11th August 2016

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Ed Smith
Chair of Not-Monitor, or whatever it's called.  In conversation with Roy L
Good conversation, networking and a glass of wine.  What's not to like!  Tickets are slipping away!  Get yours.
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News and Comment from Roy Lilley
Very likely you are on a sun lounger, stretched out on a nice fluffy towel, watching a petal of bougainvillea drift across the azure pool; wondering where your next Aperol Spritz will come from.
On the other hand; you might be crouched over your desk, pounding the keyboard and sweating on the phone, wondering where the staff for your next A&E shift will come from.
It's easy to recite the problems.  Chancellor Osborne decided the nation's books would be in surplus by 2020.  He couldn't do it by borrowing, neither by putting up taxes, hence he cut spending... public service's budgets.
The DH dissembled and pretended an uplift of under 1% each year for ten years, against an annual demand growth of around 4% amounted to 'more money'.
It is 'more' but not 'enough'.
Add to that a complete and utter mess in workforce planning and a shortage of everyone; blame who you like for that.  

And, the clodpate CQC stumbling around the NHS telling Trusts 'they didn't employ enough nurses, ipso-facto the Trust was dangerous, badly led' and watched chief executive after chief executive, throw in the towel.
Cut off solutions for Trusts by limiting agency deals and locum arrangements and is it any wonder United Lincolnshire Hospitals Trust are considering slashing opening hours.
This is very interesting because: 
  • Lincoln County Hospital sees 190 patients in A&E every 24 hours;  
  • Pilgrim Hospital, Boston, 147 per 24 hours and 
  • Grantham and District Hospital, 80 per 24 hours.
By way of contrast and in no way comparison, Frimley Park, my local Trusts, has seen 350 in 24hrs.  

If Grantham can't provide a service for 80 people across 24hrs we have a real problem.
Why can't they do it?  Make a list; geography, commissioning, local health economy for starters and then comes the more subtle stuff.  

Why would a highly qualified, rare as hen's teeth, A&E virtuoso want to live in that neck of the woods?  What are the schools like?  Housing?  What are the prospects of being forgotten, 'working in the sticks', against working in central London, or Manchester or Birmingham...
The kids with the lap-tops working at the likes of McKPWC will say circle the wagons, amalgamate, consolidate, combine, merge.  

Fine, until you look at the road and transport networks in that neck of the woods.  Paramedics end up being long-distance lorry drivers.
Our problems are in the here and now.  The solutions are somewhere, out there in the future.
Even if Chancellor Hammond decides to give the NHS a bung, even Amazon can't deliver a box of doctors or a bag of nurses.
The NHS has to be put on life support.  Start with the financial pressures.
Abandon the idea that all Trusts have to balance their books.  Some will be 'loss-makers', they are socially-essential, have to be in-place, come what may, get over it.
Forget making individual components balance their activities, look for a balance across the whole health economy.  

Force people to share finances, share the risk and share the solutions.  They used to be District Health Authorities, now they will be Accountable Care Organisations.
Next, the definitions.
There are three types of A&E, rated from: 24hr consultant cover with full resuscitation; type 2, a sort of halfway house, consultant led fudge and the rest... type 3 and 4 that is pure Pedigree Chum... a dog's breakfast.  See for yourself.  Start at page five.

Have a clear out.  Ask yourself (ignoring the geography for a moment) is an A&E with less than 100 patients in 24hrs viable and safe?  Or even 150?  

Re-brand  Type 1 as Trauma Centres so the public get the idea.  

Amalgamate Type 2,3,4 and put the money and resource into hospitals, call them Front Door and Out of Hours Centres.  One simple service offering, unlike the expensive confusion we have now.
Think about isochrones, time over distance calculations and let the ambulance services tell us where to put the major trauma centres and have a say in how they are run and staffed.  Have an experiment and let them run one. Oooh!
Have the rest, nurse-specialist led, supported by tele-links to the trauma centres.  Oooooh!
Forget elective waiting lists, go back to clinical priority, let the Doc's decide who gets what and when.  Whaaaat!
Scrap the CCGs.  If there are 200 of them, with a back-office and admin cost of 300,000 each; that's 60m right off the bat.  Factor in the cost of contracting, make it a billion.  Aaaargh!
Scrap targets; use audit families and bench-marking as the tool to leverage up performance.  Collegiate, not competitive.  Ask how did you achieve that, not why did you do that.  Aaaah.

And, whilst you are about it, dump the CQC for a data driven, dashboard solutions we can all see.  Hoooray!
Don't like any of that?  Then give us the money. 
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Ed Smith 
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>>  I'm hearing - a new audit will announce one in four people with Parkinson's can't get support from Specialist Nurse.
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