LMC Chairman's blog
I never imagined I’d find a new ‘mot noir’ before we’d finished. The word ‘Brexit’ appears 69 times in previous blogs, and was nailed on as the whipping boy to blame for much unpleasantness during my four years in office. My first blog reference to coronavirus was on Brexit day-January 31st, with ‘Covid’ only appearing for the first time on Valentine’s day. It’s easily trumped ‘Brexit’, and ‘Trump’, come to that.
I picked an interesting week to retire from clinical practice. Within 24 hours of seeing my last patient, the World Health Organisation declared that Covid-19 infection was more than an international nuisance and now officially a pandemic, which it defines as the ‘worldwide spread of a new disease’. There’s nothing particularly magical there, but pandemic flu planning was a permanent fixture on almost every LMC and CCG agenda until a year or so ago. Despite the recent political decision that led to our leaving the EU pandemic warning system, which had helped co-ordinate the EU response to SARS and swine-flu, the UK has plans in place to cope with a large outbreak, and there are reasons to be hopeful.
This week I have mainly been in Weymouth, in a rented house by the sea to celebrate Mrs. Chair’s significant birthday and retirement. Friends and relatives have come and gone through the week with a couple of fallow days to allow for rest and recuperation of hosts and livers. One of the less guilty pleasures of being bolt-holed up in a monsoon is the chance to catch up on TV.
It’s Valentine’s Day, but more importantly it’s ‘Foxtrot-it Friday’ as our Practice managers will (nearly) be calling it from now on. Those who attended the LMC ‘Managing your Resilience’ day at Taunton Rugby Club yesterday know what that means: loads of shredding. Dr Phil Hammond, closing the day in brilliant and witty style assured us that we’d all feel better for it, and the important 20% of paperwork would probably appear again at some point. He also told us to do our daily CLANGERS: Connect, Learn, be Active, Notice, Give back, Eat well, Relax, Sleep.
Yesterday we were at the racecourse for my last ever Southwest Regional LMCs meeting. It’s a quarterly get-together of experienced lags from six LMCs to discuss how we’re all doing, share concerns and decide what might benefit from a regional response or action. We speculated on what might be happening with the GPC negotiations relating to the rejected Primary Care Network DES specifications. We still haven’t had any news about the special LMC conference flagged for an unspecified date in March to discuss the profession’s response. It’s getting a bit late for colleagues to arrange locums to cover their attendance.
Here I go again. Last weekend I was mainly in Stockholm and Copenhagen. ‘Scandi’ is more ‘noir’ than not at this time of year, and we had about seven hours of daylight as the watery sun scuttled along the southern horizon. As ever after a short break away there’s a lot of catching up to be done. I was back in the practice at the sparrow’s crack on Tuesday; Wednesday and Thursday were rammed with seven meetings of one sort or another, so I’ve had to wait until this morning to get some emergency dental treatment for a tooth, initially broken chomping on a piece of elk horn (probably), and aggravated by significant clenching of everything as we landed sideways into Storm Brendan at Gatwick on Monday.
'Twas two nights before Christmas, when all through the house
Not a creature was stirring, not even a mouse
My laptop was open and at the screen I’d stare
In hopes that the Network specs soon would be there;
After last week’s ectopic post-election rant, I thought I might need a compensatory pause, a fallow week blog-wise in which to calm down, but there’s just too much going on. We’ve got a brand-new government, and we’re going to be saved. Huzzah! In his first Cabinet meeting, Boris had them all chanting in unison how many new hospitals there’d be, and how many nurses they’re going to add to the NHS roster. It was all very reminiscent of my formative years at Miss Walters’ kindergarten for young gentlefolk in Ilfracombe, or maybe North Korea.
It would have been quite an ask for a man of my age to be up all night, but I had been prepared to give it a go. I last managed it nine years ago with support from the lovely nurses on Portman Ward at Musgrove, who professed admiration for my stamina and appetite. I’d spent 6th May 2010 - election day- undergoing a spot of emergency lumbar disc-chiselling. That remains the only night I’ve spent in hospital as a patient. I was pain-free for the first time in months; my surgeon said I wasn’t to slouch about, so I stayed up through the night watching the results come in, with the night staff topping me up with endless tea and buttered toast.
Welcome to my Feast! Today is St. Nicholas Day, and we’re deep into winter, with the traditional escalation calls sharing and comparing crisis levels across the providers back in vogue. I’ve been involved in several meetings recently to look at beefing up clinical (GP) input into the Clinical Assessment Service (CAS) used to validate 111 call outcomes. You don’t need to be a genius to realise that far too many people are being directed to the Emergency Departments or dispatched ambulances. The focus is increasingly on the Category 3/4 ambulance dispositions (Category 2 would include suspected MIs, and other significant emergencies). Work elsewhere, when they were able to validate more than 80% of calls, showed that in 87% of cases, they needed advice from a clinician and no further input. That’s astonishing and raises significant (and familiar) questions about the flawed process that goes before.
It’s a gloomy Friday in November, and six of us are in London for the English LMC’s conference: Karen Sylvester (Madam Vice), Tim Horlock, Rob Weaver and me as delegates, with Jill and Mandy Mason attending as observers. Somerset has been given the honour of proposing the very last motion to be debated in the ‘And finally’ section. It’s a masterpiece from Barry in which he proposes that CQC inspectors should wear Hi-Vis jackets emblazoned with ‘How’s my inspecting?’ and a Freephone number to facilitate feedback. It’s my last conference, and unless I’ve thought of a cunning excuse or come over all liverish by this afternoon, I’ll be proposing this one, if only because I’m the only member of the team who definitely won’t be inspected by the CQC ever again. If only I could think of a suitable prop…
It wasn’t until late last Sunday evening that my post-match torpor started to wane. I’d approached the weekend in a state of anticipation and hadn’t planned much past the rugby World Cup final, which promised a brief but triumphant distraction from the assorted flora, fauna and debris fleeting past the window, borne on the sodden wings of the latest Atlantic weather system. Only later did I look at the calendar for the coming week and realise, too late, that I shouldn’t have taken the weekend off.
Having been self-employed for more than 30 years, it feels a bit odd having to go through the rigmarole of securing a salaried post, no matter how nailed on it would appear to be. The paperwork is endless. Who to ask to be my referees? Thankfully nobody asked to see the certificates currently covering up some dodgy plasterwork at home, or indeed anything to indicate that I’m actually any cop at the job after all these years. As Chair of the GP Board I sit on the Alliance Development Committee, a body formed about 18 months ago to oversee the alliance between, and now the anticipated merger of, Somerset Partnership and the Taunton and Somerset Trust. At last week’s meeting I was finally able to declare some interest in something and I was also summoned to the offices of Optima who provide the occupational health cover, so that I could be jabbed with a little more Hep B, just to be sure. Thankfully I’d already had my flu jab. It appears that Trust employees only get one if they’re prepared to be snapped, grinning on the end of the needle, and sent viral on social media.
I’ve decided to take a leaf out of the Tories’ play-book. Somebody’s told them that if you say that you’re going to get something done often enough and with conviction, no matter how ludicrous, irresponsible, potentially disastrous, and destined to leave us all poorer and the laughing stock of Europe, then it will magically happen. Here we go:
It is an ancient Physician,
And he stoppeth one of three.
'By thy nervous tic and trembling lip,
Behold the CQC.
The protocol files must be opened wide,
We’ll peer in every bin;
The inspectors have met, the schedule set:
Let the bloody ordeal begin.’
Oh goody- Friday the 13th. What else could possibly go wrong? It’s been a bit frantic since I arrived back on Tuesday from a spot of wanderwegging in the Salzkammergut. The lederhosen are re-waxed and back in the wardrobe next to Mrs. Chair’s dirndl, and yesterday I enjoyed no fewer than seven different meetings, to ease me back into things.
Ideas surge into conscious thought at the most inopportune of times. Sudden inspiration can hinge me upright at 3am, or distract me half way through a complex consultation. My superannuated synapses have a tenuous enough grip on reality as it is, and struggle to snag any fleeting gobbets of innovative thought; I try to record any cerebral flash as a ’Note’ on my iPhone before it vanishes in a hazy puff, forgotten forever. For better or worse, my phone is almost always within easy reach, which is why my latest sparking was inconvenient, as at the time I was skimming the German countryside at 100 feet in Guy Gibson’s Lancaster, and closing in on our primary target, the Möhne dam.
Can any of the panel suggest what’s happened to our greengage crop? It was all looking so promising just a few weeks back, the tree laden with ripening fruit. Apologies to anybody looking for nuanced medicopolitical commentary, but it’s August, traditionally the ‘silly season’ when nothing much happens; the punters are on holiday and we’re feeling chilled and relaxed. There’s not a lot to do between checking the phones are working, and peering expectantly into the surgery car-park hoping for some casual trade, so I thought perhaps instead we could go all ‘Gardeners’ Question Time’?
Democracy rocks! The people, or at least 0.2% of them, have spoken and we’ve now got a new Prime Minister, the third of my gavelship to date, and possibly not the last. I fear we might also have the government we deserve. Boris has taken over the wheel of the bus, turned sharply towards the cliff edge and stamped on the accelerator, but maybe last night’s by-election result might have partially deflated a front tyre?
Tomorrow will be the 50th anniversary of the Apollo 11 moon-landing, but did you know that a simple URTI changed the course of history? I watched agog in my pyjamas as Cliff Michelmore and James Burke presented the grainy pictures beamed from the lunar surface during the first ever all-night television transmission in this country. Keen Blue Peter viewers (of which I was one) had heard the previous October that the first man on the moon was to be Walter ‘Wally’ Schirra, as Val and pals had profiled the crew of Apollo 7, and it was widely reported then that the same crew was nailed on to be the first one to make a lunar landing in a later mission. That it was Neil Armstrong, and not Wally Schirra, who got to make the small step/giant leap is largely due the ‘tetchygenic’ effects of a heavy cold that Schirra developed as they went into orbit on Apollo 7, coupled with regular doses of Actifed®, which made his exchanges with Capcom on the ground distinctly punchy, almost mutinous at times, and is said to have been the principal reason that none of the Apollo 7 crew ever flew into space again.
It was a genuine pleasure to catch up with our Primary Care Network Clinical Directors when the GP Board hosted a meeting to get them all together last week in Taunton. Most were able to attend, and it’s always useful to put faces to names. The overall vibe was positive, both for the meeting itself and future relationship between the CDs with the LMC and bodies such as the GP Board and Somerset Primary Health. There are some new and inspirational leaders in our midst, and we need to look after them. It wasn’t all sweetness and light, however. A few areas are struggling to get traction, and the biggest risk to PCNs establishing themselves, and providing the buttressing that the constituent practices so desperately need, is lack of clinical engagement from the GPs themselves. The reasons are patently obvious, and what we need more than ever is an early success, something palpable, easily visible to other practices/networks, that changes the way we work by reducing workload significantly and/or offering new and exciting options to those of us sitting in front of the punters for whom we can currently only stroke our chins wistfully. That’s not too much to hope for, is it?
Welcome to the longest day. Hasn’t the weather been just glorious? Assuming you’re reading this after midday, we’ve started our hurtle back to winter, and in only a few days our cleaner will tell me the nights are drawing in again. Never mind- we’ve still got bags of summer excitement to go: there’s Glastoswamp, Wimbledon, the pointy end of the cricket World Cup, and then a whole Ashes series to enjoy. Meanwhile, there’s much local activity as our networks get themselves organised and the relevant paperwork completed with the CCG prior to the July 1st ‘go-live’ date.
Panorama: Crisis in Care was a difficult watch. BBC cameras followed the Somerset adult social care team and selected clients/patients over a ten-month period and the results broadcast on the past two Wednesdays. It was a brave decision to allow the cameras in without any editorial control, but Stephen Chandler (Director of Adult Services) was clear that this was a story that needed to be told and has received many plaudits for doing so. The hope was that this would trigger a wider debate.
That was quite a fortnight. Within the first few days I’d become a pensioner, a grandfather (sort of), and then the CCG had received applications from 13 Primary Care Networks (PCNs), complete with 13 named clinical directors, by the specified deadline of May 15th. Only one Somerset practice has elected not to join a network. All the PCNs were subsequently authorised by the CCG the following day, with one or two caveats and clarifications requested. Well done, everybody. That’s quite a feather in Somerset’s cap, and from talking to colleagues elsewhere, puts us ahead of many other areas in the country. That, I suspect, was the easy bit.
With only five days to go until the deadline for new Primary Care Networks (PCNs) to submit their applications to the CCG, there’s been considerable activity around the county with most areas sounding to be making good progress. It’s important to remember that the submissions aren’t necessarily cast in stone and can be amended later. Inevitably there have been unforeseen (and many foreseen) complications with the new contract arrangements, particularly in relation to the employment of staff, and there are national representations going on behind the scenes trying to find a way through these. Some networks are not immediately intending to employ extra staff, at least until the picture is clearer, but using the new arrangements as a way of working more closely with their neighbours and improving links with community services, in an effort to shore up Primary Care.
Last Thursday afternoon, I sat down together with the Practice Manager in my consulting room for our first Annual Regulatory Review (ARR) call with the CQC. Since April 1st, these calls now form part of the new and targeted inspection regime. I mentioned them some months ago after a meeting between the LMC executive and the CQC. The idea is that the call allows a conversation between practice and inspector so that changes in service provision or anything else potentially affecting registration status can be highlighted. There’s nothing to be particularly alarmed about- the CQC website lists the framework of the ‘interview’ and questions to be asked, although the responses might elicit some further probing, if and as appropriate. Prior to the call, the inspector will have looked at other evidence they have available such as QOF data, NHS patient survey information, and any complaints or comments about the practice. The outcome of the call can’t affect a practice’s CQC rating- that can only change following an inspection visit. Within a few weeks, the practice receives notification of whether or not an inspection visit will follow. Any such inspection will focus on aspects arising from the call, and the more formal inspections (five-yearly for most practices) will still occur. Essentially, then, the aim for the provider is to get through the hour or so that the call takes, without much repetition, significant hesitation or worrying deviation that might pique the inspector’s curiosity. What could possibly go wrong?
This week’s joint LMC/Training Hub study day at the racecourse seems to have hit the spot. The aim was to build on the Transformation event last November, with the focus this time being on the new GP contract, networks and neighbourhoods. The day was superbly marshalled by Martyn Hughes, and the presentations kept short and punchy to allow maximum time for interaction- in the panel sessions, afternoon workshops, and perhaps most valuably when mingling during the breaks. It is now established LMC policy not to have individual delegate badges- partly to save money (my car is full of them), but also to encourage delegates to find out more about each other. I’ll just put the ‘other side’ of the coin- that it can be tricky for us greyer folk when confronted with somebody we’ve been talking to at similar events for the past 20 years, then to find that their name has slipped out of graspable mental reach. A special thanks as ever to Jill, Sarah, Claire and Carol for organising everything, and in particular for finding a couple of non-pharma sponsors, whose stands supplied bars of Cadbury’s chocolate and a glass of champagne to supplement the fine racecourse cuisine.
Sometime last year, I marked every future blogdate in my diary, and I knew back then that anything I spewed out today, March 29th, 2019, was inevitably going to have a tinge of gloom about it. If you’re hoping for something chirpy and uplifting, then I suggest you think of these three weeks following last week’s ectopic ‘Belfast’ blog as a ‘compensatory pause’, and tune out until April 12th. By then we’ll have had the racecourse event to tackle the Primary Care provider networks and everything will be sorted, and I’ll have celebrated a special anniversary. Brace yourselves, everybody else.
Call me Lemuel. It’s not a name I’d heard or uttered for more than 40 years, but it’s quite cool, ripe for derivations, and just now feels appropriate. This was to be a fallow week blogwise, but as the Somerset delegation boarded our flight taking us to the UK LMCs’ conference, Jill suggested I cobble a sneaky blogette to accompany Barry’s forthcoming account of happenings inside the conference hall. The executive team of Jill, Barry, Karen and myself were joined by Tim Horlock for the two-day event in Belfast. We understand the BMA were very happy to have the conference there- it’s significantly cheaper to fly delegates from all around the UK across the Irish Sea than to pay train fares to any venue on the mainland (bonkers, yes), and the hotels are about half the price of their London equivalents.
Communities around which to base care arising from transformation of honied boroughs (14)
That didn’t take me long- hours rather than days- and I’ll admit to a shameless attempt at widening the appeal of the blog, by targeting the cruciverbalists out there. The answer is the buzzword on most of our agendas at the moment, and what commissioners hope will be key to getting more comprehensive services closer to patients in the future. If you’re struggling to work it out, or feel I’ve started off with even more gibberish than usual, I could direct you to a local GP of my acquaintance who reportedly manages to complete the Telegraph cryptic crossword by 10am every day, no matter what the complexity of his first eight patients. This one will detain him but a brief nanosecond, but might snag his passing interest.
Spring is sprung, and time is tight but marches on regardless, clutching a hamstring. Neighbourhood development has been prioritised with the new GP contract stating they should be taking on services from July (yes, this one), and I was invited to an initial exploratory workshop of the ‘Neighbourhood Group’ at Dillington on Wednesday. Interested parties, and a few bemused ones, from every sector arrived to find numbered tables ready with obligatory marker pens and paper, but also activity packs complete with coloured cards, adhesive felt figures and other craft ‘objets’. The idea is that neighbourhoods develop around communities rather than existing services. Each table was asked to come up with a ‘vision statement’ for neighbourhoods, and then demonstrate it pictorially. Our scribblings and modelling efforts were collected at the end in the hope they could be collated into our own Somerset infographic to help explain the ‘neighbourhood’ concept. Mine was the bit with the dolphin.
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.
It’s been mad, but now it’s all white. Grrr and Brrr. In the last seven days I’ve had engagements in Colombo, Kuwait, Bridgwater, Taunton, Petherton and Yeovil, in addition to the odd surgery or three to keep my hand in. I’m sure like me you’ll all have stayed up beyond midnight on Wednesday gagging for the publication of the new GP contract, astonishingly arriving this year before the start date. In anticipation of the snow, Jill and I have been stood down from today’s planned trip to Cornwall for our regular meeting with other peninsula LMC, CCG and NHSE colleagues. It might have been a frostier encounter than usual, and not just because of the weather. We were going to raise the recent problems some of our dispensing practices have had with payments being clawed back, and what we perceive as a new and worrying management style from NHS England, and we are still chasing Child Immunisation payments.
And breathe. Now that 2019 is full swing (or nosedive, depending on your point of view), it was good to get the full LMC committee together again last week for our first full meeting of the year, and there was much for us to discuss. Predictably enough, after a relatively quiet Christmas period in both Primary and Secondary care, it all kicked off bigly over the first weekend in January, with practices reporting heavy workloads and the hospitals being near or at their top levels of calamity (OPEL 3 and 4) for much of the past fortnight. The Out of Hours service has coped better than in previous years. Cynics might argue that that wouldn’t have been difficult, but feedback from clinicians working in the service and from patients has generally been encouraging.
Whisper this quietly but it seems that the system overall, at least using the parameters that the NHS likes to measure, such as A and E and 111 performance, ambulance handovers and bed occupancy, has coped significantly better this Christmas than it did the last. Not surprising, perhaps, given how dire things were last year and the milder weather we’ve had recently. But how was it for you, out in the real world?
‘Tis the season to be jolly and all that, but several of the women in my life tell me that I can be a right gloomy bastable at this time of year, and I really need to cheer up. A couple of points: Firstly, this is the way my face is. If God had intended me to smile he’d have given me shorter levator anguli oris muscles. Secondly, I’m a news junkie and I read stuff.
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair....
At last ‘dateline blog’ I was in London and about to set off up the river to the English LMC’s Conference. The LMCs from the peninsula had met up the previous evening in Blackfriars for a bonding curry, and Barry and I found ourselves sharing a table with Devon’s vice-chair and Bob Fancy, their recently appointed Operations Officer. Bob proved an entertaining dinner companion and wasn’t at all fazed by the apparent lack of space on our titchy table for the standard curry paraphernalia and four large flagons of lager, being as he was an ex-submarine commander. He would seem perfectly placed to cope with the latest NHS England obsession with ‘deep dives’ into everything. He tells us there are fewer submarine captains in the world than there are astronauts, and I would venture that they have a fairly unique point of view on everything, and in every sense. It’s no surprise that they’re very much team players- either the whole crew comes to the surface or none of them do. It’s going to be fascinating to see how he gets on navigating the murky depths of the NHS. It also throws into some sort of perspective the concept of ‘risk’ in our respective trades. He has stories.
It’s a murky Friday in late November and five of us are in London for the England LMCs’ conference. Last year was the first that had separate UK and national LMC conferences, and so we’re also having to cross the water to Belfast next March for a one-day UK meeting. That hardly feels like an efficient use of 400 GPs’ precious time, or the resources of the General Practice Defence Fund (which finances the whole thing). It also creates problems for LMCs trying to get items onto the agenda, as it isn’t always clear whether potential motions should be considered at an English or UK-wide level.
The Friday before last saw Barry and I enjoying a bite of lunch together, reviewing a successful morning at the ranch. There are aspects of that sentence that might not ring true with colleagues: the fact that we had found time to eat, yet alone together, and what’s all this about a ‘successful morning’? Admittedly, it hadn’t looked promising earlier; the carer of a chair-bound 94-year old lady had requested a visit to sort out what sounded like potentially serious ‘undercarriage’ issues, never the easiest in a cramped and cluttered front room, in the dazzling glare of a flickery and distant 25 watt bulb. I phoned the community nursing hub, who arranged for two of their finest to meet me at the house, and the excellent carer came back in her own time to provide moral support for the patient. Duly historised and examined, with a nurse on either wing and suitable lighting, I discussed the options with the patient and her advising throng, even managing to get advice from a friendly gynaecologist via the Consultant Connect app whilst I was still in the patient’s house. Gosh.
I’ve spent a significant part of the last few weeks picking my way through the roadworks metastasising along the busier trunk roads in Yeovil. Meetings there scheduled for 9am now mean leaving Taunton in the misty gloom. I attend the Alliance Development Committee, set up to oversee the liaison/potential merger between Musgrove and Somerset Partnership, but Yeovil are also now represented at the meetings, and it was YDH’s turn to host this month. There was some thought-provoking stuff on the agenda.
So, who’d have predicted there’d end up being confusion around this year’s flu immunisation programme? NHS England announced a few months ago that orders for flu vaccine nationally were well down on where they should have been. I was surprised; the new ‘split’ regime was well-flagged, and I thought everybody was aware of what was going to happen this year, even if it did cause logistical headaches for practices planning flu sessions. We seem to be OK in Somerset, but at last week’s Commissioning Operations Group (COG) meeting in Saltash, we learnt that there are problems elsewhere in the region. In one county a significant number of practices ordered their entire stock as the quadrivalent version, presumably on the basis that ‘four is better than three’. The NHSE manager reporting to the meeting assured us that there is enough trivalent/adjuvant vaccine out there, but not necessarily in the right places. We understand that there has been some relaxation by NHSE on the rules about shifting stocks from one place to another, which are appropriately strict given the importance of maintaining the cold chain. My counterpart for the relevant LMC was keen to establish whether if they couldn’t get the trivalent/adjuvant vaccines in reasonable time, they would be able to use the quadrivalent vaccine in their over-65s rather than leaving them unvaccinated? NHSE agreed, but added that this was very much second best to hanging on and giving them the intended vaccine. Is it too much to hope that next year everybody might get the same thing, assuming of course that we’re able to get any medication or vaccines at all by then?
I promised myself that I wasn’t going to be looking at emails on our French road trip, but seeing that little red number on the home screen ratchet up to three figures in double quick time does tend to pique one’s interest. OK- so I’d only look at the headings, but then found myself opening one from a respected LMC colleague that he copied to me in reply to another senior GP regarding a recent CQC inspection. Amongst a long list of unhappiness was the stated view of the CQC that Fairy Liquid was a toxic substance. I banged off a few lines to the effect that I was sure the office would be happy to take up this nonsense, and immediately received a reply from m’colleague to the effect that I should turn off the interweb forthwith and enjoy my croissants and chocolate chaud. I know that he, in particular, would have appreciated my situation at the time, anchored up on the edge of a vineyard in St Emilion. There are few more relaxing situations than racing through the latest Lee Child in the September sun, surrounded by vines heavy with ripe Cabernet grapes ready for harvest apart, obviously, from getting outside the fermented result at some stage in the future.
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.
Apologies to Rupert Brooke for bastardising his last line to make my first, but needs must and all that. Some vindication as well for Mr. Wilson, my O-level English teacher, who had assured me and the rest of the hormonal fifth-form that at some stage, we’d be grateful that we spent most of a summer term dissecting The Old Vicarage, Grantchester. I begged to differ- and suspect neither of us could have imagined that it would take 44 years for Brooke’s whimsical ramblings to worm their way from somewhere deep in a temporal lobe to headline here. What happened?
I first came across Dr Arvind Madan, until recently the Director of Primary Care for NHS England, almost exactly two years go. He’d appeared on a video link at a local event to launch the General Practice Forward View (GPFV) to the masses, and I got really narked about it. Maybe I was tired and hormonal, but anybody who appears on a screen before a room full of knackered and disenchanted GPs in a pre-recorded piece to say that he’d really like to be with us, but alas has to be seeing patients instead, is seriously misjudging my capacity for pity. This wasn’t the Oscars: It smacked of self-importance, and added nothing to the evening, which developed its own spice a little later without any outside assistance (see ‘The Silly Season Blog’). I suspect I wasn’t the only one to groan, as it had quietly dropped from the programme when I went to the same event a few months later in Cornwall.
Last week, Jill and I found ourselves being simmered gently in the orthopaedic seminar room at Musgrove, for a meeting to discuss communications between Primary and Secondary Care. It was pertinent to the way things are going that of the twenty people in the room, only three of us had a link with Primary care. The rest were made up of assorted communication or liaison managers from Taunton and Somerset Trust or Somerset Partnership. I outlined the main discussion points in last week’s update, but one of the Musgrove consultants stunned us by saying that they no longer have access to the full patient record when they see a patient in the clinic, as ‘paper-light’ working means the corridors are no longer full of porters dragging tons of notes around. Communication, or lack of it, still feeds into a lot of what the LMC does.
It’s been quite a fortnight. When I nurdled the last blog into the ether, Jeremy Hunt was still Health Secretary, David Davies the lampooned and beleaguered Brexit Bulldog, Roger Federer was cruising serenely and inevitably towards yet another Wimbledon title, and everything in the garden had turned crispy brown. Two weeks later, and the countryside still looks more Gobi Desert than Somerset, but football has had a better offer and so no longer coming home, we’re being encouraged to adopt the brace position for a no-deal Brexit, and our Jezza is now Foreign Secretary. Cripes.
When as yet unborn grandchildren gather around my chair in years to come and ask, “What did you do during the heatwave of 2018, Grandpa?”, I imagine that I’ll squint at the shimmering horizon beyond the salt-tanned windows of my clifftop bolt-hole, draw on my Meerschaum, and reply with a steady but emotion-tinged voice: “I went to the seaside.” Whichever daughter is supervising the oldie-visit that day will probably roll an eye, and brace for yet another telling of the story of my trip to the coast that didn’t involve sand, whelks, rock, donkeys, candy floss, or tarry feet.
Last Wednesday, in a pleasing boost to my acronym bingo score, I found myself at the second-ever CEC meeting, which is a sort of ‘son of COG’. You’ll be aware that CEC stands for Clinical Executive Committee, and it reports to the Governing Body of the CCG. The CCG Clinical Operations Group (COG) no longer exists, but there is of course still the Commissioning Operations Group COG which is a committee of NHS England (SW): we used to be part of COG North that met at South Plaza, but now go to COG South which is just north of Saltash (we’ve been through this before- do try to keep up at the back). CEC is where the GP Clinical leads now gather. The CCG is undergoing a transformation of its governance arrangements, and as such the terms of reference of the committee are undergoing regular review, but for now at least, the papers and matters discussed at the meeting are confidential. That’s a problem for me as I can’t fill a couple of paragraphs telling you about what happened, but also presents a challenge for the GP colleagues on the committee, who are used to reporting back to their localities. I’ve seen what the plans for the future entail, and as the CCG is still a membership organisation with the practices as its members, would expect practices to learn very soon about what those plans are, so please look out for upcoming locality events to hear more.
We are starting to get a handle on how we’re expected to build a case to use the Transformation monies across the county. Hopefully you might have seen the paper that the GP Board produced for the CCG, in which we stated that we felt that where possible the focus should be on sustaining existing practices and groupings, but also funding space and opportunity for discussions to take place within localities as to how we can develop things for the future. There are numerous conversations taking place at various levels in NHS England, the CCG and in Federations at the moment, and what we really need is to turn off all our phones, ask the punters (nicely) to look after themselves for just a day or so whilst everybody gets in the same room and decides whether we’re all on the same page, or at least reading the same book. Not much to ask, is it?
At long last we have had a meeting of the new LMC committee following the elections in March, and I’m optimistic about the future, at least of the LMC. A mix of young Turks and old wizened lags met at the racecourse last Thursday for a gallop through an agenda which encompassed most of the stuff that’s currently keeping us awake at night. In his first meeting shepherding a new committee through the constitutional niceties, Bazza did a top job- he learnt well from the master. We recognise a need to strengthen the links between individual committee members and their constituency practices, and discussed the best ways for this to happen. I was heartened that all our new members were prepared to contribute to the discussions: we’ve long held that when trying to disentangle some of the burgeoning NHS nonsense, there is no such thing as a ‘stupid’ question, and being asked to clarify the LMC stance on a particular point is a useful challenge to all of us to ensure that we know what we’re talking about. I hope we looked as though we did, at least.
The Cotton Buds of May
We’ve developed a serious meeting logjam in recent weeks, and it’s getting worse. Things were quiet over the Easter break, but new groups, including six subgroups from the A and E Delivery Board, have started meeting with increasing frequency. They are all aimed at improving the way the system works together, with increasingly squeezed budgets, and several have a specific focus on helping the service survive next winter (assuming it’s coping better now, that is), and the timescales are frighteningly tight. The reasons are obvious. The figures for year-on-year increase in activity at A and E and also for emergency admissions are stark (15% up in March compared to last year at T and S, and even 10% up in April). I was at a hastily convened group last week tasked with coming up with an ‘interim urgent response team’, to provide an alternative for GPs and paramedics who might visit somebody at home who, for whatever reason doesn’t need to be in an acute hospital bed, but for whom at present there is really no alternative to hospital admission. There have been numerous fragmented efforts relating to this in the past (remember the Hospital at Home idea?), but there has to be a sustainable solution found this time.
Calor, dulor, rubor, tumor. Any first year medical student can recite and recognise heat, pain, redness and swelling as the cardinal signs of inflammation, and as she approaches her eighth decade, running on fumes but working harder than ever, it’s no surprise perhaps that the NHS is starting to feel a bit sore. In that context, yesterday’s Quality Improvement Showcase event at Musgrove was an eye-opener in terms of what’s been achieved across numerous departments, whilst coping with a huge surge in demand. Roy Lilley, the keynote speaker, was clearly impressed with what he heard and saw, tweeting enthusiastically after he left. The key is to engage and enthuse your staff, and I suspect having a dedicated team of 25 people helps a bit. The few of us there from Primary Care made the point that quality improvement happens every day in our individual practices to improve efficiency, and is formalised as part of the SPQS programme, but how we work to improve things across the system is going to be vital if we are to get through the next decade. A joint approach is already a feature of the 100-day projects currently focusing on urology, ENT and atrial fibrillation.
This week marks the half-way point in my tenure as LMC Chair. To celebrate, I found a whole new COG meeting to go to, and it was actually rather good. In times of austerity, everything gets recycled, including the acronyms. I used to attend the CCG ‘Clinical Operations Group’ meetings as LMC observer when I was vice-chair, a duty I was delighted to relinquish to Karen. The ‘Commissioning Operations Group’ is an NHS Southwest meeting, attended by the local NHS team, CCGs from Cornwall, Devon and Somerset, Chairs and Chief Officers from the LMCs and also pharmacy representatives. NHS Southwest is divided into a North and South group, and historically we were always in the former. Harry was delegated to go up to Bristol to attend meetings in the soulless South Plaza NHS building, and never seemed overly enthused by either the surroundings, or the proceedings themselves.
Not so long ago I had an iPad that enabled me to access all my email accounts, both NHS and private, and had I chosen to play fast and loose with my sanity and indemnity premiums, even allow a little online EMIS-dabbling. But for a few weeks, I have been woefully, but delightfully, out of touch. I had to return my LMC iPad to Apple for a new and less ‘footprinty’ screen, but without asking they sent me a replacement iPad- very kind, but devoid of MobileIron and the other NHS-loaded goodies that I had on the old one. North Petherton went to One Domain, which rendered old emails inaccessible unless I was physically on the premises, and the LMC had its own peculiar local domain problems that defied resolution. I’d had various IT bods poking round in the giblets of my new iPad, and despite much sucking of teeth, scratching of heads and misguided optimism, I remained stuck in my ethereal void. I was told there was a potential workaround so I could have access to my LMC emails, but it might result in nobody else in the county being able to access theirs, which seemed a mite selfish, even when I’m playing Oberst-Gruppenführer. The LMC has switched over to NHS-net earlier this week, and astonishingly, everything now appears to be working again. So that’s all good, probably. Whilst sitting in Santa Cruz airport waiting for the flight home, I logged onto the excellent LMC app to check the weekly update and see what the team had been up to.
Whilst some of us feared for what might happen when Harry left, the extent to which the Somerset infrastructure fell apart with the Medical Director’s departure still came as a bit of a shock. The wheels on his Sri Lankan Airlines flight had barely kissed the tarmac at Colombo, before practices were digging out their business continuity plans, and GPs across the patch swapping stethoscopes for shovels to keep the snow off the steps and the show on the road. The Acute Trusts were once again brimming over with patients they couldn’t discharge, and the system is only just recovering from the knock-on effects, with Musgrove having had its busiest-ever day for admissions earlier this week. There were tales of heroic dedication: practice staff staying away from home, quaffing their partner’s best whisky, and some trudging miles through the snow to get to work or visit patients. Hospital colleagues also went the extra mile, including one of the ENT surgeons who borrowed a neighbouring farmer’s tractor, which he parked outside the hospital.
It’s rare that correspondence arrives in the LMC office that leaves the team speechless, but a Taunton colleague forwarded a letter last week that left our collective flabbers well and truly gasted. It was allegedly from the Home Office, although the composition and grammar suggested that they might have outsourced this particular operation to one of those best-beloved Nigerian princes who are forever getting stuck with vast sums of loot that need to be deposited for safe keeping, and without delay, in your NatWest account. Here is a verbatim quote from the letter, under the UK visas/immigration department heading:
This week I have been mainly having my appraisal, so not much time or headspace for anything else except meeting the other Chairs, a finance committee meeting, ministering to the Pethertonians, walking the dog, sharing a recuperative 6X, an artisan pork pie and England/Wales with a discectomised colleague, clearing the garage, moving furniture, cooking risotto for Madam Previous Chair, plotting Mrs Chair’s birthday treat and Harry’s retirement do, thinking about a perinatal mental health service, meeting the Chief Exec from Musgrove/SomPar, an LMC exec meeting, and redacting my second paragraph.
It’s been a curious topsy-turvy sort of fortnight, not least when I found myself driving to work last Friday and nodding in appreciation at what Jeremy Hunt was saying on the Today programme. I’ll expand a little more on that bombshell later, but it felt that for a brief moment that the whole of the medical profession, commentators, Jezza and politicians of every hue could unite on a health story. It was just desperately sad that what united them was a human tragedy for a family, the professional standing of a junior colleague at the very sharpest of sharp ends, and what many viewed as the damaging and over-reaching actions of the General Medical Council.
Yesterday saw an emotional watershed moment in the history of Somerset LMC. You will be aware by now that Harry is retiring from his role as Medical Director at the end of February, and yesterday was his last ever LMC County meeting. He was initially appointed as Medical Secretary in 1996, and I am the sixth Chairperson to have benefitted from Harry’s expertise and wisdom. We go for informed, lively and often impassioned debate in our meetings, and Harry has always been there on my left, tapping the notes onto his iPad. Out of the corner of my eye, I’d look out for his pausing, clasping his hands together, and leaning forward, waiting to interject: “If I may, Chair….”. At which point, we all shut up, quietly and tidily put our toys back in the pram, and listen carefully, because we’re about to be treated to a nugget or two of pure gold, smelted into intelligible ingots by Harry’s unique brand of intellect, experience and common sense.
I had intended this to be a warm, mellow and comforting piece to ease us into the New Year. We waved the solstice off just before Christmas, and two days ago the earth swung past the perihelion, so the planet is now hurtling back towards the bit of the orbit that gives us our spring and summer. Can you feel the days drawing out? Admittedly only by about 90 seconds a day at the moment but hey, it’s a start.
It’s beginning to look a lot like Christmas: shoppers are becoming hysterical, England have relinquished the Ashes down under, and the festive punters once again believe that, for this week only, antibiotics can cure their two-day sniffles. The email traffic into the office quietens down over the holiday period, and to ensure seasonal tranquillity, I trod on my LMC iPad last week and smashed the screen. We won’t go into details, but needless to say, it wasn’t my fault. I baulked at the price of a repair and tried to soldier on, but the screen started shedding razor-sharp shards from my hoof print, gradually revealing more of the innards than you’d care to see. People who know advised me not to get a cheapo ‘high street’ repair, as the screen wouldn’t be as good, and there’s less redress if it goes wrong. For a small fortune, Apple were only too happy to send me the protective packaging so I could send it back to them via UPS. The nearest UPS pick-up point turned out to be a Londis store in one of the dodgier local neighbourhoods. I’ll admit to a moment of uneasy hesitation before handing over my iPad when it was my turn at the counter, having witnessed the volume of lottery tickets, fags and cheap booze being dispensed to the local hooded brethren first.
Well, that was fun. Last week I was at Musgrove for the annual Fresh Looks GP update course and caught most of the action, bar a couple of sessions when I had to be elsewhere. It’s an opportunity to catch up with old friends, and to put faces to names I’ve heard mentioned, but whose owners I’ve never met before. Some of the wizened lags are up to exciting things: an ex-LMC colleague from an exotic northern Costa has appeared in the BBC’s “Saving Lives at Sea”, another from further south ministers to Saga cruise passengers, in between sprinting onto the Glovers’ pitch with the magic sponge, running his Kenyan charity, and being something big in urine (for anti-doping purposes, allegedly).
“It is a truth universally acknowledged that a woman in possession of a single fragility fracture must be in want of a bisphosphonate. Much else in the realm of osteoporosis and its treatment, for now at least, would appear to be a complete Horlicks.”
It’s a gloomy Friday in November, and I seem to be in London. Somebody, somewhere, decided that it would be a whizzo idea for the LMCs from each of the four home nations to hold their own one-day conferences to discuss matters pertinent to just themselves. We’ll still get together as the UK-wide conference, but for one day instead of two, which will mean trekking up to Liverpool in March, and I can’t see how this is going to be more efficient, not least in terms of travel and hotel costs, or disruption to our practices.
It's Friday again and I find myself in philosophical mood. In my LMC role, I currently chair about eight different meetings with their own particular focus, function and personalities. Included this week was my first Team GP (Somerset GP Board) meeting since it became properly established. I missed the first as I was on leave, and being a new group, I'll admit to some anxiety as to how it would go. Half term meant we were lighter on numbers than we'd normally expect, but we had a varied and enthusiastic group round the table at the LMC offices. I felt it went well. The discussion was informed and lively, and whilst firmly rooted in reality, there was a palpable desire to seize the moment, and make positive things happen for our colleagues and their patients. We will be putting out regular reports in the LMC weekly update as to what the GP board (Team GP) has been up to.
No matter how grim the news, you’ll have sussed by now that I try and infuse a little levity into my bloggage, as at least I, if not you, have to get to the end of it every fortnight. I’m as partial to a peaty malt as anybody, and we’ll sashay seamlessly into my natural affinity with music and dance later in the piece, but those aren’t the principal reasons that I’ve spent much of the last ten days rushing from one meeting to another, chuntering about whisky, tango and foxtrot.
We had our regular liaison meeting with SomPar this week, and as with many meetings at the moment there appears to be a new sense of reality since the arrival of Nick Robinson at the CCG. There are likely to be some dramatic developments in the next week or so, but we also heard that NHSE/I are conducting a “deep dive” into the STP (scuba gear appears to be a vital part of NHS management equipment these days) , and when/if they resurface I’m sure there’ll be some very uncomfortable discussions going on around the county. This was a chance for us to meet the new interim medical director for SomPar, Sarah Oke (a consultant psychiatrist), and we had some fruity discussions about the home-care teams (formerly the crisis team) and their responsiveness (or sometimes, with devastating effects, lack of it). We also heard that although SomPar have recruited to the Talking Therapy teams to boost capacity, there has been a significant reduction in referrals into what has become perceived as a failing service, and there was a request that we ask colleagues to increase these so they can meet their activity targets. Hmm. It was probably the last meeting I’ll have with Nick Broughton, who is off to become Chief Executive of Southern Health. I’ll miss Nick, but not being referred to in minutes of our meetings together as NBra (to differentiate from NBro).
Of all the liaison meetings we've had with the CCG, last week’s was the most significant to date. Due to an administrative malfunction there was a mix-up over the timing, but we were keen not to postpone it, so turned up at the LMC offices at 7:45am, armed to the teeth with coffee, croissants, and the usual sheaf of commissioning queries, conundrums and cock-ups. This was our first chance to meet Nick Robinson, the new Chief Officer, after a few weeks in post. I suggested that he might want to spend 10-15 minutes before we started on the agenda proper, to let us know how he saw things. An hour later and we were still deep in discussion. He was very frank in his assessment of where Somerset was and how he felt that things needed to change.
I’m often asked, not least by myself, how I got into All This. I’m not hewn from traditional medico-political oak, unlike some of our more strident colleagues of national fame, in whom, if you were to chisel off a limb, you might find the names of Aneurin Bevan, or great GP leaders of the past, burnished through the grain. For the first 10 years of my GP career, my medical ambitions outside the consulting room were confined to occasionally startling, all too briefly, the scorers for the Bridgwater Doctors Cricket Club, popping along to the Medical Club functions at the Castle Hotel in Taunton, and spending occasional weekends away, either in the UK or abroad, enjoying the company of colleagues and learning about new asthma drugs and statins. It was mainly statins: diabetes was insulin, metformin and sulphonylureas, and dementia hadn’t yet been invented.
We’ve been putting some finishing touches to the Somerset GP Board (SGPB) over the past couple of weeks, and it now sits gleaming expectantly on the launch pad, venting steam and ready to be fired into the fray. We’re now at DEFCON one.
Let's start on an upbeat note. We had an encouraging meeting yesterday afternoon at Monk’s Yard to discuss the further development of the Somerset GP Board (Team GP). The overwhelming majority of the feedback we’ve had so far from the rest of the Health and Social Care system locally regarding the SGPB has been positive. We had invited representatives from the LMC, SPH, COG members, Federation chairs and other local GP leaders to discuss wider representation on our board, and to discuss the specifics of how the board should work. We’ve got to ensure we become the authoritative and respected voice of Primary Care, at least in the STP process initially, and communicate effectively with everybody, not least our local practices. We’d picked the date and time of the meeting from three options using a doodle poll, and inevitably there were quite a few people who couldn’t attend, given the time of year and relatively short notice.
Hey- great job, everybody! We’re all winners again, so gongs all round, no doubt. For the second year in succession, the Commonwealth Fund has named the NHS as the best overall healthcare system in the world. Hurrah. The US came bottom of the list, with 44% of the population on low incomes having difficulty accessing healthcare (compared to 7% in the UK). In a comparison across 11 countries using five quality measures, and taking data from the WHO, the OECD and questionnaires completed by doctors and patients, the UK was ranked in the top three for all categories apart from health outcomes, where it was second-to-last, ahead of just the US. But the report went on to say that while the UK ranks 10th in the health outcomes domain overall, it had the largest reduction in mortality amenable to healthcare during the past decade. So that’s encouraging.
Much has been written about the worrying and potentially catastrophic decline in GP numbers over recent years, but have you noticed that some of your local colleagues appear to be wasting away before your very eyes? I’m talking biomass rather than body count here, and not only are their waistlines shrinking, but several of them have developed an almost cult-like zeal and ocular glint. It can be a little disarming. I’ve had to gently probe several colleagues recently to enquire whether they ought to be having further investigations, to be reassured that not only are they up to their eyes in pristine physical fettle, but mentally purring on all cylinders as well. So what's going on?
The NHS has proved remarkably resilient over the years, but has been done no favours by the political own-goals of the past 12 months. Hard on the heels of the latest electoral fiasco, we’ve had a Queen’s Speech that was brief to the point of curtness, and made no mention or acknowledgement of the funding crisis in the NHS or other public services. Whilst brevity might have been handy for ensuring Her Maj got to Royal Ascot in time for the first race on the card, it telegraphed to the troops apparent indifference from the government to the mounting problems we all face.
Necessity is the mother of invention and all that, and as I'll be somewhere near the bottom end of the Via Rhona by the blog witching hour, instead of hammering out 1500 words in the early hours of Friday morning, I've been simmering most of this on a low heat for a few days. I wanted you to have a little digestif whilst you try to work out whether you've ended up with strength and stability, or a coalition of chaos. Our considered opinion from the South of France at our petit dejeuner just now is neither of those, but alas completely unbloggable. It's clearly been another extraordinary election night. If only they'd stop asking us to vote on things. Twelve months ago, Dr Chandler and I had awoken in France to the Brexit result, and having feared our TV was sur le blink and come over all hysterical, we gave it several big slaps, alas to no avail. If you're hoping for something more deep and insightful about the election from me, you'll be sorely disappointed. There has probably never been a more critical election in terms of timing for the future of the NHS, but the arguments feel tired and nobody seems to have taken the NHS as an election issue and really run with it. The title is a nod to the passing of John Noakes, who provided me with a sound grounding in the basics of health and safety in my formative years.
As ever, there’s a heap of stuff going on at the moment. Different areas of the county are starting to implement the new Improved Access arrangements, and we've been thinking a lot about how we align the different Primary Care organisations to work with other bodies in the STP process. The executive teams of the LMC, SPH and Rosie Benneyworth met at Dillington this week to refine some ideas on collaborative working, and have formulated 'Team GP'. Look out for information coming soon by email, and a presentation to the SPH AGM on our aim to present a more cohesive front to other organisations, and make best use of our limited resources. On Thursday, the executive team survived a mediation training day, reflecting our sense that this is likely to form an increasing part of our role in the future. Sandwiched in the middle of the past fortnight has been the annual LMCs conference, held this year in Edinburgh, and attended by the Somerset contingent of Karen Sylvester, Barry Moyse, John O'Dowd, Jill Hellens and your correspondent.
We could have had "Weak and Wobbly", "Feeble and Floppy", or "Puny and Prostrated", but given the state of my left peg, the Ls have grabbed the title honours. Having shoe-horned eight Ss into a fourteen-letter title a few months ago, I've developed an aversion to anything beginning with S, and especially to "Strong and Stable". I doubt I'm alone. Following the PM's BBC interview with Andrew Marr, where she was discomfited when asked why nurses are going to food banks, I suggest that every time someone says "Strong and Stable", or "Coalition of Chaos", the immediate response from the person being bludgeoned into alliterative torpor should be a blurted "Nurses at Food Banks".
A Fairytale Year
Once upon a time, long before any evil rulers had dreamt up CCGs, PCTs, PCGs, HAs and FHSAs, Somerset GP services were run by the Family Practitioner Committee (FPC), based in Weston Super Mare. My first senior partner had the FPC administrator (note the singular) on speed dial, or at least the rotary dialling equivalent. The committee, as I understood it at the time, consisted of two men and a dog (a greying spaniel called Bennie who was a dab-paw with maternity services) and their role was to administer the Red Book, that brick-like compendium formally known as The Statement of Fees and Allowances, which dictated the financial entitlements of practices. Every so often an update would be published, that colleagues of a certain disposition would promptly and meticulously insert at the relevant bit of the brick. Others like myself kept an ever-growing heap of polythene-wrapped addenda that never quite got put anywhere useful.
This week, I've mainly been herding cats, lining up ducks and identifying elephants. Unless you've been living under a rock for the past year, you'll have heard a lot of talk about the STP, but the chances are that you probably wouldn't choose it as your specialist subject if suddenly roped in as a last minute replacement for Mastermind. Don't beat yourself up about it too much though, as I've yet to meet anybody who can give a convincing and uncluttered description of the structure and governance from beginning to end. I did once have it explained to me by a colleague with considerable confidence and brio, until we discovered that his version was a few months out of date, and that I'd just come from a meeting of a new group that didn't appear anywhere on his crib sheet. The complexity of the process has now become a problem in its own right.
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.
The new Somerset Practice Quality Scheme (SPQS) specification for 2017-8 arrived in practices last week. We know from NHS England that Simon Stevens has been taking a personal interest in the scheme, not least because it's widely accepted that the days of QOF are numbered. NHSE want the outcomes from SPQS to be a little more robust (forgive me), and the new spec will include comparing data from the Rightcare programme, and practices identifying whether they are outliers in a number of areas, as well as continuing with the work on personalised care planning, sustainability and Quality Improvement. There is still the seemingly modest requirement for some poor wretch to complete the Organisational Change Tool questionnaire at least twice a year. I'm not necessarily averse to surveys, but this one is an absolute stinker- page after page of mind-numbing, cortex-contorting questions going into intricate detail about care planning and collaboration, to which the answer to each question is a somewhat vague "working very well", "working well", "requires improvement", or "not working". If you know who fills in the questionnaire in your practice, please go and find them and check they're OK, perhaps quietly removing their shoelaces as you do so. The Academic Health Science Network (AHSN) tell us that it's the best that they can come up with, and that it's "internationally validated”. Fab- but what does that actually mean? For all we know it could have been developed and validated by the Sami people in northern Scandinavia, who have at least 180 words for snow and ice, and are prepared to spend arctic days peering gloomily into a hole in the ice, dangling a hook and waiting for a nibble. I doubt very much that its been validated by a flustered older GP with heartburn, a bad knee and anger issues, who's already had 4 goes at getting past the first page, and then started wondering whether he could perhaps chisel out his own gallbladder with a teaspoon as a little light diversion. There has been a degree of convergence of QOF and SPQS in recent years- the former becoming less onerous and the latter possibly more so, but we know that SPQS has been an important selling factor when promoting Somerset to new GPs in recent years. We may be reaching a tipping point where some practices decide to go back to QOF, and the LMC has sent out a short statement on SPQS to practices in time for the quoted deadline of today (Friday 17th).
Last Friday was an important day in the calendar for Harry and I, as we both donned silk stockings, breeches and powdered wigs to celebrate the birthday of the notable diarist, Samuel Pepys. We share an alma mater, and the college would serve a slap-up 17th century meal every year on February the 23rd in his honour. Although somewhat before my time, Harry knew him well, and in quieter moments in the office, will often talk fondly of the man he called Big Sam, who went on to become an MP and Chief Secretary to the Admiralty, long after he had quilled his last blog. Sam was a martyr to bladder stones and had appalling table manners, but was a hard-tackling centre back for the college XI and treasurer of the Varsity bear-baiting club, so wasn’t all bad. His diaries tell us a lot about the mundane stuff like food, drink and sex, but like all bloggers he would, as I do now, relish the occasion when something to truly boggle the mind fell into his lap. Sam witnessed the Great Fire of London, and last week, I saw a frankly astonishing document on fibromyalgia.
No, we're not discussing the latest in six-pack sculpting apps, or Patsy and Edina’s take on the STP. Google News aficionados might be familiar with their chart displaying the timeline of trending news stories from around the world. We could produce something similar for important documents and news emanating from NHS England or the CCG, and I suspect we'd find a heavy bias towards Friday afternoon. The cynical view is that it’s a good time to push things out when people are winding down, or have already turned their brains and computers off for the weekend. I suspect though, that it also reflects managers working to deadlines at the end of the week, and then hitting “send” on the finished document. Just such an event occurred a fortnight ago, and the result was a number of worried practices from one corner of the county contacting the LMC late on a Friday afternoon. Without going into details (a delicate situation is still being unpicked and defused), it caused considerable concern and consternation over the weekend. It was a classic example of the Ab Fab: Another Bloody Friday Afternoon Bombshell.
February 3rd 2017
It's been a great fortnight, a really great fortnight. Frantic and tremendous! And fantastic. We have the best fortnights, we really do. Period.
Lord help us. The day job is hectic enough, but I also seem to have had all sorts of extra meetings and urgent phone calls shoe-horned into every calendrical nook and cranny. Friday is blog day, but my appraisal is looming, and my lovely appraiser has indicated she’s short of reading material for the weekend. I had been pretty relaxed about it, until we formed one third of a quiz team together in Trull last weekend. She'll know now that I like Proper Job, have a voracious appetite for chilli, am familiar with the TV career of Peter Vaughan, but have only the sketchiest acquaintance with cubism, the geography of the Balkans, and the members of the pop combo Suede. I sensed she might want more. With the demise of the Severn Appraisal Toolkit, I've switched to FourteenFish, which although not free, meshes seamlessly with their Learning Diary App, and they also host the website you're squinting at right now. I’m never very good at cobbling it all together, and have never enjoyed identifying and listing "learning points" (LP) and "reflections" (R). I’m pretty sure I do reflect and refract, as that's one of the many things that, this side of the Atlantic at least, keeps me awake and sobbing in the small hours. I'm sorry then that some of this blog might come across a bit appraisaloid. I’m trying to get “in the zone”.
In the months and years before I became gavel-monitor, I used to worry about the system going bosom-side up on my watch. I stopped fretting sometime last year when I realised there was little point, and I couldn't be expected to single-handedly save the NHS. We all know we're heading for a crash, but we've been doing our best to steer the thing gently into a hedge so as to limit the damage, and at least have some sort of battered wreck with wonky wheels and dented doors, in which to limp away afterwards. What we hadn't really expected was to find the PM herself hunched over the wheel of the oncoming juggernaut that threatens to wipe us all out.
So how was it for you? At least the madness is all over for another year, and I know that Spring must be nearly here as our fabled cleaner already insists the evenings are drawing out.
There’s a scene from the film “Battle of Britain”, where the RAF top brass are in the ops room, looking down on the situation table surrounded by WRAFs armed with titchy rakes who move the various markers, representing squadrons of spitfires and hurricanes, around a map of southern England. It’s the day after the Luftwaffe have thrown all their kitchen sinks across the channel, but today nothing is happening. “They’re late”, mutters Trevor Howard, while a minion checks whether they’ve remembered to turn the radars on and plug the phones in. It was a similar scene at our manor between Christmas and New Year- we always clear the decks, put on tin hats, and wait. It seemed remarkably civilized; surgeries were full, but with sensible stuff. We didn’t have extras backed up everywhere as we normally do, and relatively few visits and mail to deal with as well. The LMC Office has been closed, so there wasn’t much traffic from there either, and all in all it felt quite manageable. The problem is that we’re so ingrained with the sense that we need to be constantly overwhelmed, that anything less makes us feel guilty if we're leaving before 7pm.
***** ******* is coming to town!
Implementation is everything. As Santa Claus pokes round for that elusive can of WD40, and struggles to recall precisely how he applies Einstein's Special Theory of Relativity so he can do all he has to, the local Health and Social Care leadership are moving from the planning to the consultation and implementation phases of the STP. It's arguable who has the easier task. The main excitement at the STP Programme Oversight Group meeting this week was the surprise presence of ***** *******, recently appointed as the new Chair of the STP. Many of you will be aware of his/her national profile as ******* of *******, and of course his/her former role as ********** at ******. They are due to take on the role formally in January, but if their identity hasn't been formally announced by the time I hit the 'send' button on this missive, this paragraph will seem a load of ********. At least it will give you something to ponder as you peel the sprouts.
I’ve got my third Christmas dinner lined up for tomorrow, but still have the best part of two blogs to cobble before the big day- so how does that work? My practice staff will tell you that I love the build-up to Christmas (that’s love with a capital “H”), and so I’ll do my best to keep it festively light, or at the very least a Trump-free zone. We will also be avoiding Johnny Mathis and anything to do with mistletoe.
This week I have mainly been improving my mind, or at least refreshing my looks, at the annual GP-updating week at Musgrove. It's a great opportunity to catch up with GP colleagues and also bump into consultant friends in the corridors. The years march on, and there now appear to be tables in the Academy reserved for 12-year olds with NHS lanyards, whilst I've moved definitively into the grey cohort who shuffle round looking slightly bewildered whenever we have to leave the main lecture theatre to go somewhere else. Tony Wright does a fantastic job putting together the timetable, and the quality and relevance of the sessions improves every year. We should also recognise Doreen’s fantastic work keeping the 4 days running smoothly. One constant is the brilliant beacon of Harry's hour when he tells us what's really going on, and what the LMC/he/me are trying to do about it. This year's "State of the Nation" was typically concise and insightful (save for the odd dodgy photo), and the single-minded focus with which he'd prepared was evidenced by an impressively bandaged thumb, which he'd apparently tried to hack off whilst getting the slides together.
In times of stress and uncertainty, whether personal, professional or global, it's probably wise to have a plan. I'm sure it has absolutely nothing to do with the US election result this week and the prospect of Uncle Donald playing keepy-uppy with the nuclear football, but recently I found myself perusing an old "Protect and Survive" leaflet.
Is it just me, or has the medical news recently turned even more bleak than usual? The GMC said yesterday in their Annual Report that morale in the NHS is at an all-time low, doctors in training feel a sense of alienation, and a "state of unease" exists within the medical profession. They go on to say that patient care is at risk as a result. That's pretty heavy stuff for the GMC.
You've got to hand it to the government- they couldn't be more in touch with us hackers and hewers at the NHS coalface if they arrived with their gold-plated picks and got stuck in themselves. The problematic nub of GP morale has now got the podgy digit of Health Minister Philip Dunne well and truly on it. Speaking at a fringe event at the Conservative Party Conference in Birmingham on Monday, Mr. Dunne said that Uncle Jeremy had decided that what would really improve morale is a shedload of awards and gongs for GPs, and that recognition of this sort could provide ‘self-motivation’ for staff. So- darn the cardy and buff the brogues, we're all off to the Palace to meet Her Maj. Hurrah!
The Friday before last I found myself talking about the STP (Sustainability and Transformation Plan) again. I do seem to have banged on about it in quite a few different settings and forums, including here, but this was rather different, not least because I was wearing a dinner jacket. Those of you who know that Barry Moyse has joined our practice will not be surprised to hear that standards of dress there have improved, but even in North Petherton black tie is not required attire before 6:30 pm (on weekdays). My right hand held a glass of chilled Taittinger, my left possibly steadying myself against the ancient wooden paneling of a room known as Benson Hall. The small group I was addressing and regaling with the intricacies of the GP Forward View and Somerset recruitment problems included an actor whose big-screen break came playing a Royal Naval captain who went down with his ship in Tomorrow Never Dies, an aristocratic ex-MI6 station chief in Belgrade during the Bosnia crisis (slightly tarnished after tabloid exposés), and the previous Archbishop of Canterbury.
Kevin Pietersen and Katie Price must be chuffed as nuts- KP nuts, you'd presume- that somebody with the same moniker, has found themselves dumped into the limelight and is now taking the sort of flak previously experienced by the preening ex-England cricketer and the pneumatic reality person. The former CEO of Southern Health (a community health provider covering Dorset, Hampshire, Oxfordshire and Buckinghamshire), Katrina Percy, has recently resigned under a cloud, and taken a sideways move into a new role created solely for her, and for which she is, we are told by Tim Smart, the Trust chairman, "uniquely qualified". She is providing "strategic advice for GPs", and has retained her previous salary of £240,000 per annum (that equates to the whole funding of our LMC for a year). I'd be interested to hear how her local GPs and the LMCs view her “unique” qualifications, and would suggest that for that sort of folding money, the advice must be pretty extraordinary. It would be a cheap and easy jibe to suggest that she is her own Sustainability and transformation plan (STP)- sustaining her lifestyle whilst transforming herself into some sort of Primary Care guru- a mystical figure sitting atop the highest point in Wessex, waiting for baffled and bewildered GPs to clamber up and ask her strategic advice, but times are hard so there you are. Here in Somerset we have our Provider Support Unit (PSU) which has taken the last 12 months to develop with LMC, legal and accountancy input. It is designed to provide all the basic documentation and answer queries practices might have when considering collaboration or integration, for example. All federations bar one have signed up to use it. I’m not sure what strategic advice Ms. KP is qualified to dispense, but on the basis of cost alone she must be able to sort out all sorts of other niggles GPs might have.
This is almost certainly my last blog, as I’ve been head-hunted for a new job. I know I'm only just getting into my stride with the chairing thing, and actually quite enjoying it, but this sounds too good an opportunity to miss. Somebody wants my services and has been desperate to get me to apply, hassling my Practice Manager on an almost daily basis. It must be a staggeringly responsible position, given the hoops I'm being asked to jump through. I need yet another DBS check (that's £61.50 I won't see again), and I'm assuming that all the convictions, cautions, reprimands, warnings, restrictions, injunctions, super-injunctions, banning orders or register entries that I may have had in the past are now either time-expired or lost, given my current job as a GP, which can feel pretty responsible at times. I’ve been involved with Child Protection conferences and also Professional Performance discussions, but such is the profile of this new role that it demands a whole new level of scrutiny, and an even deeper dive into my background. Yesterday I had to present myself at the Post Office for an identity check. My passport alone was not a sufficient guarantee of who I was (ponder that the next time you're in one of those serpentine queues at BRS border security), even when presented with my driving licence, which I also had to produce. No- what clinched it was a copy of a mortgage statement from First Direct. This was curious on a number of levels, not least that it doesn't give my address or any other identifying features apart from my name and account number, and in fact all it proves is that we chose to give our daughters plenty of opportunities to play hockey, learn the bassoon and mix with the spawn of Russian oligarchs, rather than paying for the house. If I pass the DBS bit, I'll be on a similar security setting to the PM (that's Prime Minister, not Practice Manager). We haven't discussed salary yet, but I'm anticipating it will be colossal, given that the income of the organisation has risen so dramatically in recent years. I'll need to drop a few days of other work to do the job justice, and won't have time for any fun stuff like this. So what is this amazing opportunity that beckons me away from the Blogosphere? I'm thrilled and humbled to announce that the Care Quality Commission wants me to be a “Registered Manager”.
I used to enjoy August. Tales of kitesurfing donkeys and vegetables shaped like Kylie Minogue made the front pages of the papers, simply because there wasn't any other news. The world would quietly shut down for the month to go on its hols, and our practices were quieter as well. This year it's all rather different- Trump, Rio, Brexit and the calamitous state of the NHS have, between them, kiboshed the natural order.
The locum situation, previously merely dire, is now as critical as it has ever been. We know from the locum agency that there are hundreds of locum requests for August that they will be unable to fill. Not only are exhausted doctors unable to take much-needed leave, but it has also meant some of us haven't been able to get away to attend important meetings that crop up these days at increasingly short notice. It's becoming a real problem getting proper GP representation if we can't escape from our practices. The tight time-frame demanded by Simon Stevens for delivery of the STP has meant weekly meetings being arranged during August. Our practice manager made a gentle enquiry of the agency to see whether there was any possibility of a locum- she was told in no uncertain terms that there was no chance, and why do people arrange meetings in the holiday season in any event? The reality is that we simply can’t afford the luxury of waiting for things to calm down- it’s not going to happen- the whole thing is built on quicksand, and sinking.
So what do you think of the new stuff on the web social media enticing GPs to come and work in Somerset https://gpinsomerset.com (twitter @GPinSomerset)? Jill and the team have done a great job, and if I wasn't gainfully employed here already, I'd certainly be tempted to up-sticks and apply for something locally. I might even delay my retirement. Apparently we have to get anybody on Facebook https://www.facebook.com/GeneralPracticeSomerset) to "like" it, and share it and then it sort of...er...takes off somehow. Obviously (and evidently), I don't do Facebook myself, but do follow Twitter, and that's certainly been one way to try to keep abreast of all the geopolitical shenanigans over the past 3 weeks or so. @drphilhammond is an entertaining one to follow for NHS stuff (not to be confused with Philip Hammond, the new Chancellor).
It's been a busy week since getting back from France. On Monday evening we held our CRG/executive meeting, and went through the agendas for Thursday's meetings. We also discussed what implications the Brexit vote might have for the NHS. The truth is, of course, that at the moment nobody can possibly know. Before the vote the Chancellor had been clear that there would need to be an emergency budget after a "leave" result, and that there would be cuts to the NHS. On the other hand, the Brexiteers had promised extra funding for the NHS, although they rolled back from the 350 million that they emblazoned on their battle-bus. At least when the NHS appeared to be in a state of chaos just a few weeks ago, there appeared to be some sort of order around it. Now all that has changed. Any further cuts would surely destroy any pretence that the NHS can survive, and the result of the vote and ensuing chaos are likely be used as an excuse for future failings in the system.
My first brush with Somerset LMC was in September 1983, and to be frank, I wasn't that impressed. As a final-year medical student, I spent half of my entire undergraduate GP training- 2 whole weeks- at French Weir Health Centre in Taunton. One of the partners was Richard Tiner, who was then Medical Secretary of the LMC. He invited me to attend a meeting, which in those days were held upstairs in the old County Hotel, now Waterstones. To get to the meeting evidently involved a difficult journey through the bar, which I'm told could often take an hour or so, and by all accounts meetings were convivial affairs. Imagine my disappointment then, to be told that I wasn't welcome, and the Chairman had decreed that it would be inappropriate for a medical student to attend. I probably had something better to do anyway, but I know that Richard felt very embarrassed about the episode, which I do remind him of whenever I meet him (he left General Practice to become medical director of the ABPI, but still lives locally). I keep meaning to look up the minutes of that meeting to see what it was that I missed. I hope we are a bit more inclusive these days, and it's quite common for registrars or established GPs to attend meetings as visitors.
I hope most of our punters have at least heard of the STP (Sustainability and Transformation Plan). This will be the most significant document yet produced in setting out how our local health system plans/hopes to get through the next 5 years. If you haven’t read it yet, I’d urge you to spend 15 minutes or so looking at this excellent critique of STPs - Link to document.. The requirement for each ‘Local health System’ to come up with its own plan was outlined towards the end of last year as part of the implementation guidance for the 5 Year Forward View (itself published in October 2014), and I think speaks volumes about where we are. The implication is that the system is broken and heading further and further into deficit, and the centre now would like us to sort it out. Note that it talks of ‘Local health Systems’ rather than CCGs. Failure to come up with an STP that meets approval from NHS England will mean that areas will not be able to access Transformation funding. There are 44 ‘footprints’ nationally- each covering a population of (on average) 1.2 million people. We are fortunate that our STP covers the whole of Somerset- some footprints will cover populations served by up to 15 CCGs! Each area had to select a Senior Responsible Officer to oversee the production of the plan in a very tight timeframe, and we are one of only 4 in the country to have an SRO with a Primary care background (Dr Matthew Dolman).
This is the first of what I intend to be a fortnightly blogette, an insight into what being the LMC Chair involves, and some personal musings on the role and the state of the NHS around us. This is intended to be a personal account, and is not intended to be taken as LMC policy!