Harry Potter and the wizarding world of STPs
By Harry Alcock and Elizabeth Mumford
The London Clinical Senate Forum (LCSF) was established in 2010 as a gathering for stakeholders to debate the future of London’s health services, particularly looking at areas highlighted in Sustainability and Transformation Partnerships (STPs). Attendees include management from hospital trusts, CCG representatives, GPs, and members of the public. This year for the first time the Faculty of Medical Leadership and Management (FMLM) has appointed four Clinical Senate Fellows.
On Thursday 12 October two of the Clinical Senate Fellows attended their first LCSF. The topic of discussion was 'Accessing Specialist Advice in a transforming NHS'. Somewhat like arriving at Hogwarts for the first time, we were introduced to a whole world of NHS future planning which we had no idea existed. Talks focused on how outpatient appointment services could be improved to become more efficient and patient-centred. Here, we both share our perspectives on some of the topics raised.
'Conference calling, conquering fears and models of care for the future’
For Elizabeth, a core medical trainee, the LCSF journey began with fortnightly conference calls from mid-July.
This was my first experience of being involved in planning such a large event – this year there were more than 100 delegates. I found the telephone conversations very informative, learning from the experience of other senate council members. I was surprised by how keen other callers were to hear my views and experiences. Fitting calls into a busy working day was sometimes difficult, but always worthwhile. I quickly got to grips with various acronyms and ‘management-speak’ – sometimes Googling these during calls to keep up with the conversation. This was also my first exposure to ‘PPVs’ – patient and public voice representatives – who provide an invaluable viewpoint based on their own experiences of healthcare.
The culmination of months of planning was, on my part, being asked to speak on behalf of the senate fellows at the meeting. I was tasked with providing an introduction from the perspective of a junior doctor: what are the current problems with outpatient services, and where could we be in 10 years’ time when I am a consultant? This was certainly daunting, especially in front of such an experienced crowd, but provided an excellent ice-breaker as strangers approached me throughout the day to discuss my opinions. A senior physiotherapist gave me tips for how to make outpatients a better training experience for me (ask the consultant to run down the list at the start, picking out suitable patients), and a representative of Health Education England bemoaned the pressures on training (are we training doctors for today’s health service, rather than the service of the future?).
After introductions the meeting progressed into ‘speed dating’ table discussions to learn about the innovations happening around us. As our chair Dr Vin Diwakar highlighted, people are much more likely to take on change if they learn about it in a social context. In these discussions I was impressed by projects such as East London Community Kidney Service, which has succeeded in transferring renal care and follow-up into the community, to the greater convenience of patients.
'Outpatient follow-up, financing and innovations’
For Harry, formerly an FY1 in a busy district general hospital and now working in A+E, this was his first exposure to the world of NHS leadership and management
One of my most common tasks as an FY1 was sorting out discharge summaries. I frequently had at least 10 to do in a single day alongside other jobs, and often these had to be done before a certain time so that transport could be arranged and the bed freed up for the next A+E patient. As such, I often had very little time to focus on the letter and follow-up appointments needed. However after attending a talk by Dr Michael Gill, Medical Director at Health 1000: The Wellness Practice (a specialist GP practice which provides joined up health and social care services for people with complex care needs), I realised that doing this can cause problems down the line. Overzealous booking of specialist follow-ups can overburden already busy clinics and also put our more frail patients through a lot of misery for no real benefit. When a patient requires transport for an outpatient appointment they typically have to be woken up by carers at 6am, they then face an unpleasant 2-3 hour bus journey as the transport has to collect every other patient in the local area due for appointments (something I never thought of last year). They then will have to wait in the hospital waiting area for another few hours and, assuming no delays, they will be finally able to see the doctor for approximately 10 minutes before another long wait for transport and the journey home. For the frail elderly patients with arthritis and respiratory problems the cold, long journey can be uncomfortable. I now believe we should be more cautious with booking specialist follow-ups for frail patients, and only do so if it will directly change management and result in a clear benefit to them.
I was reassured to see so many new innovations being designed. For example, Dr Patrick Kerr and Dr Azhar Ansari from East Surrey developed a highly successful online portal for patients with IBD. Here they can track their symptoms, which would then be reported to the gastroenterology team who prioritise cases based on who seemed most at risk of flare-ups. New ideas have also spread to mental health services. For example Dr Rhiannon England from City and Hackney CCG has helped re-structure many of their services to give patients more flexibility when seeing their clinicians. Given that such patients are more likely to have difficulty getting to appointments when booked, this strategy has been very successful in preventing people being lost to follow up.
What are the barriers to change?
Most junior doctors are aware of some of the management issues facing their trust (especially rota problems), but much less familiar with the wider issues facing the NHS beyond the very common view that more money is needed. While this is certainly true in a broad sense, after discussion with several members of CCGs it became apparent to us that lack of funding is only part of the problem. The Department of Health pays CCGs, who in turn pay hospital trusts (and various other providers) for services. The amount they are paid is based on a national tariff for that service or healthcare item – so-called ‘payment by results’ or PBR. Neither of us had appreciated that since trusts are funded a certain amount per outpatient appointment there is financial incentive to have more outpatient appointments. The PBR system penalises trusts who try to reduce outpatient work, even if there are better patient outcomes from newer solutions such as telephone consultations and online platforms.
While lack of money is indeed a problem, the entire system of how trusts are funded makes innovative solutions difficult. Much more discussion is clearly needed to develop a new model that rewards trusts for better patient outcomes rather than simply providing more patient services. There is a whole world of NHS service planning, and decision making, which up until recently has been reserved for consultants at the pinnacle of their careers. Unlike in Harry Potter, this world is not closed to all but the gifted few. As junior doctors, we feel it is important for us to educate ourselves about these complex funding issues so that we can be advocates for the changes that are vitally important. As current and future NHS employees we deserve to have a say in what the future NHS will look like.
Conclusion
For both of us the Forum was a fascinating insight into transformations in the NHS as pressures increase: both how new technology might help, and also the complexities of financing such projects. We genuinely felt that other delegates valued our insights, especially those who were further removed from the NHS ‘shop floor’. The flat hierarchy during debates was immensely productive. We have both since made changes to how we work: discussing these issues openly with colleagues, considering whether a patient really needs to come back for review in 3 months rather than 6, or simply directly asking a patient about what is important to them.
We would strongly encourage other junior doctors to get involved with any projects starting at their local trust, to be more aware of management and funding complexities, and advocate for changes that will ultimately improve patient care. You might be surprised by how much senior clinical leaders value your insights!