There is no doubt that attendance in emergency / unplanned care has increased, but why? The analysis we are given doesn’t tell us about when people attend, but in trying to answer the question, they point to changes in GP out of hours services. That suggests that there are no problems with the availability of GP services ‘in hours’. However, when a new Urgent Care Centre was opened in this County, it was discovered that faced with the chance to attend and be seen immediately rather than wait for an appointment at some of the less well run GP practices, people chose the former. It wasn’t all about out of hours services at all.

The lack of ownership by GPs in out of hours care is also blamed, but many out of hours services are literally owned by GPs as well as provided by them (it just isn’t obvious since they are contracted out). Of course, if you contact these services you are unlikely to see your own GP, therefore you might as well go to an urgent care facility. When you get there though, you might find yourself triaged into a GP service, where the same doctors providing out of hours care are also based. Funny how that isn’t mentioned.

Patients and their individual needs, are quite rightly being recognised as central to health provision. But with that recognition comes the realisation that people will use those services in the way that feels right for them. That might mean accessing emergency care for things that they perceive as needing attention now, even if those providing the care don’t think that is what is needed. If you feel you need to see a health professional and you know you have to plan to need it to attend your own GP surgery what will you do? Probably access a place you know is always ready to take you.

Then there are the telephone advice services – first NHS Direct and now 111. In deciding to change the focus of these services, a decision was made to completely dismantle the former in order to start up the latter. As NHS Direct ran down, then more people were referred to A&E. Everyone knows that assessment and triage of the patient are the most important parts of deciding what is wrong with someone, who is best placed to help them and what should be done. The more experienced the person doing this is (on the phone or in person), then the more effectively that problem will be dealt with. It stands to reason then that if you get rid of qualified staff before the new system is in place you are asking for problems.

Finally something that no one has mentioned. Children are some of the biggest users of emergency care. They become ill quickly, in an unplanned way. Parents rightly worry that they need attention right now and take them to A&E. We know that the birth rate has been rising steeply, we know school places are under massive pressure. I wonder if some of the increase in attendance relates to the increased number of under 5′s?

Like most issues in healthcare, this is complex. I doubt there is no easy answer nor a single cause. The propensity of politicians to blame in turn the previous government or GPs is simplistic and plainly wrong!

I have begun to consider what work I would rather do in the future and on balance, while I am unlikely to find my way back to a bedside any day soon (my back has been playing up something chronic), I would like to work closer to the patient and hopefully with some nurses. A week ago I helped out at a training session for community staff, something that I have contributed to a number of times. It didn’t take longer than coffee time to dust off my brain, and I know that I could and would like to do more of that. I also stepped up and sorted out a presentation for an ex boss last week, banking a few hours of self employed work (there is more to come). Plus there is a job in the pipeline which I intend to apply for, but which I am waiting for the advert to appear.

Yesterday though, I went of my own free will, unpaid to a nurses day celebration and I am glad I did. It filled me with an enthusiasm for nursing and the NHS that I have not felt for a while. So much has been written and said about the state of the health service, about whether nurses have forgotten the purpose of providing care, forgotten perhaps how to care.

It is easy to buy into the idea that nurses who are out there now are in some way inferior to the way they once were. The concept that they have in some way lost their vocation and that they lack the compassion to deliver the best that they can. It is easy to believe that nursing leaders are lacking in some way, that they are not committed to ensuring that they set the vision, to inspire and support their workforce.

The conference took place at a local university, run jointly between acute, community and mental health Trusts. Present were all of the nurse leaders from those Trusts as well as in excess of 100 nurses from across the area. The purpose was to celebrate nursing locally and nationally, to inspire and to inform. It did just that. The keynote speakers, one from the chief nurse and the other from someone who has achieved so much despite and because of his disability were great to hear. But equally the quality of presentations from local nurses was of equal quality. It made me proud that I am still a nurse and it inspired me to get back to work soon. I want to work with these people, to be able to support their ability to overcome the negativity and continue the great work they do. To recognise the complexities of modern healthcare and to show people that compassion still exists in nursing. To celebrate nursing.

Near the end of the day, we were shown this youtube clip. I think it tells us what we need to know about the future.

A few weeks before my redundancy I received one of many letters from HR, this time offering not just redundancy, but a choice of that or taking one of two pension packages. I was surprised, despite still being in the 1995 pension scheme, and having paid in for over 30 years, I was (and still am) only 50. I sought financial advice and decided to take the maximum pension lump sum, a monthly pension and a small redundancy payment. I duly completed the forms and sent them in to payroll. Yesterday, more than 4 weeks later, I contacted NHS pensions to discover that my employers did not submit the online application to them until 2nd April and secondly that it takes up to 3 months to process a claim. Employers are meant to ensure that employees apply with 3 months notice.

Of course my employer would have preferred not to make me redundant, therefore they were late to give me any notice at all, and until about a week before they acted as if a magic job might appear on the horizon for me and my colleagues. Therefore everything was completed at the last minute, or in my case beyond that date.

Thankfully I have some money to ensure that we don’t starve before July, NHS pensions say that any payments will be backdated, but really that is not the point. This is really just about the way I have been treated from the moment it became apparent in around November that this wouldn’t be a smooth process. Consultation processes were not completed as they should have been, interview processes seemed at the best odd and then there was the whole ‘at risk’ situation and the feeling that you could be shoved into any job. One day, someone approached me and offered me a job in IT on a lower salary and for fewer hours than I was at the time contracted to work. Suitable alternative employment it was not.

I was not obstructive, I did as I needed to do and applied for no end of jobs. Jobs that I could see myself doing. I had been in this kind of position before and wanted to come out of it with my career and reputation in tact. That slightly went wrong and I am required to be compensated for that. I am annoyed that yet again the process has let me down! I am also annoyed that I can’t get my kitchen refitted yet, and that by the time I do I fully expect to be back in work (more about that when things are confirmed).

End of rant!

Redirecting services to new places, shifting care into a community setting requires the will to do so, and it requires people to be willing to shift their working practices. It requires the accommodation for clinics to take place, it requires inpatient facilities if that is what is needed or a great many community staff if care is to be provided in the home. Each time there is a suggestion that hospital services are cut back, changed or heaven forbid closed, there is an outcry within the local community and the political leaders of that area. It is hard for people to imagine the change that needs to happen to allow services to move. It is hard to see how taking the money away from one place can in turn be utilised elsewhere. Often the amount of money released might be insufficient to set up something new somewhere else.

There is also the issue of people’s attitude to healthcare, the days when everyone accepted ill-health as an inevitable outcome of life and expected to die in their 70′s has quite rightly gone. But now people expect the best and most high-tech input, they expect to have access to   specialist services and they expect it as soon as possible.

I am at heart a district nurse, so my instinct is that patients should be cared for in their homes or close to them, where possible. But I have witnessed failed attempts to persuade people that is exactly what they want or need. Yesterday, I drove past my local hospital. Currently its A&E and acute services are being expanded, pretty much rebuilt. This is partly due to the downgrading of services at another hospital. But it is also because people are using acute services much more. They are bypassing primary and community services and turning up at the Emergency room. This increase in unplanned care has been going on for a few years. the way Trusts are funded contributes to this increase, since being paid for each time a patient attends increases their income. Commissioners can try to cap this activity, but no one seems yet to have informed the patients.

In my two most recent jobs, I have learned that if you want to find out what people using your services think then you need to ask them. If you want to develop the best services, you need to work with patients in developing them and if you want to change policy you should actually consider what real people think about it. If the CCGs would like to significantly change the face of healthcare provision then they will need to weather a serious political storm (previously endured by managers) and the views of the people who will use those services.

Of course, I have not spent the week being idle, that really isn’t me. Nor have I yet worked out how to sleep in past about 7am, perhaps that is healthy since I am not finished with work by any stretch of the imagination. The first thing I did last Friday was to buy myself a new laptop; a MacBook to be exact. I am now converted to Apple, last year I got my first iPhone, for Christmas an iPad and now I have the full set. I had to get some kind of computer since my previous laptop died a few weeks ago and I had been using my work one. That and my Blackberry were returned last week. So now I have just one phone rather than two, and I am getting myself set up for some home working.

I have watched the news coverage of the NHS changes with a kind of detached interest this week. All of a sudden the news channels and papers other than the Guardian work up to some of the issues of the new NHS. Things like the conflict of interest that GPs have faced for years, but are only just being challenged about. Like the fact that many of them have shares in the companies that they commission to provide services. Then there is the role of the NHS Commissioning Board, now renamed NHS England (we did laugh last week when colleagues who have jobs with them discovered the rebrand). How will this highly centralised organisation carry out the job of performance managing the CCGs? Nothing has yet been said about the Commissioning Support Units and the duplication that their existence will surely bring about. Or about the fact that most of the hated managers still retain places within the CCGs, often they are the accountable officer rather than a GP. No one has yet asked, who is really in charge here? Does the balance of power really lie with clinicians or does it lie in Leeds and their various Local Teams. All of these questions will no doubt be asked in the future.

For me, well my week has been filled, as promised with some reading, some retail therapy, some resting up and pottering around the house. I have made a start on sorting the spare room, but need to replace the chest of drawers in there with a desk. I need to buy a printer as my lovely son has claimed the family one and it currently resides in a house in a university town. I have seen my financial advisor about investing my lump sum, but NHS pension hasn’t produced any actual money yet so there isn’t actually anything to invest. The PCT was late in offering me this option and therefore the forms were completed at the last-minute. The lady in payroll who deals with pensions told me on Tuesday that they had been very tricky to work with. I have updated my CV with the final bits that say that my job ended in March 2013 and I have updated my Linkedin profile with the same. I have arranged my first bit of paid work for next month and am expecting to hear about some more work in the next week or so. I need to complete an application to NHS professionals for another piece of work and I need to send my CV out to a few people. Work then for next week!

So at the end of week one, I feel a little more alert, a little more rested and a little more ready to face whatever is ahead.

Usually, I find myself rushing around, doing a bit of this and a bit of that. Rushing to complete things over the weekend or during a few days off. I am aware that this is different. I no longer need to rush anywhere, to complete everything in double quick time. I am also aware that I do feel weary as I said above.

I need to spend some time right now reflecting on what has happened, thinking about the process that I was involved in. A process that started with me feeling incredibly hopeful that I would get a job and a good one at that and ended with me being made redundant. I hope to use this blog to help in that process. I have been a poor blogger for a couple of years now. Firstly it was because I was unhappy in my commissioning job, then too busy in my new cancer network job and then because I feared saying something which could ultimately get me into trouble with my employers.

This morning, there is lots on the news programmes about the various changes that have come into force in both the NHS, in welfare and in local government. I feel I should be able to say some profound things about all of this, today, indeed right now. But actually I don’t think I can.

I am going to take a few days. I am going to read a book or two. I am going to get back to reading  some of the blogs around and about, and update my blogroll here. I am going to start sorting out the spare room and I am going to look around the shops. After all a girl is entitled to retail therapy when she has been made redundant!

Then in a few days, as my brain and my mind begins to clear I will write about the past and about the future. I will talk generally about my take on how things are in the NHS and also about my role in it (if I am to have one). I am not meant to work for the NHS for a month. I don’t think that will be a problem for me.

My first day has started a bit strangely. I was happily blogging, sitting up in bed when the phone rang. My son who went off to visit and stay with friends yesterday called to say he was on the train and could I pick him up shortly. I found myself scraping the ice off my car at 7.30am; not the way I expected to start my first day of freedom!

But because of my age (over 50) and the fact that I joined the pension scheme such a long time ago, I have actually technically retired. From now on, I will be receiving my pension. In reality this means the salary I need to earn through paid work is much smaller than it was. I will be able to take on projects or a longer term job, part time.

For the next few weeks though, I intend to take stock. To have a rest and to sort things out at home. I intend to meet friends for lunch, to take a trip or two and to plan a new kitchen. 

I will have lots of time to write and I intend to pick up this blog again and to write lots about what has been happening. I took the decision over the past few months not to write here. The process has been painful and unpleasant. I was fearful of writing things here that might be best left unsaid while I was still unemployed. Now I will be able to say a little more and give a bit more of my opinion.

I don’t know if I will keep the title ‘Life in the NHS’ for this blog. I am not going to worry about that yet. There is more than ever to write about the NHS and the mess that is being created in the name of progress and of change. There is even more to be written about the way nursing is being described and evaluated in 2013. There are things to be said about compassion and the way we treat people in this country, not just in the NHS. There are things to be said about the politics of health generally. 

I have lots to say still. This time my return will be on a more permanent basis!

Things in the job market have not gone as well as I would have liked, and the early optimism I had on finding I knew my new potential Network boss, turned to bitter reality. The process has been particularly bad this time. But the first interview I was mainly under prepared. i think I believed I would be given a job with little effort. I wouldn’t have appointed myself, though even then the process was odd and we were told to reapply and answer questions differently next time. Many applications and 2 interviews followed, and I definitely equipped myself well (so I was told) but to no avail.

so redundancy beckons. With it will come opportunities to get debt paid, things done at home etc. also though lots opportunities to work as a contractor so all will, hopefully be we’ll.vat last I will be able to write with freedom. But I will need to change the name of the blog!

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!

Most of the NHS Trusts (providers) have specific Patient and Public Involvement committees and groups, but these are not specific to a single condition or disease. Maternity is definitely different from the mainstream, given that in the main pregnant women are not ill and are not patients as such. Cancer (rightly or wrongly) also considers itself to be different with unique needs.  Peer review measures for User Involvement require us to have a User Partnership within the Cancer Network, laying down a number of ‘measures’ relating to both the experience of patients and the involvement of service users and carers in services.

The new NHS throws all that we know about this kind of service (or disease) specific involvement will take place. I have had the pleasure of working with some amazing people in both areas over the years. They work hard, give up so much of their own time, often in conjunction with running their own busy lives. Sometimes in the case of my current user colleagues, they continue to manage the after effects of cancer or to battle recurrences of ill-health. They are not surprisingly a little anxious of what will become of their efforts once PCTs (who have been statutory expected to manage Maternity Services Liaison Groups) have been abolished and Cancer Networks have been subsumed into Strategic Clinical Networks.

Will the clinical networks be able to support real patient involvement within the entirety of their portfolio (cancer, maternity, children, mental health, stroke etc etc). Or will it be left to the NHS Trust, CCG and other more general Public and Patient Involvement groups to pick up the mantle. Will the stalwarts of maternity and cancer involvement join in with them, will some of them who are part of the Links mechanism become part of the Health and Well being Boards. Does it matter if this is about general patient experience and involvement or should their be something special for specific groups. Or will we lose something from all of this and will some of those committed individuals walk away. From some of what I have heard, many are disgruntled and hurt that the work they have done so far will apparently be lost, and they might just.