The idea of getting more patients out of hospital and treating them closer to home has been an ambition for years in Sheffield.
But the head of the organisation responsible for guarding the city’s health money is candid in admitting: “We’ve not really achieved it - and we’ve still got a way to go.”
Maddy Ruff is the accountable officer for the NHS Sheffield Clinical Commissioning Group, and has been in the role for just over 12 months, grappling with the challenge of boosting community services closer to patients’ homes when there is little chance of an increase in funding in the near future.
The CCG is facing a £30 million shortfall this year, while Sheffield’s adult and children’s hospitals are ‘increasingly coming under pressure’, says Ms Ruff, who came to the city with more than 20 years’ NHS experience, having held a variety of board-level positions.
In essence, hers is the job of a chief executive, but with a title that suggests the buck stops with her, and a pay packet to match – around £80,000 a year plus pension and performance bonus.
“It’s been a really interesting year, in that I suppose what I hadn’t appreciated when I came to Sheffield is just how big and how complex the health system is here.”
She suggested the sheer size and scope of Sheffield Teaching Hospitals had to some extent impeded change.
“When you have a very successful hospital, in a way it’s too good, so it provides a whole range of services, whereas in other areas the district generals have struggled to recruit staff and some of the clinical specialities haven’t been able to continue.
“Sheffield Teaching Hospitals have never really had that problem. And probably more patients go to hospital in Sheffield than maybe would do in other areas.”
She adds: “If everybody’s got lots of money, they can all get along together and everything’s great, but as soon as you bring in financial challenge, if you’re not careful everybody retreats into their own organisations.
“But I think there’s a genuine willingness to look at the ‘Sheffield pound’ – all the resource that comes into Sheffield - and how we best spend that.
“We won’t get it right first time and there will be some disagreements and challenging conversations along the way, but I think the intent is there.”
A combined, single budget, collecting every penny Sheffield receives for health and social care, would total around £1.2 billion. If the city can manage this effectively it would be a radical step, and Ms Ruff is reluctant to put a timescale on its implementation.
“I wouldn’t like to nail my colours to the mast and say when it could happen, but I think we’re making all the right steps towards that happening. We’ve talked about having a ‘shadow period’ next year.”
She’s proud of the progress made in drawing up a primary care strategy, one element of which is an ‘out of hospital’ plan centred on the idea of creating 16 neighbourhoods across Sheffield, each with a population size of between 30,000 and 50,000.
“It’s not just about GP services, it’s about how we then wrap around social care and the voluntary sector so we create services that meet the needs of that neighbourhood,” says Ms Ruff.
“And the exciting thing for me is we’re not saying one size fits all. So in a neighbourhood in the city centre, where perhaps the majority of people don’t speak English as a first language, those services would be completely different to the range of services we might develop in Dore and Totley.”
Through ‘social prescribing’ – referring patients to charities and voluntary organisations – patients are even being given help with needs indirectly related to health, such as filling out benefit forms.
More pressingly, there is the need to sign contracts with health providers for the next year in Sheffield, which has to be completed early this time, by December 23.
“Andrew Cash at the teaching hospitals has got to balance his books, just as I’ve got to balance mine,” says Ms Ruff.
“There are tensions, there are bound to be, because clearly, as with any contract negotiation, they won’t want to put themselves in a position where they’re not sustainable financially. It’s a trust thing. They have to trust that services really will be delivered in the community for them to reduce their cost base – say, the number of clinics they run. That saves me some money to move it into the community – but then, if the same number of patients go through the hospital Andrew’s not getting paid for it.”
However, even if the need to make cuts disappeared, Ms Ruff believes change would still be necessary.
“We would need to change the kind of care we give people and how we organise it. Patients are living longer, but gaining more conditions. There will be other health professionals to support them and it does not have to be a doctor.”
There are difficulties in recruiting family doctors – the idea of traditional ‘partnerships’ is off-putting for new medics – and efforts are under way to increase the numbers of nurse practitioners, physiotherapists and pharmacists who can see patients for straightforward conditions.
There is also the hope that, with more support, the voluntary sector can step in to bridge the gap.
“What they manage to do on a small amount of money I think we could all learn from.
Often it’s on a shoestring and they don’t know where the next pay cheque is coming from, and so one of the things we are looking at is how to support the sector more. I think they could play an even bigger and better role in the way we develop the ‘neighbourhoods’.”
Savings have been made by buying cheaper drugs - simply purchasing a different brand of inhaler has saved £500,000 this year - and cutting the expensive prescribing of gluten-free food for coeliacs.
“People have no idea how much drugs cost,” says Ms Ruff.
“There are things that we have put restrictions on – things like plastic surgery where it is not clinically necessary. Because if we did that we wouldn’t be able to pay for all those hip operations and heart operations.”
But there remain ‘lots of red lines’ where cuts would be unthinkable, she concluded, saying firmly: “People are entitled to a health service.”
A ‘more integrated approach’ to urgent care
Sheffield’s urgent care strategy – a review of out-of-hours services, A&E and more – is taking shape, said Maddy Ruff.
The city’s four out-of-hours hubs at the Northern General, Crookes, Woodhouse and Heeley – paid for with £9.7 million from the Prime Minister’s GP Access Fund – are being encouraged to work closer together, and the role of pharmacies is being strengthened.
Mental health patients, children and adults, are also being offered more support. A mental health worker now accompanies police on busy nights throughout the week.
“Some of our services were not brilliant,” said Ms Ruff.
“Somebody with mental health problems shouldn’t end up in A&E or, even worse, a police cell.”
The status of the GP walk-in centre on Broad Lane, and the minor injuries unit at the Royal Hallamshire Hospital, has yet to be confirmed. The Hallamshire facility was once an A&E, and the decision to downgrade it sparked a furore in the 1990s.
“What we’re going to try to look at is a more integrated, joined-up approach, rather than all these different services,” said Ms Ruff. “But we have to be conscious that Sheffield is a big city, so we have to know that we’re providing services that are accessible to everybody.
“If there are major changes, we will be consulting with the public. We won’t just make a unilateral decision, we will come out with options for the public to consider. But we’re not quite at that stage yet.”
She added: “Part of the problem is that we’ve confused people. We’ve got this myriad of services and they’re not really sure what does what - the one that they’ve all heard about is accident and emergency and I think part of our A&E strategy is to simplify things so that it’s much clearer.
“Hopefully next year we should see quite a change.”