Monday, 10 April 2017

Commissioning Structured Education

Outside view of the tent pitched in my garden
April 2017
I bought a tent! It arrived on Tuesday but I was working all five days last week, and had commitments on all five evenings so I didn't even open the box until Saturday. I had to mow the lawn before I could try it out, but it's looking good so far. The first test will come in July with a camping trip to Devon.

The extra day's work last week was a course all about advanced features of the Roche Bolus Advisor. This is the algorithm that is used in one particular blood glucose meter and insulin pump handset to try and suggest the right amount of insulin in any situation. It was a brilliant course but I don't have my notes with me at the moment, so that blog post will have to wait. In the meantime, I shall complain about a different meeting I went to on Wednesday.

The Clinical Commissioning Group (CCG) for the area where I work is a baffling organisation. Maybe all CCGs are baffling, but I couldn't say. Its role is to decide which health services should be provided to the local population and, as the name suggests, commission those services. Obviously I am affected by the commissioning of services relating to diabetes, but I couldn't tell you the mechanism by which commissioning is done, or how we are paid as a result. I think I know the names of one or two people in the whole chain of management that administers this process but I have no understanding of the process at all. No idea whatsoever. Not at all.

Recently there has been a national campaign to promote the provision and take-up of Structured Education for people with Type 1 or Type 2 Diabetes. Structured Education isn't just any old course, it has a definition within the national guidelines. It has to be evidence-based, have specific aims and learning objectives, have a curriculum that is written down with supporting materials, be delivered by trained educators, be quality assured by trained, competent, independent assessors who measure criteria that ensure consistency, and be audited.

Recently a pot of money was announced for Structured Education and bids encouraged from CCGs. The email from the CCG asking what we deliver in our area ended up with me, so I responded describing our courses as well as asking more about the bid in case I could provide some insight, given that I am actually delivering Structured Education to actual patients. "No thanks, we're fine" was the reply.

I heard no more, and then a colleague forwarded a message to me describing a workshop that the CCG were proposing to hold to discuss Structured Education. All sorts of people had been invited, but not me. They were happy to add my name to the list, though, and then a few days before the meeting was due to be held we received the documents that were going to form the basis of a discussion about what is delivered in our area, where the gaps might be, and how we could improve things.

That's all very admirable, but when we came to read the figures in the documents for the programmes that we were actually delivering, it became clear that they had spoken to nobody who was actually doing the job. The figures suggested that no courses at all for Type 1's were being run in one area, and that courses that were being run in the other area were completely inaccessible.

I try not to get annoyed about how the NHS is run, but this was very provoking. The CCG was convening a workshop to discuss a service that I personally deliver along with just four other people. Not only had they not spoken to any of us, but they hadn't bothered to even invite those who deliver the service that was to be discussed, and had circulated completely inaccurate data. My colleagues tend to assume conspiracy, but I generally believe it's either laziness, ignorance, or lack of time. The seeming inability to pick up the phone is particularly annoying though.

Anyway, we wrote a short rebuttal of the data and asked for this information to be circulated (it wasn't), and turned up at the meeting anyway. The person who presented the data did express doubt about its accuracy, but we weren't given an opportunity to clarify. We will be getting together with CCG representatives as a result of the meeting, but my confidence in their competence is pretty low. As for outcomes - there was a lot of the usual talk about how things could be better, but my experience is that nothing changes as a result of a meeting, especially if there is no new money. The CCG doesn't yet know the outcome of their bid.

By chance this has all coincided with a change in the administration of our course. I had long been dissatisfied with how patients were identified and notified about courses. We would set dates for courses a few months in advance, but when people were referred they were simply stuck on a waiting list. About a month before a course was to start (which might be a very long time since the referral was made) about twenty people on the waiting list were contacted in the expectation that we'd get about eight to turn up.

So the waiting list was full of people who, despite having presumably agreed to the referral, had no intention of attending. Many of those who had intended to come had forgotten what it was all about by the time they received an invitation. Although we wrote back to some referrers, most never found out whether their patient had attended or not. And we couldn't tell how long anyone might have to wait.

I got together with one of the other educators and our administrator and suggested how things might work better. I was taken aback by their resistance to any change at all, and it became clear that if I wanted improvements I was going to have to take over the admin myself, at least temporarily. So I fired up Excel and made a start, and so I had a good idea of how things stood in time for the CCG's meeting.

Last year we were struggling for staff with only two of us available to deliver the course. Now we are getting up to full strength with four (and soon five) of us, but at the same time referrals have increased dramatically. The waiting list stands at about ninety people, and there are virtually no referrals from GPs, so if this starts to happen (as it should) we will be properly overwhelmed.

So the next thing to do is to get in touch with everyone on the waiting list to weed out those who can't or won't attend - that should reduce numbers significantly. Then I'll be offering actual course dates to fill up all the courses to the end of the year, and we'll see how many people are left over and if extra capacity is needed. We can't just put more people on a course, because (due to an error of the previous administrator) we had 12 attending the last course, and it didn't work very well at all.

The full course takes four days over three weeks - so what about those who can't spare the time for this? I am putting together a much shorter version which will be piloted in May over just four hours, and if successful we can at least offer something to people who can't commit to four days. But that won't be Structured Education.

When I started this job I was determined to keep my head down and have no bright ideas that would result in extra work. Nobody thanks you for extra hours, and I don't work with the sort of people who inspire any sort of innovation - as evidenced by their reluctance to consider admin change, even though they now see how much better it will be. I have started to hope that this job will be my last, if I can get an early retirement date. But I can't seem to help wanting to change things and making extra work for myself.

Inside view of the tent with porch and 'bedroom'

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