The application by Wandsworth’s GPs for Pathfinder status was approved on Wednesday.

Essentially it makes Wandsworth one of the country’s early adopters in the move towards GP commissioning; with the GPs (working as a single Wandsworth consortia) starting to shadow the Primary Care Trust from April in preparation for taking on full commissioning responsibilities from 2013.

Wandsworth is making good progress on the health reforms. I’ve often joked that the council has long-held imperialist ambitions for the NHS in Wandsworth, but there are massive benefits from closer co-ordination between the council and health service. While GPs are the best place for commissioning, since they are the ones who are closest to the patients using the services, there are lots of benefits from closer integration with the council.

Some will be fairly obvious to residents, for example those who use both council and health services and will benefit from a better joining-up between the two. Some will be less obvious and behind the scenes, like any benefits that derive from the council’s expertise in procurement.

But I think the most beneficial will be the tighter integration of proactive and reactive services. At the risk of being overly simplistic, the health service and GPs tend to be reactive: you get ill, they cure you. Whereas the council has responsibility for many services that can have a preventative element: education is the biggest factor, but you can include things like our leisure facilities or environmental health and even go as far as including the council’s role in economic development.

This is all in the future, we’ve spent a lot of time, and will spent a lot more time, working out exactly how it will all look in 2013. But congratulations are due to the GPs, because it’s now one step closer.

Wandsworth council chamber, Mayor's chair and crest
I need a new generic image for the Town Hall

Last night was the first meeting of the ‘wider’ Health and Wellbeing Board for Wandsworth. And a bit of a milestone in the progress towards implementation of the government’s health service reforms. In fact yesterday was something of a health reform day for me, with a meeting in the afternoon between south-west London NHS sector, councils and primary care trusts in the afternoon.

I remain convinced that the Health and Social Care Bill present a magnificent opportunity, perhaps a once in a generation opportunity, to improve health care, and most importantly, the health of Wandsworth.

The move to GP commissioning has attracted the lion’s share of comment – and criticism – but to me this is a perfectly rational move, the GP is the one who knows most about the patient in front of them. And in practice the patient will see no difference – and nor will they care – if a GP refers them on, they get referred on. The commissioning process is neither here nor there to a patient concerned about getting better.

However, the most exciting changes are the move of public health to the council alongside the structural reforms that will help develop a much closer working relationship at all levels of health and social care provision.

The Director of Public Health gave a presentation on the health needs of the borough. What struck me most was how clearly the picture emerged that most health problems are not related to healthcare, but instead to lifestyle choices.

So on each indicator Wandsworth was scoring poorly it wasn’t down (in the most direct sense) to a council, GP or hospital letting people down, but their ‘decisions’ to smoke, drink too much, eat unhealthily or engage in risky behaviour.

This is the sort of area in which I feel my paternalistic and libertarian Conservatism traits clash. Part of me doesn’t mind if people smoke or drink, that’s their choice and – generally – it’s their health they are affecting. Indeed, morally it’s very hard for me to criticise anyone for bad lifestyle choices, in my past I smoked and drank far too much. And while I’ve avoided drugs, I can’t claim to have ever been troubled too much by healthy eating. If there is anything that puts me on the side of the angels it’s my attempt to undo some of the damage with slow trots around Battersea Park.

In the world of Nudge however, there probably needn’t be that conflict between libertarianism and authoritarianism. People are still able to make their own decisions, even if we think they might be the wrong ones. But we should make it easier to make the right ones and pushing them towards those choices where appropriate.

But even there, while I would argue the council is probably in a better position than the NHS to help people make those changes we still aren’t the best people. Those present from the voluntary sector were concerned that they were still not part of the process. Personally, I can see how we will be using them far more than we ever have, working at ground level to help bring about those small improvements that make a dramatic difference over months and years.

But, where we are, it’s hard to reassure them. We’re in the middle of reform and moving towards closer working between two very different cultures. We have the broad vision for where we want to be, but we don’t have lots of the detail filled in. I have my views, but it might not be the same as everyone else around the table (indeed, I might not even be there when the powers are formally transferred from the PCT to the council and GP consortia!)

It’s an exciting time. But however far advanced we think we are – and Wandsworth is further along the process than many, if not most, places – there is still a long way to go.

Where do you think we should be? Do you know any areas we make it ‘hard’ for people to do the right thing?

Andrew Lansley in Roehampton for the public health white paper launch

Andrew Lansley, the Secretary of State for Health, came to Wandsworth to launch the public health white paper yesterday.

I’ve been very remiss in not posting much about health on here, despite the fact that it’s probably the most exciting area of local government at the moment and presents a huge opportunity for local councils and communities.

The main point of the white paper is that public health will soon be a council responsibility again (it was stripped from councils in 1974). It’s a sensible move: it’s commonly recognised that the NHS actually plays a small role in the health of the nation. We might all think of health and think about our GPs and hospitals, but in fact it’s largely a result of our lifestyles and behaviour; the cumulative impact of even small changes (a slightly healthier diet, a little more exercise) would make a huge positive difference to our collective health.

The challenge now is how we carry this out and made sure that the decisions the council takes all take account of the public health impact. And the real challenge for (much of) local government will be a new way of working, like any government publication the white paper has a couple of mentions of Big Society, but it also has references to things like nudge and the influence of networks and all three are quite alien to the traditional directive approach of councils.

A further challenge will be measuring the impacts. While the white paper hints at how they are going to baseline public health (and offer reward funding for success) it is not specific, and it’s hard to imagine exactly how we are going to measure the impact on things like life expectancy which, by definition, won’t be felt for years.

But despite those challenges the collective reforms for health offer the biggest positive change for health and healthcare I’ve ever seen – moving decisions away from a centralised bureaucracy and as close as possible to patients and communities, which is exactly where they should be.

Years ago, as a new councillor, one of the old salts told me that he now couldn’t go anywhere in the country without seeing a housing estate and looking for indications of how many of the houses or flats had been bought or how the estate was managed.

I’ve found myself doing the same looking at public sector organisations. So today, at St Thomas’ hospital I was taken with the robot dispenser in the hospital pharmacy which you can see going through the motions in the YouTube video above. Apparently it works by placing drugs where they fit, so they are stored in the most space efficient way, then remembering the location. It will then retrieve drugs within 10 seconds of them being requested. It is quite mesmerizing to watch and MiniMe and I enjoyed seeing boxes with names I couldn’t pronounce being moved around (as well as nicotine patches, they had lots of those).

However, given that the advertised wait time for dispensing prescriptions was 15-20 minutes I couldn’t help feeling that the space saved and time saved by having a robot, rather than a human, go to a shelf and get some tablets hasn’t really made that much difference to the patient experience – who still have to sit in a waiting area and have fairly minimal human contact with the pharmacist through a small, bank-style, dispensing window.

Guy’s and St Thomas’ is a good NHS Trust, so I don’t mean any criticism, but my equivalent of asking myself about the housing mix is to look and wonder whether the design took more account of measurable outputs, like how long it take to retrieve a drug, than the important outcomes, like informed and happy patients. Too often the public sector concentrates too much on what it can measure (and is new shiny), rather than on what’s important.

I’m really not that sure how interesting it is for me to write about meetings. They certainly aren’t interesting enough for people to turn up and listen. Having said all that, there were a few interesting items on the agenda of last night’s Adult Care Services and Health OSC.

I was only there for part of it, my council role is a bit of an experiment in ‘cross-cutting’ (which seems to be causing undue confusion, I have to say) so I attended only for the ‘health’ and not the ‘adult care services’ elements. To give some select highlights:

10-627 Patient records
Despite my predilection for civil liberties and occasional concerns about the expansion of the state into private life I find it hard to get excited about these things! But given the appalling track record of the state on data security in recent years it possibly isn’t surprising that the local NHS were questioned heavily about how access will be controlled and the audit trials that will be put in place to ensure record safety. I think most of the committee members were satisfied.

From my point of view the question is of balancing risk. No system will be 100% secure and, I have no doubt, whatever safeguards are introduced someone will have enough malice or incompetence to circumvent them sooner or later. However, what we need to assess is whether or not the benefits a system that means different parts of the NHS can see your relevant medical history is worth the risk of potential security breaches.

Personally, I feel happier about having an electronic medical record than old paper copies that can get lost, burnt, mixed-up, misplaced or even burgled. But not everyone would share that view, it struck me that the NHS were putting a lot of effort into creating a system that could reassure most people their information is safe.

10-628 National Patient Survey
I posted about the results from this recently. The committee members were interested in exactly why some surgeries are performing so badly when compared to some of the excellent results that other practices got.

The local NHS stated that they needed to better understand exactly why there was severe dissatisfaction with some surgeries and what they needed to do to encourage choice. They were asked to return to the committee with details of what they were doing to improve those weaker surgeries.

10-629 NHS White Paper – Response to consultation
This was an interesting discussion. I’ve not posted much about the NHS White Paper, but it represents a superb opportunity. The council has long held a policy that it should be responsible for health commission. While the white paper doesn’t suggest that it goes someway towards it.

For a start the council would take on responsibility for public health (as it did until 1974), and for establishing a ‘Health and Wellbeing Board’ however, there are opportunities to work with the GP consortia providing, for example, support on things like procurement or analytical services. In turn, this will enable a better, more joined-up set of services to residents.

There seemed to be good support for the council’s position of moving rapidly to set up the Health and Wellbeing Board here and working with GPs to establish how it could all be implement. The local NHS said they were “fully supportive”. The opposition members also expressed their support for the council’s position, but couldn’t vote for it, citing issues like the government’s naming of the white paper as a bone of contention.

10-632 Local Involvement Network – Annual report
This was an interesting report, mainly because of the thought processes that it set me on. The Local Involvement Network (or LINk) (or @WandsworthLINk on Twitter) was established a few years ago, there is basically one per borough, and is a free membership organisation that exists to formally scrutinise health and social care services in the borough. The council provides support to it.

In the white paper they continue, except they will be re-named HealthWatch and given a significant proportion of the seats on the Health and Wellbeing Board.

I am half-planning a fuller post on them because it struck me that they are, basically, an unnamed part of the Big Society. I’ve posited before that the Big Society exists, but we just don’t recognise it as such. Yet. LINks are, to me, probably in exactly the same category. They are there scrutinising local health services on behalf of residents and patients and, I would contend, in a better way than many other statutory bodies (by focusing very much on the ground level experience, than management level statistical outputs).

Maybe the first thing we should be doing in the Big Society is identifying and renaming all those parts that already exist.

There were several other health related items on the agenda. You can see the full agenda with linked reports on the council’s website.

View Wandsworth GP ‘approval’ ratings in a larger map
Given that the police aren’t too keen on the whole mapping thing I’m turning my attention to the NHS this week.

This map is a (not very good) attempt at showing which GP practices have the highest ‘approval’ in the borough. I did it largely to see if there was any geographic patterns, and there don’t seem to be any, so a bit of a waste of time. Basically the darker the blue the higher the approval. If there’s any pattern at all probably that there’s a correlation between deprivation and what people think of their GP, but not much of one.

The data are from the GP patient satisfaction survey, and use the most recent results. My interpretation of approval is to basically subtract the percentage of people expressing dissatisfaction from the percentage of people expressing satisfaction. (I’m fully aware that satisfaction if you measured satisfaction with me in the same way it would be much lower.) This also has the effect of increasing the margin of error, but since the results are in line with individual satisfaction and dissatisfaction ratings, as well as the results for a separate question on whether patients would recommend their surgery to others, I’m comfortable that the results have enough validity for a blog post.

It’s worth pointing that that these are based on subjective patient opinion, not on clinical outcomes. It’s entirely possible that some of those negatives will reflect decisions that, while made in the best interests of the patient, were not what the patient actually wanted.

The sample are, to a degree, self-selecting, because they are among the third or so who bothered to reply. And you might also question whether some of the higher scores are just because dissatisfied patients have left!

But I think there is some value in the data. You do not, generally, need to be a clinician to instinctively know if you are getting good care. And while I know, politically, saying anything that makes it seems like advocating a market within the NHS can be dangerous, I have to wonder why patients from Balham Hill (52% approval) aren’t all wandering down to Balham Park (97% approval). If anything it’s an argument that this sort of data should be more public, along with information on how to move. Without making any judgement on the individual surgeries or GPs scores, you would think that when it comes to health people should be looking to be satisfied rather than staying put with a GP practice with which they are unhappy.

One of the interesting factors that I think might be at play is that those practices that seem to be scoring really highly also tend to be those that have active and involved patient involvement groups. That’s certainly the case for Balham Park, which didn’t have anyone dissatisfied and has 99% of respondents saying they would recommend the practice (Balham Hill has only get 54%, 31% say they would not recommend it). While there might be cause and effect there, I’ve no idea which way round it goes – is there a patient group because it’s a good surgery, or a is it a good surgery in part because there’s a patient group.

I post it for interest. It’s well worth taking a look the full data on the GP patient survey website. And in the interests of openness, you can download the data I used for the map (essentially the Wandsworth data with a few sums and geographical data added in CSV format).