, could be viewed. We have listened to concerns from our secondary care colleagues and taken notice of the impact of GDPR. We had a thoughtful and considered debate, to which nearly everybody contributed. The result was that we agreed that the entire medical record should be visible, but with certain clear provisos and caveats. You will be hearing more detail about this very soon, but we feel this decision has the potential to significantly improve patient care, and improve the information available to our clinical colleagues in other parts of the NHS.

I’m worrying about my heart again, and it’s something else I’m going to lay at the increasingly cluttered door of Brexit. For reasons not totally unrelated to the fallout from the referendum, I recently requested a copy of my maternal grandfather’s death certificate, which duly arrived last week. He died before I was born, although after a Herculean effort on my part, I did get to attend his funeral. A hard-drinking and chain-smoking Irishman, he’d moved to England and somehow ended up as a GP in rural Buckinghamshire. He only made it to 58, before the fates and the fags caught up with him, and his death certificate gave his cause of death as left ventricular failure and pulmonary fibrosis. His son (my uncle) and grandson- both doctors in the US- each had MIs in their 50’s.

I had a flurry of electrical excitement some years ago, after which I was echoed, MRI’d and traced for several days. I even had a bit of diagnostic rodding- all thankfully sufficiently unexciting for my cardiologist to announce at the time that he was ‘bored’ with me. In my book and this context, ‘bored’ is good, and so you’d think that I’d be relatively relaxed about all things cardiac, especially as I try to exercise regularly and, so far at least, have manfully resisted the urge to take up smoking.

But, having seen that sobering certificate, I’m pondering my own mortality again, and lie awake at night ruminating about myocardial perfusion (inter alia). We’re told that poor sleep is itself a factor in early cardiac death. Knowing that doesn’t help: my worried brow now has furrows on the furrows, and then I read about the French study in the news recently showing that furrowed brows are associated with a ten-fold increase in cardiovascular risk compared with smooth-browed controls. So, in effect I’m worrying about the effects of worrying about the effects of worrying about my heart. Maybe I should seek reassurance from the much-publicised ‘Heart Age Test’ that was recently launched by the NHS?

Or maybe not- there’s not much to cheer about the latest NHS scheme, which appears to have slipped out without first skipping across the desk of the National screening Committee. There’s been widespread condemnation from medics that the calculator has been giving everybody older ages than justified if they are unable to state their cholesterol level, and as a result suggesting everybody over 30 trots along to their GP for a cholesterol test. Really? Was that such a clever idea? For what it’s worth, the estimate of my heart age came out as seven years older than my chronological age, and in the process has opened up a whole new can of moral worms.

I’d always viewed my cardiopulmonary coupling as a match made in heaven. Despite the misfirings of a few years ago, they’d got me through marathons and half-marathons and all the dramas and excitements that go with everyday life as a husband, father, jobbing GP and LMC chair. When I was 46, I’d had a puff on our new spirometer and been chuffed to see that my lung age was 23. I was so pleased I’d pinned the trace, now a yellowing smudge, to my notice board, just in eye line above my screen for continuing reaffirmation that I might one day get to meet my lump-sum.

But I hadn’t realised, until now at least, that my nice youthful lungs have been shacked up with a heart nearly twice their age. A ‘result’ for my heart, no doubt, but what will the neighbours be saying? Maybe those abdominal gripings last week were my spleen, left kidney and pancreas having a bitch together about the disgusting goings-on north of the diaphragm? It does raise another question, as to whether we should put an age, or at least a ‘best before’ date, on all the other bits and pieces?

This week I had to re-tax my car and found myself filling in the on-line Organ Donor card. You can specify how much of your redundant carcass you’re happy to have pillaged after your death, and whilst the notion of pottering around in your dotage shepherding along a load of time-expired giblets might not immediately appeal, just think how useful it would be to have a ‘use-by’ date attached to everything. I was less sure about the section giving you the option of how you would like to be contacted in an emergency. I’d always assumed I’d have a passive role in the process, rather than be on 24-hour standby should a matching ‘A’-lister suddenly blow a liver, when I happen to be less than an hour away.

Next week I shall mainly be invading France. The beachhead will be at St Malo, but I’ve no idea where we’ll get to after that. We’ve got an ASCI card, which enables half-price stays at campsites all over Europe, but this year we’ve also got something called a ‘France Passion’ card. I can sense that your initial reaction is much the same as mine: that for €30, Mme. Chair had signed us up for a typically continental scheme whereby adultes consentant can meet other like-minded motorhome owners in darkened lay-bys to discuss leisure battery wiring and maximum kerb weights. Alas no- it’s a scheme whereby we can stay for free on participating French farms and vineyards. Of course, we might choose to buy some produce but there’s no obligation. I must remember to check that the French farmers are in reasonably bonne humeur at the moment. I’d hate for me and my best-beloved to form part of their next fiery barricade. If there isn’t a blog in a fortnight’s time, you’ll know that things have flared up, in every sense.

If there is a blog, it will have been sent after a couple of weeks of ignoring emails and sampling the local produce, so don’t expect anything relevant to the NHS, or indeed coherent in any way at all. Much like before, in fact.

À bientôt

Nicolas

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