Lost in transition: room for improvement as “new” NHS takes slow steps in right direction

David Cameron

Many of us will have had a hard earned rest over the summer, perhaps a trip to the seaside, a good book and some time for reflection.

Our local bloggers — hard-working Chief Executives of local carers’ organisations part of the Carers Trust Network — have been reflecting on the on-going changes in the NHS.

Find out how things are unfolding for this month’s blogger who says that whilst there are still lots of challenges, there are positive developments too…

The overall structure of the NHS is clear to me but the detail and practicalities are less clear. For example the actual working relationships between the CCG, Public Health, HealthWatch, Public Health England and the Commissioning Support Unit all feel really unclear. There was a lot of hype around the change but actually, we are talking to the same commissioners. In some ways it feels like nothing has changed.

What’s working well?

CCGs have done lots of work to get out there, especially the GPs and leadership team and are presenting themselves as a new and public facing organisation ready to truly consult the population on what they want. This feels exciting.

We have been consulted on the Health & Wellbeing Strategy and Joint Strategic Needs Assessment (JSNA) which was very positive. This is being done concurrently to setting up all the organisations though!

The main challenges

The organisations seem small in terms of number of people and this is having an impact on how we can communicate with them. Additionally, the big expectation was that GPs would be available to talk about all commissioning, service planning and design, but we are talking to the same commissioners, with basically the same plans.

In many ways it’s a story of continuity rather than radical change. But this could of course change over time.

It all feels really challenging on the ground, from changes in IT systems, to offices, to big expectations being shoe horned on to a complex system that already exists!

It also feels like we often hear “that’s something we’re working through”.

It has been surprising how slowly some of the organisations have been setting themselves up. They say that they have only had 3 months since 1st April 2013, but actually there was a long lead in but it seems that the funding, people or support wasn’t available to do the work required.

Variation and a lack of clarity

Health and Wellbeing Boards are very different in the two areas. One feels more progressive and open and we even have a place for carers on the board. However this is under the guise of two places for HealthWatch, and one for carers. It is mostly a very small group of statutory representatives sat around a pretty closed table. Having said that, the demands on the Health and Wellbeing Boards feel immense.

Silence from some parts of the structure

HealthWatch is not fully up and running and again, although the national policy sets out how HealthWatch is different to LINKS, locally, it is unclear how HealthWatch will fit with the patient and public involvement that already exists.

NHS England’s regional office has been silent and given that they hold the contracts with the GPs, it feels they are an important stakeholder who we are, as yet unable to engage with.

Finally, Public Health has been the most silent in our experience. But as ever we are hopeful that all the parts of the system will start to come together and the conversation about how best to support carers will take place.

What do you think? Tell us what’s been happening in your area over the summer…

September 3, 2013 Posted by | Health | , , | Leave a comment

Do you understand the new structure of the NHS?

_mg_4712This month we set Chief Executives of local carers’ organisations a test: do you understand the new structure of the NHS? Does it make sense in your local area?

As part of the test, we asked them to look at the slides produced by The Nuffield Trust on the old and new NHS structures and what has changed.

The slides show the main changes to management, accountability and funding structures resulting from the Health and Social Care Act 2012.

In our latest blog, one of the network Chief Executives reflect on how the different parts of the new system – Clinical Commissioning Groups (CCGs), Health and Wellbeing Boards, Public Health and HealthWatch – are working together in her area.

She says that things are still confusing and that there are still lots of challenges to address as the reorganisation of the NHS continues.

I have studied the slides and whilst they are not difficult to understand, they are unnecessarily complicated and it’s interesting that the different bodies appear to work in isolation of each other. There doesn’t seem to be anything between each body, leaving plenty of opportunity for conflicting and duplicated work. Also I’m not sure whether the local structures are clear.

Some developments but more engagement needed

The Health and Wellbeing boards have identified some priorities, and they have met with some of the partnership boards (including voluntary organisations) to detail how they want to work. They have identified carers’ needs as one of their priorities – that said, they are not engaging with carers’ centres and at the moment details of membership, or approaching members of the boards to raise issues, is shrouded in secrecy. This is my experience — there may be others who think differently but I have yet to find them!

In my area there is a partnership board, which is a partnership of statutory and voluntary sector organisations, who meet every couple of months to discuss the headline issues and the Director of Public Health usually attends these.

The last two meetings have been cancelled for one reason or another, and it is at times unclear what the purpose of the meetings are as each participant appears to have their own agenda. This is particularly noticeable just now as contracts are changing and the council are opening up services for tender.

Are different parts of the structure working together?

Whether or not the Health and Wellbeing Boards are getting involved with new CCG arrangements is another unknown. This includes whether they are any good at filtering out what they are involved with and any anticipated outcomes.

There are plans for the CCG’s in my area to work with the local authority. However, how they work is not made clear to either stakeholders or wider partners in general.
There is almost an air of secrecy around who works with whom and to be honest I do not think this is entirely the fault of the CCGs. Our local authority have not been proactive in informing the communities that they serve how they plan to work with the CCG’s and what their joint priorities are, or indeed what conflicting priorities exist.

I’m guessing the Public Health are engaged, but again: what their input is, what any anticipated outcomes are, how they are working with the wider community and with the CCG’s in particular, has not been communicated.

It feels at times as though these bodies (I can’t really call them partners at the moment, because there is very little real partnership taking place) are shrouded in the Harry Potter cloak of invisibility. It is really confusing!

July 26, 2013 Posted by | Health, Uncategorized | , , | Leave a comment

Ensuring carers services are prioritised in the new system

DSC_0196We know that the moral and financial arguments for supporting carers are clear – without support, taking on a caring role can mean facing a life of poverty, isolation, ill health and depression.  For the person they care for it can mean costly hospital or care admissions if the caring relationship breaks down.

Our Network Partners have to work with a whole range of commissioners – local authority and NHS – to keep themselves viable. In recent years PCTs have had responsibility for commissioning services to support carers and with our Network Partners we have made the case nationally and locally as why support for carers should be prioritised.

However on 1 April this year, the new commissioning structure in England came into place, replacing PCTs with new Clinical Commissioning Groups.

Many of our Network Partners have told us that this change is proving difficult for them and that it differs radically from place to place. In some areas the situation has stayed fairly stable and familiar faces remain, whereas for others, CCGs are undertaking reviews of local services commissioned by the NHS and long established contacts have gone.

To support our Network Partners make the case to their local CCGs for commissioning well for carers, and in some cases start talking to new commissioners about carers services, Carers Trust has produced Commissioning for Carers: Key Principles for Clinical Commissioning Group.

The NHS reforms not only changed local commissioning systems but also brought in new accountability arrangements which means that there are no longer specific performance targets or rules for investing in carers services. This makes it more difficult to hold the NHS to account locally for what it commissions for carers.

The NHS Mandate sets out the Governments priorities for the NHS and key areas where it wants to see improvements by April 2015.

These are:

  • Preventing people from dying prematurely
  • Enhancing quality of life for people with long-term conditions
  • Helping people to recover from episodes of ill health or following injury
  • Ensuring that people have a positive experience of care
  • Treating and caring for people in a safe environment and protecting them from avoidable harm.

Commissioning for Carers: Key Principles for Clinical Commissioning Groups demonstrates to CCGS how supporting carers can help meet these key areas for improvement and led for savings across the NHS.

We know that CCGs across England are under enormous pressure to meet financial targets and the key priority areas for improvement.

Commissioning well for carers is in all our interests, including CCGs, as it benefits the people being cared for, reduce overall spending in the NHS and can help commissioners meet required their outcomes. Let’s hope that CCGs are listening.

July 22, 2013 Posted by | Health | , , , | 1 Comment

Carers remain concerned over continuity and knowledge in the new NHS

Doctor checking blood pressureThe latest contribution for our blog series Lost in Transition? How carers’ services are navigating the new NHS is from the CEO of a large Carers Centre in the south of England. In it they reflect on the impact of recent restructuring on NHS staff and how changes are resulting in a lack of continuity and knowledge about carers’ issues...

The new NHS has arrived and in many respects this month’s NHS feels no different to last month’s. For carers, the impact of the most significant NHS changes since 1948 could take many months, or even years, to become apparent.

But for those of us working with the NHS—as commissioners of our services and as partners in the delivery of support for Carers—the changes are already apparent.

The first appearance of change was in the response of NHS colleagues. Staff working in and with the NHS are used to change. For some careers are measured not in years or promotions, but in restructures and cycles of change. A hardy few wear the number they have survived as a badge of honour, but even they have been going around in recent months with a dazed look that says “no, this one really is different”.

The second appearance of change has been in the sudden rush of business that absolutely had to be concluded by the end of March. Staff who have been in limbo for months getting to grips with new briefs, partnerships and responsibilities in weeks. If only it had been the other way round: weeks of uncertainty followed by months in new jobs with adequate time to prepare. And any number of contracts, policies and strategies to be reviewed, cancelled, revised, updated, or if all else fails extended on the grounds that ‘business as usual’ will do for now.

For us, at least until recently, most business to do with carers has fallen into this last category—neither big enough (in monetary terms) nor important enough (in commissioning terms) to appear on the CCG radar. But this continuity is only temporary; the sudden rush of business has been accompanied by a massive loss of history and knowledge as staff have moved on to new roles or pastures and this presents us with our greatest threat.

Whilst review of all services is inevitable, the loss of continuity sees this being led by commissioners who start with little understanding to inform their thinking.

Commissioners with little experience of carers needs and strategies, reviewing services they have not encountered before, alongside carers and providers who are strangers to them if not to each other. Some will tread carefully, take a long-term view, and ensure change does not create discontinuity and fear amongst carers and providers.

But some will not and therein lies the third, and thus far most worrying, appearance of change: an emergent tendency to engage in what could generously be described as “action research” but feels more like ‘changing stuff to see what happens’.

Add in to the mix all the usual jockeying, that inevitably accompanies change and competition for funding and position, and it leaves many wondering what the next few months will really bring.

Lost in Transition? bloggers are Chief Executives of independent carers’ organisations, who are providing insights into how NHS reforms are impacting on carers’ services and carers across the country.

Watch this space for more updates about what the changes to the NHS really mean…

June 24, 2013 Posted by | Lost in translation? | , , , | 1 Comment

CCGs: a voyage into the commissioning unknown

Doctor checking blood pressure

The 1st April was for many of our local partners—carers’ centres and schemes who support hundreds of thousands of carers across England— approached with some trepidation.

In recent years Primary Care Trusts have had responsibility for commissioning services to support carers. Carers Trust and our local partners have worked hard—and pretty successfully I have to say—to make the case for supporting carers, explaining how putting comparatively small amounts of money in can really make the difference between carers being able to cope and maintain their health and wellbeing, or becoming ill or the caring role breaking down. If a carer is unable to keep caring, believe me, it costs a lot more.

Starting from scratch?

We’ve spent years documenting the evidence  showing how providing information and advice, breaks from caring, supportfor GPs to identify carers, and high quality replacement care can make a real difference, and in some areas of England, it is possible that little may change.

However, where there is a complete change in commissioners and decision makers, we may well have to start from scratch, making the case all over again. Very frustrating.

Already we are hearing that some of the new Clinical Commissioning Groups (or CCGs) are giving notice on contracts for local carers’ services as they intend to review all the services they commission. This is incredibly destabilising. We will keep making the case for carers, and we know our local partners do a brilliant job and will battle through this. But  if commissioners don’t understand why supporting carers is important  we could be in for a bumpy year.

Watch this space

During this year of change, some senior staff from carers’ centres and schemes  are going to be blogging for us, writing about their experiences, so we can see what all of this means for those who are trying to make sense of it on the ground.

They’ll  be writing about their hopes and fears, whether the structures are becoming clearer or more confusing, and what the impact of all of these changes have been for them, their staff, and carers and families locally. We’ll all learn from the stories they have to tell.

I have a deep feeling of unease about the year ahead. I  hope that for many, if new structures and contracts are needed these are put in place quickly to secure their future  and stability for a number of years ahead. I fear, however, it’s not going to work quite like that everywhere

What do you think about the NHS commissioning changes?  How are they affecting you?

Keep reading over the next year to hear what our band of bloggers have to say.

March 28, 2013 Posted by | Health, Uncategorized | , , | 5 Comments

The NHS Mandate – a missed opportunity for carers?

Carers at carers' centre

If you’ve been keeping up to date with the whirlwind of changes in the NHS in England following the Health and Social Care Act, you might have noticed that a thing called the NHS Mandate was published the other week. Or, if you have other things to be getting on with in life as most people have, this might have passed you by completely.

The NHS Mandate will form the way in which the Government gives a steer to the NHS on what its priorities should be.

The Government, as you may know, is not at all keen on interfering with the way things are run locally, so it was always going to be quite light on detail. It does mean, however that in the new commissioning structures, there is some way to make sure important issues which have been identified by the Government as priorities can be addressed – such as care and dignity of people with dementia for example.

A draft version was published some months ago, and it included a whole section on carers, which we were very pleased about. It gave a clear steer that carers are a key group which the NHS needs to focus on. This would have really helped us to build on the progress that has been made over recent years in terms of the focus placed on carers nationally and, in many cases, locally. Whilst national Government often can’t dictate what happens locally, there is no doubt that it has influence.

However, as time went on, we became increasingly worried that the carers elements in the draft might disappear from the final version. We responded to the consultation asking to keep that section in, and I know many others including members of the Standing Commission on Carers said the same.

So when the final version was announced, I was frantically scanning through it for the section on carers. I found carers mentioned in a number of areas, and one outcome for the NHS which will mean they need to measure carers’ wellbeing and report publicly on that. Local NHS will need to ensure there is information and advice available to carers (reflecting the same elements that are in the draft Care and Support Bill). These elements are good to see.

However, they fall short of providing the lever we needed to continue the drive towards ensuring carers are properly recognised, and they get the support they need.

It is particularly worrying because the local decision makers at the moment – Primary Care Trusts – are being disbanded, and Clinical Commissioning Groups will take over early next year. Although in some areas there will be continuity and perhaps not much will change, in other areas there will be a whole new set of decision makers. Decision makers who don’t understand or recognise the importance of the issue might decide not to put money into supporting carers.

There has been a lot of progress in the last few years, but in some areas much of this might be lost, and we might have to start all over again in making our case.

Whilst I’m pleased carers weren’t wiped out of the Mandate altogether, I can’t help but feel that it was an opportunity lost. The challenge now, for all of us, will be to keep carers up the NHS agenda nationally as well as locally.

December 4, 2012 Posted by | Health | , , | 2 Comments

The Number 10 Experience

Note: The following blog post has been written by Moira Fraser, Director of Policy at The Princess Royal Trust for Carers

“The Prime Minister requests the pleasure of your company…” came the invitation. What an opportunity to get carers Number 10issues noticed right at the top. So on Wednesday morning, determined to give it my best shot, I walked up Downing Street, said good morning to the policeman and  rang the brass doorbell. The door swung open ominously….

Around twenty charities were  invited to give their views on NHS reform. Some big household names, some tiny – a real mix, but few others with a real carer focus. Lansley opened the debate, later joined by Cameron and Clegg.

The Coalition Government is clearly in trouble with its health reforms, and I have to say I can’t see what’s in it for carers. They say it’s not about privatisation, but unless more thought goes in, the competition it will allow will end up with a focus on price rather than quality. You can’t provide decent carer’s services on tuppence ha’penny. It also means charities end up competing against each other – exactly what we want to avoid. And changing the boundaries of health consortia and making these different from local authorities will make it a lot more difficult to join up all the different services which are needed to support young carers and families with complex needs.

About an hour into the meeting, I took my chance.  I caught Andrew Lansley’s eye – he looked at me and nodded. Gulp. In what felt like slow motion, Cameron and Clegg turned and looked at me. Carers have been absent from the debate so far, I said, and you need to remember our vital role. With some notable exceptions, GPs often forget all about carers  and carers organisations. We need joined up working, and services which work together to support families  to make sure vulnerable people don’t  fall through the cracks. The Bill needs to help this happen, not hinder this.

They nodded and asked more about GP practices working with the voluntary sector. The GP present agreed that primary care sometimes forgets anyone else exists. They agreed the Bill needs changes to give more indication of how local arrangements should work but didn’t agree that consortia boundaries will make things difficult. As he left, the Prime Minister, said we will all need to work to make health and wellbeing boards effective, “to do things like making sure carers get the right kind of support”.

I think there are real problems with the Bill. I think there is a massive risk of carers being forgotten about in decision making processes. There may be opportunities for the voluntary sector, but if it comes down to price we will all lose out. I said my piece. They said they were listening. But did they hear?

April 15, 2011 Posted by | Carers movement, Carers Strategy, David Cameron, Social Care | , , | 6 Comments