I might be tempting fate here, but I’m in an unusually bold mood and I’m just going to go for it… it’s time to declare winter 2014/15 officially over.
Despite living here through the last fifteen of them, I’m still a little in awe of Scottish winters with their frozen lochs and snowfalls into April. I grew up in South Wales (which, for those of you who haven’t been there, has a broadly Mediterranean type climate…) and the adjustment to more northerly weather takes a long time. Indeed, the Ospreys rugby team’s narrow miss of the league title this season is largely accredited to our failure to wear thick enough vests during the trips to Edinburgh and Glasgow.
A typical midwinter scene at Torbay, Swansea.
Sadly, it’s hard to mention ‘winter’ in an NHS context without immediately adding ‘pressure’. Locally, this was a record breaking year in terms of winter admissions to hospital and patient activity through primary and community services, a fact which is quite staggering when you think that the previous two winters have also broken records.
We’ve experienced all the usual difficulties of Norovirus and Flu outbreaks amidst this record activity and it’s to the enormous credit of staff that we’ve maintained extremely high performance levels. For example, the 95% 4 hour wait target in A&E has proved impossible to achieve across much of the UK; our teams not only delivered it, but improved on previous years’ performance. This is much more than an impressive set of statistics; this was a major contribution to good patient experience and safety.
There are lots of other examples of the huge efforts of staff in improving services throughout the pressures of winter. We’ll be reviewing a range of such information at our NHS Board public meeting in June, so I’d expect forthcoming media reporting to be even more heavily dominated than usual by praise for our teams and their achievements…
We should take pride in these achievements but I’d also like to reflect on how this level and quality of service can be built on as we begin the winter planning for 2015/16. The ‘winter pressure’ this year has fallen squarely on teams of staff dealing with unprecedented gaps in staffing due to well publicised recruitment problems. We have succeeded for our patients this winter frankly because many clinical and support teams have worked harder and longer than ever before. I can make this statement knowing it applies right across our system, from the primary care teams coping with GP vacancies, to the cottage hospital staff managing record levels of occupancy, through to our acute teams juggling rotas around consultant and other doctor vacancies. This is a great reflection on the ethos of our teams, but it can’t surely be the basis of our long term planning; it can’t be our ambition to ask individuals and teams simply to work harder year after year to deal with rising patient activity.
It’s certainly not my ambition and I instead want us to be seen as the outstanding place to work and to develop your career in Scotland. That has to mean relieving some of this pressure on individuals and teams to allow them to focus on continuing to improve our patient experience rather than simply ‘fire-fighting’ a relentlessly rising workload. In years gone by this would have been quite a simple process; a (often young, Welsh) manager would put together some demand and capacity analysis, demonstrate the imbalance and cost out the required extra capacity in a bid to the Health Board. The Board would then consider this in the context of other priorities and, more often than not, commit a proportion of its growth monies to fix the problem. Life’s now a lot more complicated. In the next few years this ‘growth’ funding barely keeps pace with health inflation and even where money is available, we’ve no longer a guarantee that we can recruit to traditional roles.
But whilst previous solutions may no longer be as effective, I think we can still allow in some cautious springtime optimism that a more sustainable future is achievable.
Health and Adult Social Care integration is one of the reasons to believe the future could look significantly different. First the injection of pragmatism; integration doesn’t magic up one more GP, social worker or care worker, doesn’t add a pound to our stretched budgets or endow our managers with (even) greater wisdom. It does, however, give us the first real opportunity to pool our resources and expertise in each of the region’s natural localities and try to create local models of health and care that are more effective at managing complex conditions in home or community settings. We now have a bank of evidence from the Putting You First change programme of the impact of small scale redesigns, integration allows us to take the best of these and implement them at a scale that could make a fundamental difference to flows of patients and to the quality of experience of those patients. This will be a difficult process of enormous change to many clinical practices and pathways, but it seems to me that it offers promise of genuine sustainability of service quality as an alternative to a future of perpetual winter pressures. Our integration scheme is the most ambitious in Scotland, has been approved by both Board and Council and we go live on 1 April 2016 after a period of ‘shadow’ running this year.
Similarly, the ‘Change Programme’ (part of the suite of work around the new acute build) gives us a once in a generation chance to examine every aspect of our organisation of acute workload. We know that come 2017/18 we’ll have the finest DGH facility in Europe, the contract’s signed and the diggers are on site. We need now to ensure that services in the hospital from acute receiving to theatres to outpatient reviews are reorganised in a way that gives staff the very best opportunity to deliver high quality care and act as the best advert for recruitment of top class staff. This isn’t quick fix work, but again offers us an opportunity for improvement that we’d be foolish to miss.
I don’t want to put a rose tinted perspective on what are the most challenging times in health services I’ve seen in my career. I also appreciate that engaging in such major redesign programmes is particularly difficult when faced with increased demands of the day (and night) job. But I do think these programmes are our best strategy, and that locally we have a unique opportunity to create a future that feels a bit more balanced, and winters that feel a little more fun.
Jeff Ace is Chief Executive Officer for NHS Dumfries and Galloway