Balancing the books as demand on NHS soars

FOR Oxfordshire Clinical Commissioning Group clinical chairman Dr Joe McManners the challenges facing the NHS are quite clear.

The Manor Surgery, Headington, GP faces a situation where demand is increasing, but funding is not keeping pace.

He said: “The amount of healthcare we need to pay for is more than the money we are getting.”

“Healthcare demand and inflation is higher than economic inflation.

“The demand on our budgets is going up faster than our budgets. I think that is recognised across the country.”

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Not only is the cost of delivering care going up – from staff pay to new treatments – but demands on the service are changing, particularly from an ageing county population with multiple, complex health needs.

A timely example is a decision last month to remove free non-emergency transport for those “capable of walking and getting in and out of vehicles unaided” and with “minimal assistance”.

Chief executive David Smith said: “We would all like to be able to say anyone can use patient transport, you just have it completely open to everybody. The problem is, is that affordable? It probably isn’t affordable.”

Such issues have long been recognised by national NHS leaders and the Conservatives – despite pledging no top-down reorganisation in its 2010 manifesto – pushed through a major reform that took effect in April last year.

This scrapped manager-led primary care trusts (PCTs) in favour of GP-led clinical commissioning groups.

Oxfordshire was among the first areas in the country to start work on the new structure but it was a far from easy ride.

Chief executive Dr Stephen Richards announced he was stepping down last October and failed to win election to the post of clinical chairman.

Ian Wilson started as interim chairman in December – setting the organisation back £105,000 to £110,000 for four months’ work – and full-time chief executive Mr Smith started in June.

Dr McManners said: “Because we were in an environment that was pretty quickly changing, there was a major reorganisation of the NHS, it was pretty unlikely that the organisation here would be right the first time.”

He added: “Turbulent is probably the right word to use and I think that what we need really is a decent run at this because we are faced with some pretty tough tasks.”

And there are more than enough tough tasks. For Mr Smith, meeting Government targets is the cornerstone of his job.

The NHS Constitution sets out 13 key measures – the number missed at sites run by Oxford University Hospitals NHS Trust rose from two in 2012/13 to five in 2013/14, including A&E.

Mr Smith, who has to contend with one of the lowest Government funding allocations in England, said: “We have just got to deliver on all of the key national targets. They are absolutely must-do.”

A management restructure aimed at having leaders work more closely with GPs, which has led to seven voluntary redundancies, is part of Mr Smith’s approach as he feels doctors haven’t been involved enough.

He said: “As an organisation we really haven’t been able to harness properly the power and the knowledge and the expertise of GPs.”

Dr McManners said of his GP colleagues: “They don’t necessarily want to spend a lot of time designing and planning and doing the sums but they do want to have that influence on how it works.”

Changing how the system works in the right places is key for OCCG.

Keeping the emergency departments as free as possible for those who need it the most remains a major challenge.

At least 95 per cent of patients have to be admitted, transferred or discharged within four hours of arrival but this was 93.23 per cent on the two hospitals in 2013/14.

Mr Smith said the NHS does not “make it easy” for patients presented with a myriad of treatment options from community to major hospitals to advice via 111 or an emergency request on 999.

Dr McManners added: “It is a complex system. It is quite a difficult thing to link that all together into one seamless pathway [patient journey].”

The buzzword for these issues is “flow”, a smooth transition for each patients to the right department when they are ready to move.

One of the major blockages in the system is when a patient is well enough to leave a bed but cannot because means-tested social services care is not available for them to return home, also called “bed blocking”.

Oxfordshire County Council is responsible for arranging care firms to provide home support yet this is often plagued by delays and the county is often cited as one of the worst areas in England.

On Saturday we reported that the hospital trust is employing its home care nurses to help out.

Ensuring people don’t go to hospital in the first place is key to tackling this, Mr Smith said, as there are deep-seated problems within the care industry to rise to the challenge.

He said: “One or two of the care agencies went out of business and what social services is struggling with is to find enough carers.”

Dr McManners said: “There is often a problem with capacity of the providers. It is difficult to get [carers] at short notice and it is often difficult to get them to take more patients.”

This raises the vexed question of how private providers contracted with NHS cash fit into the health service is the 21st century.

Under Margaret Thatcher’s “internal market” reforms, the idea was to separate those who spent the cash – now OCCG – and those who receive it, like the hospital trust.

By providing a customer / provider relationship this was meant to drive efficiency and introduce more competition for services.

Yet it hasn’t always transpired this way in Oxfordshire. For example, NHS organisations OCCG owed cash to, such as the hospital trust, wrote off bills to allow it to break even by the end of 2013/14.

And it announced earlier this year that it would scale down plans that would offer private firms to bid to run part of maternity, OAP and mental health services, causing fears it could fragment NHS services.

Last week, we reported that the £35m mental health part of the plans is moving ahead with Oxford Health NHS Foundation Trust, the county’s mental health authority, taking a lead role.

Mr Smith said: “Working with them to redesign the service we think is a better way than the alternative, which would be that you put out to the market.”

UNIT AIMS TO EASE PRESSURE ON OUR MAJOR HOSPITALS

Registered practitioner Maggie Shepley, left, and staff nurse Lexi Smith at the emergency multi-disciplinary assessment unit at Witney Community Hospital    

Changing how the system works in the right places is key for OCCG.

It has funded “emergency multidisciplinary units” at Abingdon and Witney community hospitals to assess and treat minor complaints to stop some going to A&E at the John Radcliffe or Horton hospitals.

A further project has seen a mental health nurse accompany police on patrols at peak times so those needing an official “place of safety” do not end up in hospital or a police station.

UNBOCKING BADLY-NEEDED BEDS VOLUNTEER

Ann Thompson hopes by giving up her free time she can help tackle bed- blocking with a new project.

The 75-year-old former social worker is among those taking part in Age UK Oxfordshire’s Circles of Support project.

Ann Thompson

More than 25 volunteers were sought to provide information to people at risk of admission to hospital or who have recently come out of hospital.

And volunteers were also sought to support two charity “care navigators” at the John Radcliffe and Witney and Abingdon community hospitals.

These will help point people and their families towards where they can get help and support, such as through the county council.

The grandmother-of-three, who lives in Kingston Bagpuize, near Abingdon, said of “bed-blocking: “We have been here before. It is something that has been going on for years.”

The former county council social worker – set to work from the JR – said: “When I was with social services we always had difficulties.

“I have always volunteered. I’m just interested in people and I think I have a few skills that I have still got and I can share.”

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