A week in the life of a CCG chief executive
If winter is the season of pressures, spring is the season of workshops. I’ve attended four this week covering collaborative commissioning, 5 year plans, integrated care for Norwich, and Strategic Workforce Planning.
Regular attenders of these might sometimes substitute ‘talk’ for ‘work’ when they describe them, and for an outsider we must look at times like the Committee of the People’s Front of Judea, but system workshops endure because we have not yet found a better way to bring everybody together to tackle the problems none of us can solve on our own.
The workshop season has been particularly febrile this year; in part because of the very complex and ambitious planning guidance that requires us to plan five years ahead and pool health money with social care; but also because as problems go, we are having to face up to some big ones. Amongst them stride two colossi:
Balancing the budget
This financial challenge is expressed in a variety of ways - the cash, the demographics, the growing burden of disease, even the 24-hour society - but it all relates to the last six years of budget growth below wage growth and inflation, combined with increasing levels of demand for healthcare.
Each year it gets harder for commissioners to balance the overall budget for their system, and providers have to find efficiency savings of 4-5%. They’ve all done the easy stuff, and now have to find ways of cutting into the wage bill without reducing the quality of care.
Our mental health and community providers got less than a 1% uplift this year, but they have to treat more people, pay a small wage increase of 1-2%, and face higher costs on equipment and consumables. Our mental health provider produced a five year plan that added these 4% challenges all together and described a 20% cost pressure over 5 years. It has been unhelpfully translated by the newspapers into a ‘20% budget cut for mental health’.
These headlines are technically wrong - Norwich CCG for example has increased its spend on Mental Health in 2014/15, and ring fenced at least that level of spend in 15/16 - but there is a truth at their heart.
We cannot pay any of our providers enough to continue with their existing models of care, there is little slack in the system to fund change, and so it becomes increasingly difficult for them to balance the books, and for us to get signatures on contracts.
We have a plan for Norwich that we hope will meet this challenge, and are excited about working with the Kings Fund for the next three years. We will create a whole system model of integrated health and social care for the City - improving outcomes, reducing costs, and keeping people well, independent, and at home for as long as possible.
I believe this is represents our best chance of emerging from this period of austerity with the quality of care protected and our health system intact and solvent, but it will not be easy and we will need to work together to make it happen. And if an occasional workshop brings us together, reminds us of the mission, and creates a space for us to iron out the tensions, then I will happily sit cabaret style with a mug of coffee and some flip chart paper and give it my undivided attention.
The retirement challenge
The workforce challenge has had less coverage than the money, and yet in some ways it is of greater concern.
In Norfolk and Suffolk, 17% of the health workforce are over the age of 55, and are expected to retire within the next five years. I am told by the Local Medical Committee that almost half of all surgeries in Norfolk have at least one GP vacancy. We expect to be 2,000 nurses short of requirements in Norfolk and Suffolk by 2019. We already need 400 more paramedics for the East of England. And many hospital departments - especially A&E, Stroke, Medicine for the Elderly - report increasing difficulty in recruiting consultants.
Unlike the money problem, government cannot simply turn the tap back on. It takes between two and ten years to train people into these various careers; double the number of nursing commissions at Universities tomorrow and they will begin to join the wards, surgeries, and patients’ homes in the summer of 2018.
Do the same for doctors and it will be later than 2020. The paradox is that although we are training fewer than we need, we are training as many as we can afford.
Health Education England is responding to this challenge - looking for efficiency savings that will enable them to increase the number of commissions they can afford. Even more importantly they are investing in the training, support, qualifications, and greater recognition for the health support workforce, known internally as ‘Bands 1-4′.
If we can standardise the training and produce a nationally recognised qualification we could quickly create a large skilled and transferable workforce able to perform a variety of health support tasks, and freeing up the time of doctors and nurses.
I have taught on HCA courses in the past (from new to ready to go can take as little as three months), watched them provide care, and talked to both doctors and nurses about the opportunities for sharing their workload with trained assistants. I believe there is huge scope for reducing the costs of care without reducing quality, and this initiative should be a major part of the puzzle to the workforce challenge we face.
I asked a senior clinician that worked on our Urgent Care Unit trial this winter about what had made it so successful. He talked about the developing relationship between community and hospital staff, the proximity of the unit to A&E, and the speed of treatment and discharge.
But top of the list was the Healthcare Assistant that drove frail patients home, settled them in, and made sure they were comfortable and safe. Each journey almost certainly prevented a patient being admitted. This wasn’t nursing on the cheap; it was professional and appropriate assistance that made nursing care on a ward unnecessary.
So, money is tight and workforce is ageing? All hail Bands 1-4!