Caz Sayer: How are financial pressures affecting patient care?

Thank you very much indeed. So just wanted to introduce myself, I’ve been a local GP for the last thirty years and I’ve led the Camden CCG for the last six years and I’m really grateful to be given the invitation to respond to what I think is an excellent and timely report which will resonate with all CCGs who after all their overarching duty as a statutory body is the commissioning of high quality, safe, sustainable services for their population within a fixed financial envelope.

I think for clinical commissions it is this link between reduced spend and the potential impact on quality, safety and outcomes that causes the greatest concern, and that’s particularly when you think that for all CCGs, that operating and they face flat or minimal uplift allocations.

The requirement on individual CCGs to support other locally and nationally challenged commissioners and providers and also the challenges that arise from cuts to the Local Authority, to Social Care and also to Public Health Funds, and it’s against this and I think it is really applicable to the struggle facing all CCGs but I think that what this report probably suggests is the following.

That within elective care hospital care seems to be coping well but it could be argued that this is due to the fact that money identified in the five year forward few designed to be invested in community services has actually been used to maintain performance in acute trusts.

That forward genitourinary medicine, the report shows the tensions between financing preventative health and the other commitments that local authorities have in a financially challenging environment and within very complex commissioning arrangements and accountability, and suggests that the incidents of sexually transmitted infections is increasing with less effective service provision.

To me it also powerfully demonstrates the vulnerability of longer term investments into prevention and the wider determinants of health in a financially challenged environment. And finally the five year forward view has set out a vision and plan to transfer care for the appropriate populations from hospital to community, but this report which focuses particularly on district nursing as a barometer for the resilience of the community suggests that it’s failing, because much of the money that was earmarked has instead been used to support acute trusts.  And this is happening despite the significant shift of work and it’s not just the quantity of work that’s shifted, it’s also the acuity of the kind of work that has shifted into the community and I think that needs to be considered against the quite eye watering amount of further shift that most STPs identify with very little investments in terms of the shift to community care.

So in Camden, where I come from, unlike many other CCGs we’ve been well resourced until now and we’ve been able to take the opportunity to develop new integrated services as proof of concept, and those examples have included things such as the complex and frail elderly services, which uses a care planning multidisciplinary approach and has significantly reduced hospital admissions and bed days.

A diabetes community service that’s improved identification and management of people with diabetes and provided them with support to self-manage which measurably improves the patient reported outcome measures and reduced hospital usage, and a service which we call Mind the Gap which is a longer term investment into a transition service for 16 to 25 year olds which aims to break the link of poor lifetime health outcomes associated with early mental health problems through a preventative and planned approach.

In each case better care planning, less reliance on emergency care, less duplication and fragmentation, integration of health and mental health services and health and social care and better use of community and individual resilience supported by an integrated clinical record across health and social care have all improved patient experience and reduced costs. This is not kinds of salami slicing which I heard Clare describe.

Critical to redesigning services is understanding the needs of different segments of the population and planning and designing services appropriate to drive what we term value, outcomes per pound spent.

We’ve also recognised the need to find different ways to measure and standardise what has previously been less visible community performance and to ensure that those being treated in the community who are often the most vulnerable and least articulate consumers with limited political voice are heard.

We’ve published data in the New England Journal of Medicine and Catalyst to show that his approach can improve outcomes and reduce costs. Across a whole system, moving the CCG in Camden to an upper decile performance against peers, but it requires significant investment and that investment, as Ruth pointed out, is not just money, it’s particularly the workforce and the people, which no CCGs now have, and it needs to be investments into under resourced parts of the health and social care system to achieve it.  Without additional resource it will not be possible to upscale this type of work at pace.

In summary, I think the report is a stark reminder of the current challenges and a link between reduced financial resource and the impact on patient care, and one which will strongly resonate with the challenges facing CCGs.

We can stay with the status quo, continue to invest in acute performance for now, but recognise that the cost will eventually mean that we must arbitrarily stop doing or limit services as described, or allow patient outcomes to deteriorate or both, or I believe we can take an approach, driven by population and health data, moving to improve outcomes and reduce costs through delivery of more effective and efficient services in the right setting. Redesigning services around the needs of specific population segments but only if the investment required is targeted to this urgently before irreparable damage is done to community services, including general practice, leading to loss of confidence and credibility by patients and professionals in the provision of out of hospital care.

Thank you.