Former NHS Nurse and manager now contemplating the NHS from outside

Archive for the ‘Commissioning’ Category

Business as usual

In the middle of a chaotic reorganisation we carry on regardless. We are busy supporting our network groups, arranging workshops and training, recruiting users to help with service developments and reporting on things that have been done. We are busy full stop. We work hard and we work pretty long hours between us. But, you might ask and I often ask, why? Why are we bothering to put so much effort into things that we don’t know will continue in the future?

Well partly because we are kind of required to do so. There are rules in place, there are requirements on us and they haven’t gone away. There are also people out there, clinical people, who still need our support to be able to meet together and discuss how they can continue to improve things for people with cancer. There are campaigns for early diagnosis that we are still involved with and detecting cancer and doing so as soon as possible is a priority area. We are also trying to create some kind of legacy, to make sure that what we do, what has been done continues. While people in high places continue to work out how the new world will work, we carry on working in this world.

We are interacting now with the new CCGs; the board members, GPs who are finding out about their responsibilities to their populations. They find that we do useful work, have knowledge they can’t hope (or want) to learn. They wonder how, come April they will be supported in making sure that cancer and end of life care is best commissioned.

We prepare to apply for jobs. The adverts were meant to have been released last week, now apparently it will be this. The top job will be appointed to in the next week or two and then that person (and who knows who else) will interview us sometime in the run up to Christmas. In the new year we will know more about what those with jobs will do in them and we will discover if we continue with business as usual in the old set up.

It all feels a little unreal. But of course it is real. These are real people, with real jobs, real mortgages and bills who shop in real supermarkets and go on real holidays. It is easy to write off those who work in some kind of administration. But the fact I left clinical practice enables others still seeing patients to spend as much time as possible doing so. If there are fewer of us doing those supportive jobs, either fewer patients will be seen or else fewer patients will be able to be sure that advances in implementing best practice will take place.

Those of us who get jobs in the new world of strategic networks will work hard to make sure this doesn’t happen of course. But there are no guarantees. Of course I may be wide of the mark and the new systems may be an improvement on the old ones. Lets hope so for all of our sakes!

Happy New Year!

So 2012 has arrived. It is good at this point in the year, i.e. at the start to reflect back on the good, bad and ugly of the previous 12 months and to look ahead to the coming months. 2011 was pretty eventful. In June I was interviewed for a job which finally in October I was able to start. In December I was at last allowed to stop doing two jobs at once, just as well as the new one has just got pretty busy. There are lots to do to help support the improvement in services for people with cancer. I just hope that this job can last past the end of my secondment (March 2013); as the year goes on that should become clearer as we await a report on the future of clinical networks which is due in the next few weeks. The great thing about a new job is that it means you have new things to learn, and things have moved on massively in the world of cancer care since I was working clinically so my learning curve has been pretty steep. I actually look forward to going to work each day and that is a pretty good thing.

I am also pleased to report that my dad, who was coincidentally diagnosed with cancer around the time of my interview, has completed chemotherapy and at present seems to be doing well. This is a huge relief as the cancer is secondary and probably cannot be cured. It was great to see him eating and drinking well and buzzing around us all as usual. Fingers crossed that the scan he had a few days ago confirms this.

My son, who is studying in California for a year is home for Christmas. It has been great having him home even if it seems to have doubled the amount of washing and ironing I have to do and has increased the food bills considerably. He goes back on January 15th, but this time we can look forward to seeing him just a month later when hubby and I visit for his 21st birthday.

So I start 2012 hopeful that this might be a reasonable one for me personally. At work we continue to live through the protracted process of the new NHS Bill which is not yet law, but which is causing a fair amount of change for the sake of change. The GP commissioners are flexing their muscles but at the same time discovering that commissioning is not about telling people what to do and expecting it to just be done. From my new position within a clinical network which will be part of the Commissioning Board I am finding all of the PCT related stuff interesting. People are not surprisingly positioning themselves and that is always fun to observe!

New years resolutions? Well probably best not to promise anything but I will try to blog more (but then I have tried that before).

I wish everyone who takes the time to read this blog post a happy and healthy new year. I hope 2012 is full of promise for you too!

At last

After being interviewed for a new job, a secondment, at the end of June, I have finally got started in the role. For the last two weeks, and for probably another two weeks I am in effect doing two jobs. This is an approach I would not recommend but sometimes we have to make sacrifices in order to get what we want from life.

I moved desks, within the same building, on 3rd Oct and since then have combined induction into the world of cancer and palliative care with managing what I can physically do in the world of maternity and acute children’s commissioning. I am really pleased to say that the new team have been really welcoming, my old team gave me a good send off and all of the people within the network that I have met so far have been friendly.

My new job started with a 2 day meeting in London which was great for giving me a grounding on current issues in cancer services and also in working through some issues about how we can best approach the issue of needing to make sure the voice of the patient / user / carer heard in the way services are planned and provided. I think that hopefully there will be lots for me to write about on this topic once I get my brain properly into gear.

As for the old job, there is plenty that I would like to write about how you should not manage people, and about the emotional mechanisms a person may use to cover up their own short comings and make you feel guilty for them. However that may be difficult and what is more I think moving on rather than going on about it might be more healthy!

The Health and Social Care Bill has this week progressed further on its slow and painful journey to some brave new world that is only clear to people like Andrew Lansley. But it is now inevitable that it will soon be law; it pains me to say but the sooner the better now. We cannot continue with all of this uncertainty and what is more the PCTs are busy making the necessary changes to make it happen and it would be a crime to put the brakes on and go into reverse now. My hope is that the review of clinical networks comes out clearly saying that they need to be developed and strengthened and that what is more that my job needs to be made permanent. There is no way on earth that once I say a final goodbye to commissioning that I intend to go back. But I guess they say never say never!!

Increased choice? Unsustainable demand?

Politicians of all colours are now very keen to offer us increased choice in healthcare. There is an assumption that if you can choose to ‘buy’ your healthcare from anywhere you like then this will lead to the best becoming better and if a provider is not good enough then they will see that they need to improve or else suffer the consequences.

Choice, or perceptions of the ability to choose have been evident in education for some years. The schools that have been perceived to be ‘good’ are over subscribed, they are staffed by excellent teachers and people move house to be able to send their children to them. In some areas, where people are particularly mobile and affluent this may be the case. In healthcare choice in relation to maternity has been a particularly popular phenomenon with some people. Choice of the place you have your baby, whether this is home, a midwife led unit or obstetrics unit, or whether it is about choosing one hospital provider over another is very important to some people. Exercising choice can be a tricky thing. For one thing you have to know what choices are available, and in maternity you have to understand something of your own level of risk in exercising that choice. Perhaps your pregnancy is medically or socially risky when it comes to making some of those choices, perhaps you don’t have the means to travel 30 miles to a chosen different hospital. Perhaps also the services in your area struggle to attract the right mix of skilled staff, not because they are providing a poor service but because they are geographically situated close to an area where staff can attract higher pay.

If you are pregnant, then one thing is sure you will need some kind of maternity service, and it will be the duty of your local healthcare commissioners to make sure you can access it safely. Those commissioner will be required to make sure that the maternity services offered are safe, adequately staffed and that those staff are appropriately qualified to fulfill their role. Maternity Matters gave us a role in promoting choice and in making sure that those choices were available and that people were assisted in making those choices. When though does choice become a want or a demand? When does choice and the way it is exercised by the few mean that those who are more able to move, more affluent, more able to make choices have a detrimental impact on the many?

As a nurse working in a PCT I am obliged to take part in one of the much maligned prior approval schemes that are popping up all over the place to manage the demand for healthcare. ‘Low priority’ treatments such as removal of  non cancerous skin lesions and varicose vein surgery are judged against a set of criteria set by a panel of doctors and approval is given or not for surgery to take place. What strikes me most about the way in which cases are presented is the extent to which GPs and surgeons struggle to tell patients that their problems don’t quite meet the criteria. Often they will write that the patients ‘wants this surgery performed’, and I am left wondering; yes, but do you think it needs to be performed.

I had the pleasure of setting up a new nurse led service a few years ago for people with rheumatoid arthritis. My job was to manage the day-to-day issues that arose for patients coping with a long-term illness, while taking potentially lethal drugs and still needing to deal with normal life. We set up a great service with a help line, monitoring clinics, home visits etc. What it taught me though was that where you create choice and opportunity you will also create demand and to a certain extent want. The people who shout loudest will often if you are not careful get the biggest share of what is on offer and that may be to the detriment of those who cannot shout and indeed may not even know what to say.

Whoever is in charge, whoever does the work of commissioning or buying healthcare, whoever provides it, there will never be enough of it to go around if someone doesn’t take the responsibility for making sure that decisions aren’t only made because of what is wanted, where it is wanted and whom it is wanted from. That of course is what makes my job interesting if not tricky!

A bit of a mess?

It seems that the Health and Social Care Bill, the legislation designed to cut bureaucracy and fix an NHS that is not quite broken is in trouble. For months now, health unions, professional bodies and respected ‘Think Tanks‘ have described deep flaws within the proposed legislation. To us, despite the length of the numerous papers produced so far, firstly as white papers, consultations and discussions and now as a Bill, it has produced many more questions than answers. How will specialist services be commissioned and managed? How can we be sure that GPs will be willing and able to commission all of the services needed? How can we prevent GPs being part of businesses that are set up to provide services and then giving them huge profits? How can we be sure there will be sufficient levels of accountability? Will there be enough money / people / resources in the system to actually do the work? Will patients really get more say in their care? Do people really want choice or do they actually want a well-functioning local hospital which they can access? Can we be sure this isn’t the thin edge of the privatisation wedge?

It turns out there really are more questions than answers and apparently the bill is to be delayed while more of the answers are explored.

Meanwhile people within the much maligned PCTs are leaving. Last week we had 3 retirement lunches in one particular meeting room, two on one day.  2 colleagues within my own team have found new jobs and will be gone by summer, a third has an interview at the end of next week. We all check the job adverts weekly or even more regularly. The GPs that are currently sorting themselves into consortia are beginning to worry that even if they have the management budget to pay people there may be insufficient useful people around to employ within the new system (that is if they actually employ them since it is now rumoured that there will be some kind of commissioning hub).

I might be a PCT employee but I am not daft. Greater GP engagement and accountability in commissioning would be welcome. Less of a head count in the PCT was desirable and probably necessary. Perhaps public health might be better placed in local authority. But it actually didn’t need to be as nasty as this.

What next? Maybe little will change? Maybe progress will slow? The damage is already done though. We have been tarred as useless managers who do little for the actual patient. When actually I believe we have the potential to do much that is good. We wait and we will see!

Celebrating 30 years

Last Saturday I enjoyed a great lunch with some of the ‘girls’ I trained with. Just over 30 years ago in October 1980 28 of us arrived at John Astor House to start our careers in Nursing and in the NHS. Some of us never made it past the first year, but 24 qualified in 1983. This was only the 3rd time we have managed to get together in all of these years, though of course various of us have met up with each other at various times and some remain firm friends. What is more at this event there were just 9 of us, what with family commitments and the distance of oceans. What was gratifying was that of that 9, 8 are still working for the NHS and 8 are working clinically. I was the only one of the group not in daily contact with patients.

30 years is a long time, but strangely as we chatted over our wonderful lunch a stones throw from where the hospital we trained in used to lie, the years slipped away and we remembered days and nights on the various wards, nights out together and the amazing responsibility we were given at such a young age. We agreed that our training had been a good one, and it had prepared us well both for our careers and for life in general. We also agreed that some of the changes within our profession had not been for the best. We also wondered about the impending change; apparently for changes sake.

Ben Goldacre today in the Guardian (and on his Bad Science blog) says that there have been 15 NHS reorganisations in the last 30 years, this means that we have lived through each one. Some of those will have passed us by, after all, when you are busy working clinically, caring for patients you can often continue to provide that care as the world seems to move around you. This was the case for me until about 10 years ago just as I prepared to move into a managerial position. My employer merged with another and a number of managerial changes took place. This was around the same time as the PCTs were formed and that was where I headed for.

I left clinical practice at that time because I was weary. My job was a struggle as my patients needed access to new medications but these were expensive and they and we seemed to be fighting unendingly for them. The work was hard and I seemed to be allowed to expand my practice to take on an unending number of tasks. Fearing burn out I thought a job in education within the new PCTs would allow some relief and what is more it would mean I could make a greater difference to more people.

Clinical work, and for me, nursing remains amazingly important work. In some ways I would like to return to it, but in what capacity. Generally my student colleagues work part time and have husbands earning far greater wages than I do. If I return to practice I will have to take a pay cut, and essentially I am not sure I can afford to do this. I also don’t really know what nursing job I would want to do, or if my body would stand up to the pressure required of it.

I also happen to think that it is important to have people who have worked as nurses and to whom nursing and the care of the patient is important, working within management. When politicians belittle those of us working in PCTs they appear not to know or care about this and apparently think that we were born in a pen pushing role and have little or nothing to contribute. What is more, they don’t seem to value nurses in the same way as doctors and GPs at that. I wonder if they will yet receive the awakening they need before it is too late!

What to do next

There is no getting away from the fact that while I am online most nights, browsing facebook and generally stalking my own family I am a very lazy blogger. This is not because I have nothing to say, indeed some of what I might say could be reasonably interesting to more than just myself. It is just that often I don’t even think of it and when I do I worry about saying the wrong kind of stuff and getting discovered by the PCT higher management. I have just been reading some blog posts by other healthcare bloggers and getting discovered by your hierarchy seems to be a common fear and apparent reality to quite a few. One good thing about the demise of the PCTs might be that gradually those who might discover you drift away as people ‘move on’ to bigger and better things and have other people to consider.

It has been 3 months since the Health White Paper and in that time people have started to leave. So far we have ‘lost’ our Chief Executive and 2 other directors, as well as a variety of other senior management types. When your organisation has a limited life as ours does it is not the thing to recruit / replace people, especially when you are looking to save money. Oh no you just spread the work of the departed among those who are left. This suggests that by the end a few low paid workers could be doing everything, still at least someone will be able to switch off the lights on the way out.

Work is now underway to help the GP consortia’s as they form to be able to take on the work, and with it the employees who might assist them in the future running of the NHS. Nothing is yet clearly known about what it to be involved as there is as yet no health bill but the clock is ticking and I am sure we won’t have long to wait. The work I do will apparently be part of the new national commissioning board, but how this will work and who might be employed by whom and where is not known. What is becoming clear though is the way in which further money will be saved by paying staff as little as possible.  My pay is still protected from the previous reorganisation, and if I stay as I am in March 2012 (just before the PCT ceases to exist)  my pay will drop back to the lower level and I will lose £350 per month. In the new world however, I won’t be able to apply for a job with a pay band above that new lower level (this has been decided by very senior managers at the SHA, who will also need new jobs). This means that I need to consider moving jobs before these rules kick in.

While I am still reasonably happy doing my current job, it probably is time for a change, but there are really very few jobs around. There is no point moving to another PCT (for obvious reasons) and suitable jobs in other Trusts seem far and few between. This is because despite what we are told about health budgets being maintained, every health organisation has savings to make plus with so many people looking for work there are many more people that there are opportunities. That is not to say I am not looking and that when the right thing appears I won’t apply for something new, because I will. I am pretty nervous though; who wouldn’t be?



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