Making health services in Northumberland fit for the future - health chiefs on ongoing challenges and looking ahead

The most obvious way that most people interact with the healthcare system is through primary care – most likely their GP practice – and it is experiencing plenty of pressure and having to make changes to cope.

One of the ways this is being done is through the creation of Primary Care Networks, of which six have been created so far in Northumberland under the auspices of the Clinical Commissioning Group (CCG), which plans and buys healthcare.

Dr Graham Syers, the CCG’s clinical director of primary care, said: “I think that any effective health system has to be underpinned by really strong primary care and traditionally when we think about primary care, we think about general practice and general practitioners.

“There is a challenge at present that there haven’t been enough general practitioners trained and what we consider that more traditional model of general practice has become more difficult. Plus we do hear a lot about the workload, GPs retiring early and GPs not wanting to work full-time.

“Anything we do as a CCG has to go back to the basics and say what can we do to support good primary care.

“In my mind, there’s what patients need in terms of continuity; if you’ve got complex problems, you really need someone who understands your problems and you can have access to the same person whenever possible.

“The other challenge is we have people who actually need to be seen quickly, they don’t really mind who they see, so you’ve got to design a system or support a system that can be those things to the people that need it.

“Primary Care Networks are one of the newest ways of trying to get a community among GPs.

“GPs have tended to work in isolated practices and done their own thing for their own group of patients and, looking to the future, it seems that carrying on doing that is going to be more difficult and practices need to share what they do and support each other.

“Some practices have already taken action in doing that, so you see practices merging, because they see strength in numbers, or working more closely together, sharing back-office functions, sharing staff.

“What the Primary Care Networks do is create a structure that is a little bit more formal and allows a route for the CCG to engage with those practices in a little bit more meaningful way.”

One of the main issues they may help to address, particularly in a large, rural county like Northumberland, is the shortage of GPs.

Dr John Warrington, the CCG’s director of planned care, said: “There is no doubt about it, there’s a national GP recruitment issue.

“I know of practices that have had job recruitment adverts out for seven or eight months without a single applicant.

“This is a serious, serious issue when colleagues are retiring early or leaving the profession due to stress, which is happening nationally – this is a real thing.

“So, necessarily, we are having to look for colleagues who are not GPs to come and do the work. Primary Care Networks are allowing us to do that and providing the funding for it too.

“So we’re going to see, instead of a GP sat in a surgery, there may be a senior physiotherapist sitting there, a pharmacist, we’re going to see social prescribers and also mental-health workers.

“We need to be frank, these are in lieu of GPs, because you can’t get them, but you need to look at this positively, because these are experts too.”

Social prescribing and realistic medicine

And this all ties in with wider concepts about the best ways to improve health and wellbeing, and how we look after ourselves; newer buzzwords such as social prescribing and realistic medicine.

Dr Syers said: “What we know about social prescribing is that anything that we can do that helps the wellbeing of a patient is likely to reduce their health needs.

“In the traditional model, the GP would have been there as someone to talk to, but when there’s not enough of us and there are more complex problems around, it’s about finding someone who has the skill-set to provide company to a patient, to get them out of the house.

“There’s some really interesting schemes – Knit and Natter would be one example where patients who are anxious or sad get to have a bit of company and if the GP surgeries or whatever network around the surgeries allows you to divert people into that kind of activity, it takes pressure off the health system – and local-authority services to a degree.

“If you can do that in partnership with some of the voluntary services, that’s even better. Primary Care Networks are that hub for voluntary services to start to structure some of what they do around health.”

He added: “It’s about trying to get time with individuals. As a patient, the one thing they will often say is thank you for your time.

“If we can have a system where somebody can give people time and if we accept that that person doesn’t have to be a doctor, because they’re a scarce resource, then when you give people time, you can start to find out what it is that they actually want from life or expect.

“What a lot of them will say is I don’t really want to go to the acute hospital and have drips put in me or if you have time to care for people in care homes, those conversations lead people to say, if you can find some other options to look after me where I am, I don’t want to have those investigations, I don’t want to end up on a hospital ward.

“But often the path of least resistance is to take that person to somewhere where it’s perceived they would be safe and most people perceive the safest place to be as the big accident and emergency department or in the hospital and that’s probably wrong.

“They’re probably safer in their own homes if we’ve got the time to discuss why that would be and put the services in to keep them there.

“That’s what realistic medicine is – talking to people. Do you really want this CT scan that’s going to find lots of things wrong with you at the age of 92? That’s quite contentious in some respects.”

Communicating the changes

These concepts can be contentious not just for patients, but also for other doctors, who may challenge the CCG on changes being made to services.

As part of the CCG’s journey back from special measures to being rated good, it employed more clinicians to come and work with the organisation, while beefing up its governing body.

Dr Syers says that as well as having these clinical leaders, they also need to have the right skills to explain what is happening and why.

“In a nutshell, for half of the week Graham and I are caring for the person sat in front of us, but for the other half we are looking after the health needs of 320,000 people and treating everyone the same,” Dr Warrington added.

However, the CCG does accept that it may not have been as good at communicating with the public as it should, particularly during a time of change.

Chief operating officer Siobhan Brown said: “I want to be honest on this journey and there’s no doubt there’s a lot of learning for us, I would say particularly around engagement.

“In the press, there’s been quite a lot around the new JMAPS service, Rothbury, Berwick, the Whalton Unit and we’re really learning about how to engage and have those processes as effective as possible and be as open to scrutiny as possible.

“That’s a challenge because things will change and we have to make sure it’s based on the absolute best evidence we’ve got and they’re right for those unique communities.

“We are in a really high-performing system, thank goodness, loads of our providers have outstanding ratings and our primary care is 19th out of 195 in the country for its CQC rating, which is brilliant, but some of our health outcomes are really poor – the difference in life expectancy for men is about nine years across our populations.

“Those are the areas we need to get to and they’re the next steps of our journey in terms of reducing those variations and really having healthy life expectancy for people.”

This will be far easier now that the CCG has started to get back to a more even keel in terms of its finances, but it is refreshing that this achievement is now being looked at in the context of what comes next.

Jon Connolly, the chief finance officer, said: “I always think of this as being a journey, so you start with your financial problems – and we had really significant financial problems – then you go through a period of recovery then you go to where you’re trying to find sustainability and maintain a break-even position.

“Beyond that, we can start to look at where we invest money, it’s about developing and improving services then, because it’s not about trying to get back to that position where you can manage within your resources, as you’ve already done that.

“The important thing for me is it puts us in a really good position in terms of what we want to do next. That’s what interests me and I’m really excited about what we can do next.”

Finding the next generation of staff

One of the crucial issues affecting not just Northumberland but the country, and which goes much wider than just GPs, is recruitment.

Dr Syers said: “We have to work hard with everyone in the health and social care system to make Northumberland a place where people would choose to come and work.

“That might be by bringing on the people that are born in Northumberland, so that’s about education, making health and social care something that people locally would want to get involved in, it’s about modern apprenticeships – bringing those people straight from school that want to get involved, then it’s about where does Northumberland and the North East sit from a national perspective, why would people wish to bring their skills to us.

“You can only really do that by being an organisation that people respect and want to come and work with.”

“One of the things we need to start to do more and more is to create the supply as well as the demand,” Mr Connolly added.

“We can be a bit more imaginative about how we work with the universities around their training courses and look to perhaps sponsor some of those, so we can create more and more a pipeline of people we can use.”

Dr Warrington mentioned the new Sunderland Medical School, adding: “We need to be attractive to graduates of medical schools, we need to give them placements here when they’re students and afterwards in their early post-grad years, and make them want to return and work in Northumberland for the whole of their working lives.”

As an example, Dr Syers mentioned an outline plan for educational hubs – places for people who are going to be working in the sector to work and learn together, rather than being isolated as trainees.

Working in partnership

Clearly, tackling issues like this involves more than just the CCG and requires all health and care providers in the county and probably the region to be singing off the same hymn sheet.

“Our partners really matter to us,” Ms Brown said. “We do a lot of work with the local authority, we have partnership agreements with them and we work very closely with our providers through the System Transformation Board.”

But it wasn’t necessarily always so easy to work in partnership, with the commissioners all agreeing that the relationship between CCGs and providers has changed for the better.

Dr Syers said: “My interpretation was that CCGs were set up (in 2013) to support the payments by result system and when patients went to a hospital, there was likely to be a payment attributed to that patient attending.

“This was on the back of the agenda of patient choice and that was meant to drive up the quality of what was provided, because if there were two hospitals, the patient would go to the one that provided the best care.

“However, it seemed that the hospital system realised that the more patients it was able to see, the more money the CCG would have to pay and that seemed a perverse incentive in our system.

“Therefore it created lots of problems about relationships between a provider and a commissioner and those relationships became very transactional rather than focusing on what was best for the patients.”

Dr Warrington had an even stronger view: “The payment by results system basically set us up to be enemies – CCG versus hospital – and in a system like that there will always be a winner and a loser by definition, there will never be balance.

“I think it got in the way of strong clinical joint-working relationships and I think that was a great shame, but we’re reversing it now.”

Janet Guy, the CCG’s lay chairman, added: “There is now specific national acknowledgement that the competition that was set up to try to get better value for money in the health service has not necessarily worked as well as it was hoped it would.

“There is acknowledgement that working in partnership is going to deliver better results than working in competition. It’s very much a changing environment.”

Captions: Headshots of Dr John Warrington, Dr Graham Syers, Siobhan Brown, Janet Guy and Jon Connolly.