'Our own recovery story' - Northumberland CCG chiefs on how they turned the organisation around
A few years ago, you may well have described NHS Northumberland CCG as a basket-case. Ben O’Connell hears how the organisation, which plans and buys the county’s healthcare, turned itself around to be rated good last month:
When Northumberland’s healthcare commissioners were revealed to be out of special measures in July, there was a lot of talk of how proud they were.
Clearly, improvement is always something to be proud of, but in the case of NHS Northumberland Clinical Commissioning Group, this pride was also a reflection of just how difficult a road it was to get to this point – and the journey is far from over.
Speaking to some of the key players at the CCG recently highlighted the range of different ways the organisation tried to get back on track, while always trying to stick to some core principles and not shying away from the need to make difficult decisions so that Northumberland’s limited healthcare pound is spent as well as it can be.
As is always the case with the NHS, the problems all really come back to finance.
The NHS description of CCGs is ‘clinically-led statutory NHS bodies responsible for the planning and commissioning of health-care services for their local area’.
It says that commissioning is about getting the best possible health outcomes for the local population, which involves assessing local needs, deciding priorities and strategies, and then buying services on behalf of the population from providers such as hospitals and clinics.
CCGs were introduced through the Health and Social Care Act in 2012, replacing Primary Care Trusts on April 1, 2013; Northumberland’s came into being with a deficit of £17million.
A deteriorating position meant it was placed under legal directions in 2016-17, before falling into special measures – similar to what happens to schools under Ofsted – in October 2017.
The 2017-18 financial year saw an in-year deficit of £20.3million, resulting in a cumulative deficit of £40million, before the tide started to turn a bit. While there’s a long way to go, the CCG recorded a small surplus in 2018-19.
Ensuring the best quality of care
One of the challenges in Northumberland is trying to ensure that quality and access to services are as equitable as possible across the county.
Dr Graham Syers, the CCG’s clinical director of primary care and a GP partner in Alnwick, said: “We’ve got to remember that Northumberland is a very diverse county and I think that’s a challenge we mustn’t underestimate.
“We have a huge geographical area and within that we have some very well-defined communities with a very strong sense of their own community.
“We’ve got some pockets of deprivation, old mining towns down our east side with their own needs, and then we’ve got rural deprivation as well – distance from hospital is a real issue for a lot of people.
“When you’ve got a challenge that’s a financial one, it’s very easy to say what are the services that we could cut, because that would be a logical way to look at it to start with.
“Actually what we had to do was take a step back and say where are the issues in here on which we can do some comparative stuff about the quality of care that’s going on and improve it for these communities.”
Dr Syers and his colleague, Dr John Warrington, the CCG’s director of planned care and a GP in in Cramlington and Seaton Delaval, highlighted a number of examples of changes that had been made to improve provision while also working within budgets.
“Secondary care is expensive for the taxpayer and the CCG that is responsible for that taxpayers’ pound,” Dr Warrington said. “Our job at the CCG is to get the best bang for that buck clinically and get the best outcome for as many people who live in Northumberland as possible.
“Part of what we have been doing for a number of years is being really careful about making sure the right people go to secondary care. To help with that, we have asked GPs to look really carefully at the referrals they make.
“Our referral management scheme encourages GPs to check that each referral they make is of the highest quality and is clinically appropriate. The aim isn’t to decrease referrals, the aim is to decrease the variation across referrals.
“The effect that’s had is that we haven’t seen the growth in secondary care referrals that have happened elsewhere, we’re very happy with our low referral growth rate to outpatients and that has really helped our financial bottom line as a CCG.
“It’s been a really important part of our story of recovery. We’re also reassured that the quality of what’s happening is extremely high because of the measures we have put in place.”
Elsewhere, all CCGs were encouraged to look at their activity rates compared to the rest of the country to see where they were outliers.
Dr Warrington explained that this work resulted in Northumberland looking at why it had such high rates of endoscopy in gastroenterology.
The result was the introduction of new pathways and guidelines for GPs and consultants to follow for endoscopy, both upper and lower – that is, to examine the stomach or the bowel with a camera – as ‘it’s really important that the right patients are selected and each referral is clinically appropriate, because they’re not without risk’.
“It’s also absolutely pivotal that we pick the correct patients because that is how we pick up early cancers,” added Dr Warrington.
“That’s a massive and complicated amount of work across lots of different people to get to a result that’s absolutely necessary if you’re going to maintain quality but live within your means, which is what we’re all about.”
Northumberland was also an outlier for certain types of orthopaedic procedure, which led to the realisation of the need for a single way for patients to access musculoskeletal services, resulting in the Joint Musculoskeletal and Pain Service (JMAPS), which went live on July 1, but has proved controversial with access concerns raised in several mainly rural communities.
Dr Warrington said: “JMAPS includes our pain service, which is really, really important, because a lot of musculoskeletal stuff is back pain, a lot of our spend in hospitals was for back pain, particularly injections and operations, and half of pain clinic attendance is for back pain, so it made sense to bring these two together in a community-facing place to best manage people like this.
“We have brought in a lot of non-doctors – physiotherapists, psychologists and so on – to give a really modern, de-medicalised way of looking at the tricky area of back pain, because that is what the evidence tells us to do and it works. It’s working very well in North Cumbria where they’ve been doing it for a few years now.”
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CATCH (care at home team for complex health needs), which was started in north Northumberland and is to be launched in Blyth now as well, is another way the CCG has changed the way it works.
Dr Syers said: “We’ve got an ageing population and Northumberland has an older population on average, and older people tend to have greater health needs and we know that people end up being admitted to hospitals more.
“It’s unplanned admissions that impact on people’s lives a great deal and also if you live a distance from the hospital, that’s another big issue.”
The CATCH team is a programme of work where the CCG has tried hard to get everybody that might be involved in looking after frail people in the community across all the different provider sectors – ambulance service, local authority, GPs, community services – working together.
Dr Syers said that since its introduction in the north, it’s given a much better sense of how people can work together to look after that group of people.
“It reduces admissions, it keeps people in their homes, hopefully it keeps people happier in their homes as well,” he added.
Improvement v. cost-cutting
There is a natural cynicism that changes to any public services, particularly healthcare, are about cutting costs and specially when an organisation is facing extreme financial pressures.
But the CCG is keen to assure residents that the quality of care is what’s important to them – although people have to be aware there is no ‘bottomless pit of money’.
Janet Guy, the CCG’s lay chairman, said: “The central plank of everything we decided to do from day one of our improvement plan was, yes, we had to save money, but we had to spend the money better.
“So everything we did was about improving the quality of care for patients, getting better outcomes for patients and getting better value for money for patients and the NHS, so if it merely saved money but didn’t deliver any of those things, we had to be satisfied it was right to do it. Generally, everything we were looking at was about a better way of doing it.
“Although you would never want to be in the position of having a financial deficit, what it does do is focus your mind on how you can use resources better.
“One of the crucial reasons we went straight to good (from special measures) is everything we did had that focus on doing things differently and doing things better, not merely saving money.”
Dr Syers added: “I think we have to be as good as we can be at engaging with the patients before anything is considered really, in as early a stage as possible when you’re looking at improving a service.
“If you do that, I think the patients start to trust and know that you’re looking at things from the right perspective and you’re taking their views into account.”
Dr Warrington said: “It’s a difficult conversation and we have to be honest that there is a finite resource. We have to be extremely clear about that; there is no bottomless pit of money available to us.
“Therefore our job is to continuously drive quality clinical care and the way to do that is by decreasing clinical variation; this means making sure patients get the most appropriate prescription, the most appropriate referral, the most appropriate operation in the hospital, that the right patients gets the right care at the right time and that’s how you manage within the limited financial resource that we have and we’re responsible for.”
Changes behind the scenes
Janet Guy took on the role of lay chairman at the CCG right at the ‘interesting time’ when the financial problems were hitting their peak.
She said that Northumberland had set up a very clinically-led CCG from the outset, which had ‘really served it well for its first three years, but by then the health economy was changing, joint working was becoming much more common and the work of the CCGs generally was increasing.
“There was a recognition that as well as the financial deficit which had emerged, there was a need to beef up the governance structure, because of the changing times,” she said.
Joining with a background of 20 years of corporate governance in the public sector, Janet put a focus on refreshing the governance model to relieve some of the pressure that the clinical board was feeling.
At the time, there was a clinical board and then a separate governing body made up of lay members, but the clinical board had reserved all of the decision-making and strategic powers for itself, while the governing body simply assured its work.
This was changed so that a large proportion of work was transferred from the clinical board onto a beefed-up governing body, with expanded clinical membership.
Janet said: “We retained our lay members’ diverse experience already on there and retained the overall clinical majority then gave that much broader, stronger, experienced governing body the decision-making powers and transferred the strategic and leadership work.
“That of course relieved the clinical board of some of the growing burden of non-clinical work that it was having to spend too much time on and allowed it to be refreshed so it could focus on the real clinical issues.
“I know governance sometimes seems to be a little bit dry and away from the executive role of an organisation, but if you’ve got that strong support behind the organisation, it gives you control, leadership, you can monitor improvement and the other important thing about governance is you’ve got an overall body that says, what’s our integrated plan, what’s our vision, what are our strategic objectives and, in our case, what’s our improvement plan to get out of legal directions and special measures.
“Anything that the organisation is doing, we as a governing body would say, does this fit in with vision, strategic objectives, improvement plan? If it doesn’t, should we be doing it at all? So it gives you that strong structure around the executive work.
“It was a little bit behind the scenes when it was all done, but I think it was very helpful.”
Dr Warrington added: “When we were in trouble three or four years ago, we went on a big recruitment drive for extra clinicians to work with us at the CCG and to have formal posts here.
“I think we have 17 now, which is a lot of GPs and I would suggest more than other CCGs. Rather than us having fewer when we were in trouble, we enthusiastically went out to find more and I think that’s been absolutely pivotal in helping us towards recovery.”
This is the first of a two-part series on the work of the CCG. The second will look at the ongoing challenges it faces and how it is looking to the future.