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Dr Bob's blog - how we can help ease pressures on accident and emergency services

Posted by Amanda Crawford at 09/09/2016 18:14:20

When is summer not really summer? Believe it or not, this isn’t a joke about the weather which, as I write, is warm and sunny.

It is, rather, a point about the use of accident and emergency services in the NHS. Years ago, we used to talk about winter pressures, and to plan for surging numbers of people attending Accident & Emergency departments for treatment for injuries and illnesses linked with freezing temperatures and icy conditions.

These days, A&Es see more or less the same level of demand all year round. Right now, the calendar may say it is summer, but the weekends are some of the busiest on record.

Walk into the A&E at Tunbridge Wells and you are likely to find a growing number of people of all ages waiting to be seen – many of whom could be treated elsewhere.

As the body responsible for planning and paying for urgent and emergency care for the population of west Kent, we at NHS West Kent Clinical Commissioning Group recognise this is profoundly unsatisfactory for patients, their families, the hospitals and their staff, and is a very poor use of NHS resources.

With this in mind, our big focus is on improving the urgent care available out of hospital, to reduce the need for people to go to hospital and particularly to A&E.

Our GP practices are looking at how they can band together both to offer more  appointments outside traditional opening hours within Tonbridge, Tunbridge Wells, Sevenoaks and Maidstone and, as I mentioned in my last column, to enable much closer working with nursing, social care, mental health, health and social care co-ordinators, and other community services such as physiotherapists.

Already practices make a great effort to see, on the same day, patients who say they need an urgent GP appointment. Outside practice opening hours, urgent GP appointments are available for those who need them by phoning the non-emergency NHS number, 111.

But my GP colleagues and I think that extending access to local GPs, who can see patients’ medical records and so can treat them in the full knowledge of their medical history, will make a real difference.

We expect it to improve patient experience and to help us pick up more problems when people are still well enough to be cared for at home.

From an IT perspective, we are already making it possible, with individual patients’ consent, for medical records held by a growing number of our GP practices to be viewed and updated by health professionals working for other services treating them, including the hospices in west Kent.

Meanwhile, we are working with our colleagues from other NHS organisations and Kent County Council to build health and care teams offering a range of treatments and services based around groupings of GP practices.

These will be able to treat patients holistically, looking after both their physical and mental health needs, including when it is urgent. Our aim is for these teams to be up and running by April 2017.

In the slightly longer term, we are interested in seeing if 111 could form part of these teams too.  We would like callers to 111 to be able to speak to a range of different professionals, depending on their health.

We have already put in place a home treatment service, which sees GPs go out to patients’ homes to assess them and plan their medical care. That care is then given by experienced community nurses and doctors. We want to strengthen this further by adding input from hospital consultants who are specialists in the care of older people.

We are also stepping up medical support for care homes, to enable them safely to care for more people in the home rather than taking them to A&E.

Meanwhile, we are working with Maidstone and Tunbridge Wells NHS Trust to ensure that rehabilitation starts as soon as possible for frail people in hospital for intensive medical treatment. That means from the moment they are well enough, when they are still undergoing treatment, rather than waiting for that treatment to be complete.

This will cut the length of time they spend in hospital – vital because we know frail older people tend to recuperate faster and to retain more of their strength and independence when treated at home, wherever possible.

We believe that these changes will help us to create a health and care service for west Kent which can meet the needs of the population now and into the future. It will ensure that most care is delivered where it should be – out of hospital.

Over coming months we will be talking to you about our plans and I am interested in knowing what you think.

Please email me at westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE if you have experiences or thoughts you would like to share.

Dr Bob's blog - our vision for the future of healthcare

Posted by Amanda Crawford at 29/06/2016 17:29:18

Many of you will already be aware that the Government has agreed to give an additional £8 billion to the NHS by April 2021 to help us transform care.

At the moment, we are working with all the NHS organisations in Kent and Medway, and with social care, to decide how we can make best use of this money to make a genuine and lasting difference for local people.

We need collectively to achieve three main things: to weed out indifferent care so that whatever the time, whatever your needs and wherever you are in Kent and Medway, you get a good service; to get rid of fragmentation and gaps between services and update what they offer to match what people need now, not the way things were 20 or 30 years ago; and to put our finances on a sound footing today and for the future.  

Across the NHS in England, if we carry on as we are, the gap between our budget and what we need to spend will grow every year. It is forecast to reach £30 billion by April 2021. Clearly that is unsustainable.

Part of the reason for it is that, at the moment hospitals, which are the most expensive NHS service, are the default where people tend to end up if they are unwell and have nowhere else to go and no one to look after them.

Someone who is poorly and is also homeless or has a drinking problem or dementia that makes them aggressive may be in a hospital bed for weeks after they are well enough to leave, when what they actually need is a place of safety where they can be supported. 

To achieve our financial aim, we need both to change services now so we can meet growing demand and also to improve people’s health and wellbeing so that, wherever possible, people benefit from many more years of good health, reducing their need for health and care services.

This is a real opportunity to boost the care that people get out of hospital - at home or at their GP practice.

Imagine a world where you need travel no further than your local town for a clinic at which a consultant or specialist nurse will review your diabetes, your dementia, or your COPD (long-term respiratory disease).

A world where, if you have long-term health conditions, your care is provided by a single team who all know each other, know you, and share notes and records so you or your nearest and dearest don’t have to keep saying the same things over and over again to different people.

A world where the practice nurses and community nurses work together, along with social care, voluntary organisations, GPs, end of life specialists, Admiral nurses and consultants specialising in the care of older people – so patients get the whole package of care they need, either at home or at their GP practice. 

Where you only ever have to go to hospital in a crisis – and there are far fewer of those because by calling your GP practice, you get the care you need, whatever the time of day or night.

And where there are specialist beds in the community for people at risk of being admitted to hospital, including the trickiest cases, so major hospitals are reserved for those who really need the specialist input that only they can provide.

That is the vision we at NHS West Kent Clinical Commissioning Group have for the future.

To get there, we need to invest significantly in general practice and other community health services to overcome barriers that currently stop staff from different NHS organisations and Kent County Council working together as one team with the single joint imperative of getting care right for the people they serve.

We need to develop the leadership skills of GPs so they can provide clinical leadership to these complex teams, and to make sure there are enough GPs, in good enough premises, with enough other skilled staff to support them.

It sounds easy but it is important to recognise that if this were easy, it would have been fixed a long time ago.

Nonetheless, I think this is a once in a generation opportunity to reshape the NHS and we need to seize it. I am really concerned that if we don’t, the frail elderly patients who need GPs the most will lose out. 


  • If you have a story about local healthcare services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's blog - loneliness is a real issue for our age

Posted by Amanda Crawford at 22/04/2016 17:36:33

Loneliness is a real issue for our age. My sense is that loneliness these days is more profound and widespread than ever before.

There may be all sorts of reasons for that – scattered or broken families, our hyper-busy lives that give us no time to make friends, bereavement or even just retirement – but one thing is sure: loneliness and social isolation take a toll on our health.

We are social animals and it is often through our connection to others that we build or renew our confidence and self-esteem. Take away that connection and there can be all sorts of consequences for our health.

There is clear evidence that lonely people are more likely to experience depression and less likely to take care of themselves. There are also some studies that suggest it puts you at higher risk of a heart attack and may weaken your immune system, increasing your risk of other health problems too.

Everyone from the student starting life in a new city, to the first-time mother, struggling to cope with being at home on her own with her baby all day, or the man in his 80s, grieving for the wife he is losing to dementia, can be affected. 

Yet the solution is not just having people round you.  Research reviewed by AgeUK shows that it’s the quality of your relationships with people and their meaning that prevents loneliness.

So while loneliness increases dramatically with age – roughly half of people over 80 say they are lonely - it’s possible to be more lonely in a care home, surrounded by people, than in your own home with very few but cherished visitors.

What is the solution?  If you feel up to it, the six ways to wellbeing can be a good place to start whatever your age or your circumstances. They are:

·        be (physically) active

·        keep learning

·        give – your thanks, your time, a smile

·        connect – with other people

·        take notice – savour the moment and be aware of the world around you

·        care for the planet – make small changes to achieve a greener life.

Research shows that these simple steps can improve your mood, strengthen your relationships and help you cope when life doesn’t go to plan. (Visit www.liveitwell.org.uk to find out more.)

But for some people, this may be easier said than done. Someone who is lonely probably also finds it hard to reach out. And if you’re feeling very low or are physically immobile, you may not be able to go for a brisk walk or find a class to join.

That’s why we at NHS West Kent Clinical Commissioning Group are exploring social prescribing as a way to help people whose needs may not be fully met by traditional medical means.

There are numerous voluntary organisations doing wonderful work in west Kent but often we GPs are unaware of their existence. Now we are looking at whether we can extend the role of a team of professionals known as health and social care coordinators whose job it is to be aware of these organisations and to help west Kent residents to link in with them.

What would that mean in practice? Someone who could sit down with you to work out what your real interests are and link you to a local group or organisation that chimes with them. Someone who wouldn’t have a full waiting room but would have time to spend with you, and to follow up with you a few weeks or months later to see how you are getting on. Someone who knows not just about the vital hubs such as Age UK but also the new Live Well Kent service which provides community mental health and wellbeing support, support groups for people with different health conditions, the active retirement associations and volunteering opportunities and so much more.

We think this has the potential to make a real difference to our communities, tapping into the fun and friendliness that really is out there, and warding off the ill-health that can result from loneliness and depression.

·       If you have a story about local healthcare services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's blog - be sugar smart

Posted by Amanda Crawford at 18/02/2016 12:21:06

I hope you have already seen news about the Sugar Smart campaign. This is the drive to encourage parents to take control of their children’s sugar intake. Run by the national campaign Change4Life, it has some striking statistics.

Astonishingly, four to 10-year-olds consume the weight of an average five-year-old in sugar - almost three and a half stone - every year. That is more than three times the recommended amount for their age group.

You might think sweets and biscuits would be the worst culprits. But actually, top of the list are soft drinks and fruit juice, which contribute 30 per cent of the average child’s sugar intake.

Biscuits, cakes and breakfast cereals are almost level pegging, at 29 per cent. Then come sweets, chocolate, table sugar, jams and other sweet spreads (22 per cent) and yoghurts, fromage frais, ice-cream, and other dairy desserts (12 per cent).

Teenagers, like younger children, get 15 per cent of their calories from sugar. In adults there is a small drop, to 12 per cent – but considering the recommendation is that everyone over the age of two should get no more than five per cent of their total calories from sugar, this is still far too high.

I chair the West Kent Health and Wellbeing Board which brings together NHS and local authority colleagues to take important decisions on health for west Kent. 

We are so concerned about obesity in this area, and the awful risks this poses for people, that all of us – the clinical commissioning group, district and borough councils, colleagues from Kent County Council which is leading the campaign locally, NHS England and Healthwatch Kent - are doing everything we can to support the Sugar Smart campaign. 

From next month, Kent County Council is running an advertising campaign in various areas across Kent where childhood obesity tends to be higher, which will be supported by communications from the other members of the local Health and Wellbeing Board.

As I mentioned in my last column, in west Kent about one in five children in the first year of primary school (aged four or five) and nearly one in three in the last year of primary school (aged 10 or 11) are either overweight or obese. 

That makes them more likely to become obese adults, who will be at increased risk of a range of serious health problems. 

Yet in the GP practice where I work, I see just as many parents bringing their children in because they are worried about them being underweight as overweight. The concerns about children weighing too little are almost always wrong: parents just don’t realise that you should be able to see a child’s ribs. We are starting to lose our ability to know what normal looks like.

Worryingly, children don’t need to be overweight to experience the ill-effects of too much sugar.

They might seem fine on the outside but too much sugar can lead to the build-up of harmful fat on the inside that we can’t see. This fat around their vital organs can cause serious diseases in the future such as heart disease, some cancers and type 2 diabetes.  

That’s without going into the awful impact on children’s teeth of excessive sugar. The commonest reason for children aged five to nine to be admitted to hospital is to have their teeth removed.

I hope that if you are the parent or grandparent of a young child, you will download the free Change4Life Sugar Smart app which allows you to see how much sugar there is in everyday food and drink. You can scan the barcode of products to find out how much sugar they contain. Just search for it in the App Store or on Google Play.

Both the app and the Change4Life website have lots of good ideas and tips on reducing sugar for all the family.

Of course, although the focus is on the very young, cutting down on sugar is very important for the rest of us too.

Different things work for different people but anyone who would like support to achieve a healthy weight and become more physically active can contact the teams for their area:

•Tonbridge & Malling Borough Council’s Healthy Living Co-ordinator on 01732 876347 or at healthy.living@tmbc.gov.uk  

•Tunbridge Wells Borough Council’s health team on 01892 554201 or at health@tunbridgewells.gov.uk

•Sevenoaks District Council’s health team on 01732 227000 or at healthy.living@sevenoaks.gov.uk

•Maidstone Borough Council’s Healthy Living Team on 01622 602222 or at healthyliving@maidstone.gov.uk or www.maidstone.gov.uk/healthyliving

If you have a story about local healthcare services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's blog - my wish list for a healthy NHS

Posted by Amanda Crawford at 15/12/2015 16:02:39

With Christmas shopping sprees well underway in our towns and villages, and goodness knows how many letters posted from children to Santa, I have been thinking about the presents I would like for our local NHS and for us all.

It is a huge relief that the first chunk of the money requested by Simon Stevens, the chief executive of NHS England, is going to be in the budget from April.

We know that the organisations providing care in the NHS are busier than ever. Community nurses and therapists; GPs and practice nurses; hospital staff; mental health teams and ambulance crews  – all are working flat out, supported by a myriad of people behind the scenes. And social care staff are working just as hard.

Across the NHS in England, we need an additional £30 billion just to cope with the increasing demand. Most – £22 billion – is being found from savings within the NHS but £8 billion is coming from the government. It is great to know that the first part of the government’s contribution is on its way.

But we must make best use of it. And that is why the first thing on my Christmas present list for the local NHS is better productivity.

By that, I mean less duplication of effort and expertise, better processes and reporting, and better sharing of knowledge between different NHS and social care teams and organisations. We all know of cases where patients have to keep repeating the same information over and over again, every time a different member of staff turns up. It is tiring for the patient, exasperating for relatives and a waste of expensive staff time.

Then there are unnecessary tests that may be carried out, because of mixed messages or, in some cases, over-caution – doctors wanting absolute confirmation of a diagnosis rather than trusting to the first test and their own experience and judgment.

And repeated assessments of, for instance, people’s ability to cope at home or their likelihood of falling. A colleague tells me of her father having three falls assessments in the weeks before his death: two by different social workers and one by a community nurse. He didn’t mind but was rather bemused by repeatedly being asked to demonstrate exactly how he got out of bed in the morning.

The NHS and social care talk a lot about joined-up care. In 2016, I would like to see that become a reality, and I believe that the leadership of the developing GP federations in west Kent will start to make it happen.

What it takes is for staff from different organisations who work side by side caring for the same patients to forget the barriers that divide them and focus on what unites them – the people they are looking after.

That means finding ways to overcome different IT systems, different ways of doing things and different cultures and managing to work as if they all belong to the same organisation. Incidentally, I think it will improve staff satisfaction and retention too by eliminating petty frustrations that bother staff just as much as patients.

My second wish is for us to succeed in bringing the same approach to the very real desire there is in the NHS, Kent County Council and the district councils to improve people’s health.

While there has been some improvement over recent years, about one in five children in the first year of primary school (aged four or five) and nearly one in three in the last year of primary school (aged 10 or 11) in west Kent are either overweight or obese.

This is too high and so it is essential that the NHS and local authorities find ways to work together along with parents and schools to achieve the change that is so badly needed for our young people. We need to pool budgets, make use of the enormous amount of public health expertise available locally and support adults and children to change their behaviour.

This leads on to my third wish. This is that all of us who struggle with different issues about our health – weight, smoking, drinking to excess, workaholism, stress, being inactive or whatever it may be – find the resolve in the new year, or sooner, to make the changes we know are needed.

It is heartbreaking to diagnose people in their 40s with Type 2 diabetes. But even worse to diagnose it in teens and people in their 20s. And of course living with diabetes over decades brings an increased risk of complications and other illnesses.

Dry January and New Year’s resolutions offer all of us a great opportunity to get the New Year off to a good start.

Let’s do it! And try to keep it up so we all have a happy, healthy and, hopefully, peaceful, 2016.


  • If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - Stay well this winter

Posted by Amanda Crawford at 20/11/2015 17:01:00

This is the time of year when the NHS starts to gear up for winter. Over the next few months, like every year, we can expect to hear stories from across the country about A&Es being overcrowded, with too many people having to wait too long to be treated.

It is easy to assume that the reason for this is that more people get ill in winter. It sounds obvious – but the reality is quite a lot more complex.

You may be surprised to learn that the winter months are not when the number of attendances at A&E are at their highest. Nor do they see a surge in how long most inpatients stay in hospital.

In general, March, May, July and August are the months when the number of people coming through the front door of A&E is greatest.

And all year round, 80 per cent of people who need to be admitted to a hospital bed stay for fewer than seven days – with no obvious seasonal pattern as to when their numbers go up or down.

So why do we always hear that winter is so busy? One of the reasons is that there certainly is an increase in the number of people who stay for longer than a week in hospital.

“Safer, faster, better: good practice in delivering urgent and emergency care”, a document published by NHS England about the NHS across the country, points out that their number shoots up after Christmas (and sometimes after Easter too).

Often this is because they need more complex arrangements than other people to be able to go home safely: more equipment, or equipment that is difficult to obtain, or more staff coming in to bath or move them.

After the holiday period, it can take a while to get everything co-ordinated for them so they stay for longer which, in turn, has a knock-on effect on the hospital. 

At the same time, there may be higher rates of staff sickness in winter. And quite often outbreaks of bugs, such as Norovirus, also known as the winter vomiting bug, which mean wards have to be closed to new admissions.

You may have read recently in this paper that Tunbridge Wells Hospital is converting office space to create a 38-bed assessment unit in the New Year, where GPs will be able to refer patients without them needing to go via A&E.

This initiative should help to improve care for those frail elderly patients who are at greatest risk of having lengthy hospital stays over winter.

Of course, it is best if people can avoid falling ill. COPD (chronic obstructive pulmonary disease – the blanket term for a group of lung conditions) is the single biggest cause of emergency admissions to hospital.

If you have COPD, you should have an emergency prescription for steroids and antibiotics from your GP for use in case of flare-up. If you don’t have one, please contact your practice and ask for one along with instructions on when to use it.

Many people don’t realise they have COPD. If you have ever smoked, and you find you are getting a fruity cough after you get a cold, or feel more short of breath undertaking normal activity than you would expect, make an appointment with your GP.

I would also urge everyone entitled to an NHS flu vaccination to make sure they have it promptly. This year that includes not just people over 65, people with long term conditions and pregnant women but also children aged two to four (on 31 August) and in school years one and two.

Healthy children will be immunised with a nasal spray which is quick, painless and effective, helping protect them from flu and reducing the chance of it spreading to others.

And I also recommend you familiarise yourselves with the Health Help Now website and app – www.healthhelpnow-nhs.net or Health Help Now from your app store – which has advice and information on local services. Developed in Kent by Kent doctors and other health professionals, its purpose is to help you find the right treatment for common symptoms, especially if you don’t know what to do or who to contact.

  • If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's blog - keeping general practice independent

Posted by Amanda Crawford at 03/11/2015 12:55:29

It will be obvious to anyone who has read previous columns by me that I believe general practice contributes a great deal to the NHS.

Having worked as a family doctor for 25 years, I have seen whole generations of patients growing up or growing old, and I relish my time in the practice where I work. There is an extraordinary satisfaction in being able to offer people the advice, care or treatment they need.

Often, I see people at their saddest or most anxious. Sometimes, there is an easy solution but often there isn’t and sometimes, patients’ anxieties about their health are well-founded and we have to discuss what the future holds.

But, always, I know that I and my fellow GPs in west Kent are trying our hardest for our patients, and that we think of them as people, with a life history and family, not as a collection of illnesses.

Doctors have the privilege of being the most trusted profession – an Ipsos Mori poll published earlier this year found that 90 per cent of the public trust us to tell them the truth. What’s more, this result has been the same for the last 20 years.

I suspect some of this reflects the unique role of general practice, and the cradle to grave care it provides.

Now, however, I am starting to worry that the very existence of general practice in its current form may be at risk. This would be catastrophic for the NHS and I would like to explain why.

You may already know that GPs are not employees of the NHS. We are paid by the Department of Health as independent contractors – meaning we run practices either single-handedly or as partnerships, employing the other staff who work there.

As a result, we are not answerable to shareholders or boards, but to each other and our patients. This means we have the independence to take decisions, with patients, that we genuinely believe are the right ones for them, unfettered by other considerations.

Often, this will mean accepting clinical risk. Our ability to determine which patients need to be referred for further investigation or tests, and which do not, is one of the main reasons why the NHS can achieve so much for so many.

In west Kent, we have £1,114 per head to spend on our 479,631 population and with that we achieve care which is really good by international standards. Care in America costs nearly twice as much yet outcomes are no better. Indeed, on many public health measures such as life expectancy, they are worse.

Yet the drive in the NHS nationally is to move away from GPs working as independent contractors and towards employing them in bigger organisations – in chains of practices or in practices run by hospital trusts.

Both these end the independence of GPs and dilute their responsibility for their patients who will no longer feel quite so much “theirs”.

Currently, GPs don’t generally pass the buck – if we come across an illness we haven’t seen before, we will research it to be able to care for our patient properly.

If, however, GPs no longer feel the same personal responsibility for or link to their patients, I would expect them to practise much more defensive medicine, along the lines of the American model. The number of patients being referred for “just-in-case” tests and surgery would soar.

This has potential not only to result in unnecessary treatment for many people and distress for many more, but also to bankrupt the NHS.

We all know money can’t be spent twice – spend it on needless things and it won’t be there to pay for care for those who genuinely need it.

To avoid this, I would like to see recognition by the Department of Health and NHS England of the immense value that general practice provides in its current form, and a focus on strengthening it now and in the future.

Ethereal promises of 5000 extra GPs won’t meet this need. Our leaders need to celebrate general practice as the fulcrum on which the NHS pivots.


  • If you have a story about local health services you would like to share, you can emailwestkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.


Dr Bob's blog - we need to work smarter, not harder

Posted by Amanda Crawford at 16/10/2015 10:12:53

There has been a lot of talk in the media recently about the shortage of family doctors in this country. Some commentators describe it as a “GP crisis”.

In west Kent, we are fortunate that we do not currently have the difficulties filling general practice vacancies that some other areas do.

Nonetheless, GPs in west Kent are very concerned about:

  • Recruitment – not enough medical students are choosing to become GPs
  • The existing workforce – large numbers of current GPs are coming up to retirement
  • Increasing workload – the demand for everyday and urgent GP appointments is increasing every year, and GPs are taking over responsibility for more aspects of their patients’ care.

It is clear that it is better for patients to be seen in GP practices rather than hospitals whenever possible, and this is part of NHS England and NHS West Kent Clinical Commissioning Group’s plans for the future.

Overall, this means that more needs to be done every year, but we have no more doctors to do it and may have fewer in the future. Although the Health Secretary is promising 5,000 more GPs, we do not know when they will be available nor where they will choose to work. Realistically, we cannot expect the load on doctors in West Kent to lessen.

Speaking as a working GP, I know that one response to this is to put your head down, work longer hours week after week, and keep going until one day, perhaps, you can’t do it any more. Obviously that is no good for individuals – we do not want to have a system which expects some people to burn out caring for the health of others. Nor does it offer any sort of long-term solution.

What we need to do instead, to borrow an advertising slogan, is to work smarter, not harder.  

That’s why the GP practices in west Kent have decided to group together in two GP federations:  one covering Sevenoaks, Tonbridge and Tunbridge Wells, and the other, Maidstone, Malling and the Weald.

I should say straightaway that this will have no impact at all on the set-up of practices. Kingswood Surgery in Tunbridge Wells, where I work, will remain Kingswood, Warders Medical Centre in Tonbridge will remain Warders, and so on.

What it does mean is that practices will have a mechanism for employing staff between them, to increase the services they can offer. And it will allow practices both to share expertise and to share the load.

What difference will this make for patients? Initially, we see federations as a way for our local GP practices to provide better training opportunities for doctors, nurses and other staff; to strengthen “cover” arrangements by running a local locum bank; and to save NHS money by banding together in their purchasing of essentials. This may not be visible to patients but it will improve patient care.

Within the next two years, there should be scope for the federations to do more. For instance, a GP practice facing an unexpected problem – such as having a doctor off sick and no one available to fill in - may be able to alert its nearest neighbours, who will be able, between them, to see those patients who urgently need an appointment. This is self-evidently better for patients but it is also better for practices – reducing the isolation and pressure staff can otherwise feel.

Equally, the federations will allow patients better access to the expertise that GPs in our area already have but are not always able to offer widely.

If a GP is a specialist in neurological disorders, such as motor neurone disease and multiple sclerosis, or in skin problems, such as acne, eczema and psoriasis, it makes sense for them to be able to see patients from other practices besides their own.

And federations may eventually include staff over and above those working for individual practices, so our patients benefit from integrated teams of health visitors, district nurses and mental health specialists working closely with groups of practices.

This is particularly important for frail older patients as it will increase their chances of being treated at home.

In all, the federations will support our practices to do more, more effectively, for our patients. And that really is smarter.

  • If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's blog - healthy ageing in West Kent

Posted by Amanda Crawford at 19/08/2015 15:53:46

It is one of the great successes of our age that many more people are living for longer.

On average, people aged 60 in Tonbridge and Malling will live to be 84.3 while, in Tunbridge Wells, they can expect to reach 85 (compared to 83.9 in Kent as a whole and 84 in the UK).

Most people will be lucky enough to be able to manage any health conditions they have, without any real impact on their quality of life, for almost all their life.

But in old age, people tend to become increasingly frail. Over recent years, it has become clear that we, in the NHS and care services, need to think about people who are frail as a separate group with their own distinct needs.

NHS England’s “Safe compassionate care for frail older people” tells us: “Older people with frailty can be readily identified and are usually known to local professionals. They usually have weak muscles and, often, conditions like arthritis, poor eyesight, deafness and memory problems. They typically walk slowly, get exhausted easily and struggle to get out of a chair or climb stairs… Between a quarter and a half of people over 85 are estimated to be frail, with overall prevalence in people aged 75 and over approximately nine per cent.”

We probably all recognise that as a description of people we know.

Of course, many people in their 80s and even 90s are not frail and, while there is limited research on this, the evidence seems to be that people who are physically active and who take the usual steps we recommend for health (no smoking, not too much alcohol, healthy eating) keep frailty at bay for longer.

We at NHS West Kent Clinical Commissioning Group have just produced a guide, “Healthy ageing in west Kent”, aimed at people over 70. It has details of health walks, tea dances and falls prevention classes, and of organisations such as the University of the Third Age and Kent Active Retirement Association which offer many different activities.

This is a companion booklet to “A practical guide to healthy ageing” produced by NHS England with Age UK, which has a useful test you can use to check walking speed – an indicator of frailty.

Both guides are available on our website, www.westkentccg.nhs.uk and we are also printing and distributing them with the help of Age UK, district nurses, hospital teams, memory clinics and out of hours GP services. If you would like a printed copy, your local Age UK will have some shortly. I commend them to you.

However, having accepted that many people do become frail, it is important to think about how that impacts on the care and treatment they need. One of the characteristics of people who are frail is that they are much less likely to make a full recovery from anything, such as an infection or a fall, which causes a decline in their health.

Given this, their treatment needs may be quite different from those of patients who are on track to make a full recovery and we need to recognise this in the way we organise services.

To help us do this, we are currently working with members of the public and with health and care organisations in west Kent to review services provided for frail older people and see what needs to be improved. 

This will help us to develop what we call a “frailty pathway”, setting out the care frail, older people can expect to receive at every stage, to meet all their needs.

For instance, Kent County Council is preparing to implement a project this autumn which will aim to get frail older people straight home from the hospital ward wherever possible – rather than them going on to a community hospital or care home almost automatically.

Evidence from elsewhere in Kent, where this has been put into practice, shows that it works really well. Patients, who are often desperate to get home, love it, and just by being at home and picking up their daily lives, they are much more likely to regain independence and strength that they lose in hospital. Meanwhile, it frees up community hospital beds for people who will truly benefit from specialist rehab that they cannot have at home.

This is a project that requires no extra money, just a focus on what is best for patients and the determination to deliver it.

I am confident that by listening to the views of the public, thinking imaginatively and holistically, and always referencing what patients actually want from treatment – they generally have very clear ideas on this - we will be able to ensure that people who are frail get the best possible care. 

  • If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - We must all take responsibility for our own health

Posted by Amanda Crawford at 19/06/2015 10:36:51

As the new government starts work and all the heat and noise from the electoral process settles down, I have been thinking about how money is spent on health in this country. 

I am sure many of you are familiar with the term “military-industrial complex” which President Eisenhower coined as he stepped down from office in 1961. He warned that the combination of the military establishment and arms industry had the potential to exert too much influence on government.  

I am starting to feel that we are too much in thrall to a medical industrial complex and we need to consider whether we are using the limited money available for health and care in the best possible way. 

Currently, in our system, there is an enormous focus on developing new drugs which often achieve only marginal improvements in outcomes for patients at significant extra cost. The most notable examples are cancer drugs, but we also see this in the treatment of long-term conditions, such as diabetes. 

Meanwhile, we see recommendations for more and more conditions to be treated with medication: for instance, statins (which lower cholesterol) are now recommended for everyone with a ten per cent or greater risk of a heart attack within ten years, compared to a 30 per cent risk until 2005. This is even though evidence about their benefits for people other than men with a diagnosis of heart disease is limited and we know there are side-effects for some. 

And in the Lucentis / Avastin debate, we see two medications that can treat a condition (wet age-related macular degeneration). The cheaper one is widely used in the US but not in the UK because the manufacturer has not applied for it to be licensed, costing the NHS an extra £100 million a year. 

My quarrel is not with any individual medication or manufacturer – of course, we all want the best possible treatments for our loved ones –  but with the fact that all the time our focus is on medication, we are missing the most important thing of all: prevention of ill-health. 

Starting in the 19 century, clean water, immunisation and hygiene all transformed life expectancy.  

For the 21 century, the focus needs to be on obesity and lack of exercise, which increase the risk of a number of serious illnesses. 

Graham MacGregor, professor of cardiovascular medicine at Queen Mary University of London, has said food is the single biggest cause of death and ill health in the UK due to its high levels of salt, fat and sugars. 

There is a suspicion that 6,000 lives may have been lost because of a loss of momentum in the drive to reduce salt in food in recent years.   

So, we are in a confusing situation; we know what causes a significant proportion of illnesses and, therefore, we know how to prevent these, but we don’t invest in prevention. Instead, we put our scarce resources into treating the consequences of our failure to prevent ill health.  

I would like to see the government: 

  • require the food industry to label products prominently with their calorie content so people can take informed decisions

  • bring in legislation if voluntary agreements on salt restrictions don’t work

  • take the lead in promoting active lifestyles

This may attract cries of “nanny state” but I would far rather that than let the population slide into an epidemic of preventable illness.

In west Kent, the local Health and Wellbeing Board, which I chair, currently has as its main focus how the NHS and local authorities can make it easier for people to lead healthier lives – we are very clear that we need to understand what works and implement it.

And as individuals, we must all take responsibility for our own health. Try to cut down on sugar and salt in your diet, and to build activity into your daily life, and you will see a difference – small changes sustained over a period can transform your health.

By being the right weight and taking regular exercise, we can live healthier lives here and now, reduce the number of years affected by ill-health at the end of our lives and get more enjoyment out of life.


  • If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.


Dr Bob's Blog - the role of the GP

Posted by Amanda Crawford at 13/05/2015 16:26:42

When I started work as a GP in Tunbridge Wells, some 20 years ago, it was rare for anyone to be admitted to hospital without their general practitioner knowing and being consulted.

These days, the vast majority of admissions go ahead without any contact with GPs: we are aware that our patients have been admitted to a hospital bed only 20 per cent of the time.

Does this matter? Well, yes, I think it does and the reason it matters is because this omission prevents GPs from playing one of their most important roles: being the patient’s advocate and offering clinical leadership to a system that can otherwise be too fragmented.

This is particularly true for people who are nearing the end of life, which the approach of End of Life Awareness Week from 18-24 May throws into sharp relief.

Supposing I have a patient who is being treated by a cardiologist for his heart failure, a dermatologist for his skin problems, a renal clinic for his kidney disease which requires dialysis three times a week, an oncologist for his cancer and a palliative care specialist.

This is an impressive array of specialists and they all have their own ideas about what they can offer and what could be done to improve the patient’s condition from their perspective.

But none of them focuses on what their specialism means for the patient’s life overall. If more surgery or another drug is offered – what will this mean for the complex conditions he is living with? What is realistically achievable for him? What does he want from the months that are left to him and where does he want to die in the end?

In my view, this is where GPs’ unique combination of continuity of care (we often get to know our patients over many years, especially our frailer patients who tend to see the same doctor), our understanding of the range of specialities in medicine and surgery, and our clinical authority makes us indispensable as the patient’s adviser, counsellor and friend.

Even if my patient wants to die at home, there is a risk that an ambulance crew will take him to hospital for a deterioration in his condition which is actually part of the normal decline towards the end.

As his GP, if the ambulance crew rings me, I can assess their description of his condition and, where appropriate, countermand the decision to take him to hospital. By doing that, I accept responsibility for his death at home, knowing that this is what he wants. But I do need to be called by the ambulance crew for this to work. I also need to be available and, even if I work 12 hours a day, five days a week, as many GPs do, that still leaves a large amount of time when I am not present.

We are now developing a system in west Kent which will allow all clinical staff treating a patient at end of life to see and take instruction from a care plan written by patients with their GPs.

This should offer the best of both worlds: drawing on GPs’ clinical expertise, their knowledge of their patients and the trust their patients have in them to develop a plan which really reflects what patients want, and maps out the different scenarios which may occur in their illness.

Then each individual’s plan will be stored in a high-security online system where staff treating a particular patient can access it when necessary.

It should mean that all patients on the system have round-the-clock access to their individual GPs’ thoughts and expertise - effectively the same input as if their GPs had been contacted directly.

And it will help the NHS to get away from broad-brush guidance and protocols, and to focus instead on the particular needs of the person at the heart of it all, allowing them to die with dignity in the place of their choice.

For more information on End of Life Awareness Week, please visitwww.dyingmatters.org/YODO


  • If you have a story about local health services you would like to share, you can emailwestkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - Quitting smoking

Posted by Amanda Crawford at 02/03/2015 15:55:05

No Smoking Day on 11 March, encouraging people to quit smoking for a day as a stepping stone to giving up for good, means there will be a lot of talk about smoking this month.

As an ex-smoker myself, I know that giving up can be hard. I stopped about 20 years ago after ten years peppered by many attempts to quit. At that stage, there was little or no NHS support for people who wanted to stop so all my attempts were solo.

What did it for me in the end was the shock of my sister having a nearly fatal heart attack. That frightened me enough to give up smoking instantly.

Everyone knows that smoking can damage your health but not all of us can have a really personal experience of what that means in practice.

However, there is much more support available these days for people who want to quit, which demonstrably helps: people are four times more likely to stop smoking for good with professional support.

Smoking is also becoming ever less acceptable.  Government interventions, including the ban on smoking in public places, and the tax escalator on tobacco, have made it an increasingly expensive, slightly shameful, habit.

The number of smokers has been dropping since the 1970s, and this is feeding through into the statistics on deaths.

So what’s our local picture? Not quite as good as you might expect.

In Sevenoaks 16.0 per cent and in Tonbridge and Malling 17.1 per cent of adults now smoke: better than the south east and national averages of 18.0 and 19.5 per cent respectively. But in Tunbridge Wells, 19.3 per cent of people smoke, and in Maidstone the figure is 20.4 per cent – which is higher than the south east and national averages. It is notable that, across the country, more people with routine and manual jobs smoke than any other group.

We have clear evidence that children exposed to smoke, including in the womb, are at higher risk of cot death, meningitis, asthma and glue ear. I would urge parents and parents-to-be who smoke to think really seriously about this, and seek help to quit. 

Deaths attributable to smoking are on the way down in the NHS West Kent Clinical Commissioning Group (CCG) area, which covers not just Tonbridge and Malling and Tunbridge Wells but also Maidstone borough and most of Sevenoaks district.

However, the latest statistics, for 2006-2012, show they dropped more slowly in our area than anywhere else in Kent and Medway except NHS Thanet CCG, which kept pace with us at five per cent.

The deaths don’t tell the whole story. The toll on people’s lives and wellbeing – and on those who love them – of living with long-term conditions caused by smoking is considerable, as of course, is the cost to the NHS of providing their care.

Stroke, heart disease, cancer, COPD (chronic obstructive pulmonary disorder – diseases such as chronic bronchitis and emphysema): smoking causes years of ill-health and, often, disability.

COPD, for instance, results in the constant production of phlegm, which is very unpleasant. When COPD patients have an attack – often triggered by damp weather, or catching a cold – they can panic, feeling they can’t breathe.

In the expectation that wintry weather will continue this month, I’d like to advise people with COPD to try to stay warm, use their inhalers before going out into the cold or being active, and  speak to their GP about having stand-by antibiotics and steroids at home, so they can use them quickly if they feel an attack is brewing.

But on the principle that prevention is better than cure, I’d also invite those who may be thinking about quitting to give it a go. They will quickly find they feel better and have more energy.

Any smokers who want to quit can contact the Kent Stop Smoking Service on 0300 123 1220, text QUIT to 87023 or visit www.smokefreekent.co.uk for support. You may find the British Heart Foundation’s No Smoking Day website helpful too.

Alternatively, you can talk to your GP about help to give up smoking.

Dr Bob's Blog - Working together to prevent ill-health

Posted by Amanda Crawford at 16/01/2015 18:14:35

Most of us make some sort of resolution every New Year, often to do with self-improvement. Quitting smoking, losing weight, taking up exercise, drinking less: it is fairly clear we all know what we need to do to look and feel better and, incidentally, be healthier.

Magazines and the television at this time of year are full of stories about Dry January (something colleagues and I are taking part in – visit www.alcoholconcern.org.uk  to find out more or join in too), exercise programmes and, less positively, detox diets which supposedly cleanse your body. I would recommend balanced, calorie-reduced, diets and regular exercise for those wishing to lose weight rather than radical regimes.

However, the reality is that, despite the fact we know what we should be aiming for and we generally try to do it on and off throughout our lives, we are not, as a nation, becoming healthier.

Indeed, NHS England’s Chief Executive Simon Stevens writes in his Five Year Forward View published in October:  “The future health of millions of children, the sustainability of the NHS and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.  Twelve years ago, Derek Wanless’ health review warned that, unless the country took prevention seriously, we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded – and the NHS is on the hook for the consequences.”

So, what is to be done? Well, it does, of course, remain the case that each of us has a responsibility for our own health and parents, in particular, have responsibility for giving their children a healthy foundation as far as possible.

But there is more too that organisations can do to support us in making healthy choices and reducing our risk of ill-health.

The reorganisation of the NHS in 2013 saw the creation of the Kent Health and Wellbeing Board to lead and advise on work to improve the health and wellbeing of people in Kent.

Locally, we have a West Kent Health and Wellbeing Board which does the same thing but at west Kent level – where we have the knowledge, experience and expertise to identify the issues of most importance to our population and do something about them.

Its members are the clinical commissioning group , the four district and borough councils in west Kent, the county council including public health colleagues, NHS England, and Healthwatch which raises the public voice on health and care services.

Between us, we hold the budgets for all aspects of health, care and public health locally and, among other things, our organisations oversee:

  • planning and licensing

  • homebuilding and the local economy

  • upkeep of footpaths, cycle tracks, country parks – and most roads

  • schools

  • health education (such as antenatal classes and diabetes education)

  • healthcare from cradle to grave

The most crucial role of the Board is to ensure that each of our organisations has a firm focus on prevention and how we can take every opportunity to improve public health in the longer-term, however busy we may be with immediate issues.

For instance, we are about to start a piece of work looking at all the factors involved in adult and child obesity.

It is now generally accepted that there is such a thing as an “obesogenic” environment, which encourages people to eat unhealthily and not do enough exercise. Are we in danger of this in west Kent? If so, what can we do about it?

By exploring the issues together and coming up with actions for the different organisations that make up the Board, we can have a  far bigger and more lasting impact that if we were trying to do the same thing separately.

Meetings are held every two months and are in public. The next one is at 4pm on 20 January in Maidstone House, King St, Maidstone, ME15 6JQ. I would encourage you to attend if you would like to know more.

In the meantime, I hope you have a very happy and healthy 2015.

  • Different things work for different people but anyone who would like support to achieve a healthy weight and become more physically active can contact the teams for their area:

  • Tonbridge & Malling Borough Council’s Healthy Living Co-ordinator on 01732 876155 or at healthy.living@tmbc.gov.uk or

  • Tunbridge Wells Borough Council’s health team on 01892 554201


  • If you have a story about local healthcare services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - A weighty issue

Posted by Amanda Crawford at 11/09/2014 16:14:20

In west Kent – and indeed the rest of the country – people of normal weight are now in the minority.

Around two-thirds of those who live in our area are overweight or obese, a proportion which is steadily increasing.

This is a very significant change in my lifetime, and one which has very serious consequences, both for our health system and for the individuals themselves, particularly for around 100,000 or so people in our area who are obese. They are facing a wave of ill-health, from osteoarthritis and heart disease to diabetes and cancer.

National government is wrestling with this issue and it is rarely off the television – there has been much talk recently about a sugar tax, or fast food bans near schools, while programmes about people who are very fat or have managed to shed large amounts of fat, abound.

I think one of the problems is that overweight has become so common that we have forgotten what normal looks like. People of normal weight now look thin.

It is also evident that we have an opaque relationship with food and one which is coloured with emotion.

I have noticed that I no longer wait to feel actively hungry before I eat. Instead, I find myself eating because I am not full.

It is just so easy now to acquire calories – a couple of biscuits mid-morning, a packet of crisps before supper – extra snacks have become commonplace so, perhaps, it is no wonder that so has overweight.

We as GPs can sometimes be reticent about discussing their weight with patients because we don’t want to upset them.

When we do fulfil our responsibility to draw the health consequences to their attention, I find that some patients feel that eating is “the one thing they have got left”, particularly if, for instance, they can’t work or get out because of pain or other health problems.

It’s almost as though people feel that they would rather carry on overeating and face the consequences than change their lifestyle and reduce the risks.

I certainly don’t have a magic solution apart from the simple observation that overweight is a consequence of consuming too many calories. Some good ideas to follow are:

  • Know your body mass index (BMI): (your weight in kilos divided by your height in metres squared – there are plenty of BMI calculators on the internet and scales in pharmacies often work this out automatically). More than 25 is overweight, more than 30 is obese.
  • Watch your calories
  • Don’t snack
  • Take exercise to the point that it makes you mildly breathless or sweaty for half an hour at least four times a week.

Anyone who reduces the calories they eat will lose weight. Taking exercise burns off calories and may make you feel better too – there is quite a lot of evidence that exercise is effective in improving mood and a sense of wellbeing, both in the population as a whole and in people with clinical depression.

Being physically active should be a part of normal life, particularly in a culture where it is so easy to consume more calories than we need.

Different things work for different people but anyone who would like support to achieve a healthy weight and become more physically active can contact the teams for their area:

  • Tonbridge & Malling Borough Council’s Healthy Living Co-ordinator on 01732 876155 or at healthy.living@tmbc.gov.uk or
  • Tunbridge Wells Borough Council’s health team on 01892 554201

If you have a story about local healthcare services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.


Dr Bob's Blog - Doctors' workload

Posted by Amanda Crawford at 14/08/2014 12:29:35

Most people who have been to the doctor’s recently will have seen a crowded waiting room. Probably more crowded than in the past.

I would like to explain how much busier GPs are than we used to be, and why this is.

Ten years ago, it was exceptional if I saw 120 patients in a five day week. These days, I am in the practice for three and a half days a week, and it is not unusual for me to see 150 patients in that time. (The other day and a half are spent on clinical commissioning group work.)

In west Kent as a whole, the 230 full-time equivalent GPs carry out 1.5 million patient consultations a year for the 463,000 people who live here.

It is a staggering number. Compare that with A&E, which is rightly identified by the media as busier than ever. Our local A&Es in Maidstone and Tunbridge Wells see about 120,000 patients a year. So we are seeing 12 patients for every one seen at A&E.

This is the case across the country – everywhere, family doctors are seeing many more patients than ever before.

Why is this? Partly it is that modern medicine can do more, for more people. People’s conditions are being managed more effectively, with more proactive interventions put in place and monitored by the GP.

Take statins, for instance – millions of people take statins to help them avoid a heart attack. GPs seek out those patients who will benefit and ensure regular follow-up to pick up any problems or side-effects. And we are delighted to be able to offer that.

Secondly, as we all know, the fact people are living longer means many more patients are elderly, frail and living with two, three, or more, long-term conditions. They may be under the care of a range of consultants but their GP is, rightly, their first port of call for day to day healthcare and if they feel unwell.

Then, there are those who are under so much pressure that they call with minor problems. A young man who has had a sore throat for less than 12 hours may ask for medicine to make him feel better if he thinks he will be sacked if he doesn’t show up at work. We sympathise but really need these patients to understand that a chat with a pharmacist would be a better use of their (and our) time.

The sad thing is that this level of demand is deterring younger doctors from entering general practice. I know of a GP who cannot retire because she can find no one to take over her practice.

We need to do something about this, because GPs are the lynchpin of the NHS and without them, the system will not work.

Although it is a minor point, I think it would also help if politicians recognised and celebrated the contribution that we make to the health of the nation, rather than implying that we, in some way, contribute to the problems of the NHS.   

  • If you have a story about local healthcare services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - Have there been cuts in hospital services?

Posted by Amanda Crawford at 18/07/2014 14:32:28

When I ask people: “Have there been cuts in hospital services during the last few years in West Kent?” the audience’s answer is nearly always yes.

In fact, spending on hospital services in West Kent increased from £350 million to £520 million over the five years from 2007/08 to 2012/13, while all other parts of the NHS did not receive more money.

This is not a reflection of the Private Finance Initiative under which the new Tunbridge Wells Hospital at Pembury was funded. Nor is it in any way a criticism of the hospital trusts (these figures include Dartford and Gravesham NHS Trust as well as our local Maidstone and Tunbridge Wells NHS Trust because they show what happened under the stewardship of the primary care trust).

 It is a phenomenon that occurred across the country.  Part of the reason for it is the way that NHS spending is organised nationally. I won’t dwell here on the subject of national tariffs, Payment by Results or “trim points” but the complexity of organising payments in an enormous organisation like the NHS means that well-intentioned initiatives have sometimes produced unintended results.

This is changing now. The need to “rebalance” spending is thrown into sharp relief by the care needs of the growing number of people, often very elderly, with complex health conditions, who clearly do better when looked after at home. Yet sometimes they end up in hospital because services for them are not available in their homes.

We can all see that if spending on hospitals continues to increase as it has been, there will be less and less money to spend on the very services these patients most need, services out of hospital.

What are we at NHS West Kent Clinical Commissioning Group doing about this? In addition to our local project Mapping the Future, which I have mentioned here before and will return to in the future, Kent has recently been chosen to pioneer integrated health and social care.

Our county is one of only 14 areas in the country to win pioneer status, meaning that we will be given Department of Health support to be bold and innovative in the way we work with the county council and providers of care to develop integrated services which provide for all of patients’ needs, rather than treating individual problems simply as and when they occur.

We know that disjointed services, with different phone numbers for different organisations, are among the biggest bugbears for patients so being given national backing to move swiftly towards a different approach is really good news.

In addition, clinical commissioning groups in England are required to allocate money towards a £3.8 billion Integration Transformation Fund, starting in 2015. This is to be spent, under the guidance of local Health and Wellbeing Boards, on joined-up services to support people outside hospital.

This gives us the opportunity to create a shared plan for health and social care services, potentially bringing benefits that go far beyond the scope of the fund itself.

This is promising. The NHS has been saying for some years that things need to change – but now I believe the will, resolve and, importantly, mechanisms are there to make it a reality.

If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent CCG, Wharf House, Medway Wharf Road, Tonbridge, TN9 1RE.

Dr Bob's Blog - One year on

Posted by Amanda Crawford at 30/05/2014 16:23:32

It is now just over a year since NHS West Kent Clinical Commissioning Group took over responsibility for planning and paying for most of the healthcare for people in Tunbridge Wells, Tonbridge and Malling, Maidstone and Sevenoaks district (except Swanley).

I have been considering what we have achieved this year and thinking about the challenges that lie ahead.

With 62 member GP practices, a population of 463,000 and a budget of £481 million for 2014/15, we are almost twice as big as the average clinical commissioning group (CCG) across the country.

That gives us some real advantages – for instance, we have 12 GPs on the governing body, each of whom has an in-depth understanding of how local health services work and ideas about how they can be improved.

This has enabled us to introduce some initiatives which are already making a clear difference.

For instance, we have commissioned an Enhanced Rapid Response team, including geriatricians, senior nurses, physiotherapists and occupational therapists, from Kent Community Health NHS Trust.

They assess and treat patients in their own homes within two hours of referral, seven-days-a-week, 24-hours-a-day. The focus is on people over 75 and the team is supporting people to avoid hospital admission where possible, and to help with early hospital discharge.

With Kent County Council, we are also funding Romney Ward at Maidstone Hospital for patients who still need nursing care but no longer require oversight from a consultant. They are cared for by Kent Community Health NHS Trust nurses and therapists until they are ready to go home or to a care home.

These initiatives – along with the hard work of A&E and other hospital staff, GPs, minor injuries units staff and others involved in urgent care – have helped Maidstone and Tunbridge Wells NHS Trust (MTW) achieve its best performance in years on the four-hour waiting target.

This is at a time when A&Es across the country have been struggling to see and treat or discharge patients within four hours and when, locally, numbers attending A&E have reached a ten-year high.

In Steve Beaumont, we also have an energetic and dedicated Chief Nurse, who focuses intensely on ensuring quality care for patients.

In the autumn, he led a conference on reducing healthcare acquired infections, including MRSA and Clostridium difficile. Staff from the hospital, community services and GPs shared their determination to further reduce infections by careful monitoring and reduced use of antibiotics.

I believe it is no coincidence that the rate of MRSA infections in this area is now among the best in the country and the number of C. diff cases has plummeted in hospital and in the community.

We at the CCG have also focused on working closely with local people to develop our future plans. A group of 160 members of the public – including 120 picked because they are a representative sample of the population of west Kent – examined our proposals in detail and helped us firm up plans for the next five years.

These will be challenging years, because the rising needs of our population cannot  be met within the budgets we expect to receive unless we rearrange services to maintain high quality responsive care.

To meet this challenge, we will need to make dramatic improvements to the care available outside hospital for people, particularly elderly and frail people, with long-term conditions. We need to detect and treat illness in them early, and provide really intensive support in their own homes or care homes when needed, so a hospital admission for illness related to pre-existing conditions becomes the exception rather than the rule.

This will require shifting money into community teams, and new ways of working by health and social care professionals working in the community, including GPs, district nurses, mental health nurses, physiotherapists and other staff.

We are still looking at the detail of how this will work. We just know that we – like the rest of the NHS across the country – need to do it. And we will need your support to make it happen.

If you have a story about local healthcare services you would like to share, you can emailwestkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - Involving patients in their care

Posted by Amanda Crawford at 12/03/2014 16:57:31

Just because the NHS can do lots of things, does it mean that it always should? This may sound disconcerting but let me tell you a story to make my point.

The father of a colleague fainted in London. An ambulance arrived within three minutes and took him to the nearest A&E. He was kept in overnight for observation – he is 82, with long-standing heart and kidney disease.

So far, so good. But now, things get more complicated. As he waited to be discharged home, a blood test came back which seemed to show he had had a heart attack. He couldn’t have a routine angiogram, the standard treatment for heart attack, because it was too risky for his kidneys. So he was kept in and two days later had an imaging test which showed heart problems. Not really a surprise, given his medical history.

However, he was advised that he needed a specialist angiogram for people with advanced kidney disease, at another hospital. It took a week for him to be moved – a week of being on the ward.

When he reached the second hospital, he was found to have a kidney infection, which was treated. Then it was five days of waiting – repeatedly fasting for a slot that did not materialise - until he finally had the specialist angiogram, which found nothing that needed treatment.

The condition of his heart had not changed. The initial blood test reading may have been the result of his brewing infection.

However, after the angiogram he hallucinated for hours, and he is now much more prone to repeating himself than he was before any of this happened.  So he spent three weeks in hospital having a fairly stressful time, and had some very expensive tests, which brought him no benefit (as it happened – though, of course, they could have done), and may have caused him harm. His family now feel they let him down by not asking the right questions.

With hindsight it might have been wiser for the doctors to share their uncertainty and decision making with the patient and his family: some of the downside of this episode could have been avoided.

As a culture, in the NHS, we are now much more likely to intervene than we once were just because we can. We are risk-averse. We do not want to be the ones who take the decision not to do something, when doing it may help a patient. But we don’t always give as much weight to arguments on the other side.

A philosopher and remarkable man, Ralf Dahrendorf, said (in a context of discussing justice and liberty): “Survival is not enough; what matters is a life worth living.”

When applied to the NHS, that means for me that patients are sufficiently informed to be able to contribute to important decisions about their care, rather than just being carried along by the wonders of science.


When medical technology operates like a machine, everyone can lose sight of the individual patient at the centre of it and what is best for them.

Patients and those around them need to feel more confident about challenging the medical team, and doctors (and other health professionals) need to be better at adjusting treatments to individuals' needs.

If you have a story about local healthcare services you would like to share, you can e-mail westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - Cutting through the maze

Posted by Amanda Crawford at 03/02/2014 12:07:08

When people first start to need health and care support in their own homes, one of the things that strikes them is how many services there are – and how difficult it can be to work out which one you need and make contact with it.

For people recovering from injury or illness, the last thing they need is a maze of different teams and phone numbers to negotiate.

The NHS has grown like Topsy over the past 65 years and sometimes, well, it seems just too big. Even professionals like me sometimes get confused about exactly who does what and who is the right person to talk to about a particular problem.

The good news is our colleagues who provide these services – Kent County Council and Kent Community Health NHS Trust - recognise this too.

So they are trying to do something about it, to make it easier for everyone to get the right care from the right people in the right place and at the right time.

They are moving towards having completely integrated teams based in GP surgeries in which health staff, such as district nurses and physiotherapists, work alongside social care staff, such as care managers and occupational therapists, to provide a seamless service to those who need it.

This will mean that staff share information and skills and are able to deliver care and support which is completely focused on the needs of individual patients. It will make the whole system easier and less frustrating for patients, and by being more efficient, should reduce costs too.

Already new Health and Social Care Coordinators are being introduced in west Kent to act as a single point of contact for patients and GPs.

GPs will refer patients to their local Health and Social Coordinator who will then help the patient navigate the system and access the right services, feeding back to the surgery.

One telephone call or e-mail will be enough to start the process.

This will make life easier for patients, carers, and GP practices, will streamline referrals, help reduce duplication of services and cut down on the number of unnecessary hospital admissions.

By talking to GPs, the coordinators will also be able to identify patients most at risk and treat them earlier, keeping them in their own home for longer.

It’s not rocket science but we hope, in our own way, that it will produce the right stuff for working in the future. 

If you have a story about local healthcare services you would like to share, you can e-mail westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent Clinical Commissioning Group, Wharf House, Medway Wharf Road, Tonbridge TN9 1RE.

Dr Bob's Blog - Quality at the heart of care

Posted by Amanda Crawford at 05/12/2013 12:53:57

As family doctors, we at NHS West Kent Clinical Commissioning Group (CCG) are passionate about getting the best possible care for our patients. That’s why we have taken on the enormous additional responsibility of commissioning health services for this area, because we believe we can make a real difference.

 In general, the quality of health services locally is good but we would like it to be better, and that is part of what we are setting out to achieve.

We want services for people in west Kent to offer excellent patient experience – so that patients are content with everything from the time they wait and the information they are given to the courtesy with which they are treated and the overall result.

We want services to be clinically effective – to maximise the benefit of surgery, medication and other treatment and minimise their risks.

And we want services to be safe – minimising the risk of patients coming to harm while they are being treated.

Recently, in the Francis report on what went wrong at Mid-Staffordshire NHS Foundation Trust, we have seen the terrible suffering that can result when the NHS loses sight of these fundamental principles.

As the commissioners of health services for west Kent, we are responsible for holding the hospital, mental health, ambulance and community services in this area to account if they fail to deliver high-quality care.

I think changes brought in because of the Francis report will make a difference. All health professionals will be required, for instance, to alert patients who have been or may have been harmed by services, whether they have complained or not.

In the past, loyalty to colleagues, fear for their own careers, and worry about looking foolish may have contributed to health staff staying silent in the face of unacceptable practice.   This new “duty of candour” will end that.

It will also bring areas of poor practice within NHS organisations to light much more quickly than may have happened in the past.

The new national “league tables” for consultants carrying out different types of surgery and the new Friends and Family test – asking patients if they would recommend a service to their friends and family which is to be introduced by every NHS trust - will also shine a spotlight on services and help us to identify failings.

Quality of services is a very high priority for our CCG. We have a GP-led quality committee to look at these issues and identify as soon as possible any service that is having problems. It examines not just data, important though that is, but also what patients tell us, to give a broader picture than was possible in the past.

If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at West Kent CCG, Wharf House, Medway Wharf Road, Tonbridge, TN9 1RE.

Dr Bob's Blog - Keeping well this winter

Posted by Amanda Crawford at 01/11/2013 16:49:24

After our glorious long summer, the sudden switch to colder weather has come as more of a shock than usual.

This is the time of year when, in the GP surgery, we typically start to start to see large numbers of people with coughs, colds, earache and sinus problems. Flu and tummy bugs are likely to follow in months to come.

Many people think, wrongly, that they need antibiotics for these illnesses. In fact, they are probably viral infections, which are much more common than bacterial infections. Antibiotics do not have any effect on viruses and should never be prescribed for them.

This is something you probably already know, but its urgency is increasing. You may recall the warning issued earlier this year by the Chief Medical Officer, Dame Sally Davies, about the "catastrophic threat" of bacteria becomingly increasingly resistant to antibiotics. She ranked it alongside terrorism and climate change as a critical risk to the nation.

The problem is that using antibiotics too often and when they are not needed can lead to bacteria in the body building up a resistance. Then antibiotics simply can’t do their job when they really are needed.

Dame Sally warned that, in the future, people could die of a simple post-operative infection for lack of effective treatment.

Here at NHS West Kent Clinical Commissioning Group, we are trying to play our part in the national challenge to preserve the effectiveness of antibiotics.

We as GPs can do that by prescribing antibiotics only where necessary. You can help us by visiting your local pharmacy for over-the-counter remedies for simple coughs and colds and, if you are prescribed antibiotics, ensuring you take them as indicated and always finish the course.

Looking ahead to winter – and there seem to be rumours galore that we are in for a prolonged cold snap – there are simple things you can do to improve your chances of staying well.

Washing your hands thoroughly with soap and hot water, especially after going to the loo, before preparing food, and when you come in from work, shopping or school, is your best weapon against infection. Use a tissue (not a handkerchief) to catch coughs and sneezes, throw it away and wash your hands – as the slogan goes, Catch It, Bin It, Kill It.

I would encourage anyone with a bad chest or impaired immune system to make sure they have their annual flu vaccination. The flu virus changes every year and the vaccination changes accordingly.

Many people will have searched out the green cross of a pharmacy on their summer holidays for advice and treatment for insect bites, tummy bugs or other infections. Our pharmacists are just as good as those overseas! And Tunbridge Wells, Tonbridge, Sevenoaks, Aylesford and Maidstone each have at least one pharmacy open until 10pm and on Sundays. Yet not everyone makes full use of the expertise that pharmacists offer.

Check with NHS 111 for advice, or your pharmacy or GP if your symptoms are worse than expected or not improved by over-the-counter remedies.  For more information and a useful symptom checker, visit  www.nhs.uk

Finally, I would urge older people particularly to make sure they keep warm. Being in a cold room puts a strain on your heart and your immune system.  The Kent and Medway Green Deal Partnership (a consortium of local authorities in Kent and Medway and Housing Associations) is working with Enterprise to offer free home energy improvements for warmer, more comfortable homes and to help reduce energy bills.

Homeowners can check whether they are eligible for the scheme and sign up at www.kent.gov.uk/warmhomes, or by calling 0800 521 660, quoting "Warm Homes".

I hope you have a healthy winter.

If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at West Kent CCG, Wharf House, Medway Wharf Road, Tonbridge, TN9 1RE.

Dr Bob's Blog - What’s going on in urgent care?

Posted by at 19/09/2013 10:36:30

There has been an awful lot in the news recently about attendances and increased waiting times at A&E and not all of it has been right. I am going to try to set the record straight.

The Health Secretary, Jeremy Hunt, blamed longer waits at A&E on GPs no longer working 24 hours a day. As I and most of my colleagues routinely work 50-hour weeks, I cannot agree that adding night shifts would increase our efficiency or the quality of patient care we provide.

Some hospitals blame the new helpline, NHS 111.Others blame cuts to social services budgets, for leaving patients stranded in hospital wards.

And, of course, we’ve all heard about members of the public who turn up in A&E because they’ve cut themselves shaving or broken a fingernail.

What’s really going on and why? It is complex and, while some of the factors above play a part, none of them gives the whole picture.

First of all, it’s not the case that attendances at our A&Es are climbing steeply. They’re holding fairly steady: around 105,000 patients from west Kent (and a further 15,000 from East Sussex) have come to one of the two A&Es in Maidstone or Tunbridge Wells in recent years.

It is true that some of them are in the wrong place. Our local consultants say between 10 and 15 per cent of patients come to A&E with problems that could be treated elsewhere.

On the whole, however, the increased pressure on our local A&Es and hospitals is because they are treating more patients who are severely injured or very ill. This means that, on occasion, people who attend with relatively minor problems are waiting longer to be seen.

What can be done about this? While it is absolutely right that everyone who needs A&E should be treated there, we would like to see more options for frail, vulnerable people, especially those reaching the end of their lives.

We at NHS West Kent Clinical Commissioning Group are investing in training for care homes so staff are able to detect problems before patients deteriorate and become an emergency. And we want patients to decide what care they want in their last weeks and months.

When this was piloted locally, the number of care home residents dying in hospital rather than the home where they lived fell from 57 per cent to six per cent.

We’d also like to see people making better use of services in the community such as the minor injuries units at Edenbridge and Sevenoaks hospitals, their GP surgery or their local pharmacist.

We all need to make sure that hospitals and their A+E departments remain effective for those who need them by using other services when we can.

If you have a story about local health services you would like to share, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at West Kent CCG, Wharf House, Medway Wharf Road, Tonbridge, TN9 1RE.

Dr Bob's Blog - Helping people to live well with dementia

Posted by at 19/08/2013 12:15:15

Dementia is one of the real challenges of our time. As more of us live longer, more people are developing dementia, and the numbers are set to carry on rising.

A progressive, degenerative illness, dementia affects not only people’s memories and thinking but also, as it progresses, their behaviour, balance, speech, and physical functions.

Further on in their illness, patients can be confused and unsettled by being in an unfamiliar setting, but unable to communicate with those around them, making them particularly vulnerable.

This is why it is so important for the NHS and social care to do everything we can to treat them in the place where they live – be it their own home or a care home – at the end of their lives.

There are around 2,500 people with a dementia diagnosis in West Kent and we estimate a further 3,000 people are undiagnosed.

Improving this is a priority for us at NHS West Kent Clinical Commissioning Group (CCG). To make diagnosis faster, we want the assessment to be carried out by the patient’s GP, supported by a specialist mental health nurse, rather at an appointment with a psychiatrist.

Early diagnosis enables: patients and their families to talk about what is happening and make vital plans for the future; treatment with medication, which helps some patients; and family carers – usually the husband or wife of the patient – to be supported from an early stage.

We and Kent County Council are investing this year in improved services for both dementia patients and their carers.

In west Kent, we have long had Admiral Nurses, experienced mental health nurses, who specialise in supporting carers of dementia patients.

There are now also dementia cafes once a month in Tonbridge, Tunbridge Wells, Maidstone and Sevenoaks for people with dementia and their carers, and peer support groups, where newly diagnosed patients can talk through their feelings and support each other.

Full details about these are available at www.dementiawebkentandmedway.org.uk or from the free Kent and Medway 24-hour dementia helpline, on 0800 500 3014, which also offers support with relationship problems, loneliness, isolation, stress and other issues.

To combat loneliness, the NHS and local authorities are working with local organisations and businesses across Kent and Medway to develop dementia friendly communities, where people with dementia will feel safe and well supported.

And the Alzheimer’s Society is encouraging people to sign up as Dementia Friends, so they can get more information and be a dementia champion – more information at www.dementiafriends.org.uk

If you would like to share your experience of dementia with me, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent CCG, Wharf House, Medway Wharf Road, Tonbridge, TN9 1RE.

Dr Bob's Blog - Mapping the Future

Posted by Samuel Jackson at 08/08/2013 16:11:57
Every year, people in West Kent need more health services than the year before. On current trends, demand will increase by a staggering 20 per cent over the next five years – largely because more people are living longer, and the older people get, the more healthcare they tend to need.

The NHS has been fortunate that our funding has not been cut. But the state of the economy nationally means we are not getting any increase to pay for increased demand.  We cannot risk running out of money to pay for services or people to provide them.

We at NHS West Kent CCG have decided to do something about this now, to avoid facing crisis further down the road. 

We have set up a programme called Mapping the Future which brings together all the lead health and social care providers in this area -  the hospitals (Maidstone and Tunbridge Wells NHS Trust), community services (Kent Community Health NHS Trust), mental health trust (Kent and Medway NHS and Social Care Partnership Trust), ambulance service (SECAmb) and social care (Kent County Council) – along with patient representatives, to look at a blueprint for the future.

We are looking at how patients are treated now and what could be improved for the future in four key areas: mobility and falls; cognitive disorders, including dementia; urgent care; and respiratory disease.

So far, we agree there is more that can be done to keep people well – and people can also do more to look after their own health. There are ways of helping people to stay healthy, mobile and independent which are not always used consistently, and we need to get better at identifying and diagnosing illness and diseases.

While the quality of health services is comparatively good, there is scope for improvement and there is clear evidence that the hospitals are over-used. Many conditions are better treated in the community, and some people who are admitted to hospital stay longer than necessary.

We have heard from patients and carers that their care is not always well co-ordinated, particularly if they have several physical or mental health problems, or use both health and social care.

The way people are cared for as they approach the end of their life needs to improve. Most people would prefer to die at home rather than in hospital and we need to help make that a reality.

We can see that future patients need a more integrated approach to their care, leading to a much better experience of access to services, diagnosis and treatment plans.

We are now developing a first draft of our thoughts for discussion with health and care staff, voluntary and community organisations, patients and the public this autumn.

If you would like to get involved, you can email westkent.ccg@nhs.net or write to me, Dr Bob Bowes, at NHS West Kent CCG, Wharf House, Medway Wharf Road, Tonbridge, TN9 1RE.

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