Claire Fuller: 2018 - A crunch year for the NHS?

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  • Posted:Tuesday 05 December 2017

Following the Chancellor's Autumn Budget 2017 announcement, Dr Claire Fuller, Senior Responsible Officer, Surrey Heartlands Devolved Care System, discusses the prospects for the NHS in what promises to be one of the toughest years in its history.

This presentation was recorded at a breakfast event at The King's Fund on 5 December 2017. 


Good morning everybody.  I’m Claire Fuller, I’m a GP in Surrey and I have now moved from being the clinical chair at Surrey Downs to being the senior responsible office for Surrey Heartlands Devolved Care System, so STP.  So Surrey Heartlands, we have a population of 850,000, combined budget of £1.3 billion and consist of partnership of ten organisations that sit around our transformation board.  If you talk to anybody from Surry Heartlands for longer than five minutes, we will start to tell you about our three distinguishing features from the three other STP footprints, and they are: clinical leadership and our clinical academy which is how we are tackling our more variation standardising care across our footprint, spreading best practice and making sure innovation is involved in all of our pathways.  We are also known for our citizen engagement.  We’ve come about citizen engagement in a slightly different way, partly I think due to the close working we have with Surrey County Council, and have recruited a panel of 3,000 citizens that match exactly our demographics.  So in Surrey, as you would imagine, we have a number of articulate people who are very good at getting their points of view heard and so we have gone out and deliberately made sure we are in touch with all of our demographics including the hard to reach group and are using them as a virtual panel to test prioritisation and test questions on our work so currently there are questions going out from our mental health workstream on the priorities and the work that’s going on there. 

And we’re also recruiting in conjunction with Health Watch 20 Citizen Ambassadors that they wanted to call Naked Citizens but thankfully we managed to move from that and they’re now Citizen Ambassadors and they will be embedded within all of our workstreams.  

And then possibly the most pertinent difference for today is our close working and leadership from our local authority and David McNaulty who until recently was the chief exec at Surrey County Council has always been the chair of our transformation board and then in June we signed a devolution agreement with NHSE and NHSI.  

So Chris asked me to reflect a little bit on the autumn statement from an STP point of view.  So I live in a land of low expectations and low expectations were met in terms of no social care, no increased taxation around the prevention agenda, so alcohol is an issue in Surrey and one of our main areas of work is actually improving use of alcohol and reducing admissions related to alcohol.  However, delighted and pleased really to see the capital funding and particular,.. we have at St Helier, with the Epsom site of Epsom St Helier within our patch and just really to reiterate this is not about gutters and downpipes, there is significant maintenance that’s needed to be done.  So Epsom St Helier is one of the top six most needed acute trusts in the country and there are areas at St Helier, you’ve got tarpaulins over the A&E.  You’ve got stroke patients from the Epsom site that to get from A&E to the stroke ward you have to take them with umbrellas to protect the patients.  This is significant maintenance, it’s not just the tinkering round the edges, but also very pleased to see the commitment to capital transformation funding so that we can actually go on and start to look at our new models and different ways of working. 

So pleased to see the funding for winter, although anxious that it’s now December and we haven’t got it yet.  The distribution of funds seems to again be on the usual quick turnaround, sort of 48 hours to get your plans in.  So my fear again is that this will be dominated by acute trusts rather than having the funding spread across the entire system.  So we’ve tried to tackle winter slightly differently this year in Surrey Heartlands.  We’ve had weekly senior, so CEO and COO level calls across all ten providers and have managed to, for the first time actually agree agency caps and locum spends as a collective as previously a number of organisations have been disadvantaged by unilateral decisions and we’ve also managed to prioritise resource going into general practice, into social care and into community services rather than focussing purely on acute trusts in terms of delivering the four hour wait over Christmas. 

So although the funding is welcome, I think it’s clearly acknowledged it’s not enough to meet the need that we have and it’s good to see that we’ve started having a number of the difficult conversations in public, so I’d very much like to applaud and thank NHS clinical commissioners for the work they’ve done on the low value medicines.  This has worked previously that CCGs have done individually so we’ve had more than 200 conversations going on, each with slightly different remits and coming up with slightly different answers, so it’s really refreshing to actually have centralised involvement in this and standardisation.  So I would say, please can we now move on and start looking at the procedures of low clinical effectiveness and also procedures not routinely funded, and can we do this once not 200 or at best 44 times.  

So my new job is I’m the senior responsible officer for Surry Heartlands and as part of that I’m accountable really for the delivery of the five year forward view, and we all talk about and we are all very familiar with the three gaps.  We spend a lot of time talking about the finance efficiency gap and the care and quality gap and we’ve got some really excellent work from girth from Right Care, from model hospitals and Lord Carter’s excellent work.  One of the things that we’ve got in the south is actually Ann Eden has been made our south east regional director covering both NHSE and NHSI and this has made an enormous difference, actually more than I even thought was possible, in actually the alignment of regulators and having a single point of contact for us to go to.  My plea really around the very excellent efficiency programmes is, and I’m pleased that obviously the programmes are being embedded with the regions which is helpful, we need one person to go to.  We need to have any efficiency programmes rather than having our Right Care delivery partner and our girthed person and then somebody else on modern data and we need to share this data so we’ve all got it.  

The third gap is the one that I think in my current role I’d previously under estimated but now really feel is the most important.  It’s the health and wellbeing gap.  And the only way that actually we can stop the demand and can actually, we will be back here next winter saying how we’re going to deliver winter, we haven’t got enough money, the only way we can change that conversation is actually starting to address the demand and if you’ll forgive the somewhat heavy-handed analogy, it’s starting to turn the tap off rather than continuously mopping the floor.  So I have a number of favourite facts at the moment that I’m just going to share with you.  

So, no matter how efficient and inclusive we are as health on our own, we can only ever improve the health outcomes for our patients and our population by 20%.  If you enter school at the age of 4 with an inequality that gap will never close and the best indicator for entering school with an inequality is your mother’s mental health at the age of 14.  So we must invest in mental health for our young people.  We must invent imprevention and we must be including partners beyond health and social care to truly make sure we are involving and using the wider determinates of health.  So we must be talking to housing and we must be talking to education and that’s why we’re a devolved care system rather than accountable care system.  We must be meeting and talking and sharing priorities with our wider partners.  

So my last to end is really a plea into the ether.  Please allow us to identify the longer term needs of our population and allow us to work out the staffing and funding required to deliver the change and please allow us to plan for longer than one political cycle to enable us to bring about the generational change that’s required.