Month: March 2013

The birth of CCGs: so much to do, so little time

ImageThis blog was first published in Practical Commissioning on 19 March 2013.

Although Donald Rumsfeld was a US Secretary of Defence, he will probably be remembered for a statement he made in 2002 about the Iraq war, though we’ll ignore that symbolism. Anyway, this is what he said:

‘There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say, we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know.’

As CCGs prepare for their formal birth, Rumsfeld’s aphorism is a useful guide to thinking about their developmental needs, as long as one adds the one missing category, the ‘unknown knowns’  – the things we don’t know that we know.

CCGs are designed to combine two important elements of healthcare into a single, seamless function. Although their stakeholders are intended to be clinicians generally, their focus is on GPs, whose key purpose is to integrate healthcare delivery with referral decisions to ensure that the services in the specialist (hospital) sector effectively and efficiently fill any gaps in primary care provision.

For jobbing GPs, there will probably be little difference in their routines; they will still see patients, and refer those who cannot be adequately treated in the consulting room. In their referral decisions, they may be expected to conform to CCG rules as to where and when patients should be sent, but other than that, the transition to CCGs may – and it’s not such a bad thing – have little impact for the ‘grassroots’ GP.

It is at the organisational level that Rumsfeld’s aphorism may have more relevance, for CCGs will need to consider the strategic and operational aspects of commissioning, and indeed make sense of the term itself. Thus for example, at an operational level they will quickly need to understand the business models of their local trusts, link service availability with local population needs, identify and fill any gaps, and develop referral policies for which their member GPs will need to become accountable.

At a more strategic level, they will need to understand how the needs of their population may be compared and combined with those of neighbouring CCGs, grapple with medical and societal trends and juggle these issues with the political pressures that will constantly intrude.

They will also need to wrestle with the issues of probity that bedevil the whole of the British welfare state, but are probably worst in the NHS, where life and death issues overlay rational decision making, whether financial, legal, or clinical.

These are just a few examples of the tasks facing CCGs; the questions they raise concern the skills needed to succeed in them, how well equipped are they in these skills, and what help will they need to develop the ones they lack?

Which brings us back to Donald and his various permutations of known and unknown. There are skills in the CCGs that are so well established that their clinicians don’t even have to think about them: good general practices are so effective at understanding the interweaving complexity of patients’ physical and psychological problems and handling the uncertainties and probabilities underpinning good care care that they do these almost unconsciously. These are the skills that Rumsfeld missed out: the unknown knowns. We are so good at what we do that we forget how hard it is to do. Like experienced cyclists who give no thought to balancing their precarious machines whilst ducking and weaving through the traffic, good primary care clinicians are unconsciously competent at what they do. We should celebrate the dedication and training needed to achieve such effortless effectiveness.

However, there are many tasks for which CCG leaders will need new skills. They (generally..) realize that they need more financial and political skills to cope with their Local Area Team, the NHS Commissioning Board and the rules and regulations that could explode around them like land mines. These are ‘known unknowns’ where they are consciously incompetent, and where training is already under way. I have slight misgivings about the nature of such training, as the need to produce programmes ‘at scale’ for so many CCG leaders and senior staff feels at odds with the highly individual developmental needs of each person; it’s important to understand accounting systems, and the latest version of the NHS Operating Framework, but it needs a defter, more crafted approach to discuss how to cope with personal and organizational politics, or how to manage the care of too many people with too little money.

Finally, there are the ‘unknown unknowns,’ those problems that only become apparent when they become apparent. For instance, it’s likely that much work will be required to manage autonomous clinicians without losing their enthusiasm and dedication, or in re-invigorating the caring culture that has been so deficient in recent years, especially when the NHS (like every other vast bureaucracy) will continue to be reductive and punitive.

But even an external dispassionate view cannot predict unknown unknowns (or they’d be known unknowns…). The challenge is to have mechanisms in place in anticipation of the new, difficult issues, less to help in solving them than to support CCG leaders as they cope with their implications: for it is when blissful unconscious incompetence (‘commissioning is just an extension of what GPs do’) turns into conscious incompetence (‘OMG, what do we do now?’) that the risks are highest of the wheels coming off the wagon. And in this case, the wagon may be CCG leadership itself as much as the mechanics of CCG function.

Having high level, developmental support in place working with CCGs leaders will be crucial in allowing them to grow and mature in ability, confidence, and effectiveness.

Links to two recent papers

Here are links to two papers that may be of interest; the first is useful, not just because my wife Sarah is the first author, but because the finding that the NHS Health Check could be easily and cost effectively be improved. The link to that one is

http://tinyurl.com/c9zjuye

The other paper is based on work in which I was involved that looked at the process and impact of staff engagement in four NHS Trusts. It showed how leadership, genuine ‘buy in,’ and a dynamic programme all help to develop and maintain effective staff engagement. The link to that is at

http://tinyurl.com/dybudgj

You can take GPs to water, but can you make them drink?

This article was first published in Practical Commissioning on 12 December 2011, and shows the origins of some of the ideas cited in my blog about managing expectations (1 March 2013).

Image

What makes doctors choose general practice? When I made that choice, I was attracted by the idea of holistic whole person care, and of developing long term relationships with patients, their families and even their communities. There was also the appeal of ‘divergent thinking’, rather than the reductive mechanical approach that was followed in hospitals. But there was something stronger too, a pull towards the community as much as a push away from hospitals, something about self determination and control; doctors in general, and GPs in particular, are individualists who don’t think corporately. Is this down to nature or nurture?

As far as nature is concerned, medical schools select bright students with scientific backgrounds, and enough ‘open’ thinking to allow them to develop good clinical judgment. On the nurturing side, the emphasis throughout medical training and postgraduate development is on autonomy and the importance of personal accountability to back the primacy of the doctor/patient relationship, based as it is almost entirely on individuals.

We take this approach because society values the ‘sanctity’ of the consultation, and the fact that what happens between doctor and patient remains entirely between them. This mutual trust depends on this axis of confidentiality, and so anything that threatens the primacy of this relationship would be extremely hard to sell to GPs.

These thoughts came to mind when I was at the NHS Alliance conference recently, talking about the future of the NHS. I was thinking about what it takes to persuade the autonomous, self-determining, (generally) self-employed individuals who are GPs to change at all, never mind acting in a corporate fashion and taking on a externally imposed agenda, with a budget deficit and bureaucratic rules that would make even a seasoned civil servant blanche…

There isn’t a simple answer, but generally, if you want people to take on a new and risky role in a meaningful manner, you need to follow the dictum of ‘sell it, don’t tell it’. Those taking on the role need to believe in its value, see some benefit from doing it, and be exposed to as few surprises in its implementation as is possible.

Does this work if we consider the moves towards genuine clinical commissioning? Although the jury is still out about its effectiveness, most GPs like the notion of having more control over what happens to their patients in the secondary care arena. They are however highly suspicious and extremely cynical about the motives of the Government in setting out this agenda, many believing that any benefits will be in terms of money saved for the Government, rather than for improving services for patients or (dare one say it) benefitting GPs themselves.

Increasing the bureaucracy of the system (as already seems to be happening), making the approach ever more parental, and limiting the scope for innovation and diversity would all be excellent ways of smothering the changes before they even start; just look at what happened to practice-based commissioning, which ground to a halt even before it was fully established.

Moreover, in the words of the aphorism, ‘an expectation raised and dashed is worse than no expectation at all’, and over the past 20 years, GPs have had their expectations raised and dashed many times; whether we are talking about fundholding, ‘a primary care led NHS’, PCGs, PCTs, or PBC. In each instance, much effort was put into persuading the GP community that this was their breakthrough moment, only for each initiative to become diluted and eventually scrapped. For the evangelical GP, each step along this Via Dolorosa may be seen as inevitable on the path to salvation, but for the jobbing GP, perhaps vaguely interested but certainly not prepared to subsume her mortgage payments for the sake of eventual paradise, each dashed hope merely increases their sense of disengagement and cynicism.

If the current round of reforms isn’t fully implemented (and the current tussle between the centralising clusters and the nascent CCGs doesn’t look promising), Dr Average may well take his or her ball away for a very long time, and simply get on with the day job; and given that the day job includes indirect control of most of the resources of the NHS (wisely or otherwise), this scenario may be one that the Government wishes to avoid..

Will aptitude tests do more than paper over the cracks in the NHS? (first published 19 Feb 2013)

wallpapering

One of the recommendations made by the recent Francis Report is the introduction of aptitude tests for nurses at entry into the profession, though interestingly, not for doctors. These tests would ‘explore, in particular, candidates’ attitudes towards caring, compassion and other necessary professional values.’

Like so many other ‘shutting the stable door after the horse has bolted’ reports, Francis seems to assume that cause and effect can usually be linked; in this case, a nurse with aptitude for caring can care, whereas one without it can’t.

It is clearly a truism that people who do not have an aptitude for caring really shouldn’t go into any of the caring professions, be they potential nurses, therapists, or doctors.

However, life isn’t that simple, and the report really misses the point by assuming a) that aptitude is the only determinant of caring, and b) that it will remain rock steady, despite all the prevailing pressures. The reality, as almost everyone who has worked in the service will tell you, sacked chief executives included, is somewhat different.

In practice, nearly everyone who joins the NHS is highly motivated, and with a strong vocation both for caring and working in the public sector. Let’s take myself as an example: as a bright graduate, I could have chosen to go into banking or commerce, or industry, where the working conditions and the pay would have been considerably better. However, I wanted to become a doctor in the NHS because it was there that my need to put something back into society, to care in its broadest terms, would be satisfied.

However, when you have a dedicated, motivated workforce, the inevitable temptation is to exert a kind of moral blackmail, exploiting the ‘aptitude’ for caring, and increasing work place pressures.

Rare is the health visitor who refuses to take on a new patient because (s)he has reached their recommended caseload; curmudgeonly is the doctor who refuses to see an extra patient at the end of surgery; and slippery is the slope down which we slide if indeed we do get into that ‘jobsworth’ mentality.

Staff usually accept such pressures, but their acceptance assumes a certain ‘reasonableness’ in return. Such informal understandings, based as they must be on handshakes and unwritten agreements, can work between individuals, but do not sit easily when formal organisations with their need for transparency are involved, and it is here where much of the NHS cultural difficulty begins.

The National Health Service is a massive, politically driven system, where the welfare of the individual – staff or patient – ultimately takes second place to the welfare of the whole. The utilitarianism of ‘the greatest good for the greatest number’, was explicit when the NHS was founded, but even in these days of patient choice and consumerism, the system is bound to use a ‘currency’ that looks for egalitarianism and equity over the needs or job satisfaction of the individual.

So staff expect and are prepared to be somewhat exploited when they recognize the problems and agree with the issues. However, once the gargantuan monolith of The System begins to place importance on priorities that have little or no meaning to individual staff members, they then see themselves as unwitting slaves to a master whose cause they don’t recognize at best, or willfully resent at worst. When that stage is reached, then their willingness to be exploited lessens, their resentment begins to grow, and their ‘aptitude’ may be a little weaker.

In Mid Staffs, the financial priorities imposed by Monitor probably had little resonance with clinical staff; and when staffing levels were reduced, putting extra work onto the remaining staff who were not ‘on message’ with the task, it was perhaps inevitable that standards of care dropped. Not much about aptitudes, more about abusing the basic tenets of human decency.

Valued staff usually exceed their job descriptions, often by considerable margins. Staff who feel themselves to be ignored and undervalued will eventually underperform, however strong their initial commitment and aptitude.

There are two lessons to be learned here: the first is that the creation of  ‘aptitude tests’ to see whether candidates are worthy of joining an industry that will then almost certainly chew them up and spit them out is unlikely to solve many problems. The second, and more important, is that people respond to their environment; initial aptitudes are bound to wither if staff are always blamed and castigated for problems over which they have no control, whereas staff who feel as if their input is genuinely valued will maintain and even increase their ‘aptitude’.

Symptom control is never as effective as diagnosis and treatment; the medical metaphor is entirely apposite, and one that looks as if it is once again being ignored.

Keep it simple, stupid – The KISS principle of managing conflicts of interest (first published 4 May 2012)

This article was first published in Practical Commissioning in May 2012

plumbing-basics-ga-1Over the years, I’ve been intrigued by the debates about conflicts of interests in the NHS. Are CCGs providers of services or genuine commissioners? Do GPs act in the interests of their patients, or do they more often line their own pockets? What are the most effective ways of ensuring that services are delivered effectively, efficiently, and within a national framework?

I have always been bemused by the issue, but perhaps I have an unusual view of the NHS, as I see primary care, incorporating GPs and CCGs, as the control centre from which all health services are co-ordinated, rather than simple service providers.

Let me illustrate this:

We recently had a new bathroom fitted at home; it’s very smart and it cost us a lot more than a ‘trip of a lifetime’ holiday. The work involved plumbers, electricians, carpenters, and tilers. I could have contracted with each of them separately, but not only would I have had to understand the details of each of their jobs and the limits of their capabilities, I would have had to carry all the ‘risks’; if anything went wrong, or more money was needed, the issue and the cost would have come back to me.

Instead, I went to a  bathroom centre, let’s call it ‘Baths 4-U’ and negotiated a deal; I don’t know whether the person with whom I spoke was a plumber, an electrician or even an accountant, but basically, I determined the ‘output specification’ of the bathroom, and left it to him to deliver the finished product. My obligation was to specify the functionality of the new bathroom, plus any specific details about which I felt strongly (please remember that the shower must accommodate my 6ft 9in height…), and between us we agreed the quality, the timescales, and the money.

This meant that I didn’t need to understand the technical details of the work, and that (within limits we agreed) it was up to ‘Baths-4-U ‘ to carry the ‘risks’. The plumber/electrician/accountant with whom I dealt then had to deliver the work; if he was indeed a plumber, he could do the plumbing himself, and sub-contract the other non-plumbing tasks to the appropriate technical specialists; if he was a generic accountant, he’d have to buy in all the technical services, and would probably be less successful than if he were a ‘content expert.’ As long as the finished product met the specifications of quality, timing and costs that we had agreed, then how he did it remained entirely up to him, and what profit he retained was none of my business. The key message is that Baths-4-U  were the body accountable for the work done

So how does this relate to the current NHS? Several parallels may be seen: at an individual’s level, patients are the ‘clients’ with a general sense of what their needs are, but without the technical knowledge or skills to manage them effectively. GPs are Baths-4-U, able and prepared to carry the risks (and reap the benefits) of providing a service; they provide most of the basic service themselves, and then sub-contract the more specialized technical services to the expert ‘tilers’ or ‘carpenters’ that are the hospital consultants.

Unlike home plumbing systems, health services also function at a larger, population based level, where decisions are required that affect whole organisations, rather than individuals. Although the principles remain the same, in this case the CCG is the accountable body, with the responsibility for organising and delivering all healthcare for their entire population, The ‘client’ is the NHS Commissioning Board, or any emerging local representative, that will need to define the outcomes being sought (quality, timing, price). As with ‘Baths-4-U’, how they do it should not be overly prescribed, or the creativity of the provider will be stifled while the ‘risk’ will be repatriated to the client, who does not have the appropriate technical knowledge.

In either case, if the accountability arrangements are clear, then there should be no conflicts of interests; quality, timing, and cost are the paramount measures, with the ‘client’ determining the ‘what’, and the provider having the freedom to decide ‘how’. At the ‘micro’ level of the individual GP, this is generally understood, but it is yet to be seen whether at the ‘macro’ level the central NHS ‘client’ will manage the three main tasks required to make the accountability work and to obviate the potential conflicts: can it resist over-defining the ‘what’? Can it bear to let the CCGs decide the ‘how’? And will it actually be able to hold the CCGs to account for those three outputs: quality, timing, and cost?

What Francis should, but probably won’t, say (first published 5/2/13)

This article was first published in Clinical Commissioning on 5 February 2013

The Francis report, due to be published tomorrow (6 February), is Robert Francis’ final report on events at the Mid-Staffordshire NHS Foundation Trust, and is expected to make far reaching recommendations to prevent such failures from happening again.

Whilst there is no doubt that events in mid-Staffs reflected cultural and operational problems unique to that Trust, I would suggest that there are a number of more deeply seated issues that affect the entire NHS, that could no more be solved by tighter regulation than could the seven deadly sins.

Paul Batalden’s famous aphorism that ‘every system is perfectly designed to get the results it gets’ has become something of a cliché, but the NHS illustrates this truism over and over again. If Francis is to have any impact, it would do well to acknowledge some of the design issues that have led to the system delivering the services it currently does; perhaps by addressing just some of these, the cultural issues that drive any large iconic institution may begin to change. What is certain is that new regulations, however draconian, will only reinforce the current culture, and do nothing in the longer term to prevent further mid-Staffs type crises from happening.

Let me highlight just a few of these design issues:

 

Clinical/managerial dissonance

The Griffiths report of 1983 was an important milestone in the history of the NHS in that it introduced the notion of general management, by which the running of the health care system was effectively separated from its clinical function. To paraphrase the reason, it was to liberate clinical staff from the onerous administration of the NHS, and allow them to get on with treating patients.

There were two main consequence of this separation, both of which were, in hindsight, entirely predictable: the first was that clinical drivers and financial pressures effectively became polar opposites, with the call for better treatment inevitably countered by the political and economic need to squeeze more out of every health care pound.

This dichotomy led to the inevitable result that managers became the champions of the financial end of the tug-of-war, whilst clinicians fought for clinical improvement; the traditional tensions between practitioners and ‘the system’ had become formally entrenched.

In the case of mid-Staffs (and perhaps in many other financially challenged Trusts?), this tension was played out in ever poorer levels of staffing, and in money-saving clinical shortcuts that adversely affected the standards of care, sometimes terminally. In system terms, the only way to overcome this tension is by developing some congruence between the different champions, giving them common purpose rather than creating artificial rifts.

Organisational welfare, which encompasses financial health, reputation, clinical outcomes, and even the ‘friends and family’ test, would make a better (if necessarily more vague) target for all staff than separate, often conflicting, aims for each professional tribe. A utopian ideal? Only insofar as it pre-supposes a solution to the next design issue:

 

Lack of ownership and disempowerment

The NHS is large; it’s HUGE; it employs a significant percentage of the entire population, and moreover, it’s nationalised, belonging to the country. Like anything else that belongs to us all, it actually belongs to none of us; it is ‘they’ who run it, ‘they’ who tell us what to do, and ‘they’ who carry the responsibility for it, not us, who are just trying to get on with our jobs under difficult circumstances.

You get the idea; the NHS is so large, that it is hard to feel any real sense of personal involvement and pride beyond the specifics of one’s own particular tasks. There is an overwhelming lack of ownership, and the current culture in the service only increases this. As long as the rhetoric of ‘localism’ and ‘involvement’ is matched by the reality of central command and control, cynicism can only grow, and disenfranchisement flourish.

Creating stronger, more locally based organisations (as Foundation Trusts were perhaps intended to be) might have been one way forward, but the pressures for transparency and value for money in our nationalised system mean that even they are now driven more by external pressures than by any internal sense of pride or aspiration. If you and I were to set up a business together, just the two of us, with our own money, then we would have total ownership of it, and it would be clear that we would succeed or fail entirely by our own efforts. Once there are several thousand of us, that sense of pride becomes harder to sustain, but not impossible, especially when many of those thousands are autonomous, self driven professionals. However, once those thousands are not only told precisely what to do but exactly how to do it too, then it becomes virtually impossible.

For people in general, and autonomous professionals in particular (managers as well as clinicians), to retain their enthusiasm and drive, they must perceive the problem as theirs, and see the direct benefit of its solution; if the problem is perceived as artificial or irrelevant (as was the case with many of the procedural targets such as trolley waits), then solutions emerge that owe more to gaming theory than to good clinical practice, and the downward spiral of rules leading to malaise leading to regulations continues inexorably to tighten. The system is perfectly designed…

As with any cultural issues, their solution is not simple, but the principle set out when the purchaser/provider split was first set up may be helpful here: the purchasers defines ‘what’ needs to be done, and the providers determines ‘how’ they will do it. In that way, those working in the provider Trusts may feel that they are included, enfranchised, and with good leadership, can happily accept the mantle of responsibility that is part of the pleasure of working in a professional capacity.

If purchasers prescribe the ‘how’ as well as the ‘what’, then not only will the disempowerment worsen, but any benefit of the separation will also be largely lost, as the system is intended to capitalise on the expertise of the providers on provision, not expect purchasers to know everything about provision as well as commissioning.

A third design element within the NHS that Francis would do well to address is that of the role of the Board.

The reforms of the last thirty years or so have emphasised the notion of giving NHS provider organisations a degree of independence, perhaps in an attempt to pre-empt some of the issues raised above; and as quasi-independent bodies, they have been obliged to have rigorous governance in place, overseen by a Board comprising non-executive as well as executive Directors.

If you were creating good governance in an organisation providing health services, what roles might you ask the Board to fulfil? Yes, it would need to ensure legality of process by having some legal expertise, and sure, it would need to be financially sound, but we’d be sure to include some non-executive governance of its core function, wouldn’t we? We’d give at least the same priority to the clinical aspects of care as to the procedural issues of money and law, and we’d make sure that the Board membership encompassed all these roles.

And yet, I have never seen advertisements for Trust non-executive Directors or Chairs that mention clinical oversight as a core part of the job description; indeed, I left the Trust I had chaired for over five years when it became apparent that Monitor expected the Chair of an aspiring FT to be an accountant first and foremost. In my view, borne out by events at mid-Staffs, governance needs to comprise four aspects of organisational life: core content (in this case governance of the clinical function), financial and legal surety, and workforce governance. The Board needs to juggle all four to be successful, and once again, Batalden’s aphorism rings true: if the system is designed to provide only financial surety, that is what it will do.

So Francis would do well to cover at least these three design flaws; how the system deals with them is a further and genuinely ‘wicked issue’, as true cultural change is generational in its timescales, and can’t easily be condensed into eighteen months to meet the needs of the political cycle. I have one radical suggestion to offer, as my starter for ten:

If you let me open my own hospital, and recruit all the staff from scratch, using criteria that correct the design issues I have described, I think I could give you a healthy, functioning, successful organisation. Let that organisation define the skills and expertise of its staff, and let it determine ‘how’ it will deliver the commissioners’ ‘what’, and we might have the basis of an exciting and vibrant health service.

Do any of us expect Francis to deliver such vague recommendations? Of course we don’t; government sponsored reports are almost always based on numbers and rules; but if the report makes no reference to the ‘soft’ elements that are so hard to deliver, then it will have solved nothing, and indeed, may be seen in the fullness of time to have compounded the problem.

Raising and dashing GPs’ expectations

Charlie BrownMichael Dixon was on the radio again on Friday; this is such a normal part of life that it’s not usually worthy of comment, but this  interview raised issues for me that went far beyond the vagaries of ‘any willing provider’ (important though that may be), and went into the broader areas of how human nature responds to external stimuli.

Ever since 1989, GPs have had the carrots of increased prominence and influence in the NHS held in front of them; whether it was the creation of the purchaser/provider split, the introduction of GP fundholding, the appearance of PCGs and PCTs, or the publication of White Papers with enticing titles like ‘A Primary Care Led NHS,’ the GP community was repeatedly promised that each round of reforms would increase their profile and improve the lot of their patients.

But like Charlie Brown having the football he longed to kick always removed by Lucy at the last moment, the promises made to the primary care community have never been properly kept; unlike Charlie Brown, there is now a real risk that GPs will finally recognise the pattern, and refuse to play.

As has been drummed into us for so many years, GPs are generally independent contractors, and their obligation (and the reason why most of them came into practice) is to deliver personalised care to individual patients, ‘doing what they can, and buying in the rest’. Additional wrinkles such as revalidation and QOF points have been added over the years to strengthen this central plank of their existence, but it would be nigh on impossible to compel them to consider the broader issues of commissioning (with its implication of dealing with populations rather than individuals) as part of their ‘day job’.

The only way of engaging the general GP workforce in this work is by ‘selling it’ rather than ‘telling it’, but when deals are promised and not kept, potential buyers move from disappointment to cynicism, and eventually walk away completely.

Fundholding was never allowed to realise its potential; Primary Care Groups lost the centrality of clinicians in the main decision making processes as soon as they became PCTs; the ‘primary care led NHS’ was distorted by the behaviour of large acute provider Trusts, and the move towards clinical commissioning groups (itself a dilution of the original GP commissioning groups) looked as if it was the last chance to add significant primary care common sense to the commissioning of NHS services.

And now, even that promise is being eroded: the introduction of senior managers into CCGs is not the problem per se, because CCGs will need very senior managers to turn GPs’ decisions (whether strategic policy decisions or operational referrals of individual patients) into action; it’s just that the ones being hired are generally bringing with them the culture and bureaucracy of PCTs, and are not the innovators and influencers that are really needed to make change happen. And whilst we do need accountability in the CCGs that will be spending enormous amounts of public money, are the mechanical competency hoops through which aspiring CCG Chairs and Accountable Officers are being required to jump the most appropriate ways of developing that accountability?

And whilst we clearly need to prevent unethical ‘gaming’ in procurement, are the slow, ponderous processes that favour only the largest and most conservative providers the best way of controlling the potential conflicts of interest?

Finally, despite the obvious need to control spending in the mega-industry of the NHS, is the repatriation of so many of the ‘high end’ commissioning issues into central bodies the best way to engender the localism and ‘buy in’ needed to ensure the success of this round of reforms?

My questions are deliberately framed in a one sided way, as there are few people who would argue that the mechanisms currently being developed are anything other than reductive sops to the political pressures being exerted; for any chance of success, I would suggest only a few key principles are required, and that the Great and the Good should be expounding on these, rather than responding to individual operational ‘symptoms’ being raised in the media on a daily basis. These are:

  • The Centre should be determining what is required, and letting the CCGs work with their providers to establish how this is going to be done. This works to everyone’s strengths, empowers local professionals, and means that there would be considerably less micromanagement than at present.
  • CCGs should be considered as the health maintenance organisations responsible for the healthcare of their populations, making the allocation of specific roles and funds for provision more like sub-contracting than strategic commissioning. This would simplify the perceived conflicts of interest, and reduce the stranglehold on progress being exerted by the artificial bureaucracies of the current tendering process.
  • Finally (and probably the most difficult to enact), professional clinicians (doctors and nurses) need to be treated as professionals, and encouraged to make individual decisions within a corporate framework. In that way, one can overcome the paradox that it is only when professionals feel that their autonomy is being respected that they are prepared to act more corporately.