This is a challenge to conventional wisdom. Meet Rose Oldham, pictured here with her GP Dr Bhatti, and our Practice Manager Lynn at my surgery donneybrook Medical centre.
I met Rose as her Practice nurse a few months ago, when up popped the dreaded tick box on the clinical records system Alert: ‘Frailty’ in front of me. A wonderful 82 year old lady with normal body habitus who bounds energetically into the clinical consultation room, carries a healthy glow, and a smile and proceeds to tell me what keeps her fit and well. Rose has a loving family, and for many years cared for her husband with Parkinson’s. She lives on her own now, and is determined to make the most of life, in the form of living and not just waiting for ‘old age’. Rose has a twinkle in her eye! She has recently fulfilled one of her lifelong ambitions to do a skydive. Not satisfied with this achievement, she tells me to watch this space, as she may yet complete a ‘wind walk’ an experience for her that would count as ‘one of life’s greatest aerial adventures’. Here is Rose pictured in all her glory!
Needless to say, none of this rich information is contained in the electronic records. Time to ask why?
The tapestry of information provided by Rose sets the scene for a truly holistic discussion around well-being. To coin a phrase by my mentor Heather Henry, this discussion leads to an ‘asset based approach to nursing care’. Rose is not a lady without any medical issues that is indeed why she has come to see me today. She has Angina, hypertension, she requires a medication review. However the bio- medical model of care labels her as ‘frail’ and the computer system asks me to initiate a conversation around her needs rather than her strengths.
Here is the official definition of frailty from the British Geriatric Society:
What is frailty? Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Older people with frailty are at risk of unpredictable deterioration in their health resulting from minor stressor events.
Whilst I do not question the evidence around frailty, and indeed we must look closely at the quality of health and social care provision for vulnerable groups, I want to challenge the application, the assumptions and the deficit based model of care. Are we a health service or just an illness service?
How can we encourage health creating practice, when systems, policies and frameworks are designed purely on people’s deficits? Whilst it is extremely important to prevent unplanned hospital admission, and improve the quality of care we provide for older generations, it is of equal importance that we focus on what keeps people well. We have an array of good quality evidence for this, but we do not universally apply this in practice. Why?
Over the years, multiple frailty screening tools have been developed, refined and utilised for risk assessment and epidemiologic study. I believe the utility of these screening tools in the clinical setting are limited, and as Rose clearly demonstrates old age itself does not define frailty.
This is not a single story. Up and down the land, we meet greet and see people with strengths, gifts and attributes. But do we really see them? Perhaps we are not having the right kind of conversation. As cormac Russell, pioneer of asset based approaches states: we need to focus on what’s strong, not just what’s wrong. This does not mean we ignore problems, or risks. In Rose’s case, I know my GP was genuinely concerned about her safety for a sky dive, given her medical history of angina; however this was stable, and carefully negated through the power of conversation, mutual exchange, and a focus on well-being. Personal values, preferences and goals should trump over policy based practice every time. As a general practice nurse, I learned very quickly to move beyond the security of the tick box, the framework, the guideline… and to see people for who they are, and not what the system dictates they should be.
We must start from a position of strength, moving away from a culture that just deals with needs and problems. In our area, we have an award winning Healthier at home project. This combines the skills of a multidisciplinary team who work collaboratively to enable older people who really need support. This is working well, and takes a health creation focus, that sits side by side the traditional medical model of care.
The ‘Building bridges, breaking barriers’ report looked at existing integration across health and social care and the impact this has had for older people. GP magazine Pulse recently reported their concerns around the unplanned admissions designated enhanced service. ‘’ analysis of official figures showed that GP practices that devise care plans for the majority of their most vulnerable patients have higher rates of unplanned admissions.’’
We need to get this right for our future, and the stability of our beloved National HEALTH SERVICE. Yes, tap into the good, balance the big data with the stories, with what really matters to individuals, communities, families. Age UK’s vision is for a world where everyone can love later life. They achieve this by’ inspiring, supporting and enabling’ – a motto we should all adopt in general practice.
As many will continue to fill in their frailty index… I am off to start a Feisty Folk register, inspired by local people who have amazing strength, have overcome adversity & can teach us professionals a thing or two about life!
This blog was inspired by the all the red devils out there! The young at heart. Rose Oldham, Zulf Bhatti, Jocelyn Ward, Margaret Murphy, Ian Kenworth Heather Henry, john Walsh, and Lynn Wilkinson.
Practice nurse, Clinical Development Lead Practice Nursing, NHS Manchester CCG’s, GPN advisor NHS Alliance, National Executive.
This evening is a time to reflect and renew. I am going to do the reflection. What have we achieved in eighteen years, what lessons have we learnt what and of the future?
First, some more very heartfelt and overdue thankyous. To all of you – friends and allies – for coming here today and being such an important part of the NHS Alliance journey of my past eighteen years. Particularly our “old” team – Kaye Locke, who kept the organisation going through thick and thin for well over a decade. Mike Sobanja, our previous Chief Executive, such an important and steadying influence on me and NHS Alliance during my younger more hot headed days. Pat Goodall, who taught me most of what I know about communications and media. The “new team” of the past few years. Rick Stern – Chief Executive – who was a vital part of launching NHS Clinical Commissioners and provided us with new direction during challenging times. Rick – thanks for all your patience in coping with me. NHS Alliance will miss you enormously as you also stand down today. Vice Chairs Donal Hynes and Yvonne Sawbridge, who have provided brilliant leadership. Sarah Wrixon, Stewart, Anouska and the team at Salix, who have given us an office and excellent media profile over the past few years.
The new team – Mark, Heather and Merron and all our inspirational National Executive for taking Alliance so energetically in to the future.
Finally Christine who has worked her socks off at all hours for the past twenty years. Last, but not least, my wife Jo and family, who have been so supportive and paid so much over the years. Anything that NHS Alliance or I have achieved is because of these people.
NHS Alliance was conceived on a misty March Saturday morning in Telford in 1993. A group of us had developed GP Commissioning Groups and met to form “The National Association of Commissioning GPs”. Soon afterwards Secretary of State, Stephen Dorrell, graciously accepted our demands to establish Locality Commissioning Pilots even though they were against the grain of Government policy. Later in 1997, the new Labour Minister of Health, Alan Milburn, commissioned 12 of us to produce a paper on the future of the NHS, which we did during an intensive weekend in Stratford. With the Iron Bridge at Telford our logo, we announced a vision “To develop a comprehensive NHS that is fair to those who use it and those who work within it, efficient and effective in its use of resources, sensitive to the needs of individuals and communities and openly accountable for its actions”. We proposed the development of Health Commissioning Groups that went beyond just GPs, which is why on a hot May Day in 1998 NHS Alliance was born in the bowels of a dingy Euston Hotel.
It was just Mike Sobanja and myself, three rather bored journalists and a very large bowel of fruit, which we all polished off.
Then came the new Government’s White Paper “The New NHS – Modern and Dependable” proposing our idea of “Local primary care based commissioning organisations”. That led to the “NHS Plan” and someone thought it would be a good idea to get all NHS leaders to sign it.
At the time, I was on summer holiday in Jersey with my family. My Son, Finn, and I had just discovered how to catch fish from a pedalo. I was struggling with a particularly large fish, when the Minister of Health phoned my mobile. “Would I sign the NHS Plan”, John Denham asked. “What does it say?” – I replied. “Can’t really tell you. Anyway we are not asking you to sign the plan itself – just the principles”. “What principles?” “They are all quite straightforward and anyway, everyone else is signing.” So I signed, and along with my 21 co-signatories, it was assumed evermore that we had all signed up to a plan, which none of us had actually ever seen!
My worst NHS Alliance moment was to come a year later in 2000.
Having allegedly signed the NHS Plan, we were concerned about its implementation and raced off to another hotel for a weekend and produced “Implementing the Vision”.
Some of it sounds horrifyingly familiar even fifteen years later. I quote:- “Primary care organisations should commission unified services across primary and secondary care boundaries… Budgets should be pooled with social care facilitating access to the most appropriate care… A person from the inner core of the primary care team should act as care coordinator for each patient. Large general practices will offer an increasingly wide range of services, while small practices will work cooperatively within small confederations”.
Anyway, one proposal attracted huge media interest. We said:- “At defined intervals, the Government should publish an explicit description of the service that it aims to finance (could that be a Mandate?) and it would then negotiate provision of that service with the NHS Executive. The Government and the NHS Executive should be separated, with the NHS Executive becoming an executive non-departmental body”. We had proposed NHS England! All hell broke loose.
The night before our launch, Michael Farrar (then Head of Primary Care) phoned me at 10:00pm and said the Minister had re-read our report and didn’t like that suggestion and that it should be go or he would remove his foreword.
As I left for London, Christine and her family spent the next day removing the foreword from all 2,000 copies ready for posting.
Next morning’s Today Programme was a slow car crash. John Humphrys and his team were discussing an earlier news item. Someone had bled to death from a burst varicose vein. He asked what I would do. I lifted John’s leg in the air to show him that venous blood can’t flow against gravity just as the studio light turned from red to green. It was ten to nine and everything was OK until five minutes later. That was when someone rushed into the studio and put a piece of paper in front of John. I craned my eyes to read it – “Ask Dr Dixon about the Minister’s decision to remove his foreword”. John lent forward smiling, which is always a bad sign. “Tell us about the Minister’s decision to remove your foreword?” I had five excruciating minutes to defend our idea, while not totally alienating a Government that had supported all our other ideas and would be required in their implementation. I have never been so relieved to hear the pips of the nine o’clock news.
Meanwhile, there was a push for Primary Care Groups, chaired by a clinician to develop into Primary Care Trusts with the chief manager as Accountable Officer. We argued this might lead to managerialised organisations more worried about managers higher up the food chain than the needs of their local patients and clinicians. The rest, of course, is history. One of my worst mistakes was to bow to universal opinion and pressure that the chief of the PCT could not be a clinician.
In 2001, we produced our second document “Vision in Practice” with a sub-title, now a cliché, “Delivering a Patient Centred NHS”. We argued that local commissioners should become “The strong arm of modernisation” and that “earned autonomy” should now be replaced by “assumed responsibility” throughout the NHS.
We were growing rapidly. Our first conference, with barely 100 delegates, had taken place in a Blackpool hotel resembling the Kremlin in a ten force gale. Now we were alternating between Manchester, Bournemouth and Harrogate with over 1,000 delegates and regular meetings with Prime Ministers, Ministers and Advisors. Our star faded a little with our insistence that GPs, nurses and allied professionals were increasingly disengaged from the new Primary Care Trusts. We produced three further documents “Reengaging GPs, Reengaging nurses, and Reengaging allied professionals in the NHS”. No Ministers or senior managers came to our launches. Eventually, the penny dropped and Government tried to re-engage with Practice Based Commissioning, which is another story.
In other respects, things were going better. Patricia Hewitt’s White Paper on “Out of Hospital Services” reflected exactly our thinking. Ara Darzi was asked to produce a new strategy for the NHS. It was clear that early thinking hadn’t taken account of primary care or patients with complex disease. Steve Field and I made a nuisance of ourselves and a quite separate primary care strategy was produced under the excellent leadership of Ben Dyson.
The sun set on the Labour Government and Andrew Lansley produced his controversial Health & Social Care Act. We were positive about creating Clinical Commissioning Groups (CCGs) but questioned both privately and publically whether our new commissioners needed quite so many complicated rules on markets and competition.
It was clear to me that the new CCGs would require one unified and powerful organisation to represent their interests. Merging the competitive commissioning arms of NHS Alliance, NHS Confederation and NAPC was a pretty exhausting and sensitive process but eventually white smoke emerged and NHS Clinical Commissioners was born. Today, it is brilliantly led by “our Julie” and those who are leading the Clinical Commissioning Groups.
Handing away our main source of income and membership was organisational suicide but our National Executive and new Chief Executive, Rick Stern, were now adamant that primary care provision itself needed a progressive and effective champion. Especially as our ideas on integration had moved from politically incorrect to flavour of the moment. This led to our most recent documents – “Breaking Boundaries” and “Think Big, Act Now”. We described how general practice might work at scale and how patients and communities could become assets in their own health and care.
We also recommended a reduction in bureaucratic workload, which has now been taken forward in our most recent report and is currently being implemented.
So, for eighteen years, NHS Alliance has been critical friend and grit in the oyster to Government and NHS with, I believe, a positive effect on policy and implementation. But I have to say that it is now more difficult than ever to run an independent organisation of progressive clinicians with strong values and also get the necessary funding, media profile and political attention. The NHS is reverting to its traditional battle lines. If this continues, then organisations like NHS Alliance will disappear just like the British Association of Medical Managers and we will return to an NHS run by “force of might” rather than “force of right”. The first signs are visible already.
What of lessons learnt? One of my first medical boss’s told me – “If you haven’t a clue what you’re doing then at least be kind”. Grace and good manners are important in this business as is challenge but you must also produce solutions.
Mike Sobanja taught me three things:-
- Feel flattered if people steal your ideas. Even if, as with our NHS England idea they get the praise when you have shouldered the blame.
- Never watch competitors. Do what you do best.
- Don’t underestimate quite how unimportant you are and don’t take yourself too seriously.
And… always be yourself. The night before one of our first large conferences, it was thought to be a good idea (I have to say by all but Mike Sobanja) that I should be tutored by Margaret Thatcher’s speech director. He told me “You must learn to shout much more”. The following day I delivered my first Nuremberg rally, I asked friends what they thought about it. “Interesting” they replied “Are you all right?”
Finally, to Jonathan, Mark, Phil, Nav, Rob and Sam and all those leading new models of primary care. I urge you to ensure that primary care and general practice have a very strong and unified advocate similar to NHS Clinical Commissioners. One that will talk up personal care and continuity, improved access, extended services outside hospital and also, possibly more important of all, the crucial and unrealised role of primary care in improving local health.
Five minutes, finally, on the future. The Five Year Plan is a stroke of brilliance and Simon Stevens was more than generous in crediting us with many of its ideas. But there are three issues of implementation that now need sorting because:-
- Clinical Commissioning is in a straightjacket.
- Frontline clinicians are not insufficiently engaged.
- Primary care is still locked out of the NHS.
Why is commissioning in a straightjacket? When we created Commissioning Groups in the early 90’s, our aim was that frontline clinicians and their patients should, for the first time, have a real say on what services were available and how they might be improved. We did this by talking to those providing services , encouraging them to do better and going elsewhere when they couldn’t or wouldn’t.
CCGs represent our best hope to date of achieving this. But…. as I have said far too often, they joined a party that had started without them. They have to play by rules created by NHS England, Monitor, The Care Quality Commission and TDA. They are all tied up in red tape with over complicated accountability processes, a very flawed payment system and the oxymoron of market bureaucracy. They are now far too bogged down in contracting and long and expensive tendering processes, which will de-motivate our clinician leaders. They must now be emancipated to fulfil their crucial role freed them from the chains of historical power structures, vested interests and political ideology.
Second, you will remember that NHS Alliance in “Vision in Practice” proposed the concept of assumed responsibility rather than earned autonomy. Frontline professionals are disengaged today because they are not being treated as professionals and are constantly being told what to do.
Doctors went into general practice in the past because they valued their autonomy and ability to meet the needs of local patients and population in the way that they and their patients saw best. They must now be liberated from bribes and rules and properly supported to solve the problem of an unmanageable working day.
That will mean rebuilding primary care teams with new members such as pharmacists and social prescribers and with attached district and psychiatric nurses providing integrated care for the elderly and those with mental health problems. New models of care and new contracts have enormous potential but it is imperative that we also have a plan to resuscitate beleaguered mainstream general practice at the same time. I don’ see one yet.
When it comes to general practice working at scale, frontline clinicians must be given a level playing field in their relationships with hospitals, which are in every sense institutionally stronger. The default position in current health power politics must never be hospitals employing GPs because that is the exact opposite of a “Primary Care led NHS”.
Finally, we can’t move forward, while primary care remains locked out. How can I possibly say it is locked out when it is so firmly embedded in current NHS policy? First, because it is locked out financially.
In an NHS which is funded 25% less than Germany or France, general practice has itself lost 25% of its share of NHS funding in the last seven years, which was only 10% to begin with. It has carried a disproportionate share of austerity at a time when it has been expected to extend its role. I can’t see any plan to change this. Even with the £4 billion announced two weeks ago, all the press talked about was more operations and shorter waiting lists. Same old and I have no doubt that half of that amount will go in to hospital deficits. Deficits, I should add, that primary care is never allowed to have – instead we either get paid less, offer less, squeeze more or simply go bust. Then as if to add insult to injury, quite unbelievably, NHS England’s allocated budget for primary care this year was once again substantially underspent and the money so necessary to resuscitate general practice and primary care was used, instead, to cover further financial deficits in secondary care.
None of this is because anyone wanted it to happen. It is because no one is now responsible for it not happening. Our old NHS Alliance cry of “Primary care is absent in Whitehall” is still as relevant today. Hospitals remain the senior service and their Chief Executives are the powerhouse of the NHS. Specialist numbers are still increasing at several times the rate of GPs. Secondary care takes all the top positions, whether it is Medical Director of the NHS, clinical leadership at the Department of Health, occasional ministerial positions or even non-hereditary peers in the House of Lords, where there is no primary care clinical voice at all.
So on the one hand, we have all the evidence from WHO and others that moving services from secondary to primary care leads to less deaths, better health and a more cost effective service. On the other an NHS food chain that makes sure that the rhetoric of a primary care led NHS never happens. I say these things neither as criticism or political statements but as a positive and practical challenge to some of the greatest brains that we have ever had – Jeremy Hunt, Simon Stevens and so many at the Department of Health and NHS England – to now turn that rhetoric in to reality and reverse the inadvertent decline of primary care.
I am confident that future NHS Alliance leadership will carry these and many other crusades forward with passion and fire. Passion is what we do best but I will also miss the laughs. Moments that are imprinted on my mind for ever. Sitting on the Prime Minister’s Cabinet Committee on GP Bureaucracy and having the Cabinet Minister, Mo Mowlem, throwing bits of bread at anyone that she disagreed with. Mike Sobanja and myself being caught with our trousers down while changing for a dinner at the King’s Fund and having to explain ourselves to the Health Service Journal. Standing next to Tony Blair in a Birmingham hospital, when a Brummie lady, towing a drip stand behind her, shuffled up to us and asked him “Who are you?” and he replied with a little irritation “I am the Prime Minister!” They were good days and we have maintained a toxic mix of values, mission and unrelenting irreverence.
I won’t miss eighteen years of 5:00am starts on Tuesdays and Thursdays between three full days in surgery. Both my brothers died more than ten years younger than I am now so I am becoming aware of mortality and need to pursue a few final projects. What I do know is that I am leaving NHS Alliance in very good, very capable and very committed hands.
I have always described those who lead NHS Alliance, in the words of Miss Jean Brodie, as “la crème de la crème”. For me, you will always be just that. Because, in the end, relationships are the only things that matter. Thank you for those relationships and thank you, all of you here, for the very happy and inspirational times that we have had together.
Thank you and goodbye.