Monday, 12th February 2018

Beyond Repair?

Beyond Repair?

I was at a conference last week for District Councils and heard two stimulating contributions calling for councils to focus on the wellbeing of their residents.

What a useful objective for us.

The trouble is, despite the invention of Health and Wellbeing Boards, no body has oversight of our health and wellbeing. The Surrey Health and Wellbeing Board is a talking shop which makes no difference to anything- least of all the most pressing public health crisis of our time- the mental health of our children and young people. The commissioning of our health services is done by Clinical Commissioning Groups (CCGs). They are performance managed by NHS England for whom the priority is balancing the budget, and they are too small to design services at scale. Since the NHS is historically underfunded, especially (like everything else) in Surrey, the imagination of the commissioners is cramped by financial constraints. So children have to be seriously self-harming and suicidal before they get an appointment with a mental health professional.

The first port of call for all of us, since the foundation of the NHS, has been primary care. Primary care is under huge strain like every other part of the NHS.

Primary care is commissioned and funded by NHS England. (Because CCGs have GPs on their Boards there was thought to be a conflict of interest- i.e. GPs can’t be trusted with their own contracts.) NHS England is far too remote to know the quality of service GPs provide so rely on the CQC to inspect from time to time. The CQC has earned a poor reputation and is not able to fix anything.

At the beginning of this century, primary care was boosted by the then government by extra funding and a new contract, designed to promote recruitment and increase access to a growing range of services they could provide. This funding and the new contractual terms genuinely increased GP recruitment (as GPs didn’t have to work over night or at weekends) and programmes and targets were introduced to enable patients to get appointments more speedily. However, by 2010, a new government, prodded by the right-wing press, decided that GPs were over paid and started to trim the contracts and funding where it could. So now funding and morale are virtually back to where they were at the turn of the century and people have to queue at 8am to get an appointment again.

Being a GP can be hugely stressful so not unreasonably they are looking to their own wellbeing. The GP suicide rate is not high (despite the fact that they have access to the means). There may be a number of reasons for this- peer support is hugely important, but so is their life-long commitment to their patients- their calling drives them.

They are acutely aware of the concerns patients have about access, so do their best to recruit to fill their teams. It is not easy- new trainees don’t really want to be partners, as they have to buy in to the equity of the practice and don’t want the extra stress. Many, if not most, want to work part-time so they can raise their families (most new GPs are women).

A surgery can be very long- they may have to see more than 20 patients in the morning. Ten minute slots mean they are supposed to see 6 an hour. They can easily over run the slot if the patient’s needs are complex, their diagnosis distressing or they simply need to be counselled. A surgery can last over 4 hours and any patient could have a severe illness which might be missed. Patients are prepared to sue if a doctor misses something. Then there’s the paperwork, letters to and from Consultants, test results and home visits. Then there is the evening surgery and perhaps another 4 hours. I would never say they are over-paid.

The only process of accountability for the NHS is a General Election. No council at any level makes any serious decisions about NHS services, though to its credit SCC has recently injected money into the children’s mental health contract. We will be looking at an update on the performance of the contractor for children’s mental health (CaMHS) at the Children’s Select Committee next week. The papers can be found here:

The democratic deficit around the NHS needs addressing. It is the least accountable service we encounter. I accept that fixing that will be a long game.

Community Matters

In the meantime, local councils looking at programmes which promote our wellbeing, whether through leisure provision or schemes to befriend the lonely, have to be supported. (A Surrey commissioner who funds a local befriending scheme wants to cut the funding by only supporting less well-off people- means testing loneliness!) Libraries and community centres matter and play a key role not just in our wellbeing but in providing the glue which holds communities together.

The sense of community and of shared experience plays a huge role in keeping us well. Schemes which encourage walking together, which promote continued learning, like U3A (University of the Third Age), are invaluable to our sense of self-worth, and being part of something.
So let us be wary of any plans which cut funding to schemes like these.

The ones I have mentioned support older people but services for children, which engage them, help them to become self-confident and independent, have disappeared. We have long lost music tuition in schools (I honestly believe that singing in a school choir which performed in cathedrals saved my childhood sanity) and we now have generations for whom much music is beyond the unknown region. I went to school in Kent, which had an outstanding Youth Orchestra developed through peripatetic music teaching which was accessible to everyone at minimal cost to parents, including the loan of instruments. Now long lost of course. (I played the triangle in Haydn’s Toy Symphony and missed my first cue! The fact that I remember it indicates the mark such experiences can make on a young mind.)

Adult Social Care is going bust.

The palaver over Council Tax increases was mostly silent on the elephant in every MP’s room- social care funding.

Four Seasons Health Care, one of Britain’s largest care home operators, has been given a £70m lifeline by its American hedge fund owners to keep services running in the face of a deteriorating financial situation. This is symptomatic of the fact that so many homes are now struggling financially, with people who fund their own care massively subsidising those residents funded by the Local Authority- a scandal in itself.

Those who grew up believing there was a safety net which would catch us all, which was the welfare state, are finding that the net has holes in it everywhere, and that one of the greatest achievements of our political system is falling apart. For our children, for our elders, for us, the net is broken.

Is it beyond repair?