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As she battles to balance the books, Louise Patten, a registered nurse and Chief Officer of Aylesbury Vale CCG, on the need for transparency across the health system:
It’s payday again, so I pop down to my local secondary care provider and follow the ‘Pay Here’ signs.
I note the monthly amount I have to pay looks like a telephone number and mentally count the groups of three digits to ensure the millions are right before I pass over the CCG debit card. While the hospital trust’s finance officer waits for my card to be authorised (phew, just about enough money, but it’s tight) I ponder on whether my CCG population would consider the commissioned services value for money.
My Aylesbury Vale CCG population has more unplanned admissions to hospital than we have money to pay for; people would rather be at home being supported to be independent but we can’t get the breathing space to put the services in place that would help them help us. Because our activity is over plan, I have to find more funds to meet payment required, so I raid all the CCG coffers including the one that had been inspirationally labelled ‘development ‘. Bang goes any idea of transformation and off we go around the mill-wheel that continually throws water on the overheated acute system.
The latest planning guidance enhances thinking about the longer term. Our ‘unit of planning’ across Buckinghamshire is developing a five-year strategic and two-year operational plan that’s aligned to our Health & Wellbeing and CCG strategies.
Work is well under way; as lead contractor for our local healthcare trust I have a small team of individuals permanently stooped over spreadsheets, eyes all over the labyrinth of cells within the returns. Their biggest challenge is how to describe our clinical leaders’ qualitative plans as quantitative realities.
Our local health and social care leaders have a collective understanding that the only solution is a whole system integrated care model. In our localities the patients, carers, health & social services and voluntary groups are describing what this will look like for their communities. This varies, as some areas are rural with much loved community hospitals, while another has the acute provider on the patch.
Developing a bottom-up plan that acknowledges local populations encourages involvement and a feeling of ownership, making it slightly easier to develop conversations around our Call to Action challenges.
We are all aware that good planning means true alignment across commissioner and provider strategies, with shared incentives based upon outcomes for patients and local populations. However, the fragmentation of secondary, specialist and direct commissioning means that a much greater proportion of my CCG budget is taken up by secondary care activity.
I have nowhere else to turn in order to make economies. Locally, we have no easy picking areas to choose from – all our care is ‘must do’ for patients; the next steps will have to be significant reductions through a more upstream approach in primary care.
At this point, the elephant in the room becomes apparent. If we are to make significant shifts in activity, then we need to do it in a way that enables our providers to reduce cost. While some of this is obvious, for example we accept that all services cannot be provided from all sites (still need to win the hearts of our patients on this issue) we need a clearer idea of where each part of our system makes money and where it maintains a loss making service.
In order to support high quality service delivery through a balanced health and social care economy, we need to achieve a level of transparency about commissioners’ and providers’ profits and losses in order to set our plans for future service delivery.
Once we are more sighted on this, we can work our system design and align timescales for transformation that take cost out at the same time as establishing new out of hospital services.
In Buckinghamshire we are just starting on this path of transparency, but the culture of commissioner provider split is, as elsewhere, embedded and we are all aware this will be an interesting challenge in the months ahead.
I awake from my pondering as I remove my CCG debit card, having paid my bill. As I put the card away until next month, I turn to look at healthcare beyond the hospital boundaries; 21 GP member practices, beavering away seeing 90 per cent of the total healthcare activity across the CCG.
If I called them all up and promised to shift 25 per cent of my secondary care spend to primary care in six months’ time, would they be organised and ready?