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Incidental Music

Friday 15 February 2019

You won’t be surprised to hear that we’ve spent much of the last fortnight dissecting and digesting the new GP contract. It’s a weighty tome, and the devil will always be in the detail but overall there don’t appear to be too many surprises. It aligns with, and supports, the neighbourhood work that’s gathering pace across the county. In the GP Board proposals for allocating the transformation monies, we had included provision for clinical leadership roles, but the new contract takes it further, specifying that each Primary Care Network should have an ‘accountable clinical director’. They will be funded for one day per week (0.25 WTE) and need to be identified by the middle of May. That’s quite an ask, but we know that in some areas colleagues are already stepping forward. We are working on a job specification, and also identifying the support and mentoring available locally for what will be an important role as the networks/neighbourhoods develop in the months and years to come. We’ll put out some more information soon about this.

What’s the difference between networks and neighbourhoods, you ask? My simplistic view is that GP practices are arranged in Primary Care networks (utilising transformation funding as agreed between the GP Board and the CCG), with community services wrapped around them (imagine/remember that?), and all the other bits like the voluntary sector, village agents, health coaches, police, fire service, CAB etc. arranged alongside them to form the ‘neighbourhoods’. In Somerset, at least, they will tend to be contiguous. We have heard our Public Health and local authority colleagues express concern that the NHS assumes a monopoly of the term ‘neighbourhood’, fearing that we’ll focus on the traditional ‘illness model’, whilst ignoring the whole self-care and prevention agenda. Fat chance, in more ways than one.

It’s helpful to have a five-year contract to ponder, which makes sense for all sorts of reasons. We had a preliminary negotiation meeting with the CCG yesterday to discuss the future of local Enhanced Services, and there are two forthcoming events that we’d want to flag up for you: Mark Sanford-Wood, our GPC representative and Vice Chair of the GPC, will be presenting a contract workshop in the evening of March 13th at The Holiday Inn, Taunton, and there will be another LMC/CEPN study day at Taunton Racecourse on April 9th concentrating on ‘neighbourhood’ development and making sure we’re aligning everything with the new contract. Both events are, or will shortly be, bookable via the LMC website.

Last week, Jill and I were invited to Wincanton Health Centre for the visit of Professor Steve Field, the Chief Inspector of Primary Care for the CQC. He and his team were visiting Somerset to meet representatives from Symphony Health Services (SHS) to hear their story, but also to discuss how integrated systems should be inspected and regulated as they become more prevalent. One criticism of the current CQC process is that practices are inspected as individual entities, with no recognition that they might be part of larger organisations where many of the functions of interest to the regulator are performed in a central hub, for example. Professor Field was candid, acknowledging that he didn’t know how this might turn out, but supposed and expected it would be something that his successor, our very own Dr Rosie Benneyworth, would have near the top of her in-tray when she inherited his desk in a month or so’s time.

There were two past LMC Chairs also in the room: Berge Balian, the mastermind behind Symphony, and Harvey Sampson, who stepped in as Clinical Director to turn around one of our larger practices that was in danger of sinking below the waves. Both have played a critical role in Somerset being in the rare position of not having had a single practice to date hand back its contract. There are occasional mutterings in the wider system about the Symphony funding model, but nobody questions that the costs to NHS England of reprocuring services to replace failed practices would have been huge, and the damage to the local system as a whole incalculable. Just look at the problems that Plymouth has had in recent times.

By chance, we already had a trip to Yeovil planned for the following day to visit the SHS hub, the nerve centre providing logistical and managerial support for the Symphony practices. They live in the same building as, and directly below, the CCG in Yeovil, and, for now at least, are distinguishable by their garish pink lanyards. It was what I imagine speed-dating to be like (not that I know) as various people whizzed in and spent a few minutes across the desk from us describing their role, before whizzing out again, to be replaced by two more of their colleagues. There is a lot that’s impressive- the quality of their data showing reduced admissions where they’ve introduced new models of care, and in stark contrast to what’s happening elsewhere in Somerset, is now more widely accepted across the system, and they are looking to innovate wherever they can, sharing their learning across the patch. How Symphony Health Services and its staff develop in the future remains to be seen, but Lord Balian of Crewkerne has a certain ring to it.

The Friday before last was a ‘snow-day’. In North Petherton all our staff got in, but many patients cancelled. There were rare gaps in surgeries, and I even had time to throw some titbits to the ravenous QOFmonster. No surprise then that last week was especially hectic, among the busiest that the practice has known. One of my colleagues had been at the rugby in Dublin, and perhaps anticipating a bit of downtime in a Lansdowne Road gutter, had booked the Monday off as well. I’d stepped up to help, and didn’t regret my decision until about 8:15am, by which time it was obvious it was going to be frisky, especially with another clinician coming over all viral, and remaining poleaxed for most of the week.

It was pleasing then, that at the height of that Monday carnage, I made time to get a cuppa, barricade the door, ignore the growing schedule of excitement on EMIS, and within a minute or so found myself shutting my eyes and listening to a favourite bit of Mozart. Less pleasing was that I was on ‘hold’ waiting to speak to an advisor at my Medical Defence Organisation. Even so, Wolfie still managed to refresh and calm the parts other composers couldn’t have reached- quite a feat under the circumstances. That particular track (K466 II, in case you care) would have been number three on my Desert Island Discs, had I ever been asked to step-in as a late replacement for a celeb who’d overslept, or perished in the waves trying to get ashore on the fantasy island. Music has always been part of my life, and I reckoned that my (pre-streaming) CD collection was as eclectic a mix as you could have shaken a baton at. Music matters, and there are chord changes and key progressions out there that will always provoke a tear, even in the most euthymic me.

During the reign of Dr Sam Barrell as its Chief Executive, Musgrove installed a new phone system, and the ‘hold’ music was a jangly mess of discordant and staccato stanzas, repeating on a frenzied loop. Had Hitchcock been offered it when looking for a ditty to accompany the shower scene in ‘Psycho’, he would have shuddered, before politely declining on the basis it was too disturbing. It did nothing to soothe the nerves of an anxious GP waiting on ‘hold’ to be put through somewhere/anywhere. One day, as my limbic system was being sonically mashed into an axonal soup by the noise in my left ear, I tapped out an urgent email to Sam pleading with her to change the music. Hence the rather anodyne piano thing you get today- bland yes, but less likely to result in you eating your knuckles.

So why did I need my MDO’s tender counsel? I’d mucked up, but it wasn’t a clinical problem, so wouldn’t have been covered by the imminent state-backed indemnity scheme. I’ll bet the Germans have a word for it- they usually do- when you’ve gone out of your way to try to help a patient or a colleague, and it’s all gone bosom-side up and come back to bite you on the buttocks. Until I know better, I’m calling it Unfährarsegebeiten. To save a patient time and a colleague work, I’d filled in an important form that I’d retrieved from my partner’s tray but included an errant tick that caused our patient some difficulties. I corrected the situation as soon as I learnt about my error and couldn’t have been more apologetic, but it still resulted in a complaint, with a hint there might be more to come.

My post-Mozart advisor turned out to be delightful, interested and supportive. Theirs must be one of the most demanding jobs of all, waiting to field queries from anxious and sometimes terrified clinicians. Honing a suitably contrite letter and winging it back and forth to the advisor a few times between appointments, before dispatching it patientwards, added to the stress of Monday afternoon. Colleagues will be aware that any such missive these days has to include the obligatory wrap inviting the patient to take things further, including to the Ombudsman if they really want to make our day, along with helpful phone numbers and websites to make this all the easier for them.

If that happens, I’ll be looking for something substantial in D-minor.

Nick

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