Shoot Up or Put Up

Dearest darling GP,

I moved my healthcare to your business a couple of years ago because my previous GP was failing to deliver. He was medically mediocre and administratively hopeless. I like your surgery because you take in a lot of trainee GPs. Terrifying as this may first sound, they’re actually rather good – they’re young and enthusiastic, they haven’t heard it all before so they actually listen to what I say and when they don’t know something they run off and check with a grown up, rather than just making stuff up. I find all that quite endearing in a doctor.

Overall, you’ve been doing very well. Medically you’re performing. You developed a worrying interest in delivering my diabetes care but I managed to steer you away from that and we’ve agreed that you won’t meddle in things that you don’t really understand. We’re getting along just fine.

Administratively you’re above average in my experience, although my benchmark for good GP admin is pretty low. If I ask for a repeat prescription you normally manage to issue one within 48 hours. And most of the time it’s more or less correct. You also get extra brownie points for not accidentally giving my medical records to a little old lady to read whilst she was in the waiting room as one of your predecessors did.

It’s not all good though. We’ve been having a little issue for a while now. You understand that I need blood testing strips and you’re happy for me to have as many as I need. You’re not misinterpreting any silly PCT guidelines about rationing strips like some of your less bright colleagues. More brownie points there. Sadly, while your intentions are good, your delivery is a little random in this area. If I request blood test strips sometimes I get them, sometimes I don’t.

We’ve talked about this and you explain that the nasty PCT won’t let you put blood test strips on my repeat list in case I order too many, start selling them on the black market and the NHS isn’t left with enough money to buy biscuits with. I explain I’m happy for people to put sensible measures in place to manage budgets, but we still need a process that works. At the moment if I order blood test strips I sometimes get them and I sometimes don’t.

You say that I should ask my pharmacist to check my prescription when he collects it for me. I say it isn’t his job to double check your work. You say I should highlight when I’ve requested blood test strips. I say the list I sent in only had 5 things on it and blood test strips were in bold size 14 font and you still managed to miss it. Short of sending a singing telegram I don’t see what else I can do.

For the love of god this shouldn’t so difficult. Please put a process in place that means I get blood test strips when I ask for them. I’ve spent a couple of years training you to deliver my healthcare and you’ve been doing it well, I don’t want to have to start all over again with someone new.

Lots of love

Alison

Or Brutal truths shouted from the Dispensary

Drugs, yesterday

In a guest post, my pharmacist gives the view from the other side of counter; take it away Simon -Tim

Right, time to let you bunch know the grim truth about how NHS payment works and your place in the grand scheme of things.

Here it is: every GP surgery in the land is – a business. One that deals in healthcare and in a very professional and dedicated manner, but a business none the less that has to deliver a year-end profit (where did you think the big houses and fancy cars came from? Do you think that Doctors started off as rich people and went into medicine because they wanted to give something back to the people?) And every Pharmacy – exactly the same – is a business (the front shop with the cash registers probably makes this slightly more obvious: the cars and houses are somewhat further down the scale).

Now, the day to day financing of the medication that keeps you lot alive is one that you fortunately don’t have to dwell on too much – be glad that you were born in the UK after the creation of the NHS (apologies to all the non-UK based readers; our climate may be soggy, our cuisine second rate, but we do have the NHS). So you do at least receive your medications free of charge. But of course it is being paid for behind the scenes – the prescription forms you present to your friendly Pharmacist not only represent the instructions regarding what insulin, etc., you are to receive but are also a form of currency.

After passing through our greasy palms, we submit them to the payment bureau, who eventually reimburse us for the medications (plus a small fee for actually doing the work). But where did that money get drawn from, I hear you ask? Why from the budget of the GP surgery that prescribed the medications of course – money which was originally provided to the surgery, from the NHS budget, on the basis that they have a certain number of patients on their books.

So basically, every GP surgery receives a certain amount of money from the NHS for every patient to finance their healthcare. But of course some patients are more expensive to look after than others. I, for example, in a personal capacity represent the perfect patient from a GP’s financial point of view; I am registered with the surgery, so they receive payment for my care. But I have no conditions requiring treatment, and in fact never darken their doorstep. Hence I represent pure profit to them.

But frankly, you lot are a bit more expensive to keep healthy. Lantus 3ml cartridges – £39.00 for a box of five. Humalog – £28.31. One Touch Ultra test strips – £14.64 a box.  All this coming out of your surgery’s budget and hence reducing their profit. And to make matters worse, it’s not even as though you lot  were healthy for seventy years then deteriorated in the last five years of your lives, nor are you likely to quietly die off in the next few years – you are going to keep draining those budgets for many years to come. In summary, from the financial point of view, you are amongst the worst patients out there – a blight on the budget. Shame on you all.

But before your collective guilt drives you all to overdose on Novorapid, take heart. Your GPs may despise you for the drain you place on their “another week in Dubai” fund, but you are still loved. By whom? Why by your friendly local Pharmacist of course. And we love you for exactly the same reasons your GPs hate you. Those endless prescriptions represent a constant income stream for us. And of course, you have no chance of ever being cured of your woes (Note to self – remember to sabotage new research at Islet isolation laboratory), so of course we will be happily deriving income from you for many years to come. What wonderful milk cows you make.

Right, so now you are aware of your place in the financial pecking order. But what use is this to you?

Well dear diabetics, it really is very simple – you may be milk cows, but that doesn’t mean you have to act like cattle. Each and every one of you is a valuable asset to your Pharmacy. So get out and there and sell yourselves. You should be demanding a high level of service from your Pharmacy for your valuable custom.

Is your GP surgery yanking your chain by continuing to prescribe those test strips you stopped using six months ago, but not prescribing the ones that go with your new meter? Are you tired of trying to get them to sort it out? Well for heavens sake, get your pharmacist to sort it out for you – okay, it is your GP’s job to get these things right, but in their defence its not that easy when you aren’t the one who actually gets to see the things in the real world, that’s what we Pharmacists do.

More drugs, the day before yesterday

As an example of what you can demand, I shall tell you of a patient of mine. In the interest of patient confidentiality, we shall call him “Tim Brown”. Okay, I confess – to my shame I have known Tim for many years, back to the days when he had no grey hair and a fully functioning pancreas [a long, long time ago -Tim]. But these days I am also his Pharmacist.

The process goes something like this: I will be busy at my place of work, when I receive a message from Tim, demanding further supplies of insulin, needles and test strips – normally accompanied with a threat of hideous violence that will be inflicted upon my person if I do not comply with his demands. I immediately spring into action – forwarding a request for a new prescription to his GP surgery, while at the same time ordering in the stock I will need to fill the prescription.

A few days later, the prescription form will arrive (Tim’s surgery is not one of the local ones we send a driver to, hence it arrives by post in one of the stamped addressed envelopes previously provided to the surgery for this very purpose).  The prescription is dispensed (all the stock previously ordered will have already arrived by this point). Tim receives the message that his gear is ready. We have been known to deliver it to his place of work, but mostly these days we presents himself at my pharmacy to collect it and deliver insulting remarks.

Now of course this example is an easier process because I know Tim personally, the message normally being communicated by text message straight to my mobile. But he has also been known to harass me by email. No reason whatsoever why your local Pharmacist should not be able to do the same for yourself. Please note – if your Pharmacist tells you they don’t have an email address you can use, please point out the following; THIS IS THE YEAR 2009. Every Pharmacy in the land is connected to a perfectly good broadband connection, courtesy of the NHS. If they cannot be contacted by Email, it is either because they can’t be bothered, or because they are part of a large chain of Pharmacies that will get around to sorting this out sometime in the next decade or so.

So in summary, remember that your condition makes you very valuable to those of us who feed off the sick. Get into your Pharmacy and demand:

“I’m a valuable income stream – what are you going to do for me?”

——————————–
Simon Wilson insists that he is a real Pharmacist, working in a real Pharmacy. On particularly challenging days, he does suspect he may be a fictional character of his own imagination.

Last Saturday at 9.30am (which, as any normal person will realise, is far too early for a Saturday morning) I arrived at Napier University for the famed annual LDRG diabetes conference.

I was slightly the worse for wear after a work-colleague’s retirement do the night before (I’m certain one of the glasses of champagne I quaffed was off) but things got better after a few cups of vile coffee and meeting cheery folks Aileen, Mary et al from IPAG Scotland – everyone’s favourite Scottish insulin pump support group.

The day progressed with some incredibly dull PowerPoint presentations of facts and figures relating to diabetes in the Lothians, which was wrist-slashingly fascinating. But things improved with some useful workshops – I went to one about putting health records online, which was presented by a GP who’s done just that and put all his patient’s record securely on the Internet. This allows the lucky blighters within his catchment area to be able to order repeat prescriptions, get test results and book appointments and so on from the comfort of their Internet-enabled whatever. Said GP has plans to convince the Scottish Government to roll this out throughout Scotland – and it would be great if he succeeds.

This was then followed by a session of chatting to the meter and pump reps over coffee in the foyer. So you’ll all be pleased to hear (unless, of course, your one of the reps I spoke to) that I’ve got a whole new load of meters to review – first impressions are not promising, so that’s something to look forward to!

This was followed by a buffet which wasn’t actually as vile as I thought it would be and an interesting workshop with a Q&A session on insulin through which we learnt a few tit-bits.  The afternoon went on with another useful workshop on insulin pump therapy, which just made me curse the NHS Gods that won’t give me a pump until hell freezes over (something which often happens in a Scottish winter. I say “hell” I really mean “Glasgow”).

Anyway, a good time was had by all and there was a lot of useful information but, as always, chatting with the rest of the pancreatically-challenged hoards was the best bit. Roll on the Shoot Up meet up at the end of the month!

A needling problem

Avid readers of your soaraway Shoot Up will know that I’m currently on an 18-month long NHS waiting list for a pump. You’ll also recall I’m not too chuffed about this for obvious reasons. As, on the whole, I’m generally a pain in the arse I’ve been writing polite letters to everyone concerned about this sorry state of affairs.

I’ve generally had sympathetic replies from my MSP, the chief pump honcho at the hospital and the Chief Executive of the health board wrote to me the other day to say he’s asked someone to investigate and report to him about pump provisioning. It does seem that people are generally supportive, which is nice to know but – of course – not actually of any practical help to diabetics.

Certainly in my area the main sticking point appears to be the lack of funding – not, as you might expect, for the pumps and supplies themselves but for the training required for new pump users. I do agree that pumps are slightly more complicated than administering MDI, as there seems to be a greater possibility of complete cock-up with a pump compared to MDI. Though, as we all know, it’s very easy to utterly mess up with MDI – I do it quite often!

My health board undoubtedly has some great DSNs and the training I received when I was first diagnosed was relatively brief but was of a very high standard. But, unfortunately, there just doesn’t seem to be enough of them to go around. Currently their policy is to train about 5 or 6 new pump users every two months. This just isn’t enough throughput to increase Scotland’s woefully low number of pump users up to levels that are on a par with the rest of the country, let alone the rest of the western world.

If training genuinely is a bottleneck (and not just a slightly cunning feint to avoid funding new pumps without breaking the rules) then there seems to me to be a possible solution in the form of a public-private initiative in which everyone could win.

So here it is – what about the NHS partnering with the pump manufactures to provide training? The pump manufacturers will, obviously, know exactly how their pumps work, how they’re best used and will have a wealth of experience in supporting their customers in using their products. Everyone knows that diabetes is a nice earner for our favourite pharmaceutical companies and so the cost of training could be recouped on a cost-recovery basis or even as loss-leader set against the ongoing purchase of pumps and supplies.

Pump manufactures would surely have a reasonable amount of available resource to chuck at training (especially if it benefited them through long term and ongoing sales) and such an arrangement would free up NHS staff to do what they do best – supporting diabetics.

But might this lead to reduced patient choice? If, for example, Small Manufacturer A wasn’t able to supply training while Large Manufacturer B did, then might there be an inherent bias in the NHS to encourage diabetics to get a pump from Large Manufacturer B as they could then save on training costs?

I don’t think so, as any such arrangement would necessarily reduce the training overhead for the NHS allowing them to concentrate their resources on supporting patients who wanted, for whatever reason, to use a pump from Small Manufacturer A.

In this scenario everyone wins – patients get training and pumps quickly; the NHS’s training costs are reduced; the pump manufacturers get a loyal and going supply of lucrative diabetics.

But what about the issue of the bifurcation of training? After all, training from a pump company might not be at the same standard as NHS training? (Of course, it might be better). But given that standards of training and pump provision vary wildly around the UK, I can’t see that this would make any significant difference from the current position.

Scottish readers (and I know you exist) will be interested that Scotland’s SIGN Diabetes Management Guidelines Consultation is now taking place. Aileen at IPAG Scotland reminds us that any responses from the pancreatically challenged hoards need to be submitted before 16th October 2009.

In particular, the section on pump therapy (4.3.1) looks like it was written back in the Dark Ages of diabetes care and isn’t all that helpful to anyone in Scotland considering taking up pump therapy in the next ten years.

So have a look at the draft guidelines at http://www.sign.ac.uk/guidelines/drafts/diabetes.html (especially that thrilling 4.3.1 bit) and bash in a response giving them your views. Our beloved health authorities need our help and guidance to make sure they get it right!

You'll just feel a little scratch

Well it’s that time of year again, the time of year when I usually ignore my letter from my doctor reminding me to go and get my winter ‘flu jab.

But not this year, oh no. No, this year I’ll definitely be subjecting myself to the joys of a slightly achy arm for the day. I’m not particularly worried about swine ‘flu (oink), as from what I can see it doesn’t seem to be much worse than usual seasonal ‘flu. I suspect it’s been, perhaps, blown a little out of proportion. After all the British press absolutely loves a health scare – especially rancid rag The Daily Mail, which seems to be made up of little else. If I’m wrong, however, please feel free to crow over my cooling corpse saying “we told you so…”

Anyway, I’m just terrified of the usual plain old common or garden ‘flu. Why? Because last year I actually got it and I have to say that it was far from being a week-long chucklefest. I picked it up at a family birthday in France from my brother – yeah, thanks Ben – and on the return trip spent a merry afternoon in Gatwick airport waiting for connecting flight  steadily feeling more and more awful (and, coincidently, probably passing on said ‘flu to 30,000 passers-by who were flying to every corner of the world – go me!)

The next five days or so were spent in bed, sweating, shaking, coughing, spluttering, checking my BG every hour, injecting extra insulin and generally wishing I was dead. Everything hurt and I could hardly summon the mental energy to get up and do something as simple as visit the bathroom (I did eventually go, you’ll be pleased to hear). It was the second most miserable five day period I’ve ever had. The first most miserable was the last time I had ‘flu – at boarding school in Northern Ireland. What fun that was!

So, never wishing to experience the misery of proper ‘flu again (man flu’s fine – I can deal with / put that on any day) I’m ignoring the inevitable health scares concerning vaccines and I’ll be at my doctor’s next Saturday at the front of the queue for the jab.

I have to confess that despite all that, I probably would have ignored the doctor’s reminder as usual. But after consistently disregarding her advice to “go and get your bloody ‘flu jab” last year, Katie very sensibly just made an appointment for me yesterday. I have been told.

Well chaps, it’s that time of the month again – poll results time. Hurrah! As always, our highly scientific, balanced, bias-proof, carefully weighted survey has caught the mood – the Zeitgeist, if you will – of the diabetic community.

The majority of people answered our question “I know… a) everything about diabetes; or b) nothing about diabetes” with a). Therefore our beloved readers are either experts on diabetes, whose knowledge of chronic illness far exceeds that of the national average or they’re all pathological liars. The jury remains out.

This month, we’re quizzing you about your local health care provider – whether this is your local clinic, hospital, doctor, endocrinologist or whatever – and how good you think they are. You can give your answer to the question “My local healthcare provider is…” over on the right from the following range of possibilities:

• Faultlessly brilliant. I’m in awe
• On the whole not bad at all
• Neither good nor bad – health purgatory
• Needing a lot of improvement
• So bloody awful I may as well use a witch doctor

With regard to the last option, I have to confess I’ve never consulted a witch doctor about my diabetes. So if they are, in fact, absolutely marvellous at treating diabetes I apologise unreservedly to any witch doctor readers that might be offended by the disparaging tone of the option. Please don’t turn me into a frog.

Despite my championing multiple daily injections in a previous article, I have to finally come out and confess that I’m getting a pump. Eventually.

Back in the heady days of July, I popped along to my diabetes clinic and spoke to the specialist diabetes nurse about pumps. We discussed my diabetes and the problems that I have with it – the main problem being my BG range is huge – first really high, then really low.

We then had a chat about pumps in general and discussed the research I had done and how I thought one could help me to level out my BG, so that the graph of my results could resemble something less like a profile of the Himalayas. We also had a fiddle around with a pump and got very geeky about how they could be configured and programmed to precisely match my insulin needs. After an hour or so of jolly chat we both reached the considered conclusion that pumps were very definitely the Way Forward.

A month later and I received confirmation that lo! I had indeed been placed on the waiting list for funding and training. The email also casually mentioned said waiting list was eighteen months. Grr.

I would, in other words, have to wait until 2011 to get my pump. By then I would have reached the ripe old age of 34 and would be 2.8% of my lifetime closer to the cold, unforgiving grave (assuming I get my full three score years and ten). I was not, and indeed am still not, pleased.

As I have a legal background in contentious stuff (to use a technical term there) and having been educated in the “Alison Finney School of Badgering Primary Care Trusts” I have decided not to stand for this. This is not because I want to skip the queue to get a pump ahead of everyone else – I want anyone who needs a pump to get one quickly. Healthcare provision is partly about serving the patient’s needs and unless patients let their healthcare providers know what their needs and expectations are nothing will ever change.

Realistically I’m not expecting the NHS to hand pumps out like sweeties (sweeties and diabetes never mix, after all) but it’s not unreasonable for diabetics to get the healthcare support and resources that they need. Especially when an increasing number of studies have shown that provision of pumps and good healthcare lead to fewer complications, which in turn leads to lower healthcare costs in the future. In other words, spend a bit more money now and save a hell of a lot later.

As I mentioned in my article about pumps being debated in the Scottish Parliament, Scotland seriously lags behind the rest of the western world in pump provision. Out of population of five million, only 416 people in Scotland have pumps for goodness sake! Scotland and the UK really do need to be dragged into the 21st century in relation to diabetes care.

So what have I done so far? As a starter for ten, I’ve corresponded with the various groups that support pump users including iPAG Scotland, the tireless Lesley at INPUT and Diabetes UK Scotland. In addition, I’ve written to my Member of the Scottish Parliament (health is a devolved matter – so Scotland deals with it, rather than Westminster) and asked for his support, which he’s confirmed he will give. I’ve also bashed off a note to the doctor who heads up the pump provision at my hospital to ask for his comments.

So, dear readers, the saga continues and I’ll keep you up to date with the thrills and spills of pump provision within the NHS as it happens. As always your comments and experiences are always very, very welcome here and on the forums.

Chatting on the Intermaweb the other day with other British diabetics, we suddenly and collectively realised that we didn’t actually have any idea how much our diabetes cost the NHS each year. Unlike some of our American friends, because of the wonders of the NHS, we’re almost completely shielded from the actual cost of our life-giving supplies.

Therefore last time I was collecting my monthly prescription I talked my friendly pharmacist into letting me go behind the counter after closing time to check out the wholesale prices of diabetic supplies in the UK.

Unfortunately, being a model of incredible efficiency, he couldn’t find his latest price list, so we had to rely on one that was a few months out of date – but you’ll get the idea. Anyway, those prices in full:

• Lantus – £39 per pack of 5 bottles
• Humalog – £28.31 per pack of 5 bottles
• Test strips – £14.53 per pack of 50 strips

Of course, these are the UK wholesale price and the eventual cost to the NHS will almost certainly vary from this. There’s a whole new world involving grey-market imports & exports as well as practices that I consider to be very close to price-fixing between the pharmaceutical companies – but we’ll leave all those fun things for another article. The long and short of it is, based on my back-of-cigarette-packet calculations, I cost the NHS about £175 a month or (to save you working it out) £2,100 a year.

Of course, these calculations are very rough and are for mere supplies only. They don’t take into account the costs of my regular check ups at the ERI, the time it takes for my local doc to sign off my prescription every month or the costs to my employers of my time off work to go for check ups and the myriad other costs that my diabetes incurs.

I’ve also quickly worked out the amount of tax I pay and the National Insurance contributions my employers contribute to the Exchequer’s coffers. When you take into account all the other non-health related services I use then, hurrah, I’m almost certainly a drain on the nation’s finances! I’m so proud to be diabetic!

If my inbox is anything to go by, how to secure NHS funding for insulin pumps and/or CGMS is a bit of a hot topic at the moment. There aren’t any magic answers, and personal experience taught me that tenacity and perseverance were pretty key to winning the battle, so for what its worth, here are my thoughts.

Understand the product – what is it that you want and why? How will you use this kit to improve your control or your quality of life? Be clear in your own mind about the benefits to you. Speak to the local rep – could you maybe trial the CGMS for a week to see if you like it and if it makes a difference to you? Take a look here for what I think are the main benefits to me.

Understand the market – what guidelines are out there? For pumps, INPUT have a great summary of the guidance.  For CGMS, there is very little guidance out there so you’ll probably need to fight on an individual basis. Medtronic have a summary of what little guidance exists.

Get your healthcare team on side – if your consultant is vehemently anti-pumps I’d recommend you find a new one. Try INPUT to find out who in your area has a good reputation for supporting pump use.

If your diabetes team just need a bit of gentle persuasion, show them the evidence. The download-able marketing literature from Medtronic covers the basics and quotes some of the major research projects that prove the benefits of CGMS. If you want more detail, try here for a reasonable summary of the research.

Use the suppliers - at the moment there’s only Metronic who provide CGMS in the UK. Contact them and ask to speak to your local rep. See if they know of any Drs in the area who are pro CGMS. When you know which clinic would suit you, head down to your GP and explain why you’d like to be referred for your diabetes care to that particular clinic.

The Dr says its too expensive – “Every time I have brought up continuous glucose monitoring with my diabetes nurse, she has said there is no way the NHS would cover it (no point even trying, apparently)”. To be blunt, it isn’t the job of your Dr or nurse to decide what the NHS will and won’t fund. Their job is to work with you to decide what is clinically the best treatment for you. Your local primary care organisation decides what they will and won’t fund, based on NHS guidelines or on an individual assessment of your case.

With your healthcare team on side, you now need to get financial approval. In the UK this will come from your local primary care organisation (PCO) - basically the NHS body who use our taxes to commission healthcare from hospitals and other providers on our behalf – in England and Scotland they’re called Primary Care Trusts (PCTs), Wales have Local Health Boards (LHBs) and Northern Ireland have Health and Social Services Boards (HSSBs). So we don’t lose the will to live amongst the complexities of the NHS, from now on I’ll call them PCOs.

If they agree that what you’re asking for is medically necessary, your Dr should write to your PCO to request that they fund the treatment. Ask for a copy of this letter, that way you know who its gone to and can chase it directly rather than via your Dr.

Personal experience showed that it took my PCO 6 weeks to respond to a letter. If I took that long at work to respond to a letter, I’d be sacked. I now give the PCO 2 weeks to respond, and then give the addressee of the letter a gentle nudge via phone or email. “I’m just calling re X to check you’ve got all the information you need” is a good opener – it brings it to their attention and means you get to know early on if they need more info.

Question, question, question. Without wanting to tar everyone with the same brush, we do seem to have a culture of prevarication in the NHS and a desire to do anything other than actually make a decision. Don’t be afraid to ask questions. Do they have everything they need to make a decision? If not, what else do they need? When can you expect a decision? Who will make the decision? What criteria will they use? What’s the appeals process?

Have your evidence – you want this, so make it as easy as possible for them to say yes.

Are there any NICE guidelines? If so, be clear about what they are and how you meet them. If there aren’t you need to point out this is not a general policy decision they’re making for everyone in the PCO area, this is something they should decide based on the merits of your case.

What are the consequences of not funding this request? eg severe hypos impacting on your ability to work, fear of night-time hypos as you live on your own. If you’re a woman, talking about the impact of poor diabetes control on any imminent planned pregnancy soon gets attention.

I felt I was being fobbed off and generally ignored when I applied for funding, so I went straight to the top and emailed the Chief Exec, cc my local MP. I explained the issue and that I felt I wasn’t getting a good quality service. The Government promises patient choice within the NHS, but I felt my PCO wasn’t making appropriate efforts to enable this.

There aren’t any simple answers to getting funding for CGMS, it is a battle but as more people fight that battle it will get easier. To summarise, here are a few things that I think are important:

• Be clear about what you want and how it will benefit you in the short and long term
• Get the support of your medical team – if they won’t support you, consider finding a new team
• Gather the evidence to show that what you’re asking for actually works - if you’re struggling, ask the suppliers to provide you with the evidence – this is their product, they should be able to point you to the research that shows that it works
• Keep the pressure on - you want this funding so you need to drive it through the system. Find out who is dealing in your PCO and speak to them regularly. Understand the process and always know what the next step is. 
• If you’re not getting anywhere, escalate. Writing to the Chief Exec and getting your local MP on board generally helps to clear any blockages. 

That’s what worked for me. If there’s anyone else out there with pearls of wisdom on how to get NHS funding, please share!