Primary care: gatekeeping or weaving?

warp_and_weftThis is a slightly revised version of an article submitted to the BMJ on 5 October 2016.

There is an interesting article in the BMJ this week[1] by Greenfield et al on ‘Rethinking primary care’s gatekeeping role’ that covers only one element of primary care, and in excluding other, more important, aspects of the role risks these others being left out of the debate entirely.

Greenfield’s premise is based on a model of health care that is currently fashionable, but which is simplistic and linear in its philosophy: ‘I’ve been diagnosed with prostate cancer, it needs treating, I need to see the right specialist as quickly as possible’. Such a symptomatic approach to medicine is clearly important, but assumes an entirely straightforward, physical spectrum of disease.

The reality of modern health care is that it is being overwhelmed by complex illness that combines multiple physical diagnoses, often chronic in nature, with social and psychological overlays. Treating my prostate without considering my diabetes, my hypertension, the impact of my illness on my job, income, and mental wellbeing is reductive and sub-optimal, not only in clinical terms, but also in terms of cost-effectiveness.

Whilst the role of general practice clearly includes gatekeeping, that function needs to be put into the context of care co-ordination and the management of complexity. In the multilayered fabric of the NHS, the warp of clearly defined clinical pathways being organised in efficient straight lines needs to be held together by the weft of primary care, weaving the intricate patterns that make up genuinely effective care. Just as the conductor of an orchestra balances the dynamics of the different sections of the orchestra to produce an harmonious melody rather than a cacophonous row, so effective primary care juggles the different (and often conflicting) drivers that influence us all, to produce coherent and effective care.

When this is done well, the whole system benefits, and researchers such as Barbara Starfield[2] have pointed out that the cost-effectiveness of health services is proportional to their degree of primary care orientation, not because of gatekeeping per se, but because of effective and appropriate holistic case management.

The risk is that an article like Greenfield’s (which doesn’t mention anything outside the linear referral model) is that it reinforces our increasingly symptomatic approach to medicine, where we treat diseases rather than people, with the inevitable result that demands and costs rise, duplication and inefficiency ensue, and everyone suffers from care that is completely at odds with the human condition.

What is required is a model that is more co-ordinated professionally and organizationally, that aligns incentives appropriately, and that carries public opinion with it. As long as the public continues to expect the linear simplicity described by Greenfield and colleagues, that is what will be provided; only when there is a better understanding of the subtlety and complexity of health care will we have any chance of rebalancing the system. Articles such as this risk moving the debate in precisely the wrong direction.

[1] BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4803 (Published 23 September 2016)

[2] Starfield B: The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998 Health Services Research Volume 38, Issue 3, pages 831–865, June 2003 DOI: 10.1111/1475-6773.00149

Visual ref: http://commons.wikimedia.org/wiki/File:Kette_und_Schu%C3%9F.jpg

Clinical commissioning groups: how to ensure their first birthday isn’t their last

Cake

It is more than a year since clinical commissioning groups (CCGs) formally came into existence in England, and although strategic plans are slowly beginning to emerge, CCGs continue to struggle with an infrastructure originally designed to control a national system.

The 2012 Health and Social Care Act saw CCGs as the mainspring of commissioning, capitalising on general practitioners’ twin roles: dealing with patients at the ‘front door’ of the NHS and referring and coordinating their journeys through its complex institutional pathways when necessary. The notion was that general practitioners’ (albeit anecdotal) knowledge of local services could be synthesised to inform operational and strategic commissioning throughout the NHS. Giving CCGs the freedom to change services in their local health economies was intended to encourage innovative models of care that were more user friendly and (hopefully) better value for money.

However, CCG leaders found themselves the late arrivals at a party already in full swing. NHS England had established the ground rules, subsumed specialist commissioning and primary care, and determined how CCGs should work and be managed. And adding to the harsh financial pressures, CCGs found their budgets being raided for contingency and efficiency funding as well as for augmenting specialist commissioning, maintaining pre-existing private finance projects, and supporting social care initiatives.

In terms of how to engage and enthuse newcomers, this is not what textbooks recommend, but for the current policy to work CCGs must pull their weight. How can this be achieved? CCG development seems to parallel adolescence. By the time children leave home to live independently, they need to be able to deal with the physical, financial, and emotional hurdles that they will inevitably face: they must shoulder responsibility and risk.

Similarly, CCGs were intended to assume increasing responsibility for services and develop a mature relationship with NHS England through the area teams and commissioning support units. Many have commented that this is not happening and that a form of indirect cajoling has developed instead. Despite a few signs of change (such as NHS England accepting an annual survey of its performance by NHS Clinical Commissioners), the general sense is that CCGs are under-resourced in human and financial terms and that the need to cope with what is operationally urgent is preventing them from dealing with what is strategically important. If CCGs are not allowed to develop sufficient self determination, their growing frustration and enduring dependency will drive their participant general practitioners to lose interest at best and throw adolescent tantrums at worst.

CCGs were intended to be clinically driven by autonomous professionals who function better as volunteers than as conscripts. However, such professionals (especially independent general practitioners) traditionally lack experience of corporate working, and so encouraging them to consider collective needs as well as those of their individual patients and practices is key to the success of their CCG.

This is a complex challenge that needs tackling at various levels. Overt CCG leadership requires organisational expertise as well as a thorough knowledge of local context. Many of the clinical chairpeople and accountable officers still need to learn more about strategic thinking, which takes commitment as well as protected time and funding. Whether it is even possible remains to be seen; CCGs vary greatly in their arrangements and ambitions and even the roles of clinicians and managers differ considerably.

Leadership needs to be mirrored by support among members; clinical commissioning cannot succeed without ‘grass roots’ input informing strategic thinking. Support will vary, and senior (strategic) CCG staff will have different perspectives from frontline (operational) clinicians. Such differences have never previously been bridged, and consequently individual clinical decisions have rarely influenced high level strategy. If CCGs are to exploit their potential fully, this aspect of their functioning needs a lot more development, which also takes time and money. So far, neither has been prominent, with most attention being paid to traditional senior NHS leadership, and almost none apparent to its corollary, what we might call ‘followership.’

Another obstacle to the successful development of CCGs is that the commissioning of primary care is separate to that of secondary and community services. CCGs control most of the latter two but none of the former. If a CCG decides to replace a traditional hospital service with a primary care alternative, it can decommission the first but cannot directly commission the second.

If CCGs are to hold responsibility for providing healthcare for their populations (the idea implicitly underpinning their creation), then this mismatch must be removed to give them the tools and accountability needed to provide services. If we believe in localism at all, then how they use these tools should be their decision; if they choose to provide services within their own organisation rather than subcontracting with local NHS Trusts, then that needn’t constitute a conflict of interests as long as the accountability is in place.

Outcomes such as agreed levels of morbidity, patient satisfaction, timeliness, and financial probity all offer measures of accountability irrespective of the agency involved. As it stands, CCGs are unlikely to change their paradigms of care because current mechanisms discourage change rather than rewarding it. Moreover, any existing momentum is likely to dissipate as those involved become increasingly disillusioned.

With the NHS caught between rising demand and lessening funding, the system will increasingly have to do more for less. Giving working clinicians some responsibility for achieving this, by connecting their daily activity to strategic leadership, seems logical. But CCGs will have to be supported much more emphatically, politically and operationally, if we want health service policy, local services, and the needs of the whole local population to be brought together coherently.

This is a slightly revised version of a paper prepared in collaboration with Michael Dixon, and first published in the BMJ (online 2 April 2014 as BMJ 2014;348:g2306).

Open letter to Simon Stevens

writing-query-letterDear Simon

 

Despite the fact that most open letters probably never get read by their addressees, I thought that I would join the throng of correspondents writing to you: after all, if ‘crowd-sourcing’ can raise funds and drive international campaigns, maybe it can influence policies too…

As I’m sure you’ve recognized, the NHS is in a weird place at the moment. The cognitive dissonance we all accept as part of running a state controlled (i.e. politically sensitive) system in the 21st century has reached new extremes, with the rhetoric of localism (Clinical Commissioning Groups, local choices, patient involvement) being totally at odds with the reality of national inspection regimes, the imposition of ‘Clause 119’ and the central pressure to save costs that is currently exercising us all.

The short term ‘patch it and move on’ measures of the past few years have led to so many unintended consequences that we seem to be tying ourselves into ever tighter knots physically as well as politically. Here are just three examples, but there are many more:

Emergency departments are very busy because they’re available and GPs aren’t, so we try to discourage people from attending by….extending the range of services provided at A&E.

Lewisham Hospital is really successful, so its staff are rewarded by… their assets being threatened in order to prop up the failing South London Healthcare Trust.

CCGs are tasked with responsibility for the health of their populations, and encouraged by… having their resources cut and their nascent power diminished.

And so on and so on….

If we are ever to cut through this Gordian knot, here are just a few simple principles that might help:

  1. There should be clarity about the separation between procurement and provision of services: the Government is the commissioner, and the NHS is the provider. That boundary is where the strategic overview needs to be implemented, and where the money is exchanged. The NHS is then supposed to consider how services might best be delivered, with the CCGs intended to be pre-eminent in this process, providing what services they can through their GP networks, and subcontracting the rest to agencies such as hospitals and other specialized providers.
  1. Work with human nature rather than against it: people work best when they agree with their organisation’s overall purpose and when they can see some benefit from what they are doing. Thus, a consistent approach with obvious logic works better than a series of mixed and contradictory messages, especially when those messages are clearly disingenuous and even dishonest. NHS staff don’t have to agree with everything, as long as it is clear how decisions were made, and they can rest assured that there will be consistency and stability in their working lives.

Moreover, those benefits don’t have to be financial; people join the NHS because they want to make a positive difference to the lives of ill people, and want to be proud of what they do. Approval, appreciation, peer recognition, these are all useful and not nearly as inflationary as monetary markers, whose price has to constantly increase to retain their value.

  1. Make policy and stick to it, even if the Media pundits don’t like it: democracy is great, but where long term policies are concerned, the ballot box is a better place make judgments than the daily press. Populist government leads to uncertainty and instability, and in the end, loses the respect of the populace anyway, so the system should think in years, not weeks, when it makes policy.
  1. Society needs to acknowledge the clash between rising expectations and finite resources; efficiency is clearly a good thing, but no amount of cost improvement is going to keep pace with a population that expects everything, constantly, and for free. At some stage soon, we are going to have to grasp the nettle of putting the brakes on demand, whether by formally introducing the notion of rationing, charging, or excluding.

With these suggestions in mind, Simon, perhaps you should empower the CCGs to do what they are being asked to do? That’ll mean giving them more control of (and tighter accountability for) the mechanisms and the money; they’ll need a lot more development too, internally and in the way that they deal with the rest of the service.

Perhaps too, you should think of simplifying the fog of micromanagement and punitive regulation that has descended over the NHS? At a local NHS acute Trust for instance, the 200 pages of specific measures that have to be discussed at every Quality and Safety committee bring its members to their knees. Most clinicians have a positive intent, and are prepared to have their effectiveness measured, but to do it in such prosaic, reductive ways is not only counterproductive in the short term (the measures aren’t usually helpful) but in the long term too (they de-professionalise the workforce). A few outcome measures, measured by peers and patients, would pass the responsibility and ‘ownership’ of the service back to those who are best placed to run clinical services.

Another (albeit more difficult) objective would be to resist the pressure from the acute sector; crises are always more interesting and newsworthy than chronic and often insoluble problems, but they divert attention from what is truly important to what is often merely urgent. To achieve such an objective would be countercultural in today’s world of instant gratification, but if we don’t manage to stem this tide even a little, then the future of a sustainable service is bleak.

On a more positive note, almost everyone in the NHS (and most members of the public) are aware of these issues in some way, and would be willing to throw their weight behind policies that begin to address them. Sure, the traditional tribalism of the different parts of the service will always exercise us, but there is nothing like common purpose to bring people together, and there is plenty of that where the NHS is concerned.

It’s a daunting task, that will need stamina as well as a thick skin; but modernising health services is a worthy end, and we’ll all help where we can.

Good luck, and kind regards

Jonathan

CCGs need to evolve and mature, NOW!

I have writEvolutionten before about the difference between ‘unconscious incompetence’ and ‘conscious incompetence’, and how one has to recognise a deficiency before one can address it, but I have rarely seen such an acute example as the one that currently exists in the CCG world.

As new organisations, often incorporating senior GPs with little if any experience of strategic leadership, it is perhaps not surprising that CCGs have taken time to grasp the breadth and the depth of the issues that face them; not only are they notionally responsible for an annual budget of over £60 billion of public money, they have to ensure that their own primary care house is in order, and deliver a degree of corporacy amongst their members that has never even been envisaged, never mind achieved.

However, now that they are nine months into their first ‘live’ year, one might have hoped to see more recognition of these issues, and a wealth of initiatives both locally and nationally to try to jolt the young groups into a maturity that admittedly needs to be well beyond their years. It is disappointing therefore to note that (certainly in my universe), there appears to be little if anything happening at a systemic level. The Leadership Academy seems intent on setting up a production line to manufacture senior leaders (an oxymoronic concept if ever there was one), and attracting mainly managers from provider organisations.

Others that might be expected to be compiling effective, accessible programmes to fast track CCG development (NHS Confed? BMA? RCGP? NHS Clinical Commissioners?) seem at best merely to be considering setting up such initiatives. They appear to be more concerned with meeting DH/NHS England operational edicts and maximising contractual benefits, beginning to replicate what CCGs were intended to end once and for all: doing things right at the expense of doing the right things.

In the meantime, NHS England, in its unreconstructed macho fashion, is starting to exert more direct pressure in the only language that its political masters seem able to understand: reductive operational targets. The whole notion of culture change and clinically led progress is rapidly being diluted, to be replaced by structures that will look more and more like PCTs, or the even older Health Authorities.

So what is required? The first thing is for CCGs themselves to recognise the need for internal development; even in my own small way, I have been trying to encourage the development of locally focused leadership programmes, learning sets, even stand alone workshops for CCG staff and their members to start to get to grips with the agenda, but it is proving to be a steeply uphill task. CCG chairs and accountable officers should think about resourcing such work themselves, as large scale mass produced products can never achieve the kind of cultural and organizational ‘fit’ change that a ‘bespoke’ programme can. The larger players (see above) should support and facilitate these local processes, and some central resourcing would be very helpful to oil the wheels and get the show on the road.

Do it now, applying a bit of welly to the process, and progress will be satisfyingly fast; leave it much longer, and those in the rank and file of the CCGs, the GPs who really need to ‘think differently’ to achieve systemic change, will have lost interest and gone back to the day job. Without them, not only will CCGs not succeed, the ‘supply side’ drivers (hospital crises, by and large) that have steered the NHS for so long will come to dominate even more strongly, with the only levers available to control them being the traditional blunt, insensitive, centrally controlled levers that have never really worked.

As the adage has it: ‘if you always do what you’ve always done, you’ll always get what you’ve always got.’ Isn’t it time that CCGs started taking control of their own destinies?

Square pegs in round holes: why new structures never solve functional problems

ImageWhen you sit down for a meal, do you choose your food on the basis of the cutlery and crockery in front of you, or does your food determine your choice of utensils?

For most of us, it’s the latter; for soup we need a bowl and a spoon, a steak needs a plate and a sharp knife. What we do drives how we do it, form reflects function.

So why is it almost always the other way round in the NHS? Despite the fact that we all understand the theory, we continue to look at (and change) structures, with barely a thought given to the manner in which we would like the functions to evolve.

Thus, only recently, NHS England deputy medical director Mike Bewick apparently suggested that ‘GPs should form larger provider organisations’ in order to improve access, a structural solution to a functional problem if ever there was one. Nothing was reported on what the problems with access actually comprised, suffice it to say that larger practices were deemed to be the answer.

Now I don’t know about you, but it seems to me that if I want good service in my personal life, I tend to go to small providers (restaurant, butcher, vet) rather than the faceless bureaucracy I get when I deal with a mega-provider; the only advantage that they offer is lower pricing, usually at the expense of customer service.

But that specific example is missing the overarching point; to solve the GP access problem properly, we need to understand its underlying causes; the sticking plaster of any simple structural solution simply isn’t enough. If the issues are about inappropriate demands (A&E anyone?) then putting in more ‘supply’ will merely exacerbate the problem. If it is about inflexibility in skill mix adaptation, then larger practices would be a very expensive (and equally inflexible) way of solving the problem; and so on…

So why do we seem so ready to turn to structural solutions? Firstly, structures, whether physical buildings or organizational hierarchies, are easy to conceptualise, and we all prefer things to be simple rather than complicated, even if simplicity is reductive and ultimately unhelpful.

Secondly, simple interventions are usually easier to measure than complex ones, something that is particularly important to politicians, who want to be able to point at new edifices (preferably with walls, roofs and a plaque to unveil) and say ‘I did that.’

Thirdly, structural solutions calm the insecurities we all have when life changes (as long as I know where my desk is, my job must be safe) and so help us to cope with uncertainty, even if that protection is illusory.

However, apart from the fact that structural solutions are rarely more than symptom control (using a medical analogy), they also distract us from sorting out the underlying problems. If my non-steroidal medication keeps my repetitive strain injury quiet, then I don’t have to think about changing my working practice to make real changes to the way I work, thus keeping life simple, immediate, but ultimately still broken.

The only way to start solving the underlying problems of the NHS (and of most large macro-systems, for that matter), is to take a cool, dispassionate look at what we’d like the system to produce, and then work out what is required to meet that brief. Of course, much compromise and sleight of hand will still be required, as we can never really start from a blank sheet of paper once such a large system is running.

But at least we can sort out the real diagnosis and come up with a treatment plan, rather than botching yet another short term fix merely because there are twenty other similar problems sitting in the waiting room.

The best compromise may well be to carry out such ‘whole body diagnoses’ on small but complete ‘micro-systems’ (a single practice, a CCG, even a hospital Trust), rather than looking for root and branch reform of the whole creaking organization at once. As long as the analysis and the treatments in the small unit take into account its interfaces with the larger system, then one may have a way of carrying out an holistic, meaningful analysis of the functions of an entire entity, and beginning to introduce the changes needed to improve that functionality.

Not only would the scope and size of such an approach give it a better chance of being effective, it would also allow the inclusion of two other key factors vital to the success of any change management programme: ownership and ‘buy in’ from those involved, and the start of a cultural change ‘cascade’ whereby success amongst those who are in at the start of the process appeals to the later adoptors and tempts them into the programme.

So, CCG Chairs and practice managers, are you up for having your micro-system analysed and put onto a change management regime? It’d be enlightening, cost effective, and very productive.  It’s something that I would be really keen to explore; all we need now are the pump priming funds…

This article is based on a piece published in Pulse on 27 August 2013.

The NHS in 2013: plus ça change…

Just over three years aPlus ca change 1go, ‘Clinical Medicine’ (the journal of the Royal College of Physicians) launched a series of articles in which the history of the National Health Service (NHS) was reviewed, and several eminent commentators surveyed the health- care landscape that was expected to emerge once the dust from the 2010 general election had cleared.

Thus, there were articles by the likes of Mike Farrar, chief executive of the NHS Confederation, Michael Dixon, chairman of the NHS Alliance, and Mark Britnell, from the management consultancy KPMG, as well as contributions covering subjects as diverse as system reform to improve NHS efficiency (Jennifer Dixon), the risks and challenges for a new public health system (John Middleton), the future of patient and public involvement in the NHS (Jo Ellins), the role of the National Institute of Health and Care Excellence (NICE) in assessing new technologies and value for money (Andrew Stevens et al) and the then impending commissioning reforms (Elizabeth Wade).

We are now well into the current round of reforms and, with less than two years until the next general election, it is a good time to review the events of the past three years, and speculate on future possibilities and developments.

Political context

The first thing to say is that the initial White Paper presented by the then Secretary of State, Andrew Lansley, during the summer of 2010 took most commentators by surprise. In the lead-in to the election, it had been observed that there was a basic convergence in policy and even organisational style on both sides of the political divide: the concept of the purchaser/provider split was an integral part of both Labour and Conservative policy; the independence of acute provider trusts was taken as read; and the centrality of primary care in coordinating their local health economies had been generally accepted.

Thus, it was largely assumed that, if a Conservative Government did win the election, its policies would be aimed at tweaking and refining the pre-existing direction of travel, rather than overhauling it radically and, indeed, the tenor of the manifesto of the party gave no hint of major structural changes. Such tweaking could even be interpreted as being helpful in making the NHS increasingly able to resist political change, as the policies of the main parties began to resemble each other, even if only in principle.

In the event, when the Liberal Democrat–Conservative coalition was formed and Andrew Lansley was confirmed as Secretary of State for Health, the coalition White Paper incorporated significant restructuring, and a philosophical ‘decentralisation’ that was seen as almost libertarian in its extent. The key suggestions of the document are detailed in Table 1 at the end of this piece, and now look faintly ironic, even after only three years.

A difficult gestation

As with all White Papers, the document was intended to form the basis of a Parliamentary Bill, but during its gestation, there was perhaps more debate among the various vested interest groups than was the norm; nearly all of these groups, lay as well as professional, opposed parts of it, with the most strident criticisms concerning the transfer of so much of the NHS resource to the control of general practitioners (GPs), the apparent abrogation of their responsibilities by politicians and the intention to allow the NHS to be driven so locally, with the variabilities that that implied. The fact that all the debate was being carried out under the cloud of the ‘Nicholson Challenge’ (a call for the NHS to save up to £20 billion over five years that had been issued in 2009 by Sir David Nicholson, the chief executive of the NHS as a response to the increasing austerity being rolled out across the country) added to the tensions and mutual paranoia being felt both politically and in the service itself.

In hindsight, the outstanding lesson from the launch of the White Paper was less about its content, most of which was more or less in line with the aforementioned direction of travel, than the manner in which it was introduced. The Secretary of State seemed to show a degree of political naivety in his approach to the powerful lobbies with which he had to deal and he introduced a whole raft of structural changes that were both unexpected and unwelcome, as well as perhaps unnecessary to enact the proposed reforms.

Such was the level of ‘noise’ concerning the White Paper that an official ‘pause’ was introduced, during which a Future Forum was convened, led by Professor Steve Field, the outgoing chairman of the Royal College of General Practitioners. Its official brief was to carry out a ‘listening exercise’ to consult widely and to modify the White Paper in line with its findings; to this end, the Forum comprised primary and secondary care members, nurses and Allied Health Profession (AHP) members as well as doctors, managers and representatives from other groups, including various patients associations and the voluntary sector.

The unofficial remit of the Forum was to ensure that the White Paper could be turned into a viable bill, although there were also suggestions that mechanisms were needed to counter the centrifugal force of Lansley’s ideas with some centripetal pressures to maintain parity across the service and behaviours in line with central Government policy.

The Forum met for some months (and, indeed, at the time of writing, has yet to be disbanded) and, although its activities did smooth the edges of the original proposals, some might say it changed their original intent. Enough organisational restructuring was introduced following its interventions, for instance, to obviate completely the promise concerning the ‘radical de-layering and simplification of the number of NHS bodies’. Its findings were incorporated into a revised bill, which was followed by more political wrangling in Parliament before the bill was finally turned into the 2012 Health and Social Care Act, which was fully enacted on 1 April 2013.

The 2013 Health and Social Care Act

Its final intentions and structures include the following, although it is too early to draw any conclusions about their effectiveness.

The major structural changes mainly concern the commissioning or procurement side of the NHS. The primary care trusts (PCTs) that were responsible for commissioning the vast proportion of all care for their local populations have been dissolved and many of their functions devolved into the new clinical commissioning groups (CCGs), which are each headed by a chair (usually a GP) and an accountable officer (AO); some AOs are clinical, whereas others are managerial in their backgrounds.

CCGs hold most of the budget for traditional hospital services and have the responsibility for planning and procuring these services, as well as holding them to account. In this task, they are assisted by the commissioning support units (CSUs), which are able to provide a variety of support tools, including payroll and human resources (HR), information and communications.

The CCGs have two strands of accountability within the system. The services provided within primary care (mainly general practice) are governed by the area teams, each one overseeing several CCGs. The strategic oversight of this, as well as the accountability for hospital services commissioned directly by the CCGs, sits with one of four regional bodies linked to NHS England. Clearly, each is holding responsibility for a large population and needs to develop the notion of locally developed services that are in tune with national policy while also knitting together the various funding and delivery streams that encompass primary care and hospital services to create a seamless and effective service map.

The public health function (traditionally involved in the prevention and health improvement agenda, health protection (including immunisation and screening) and generic service planning) has been split in two, with the mainstream operational services being moved to the control of the local authorities and the more strategic functions that cover larger populations, being housed in a new entity called ‘Public Health England’.

The whole system is intended to sit at some distance from its political masters, to try and insulate them from the public and media pressures that often divert policy from its intended direction. This approach was first tried during the early 1990s, under a previous Conservative government, which created the ‘NHS Executive’, housed in Leeds, in a finally futile attempt to create a similar gap between policy and service delivery.

The basic aims of all the NHS reforms of the past 30 years have been to try to bring into line behaviours and expenditure in the acute sector so that they fit with national policies and budgets. In the current round of changes, the main overt objective for this sector is simple: to ensure that all acute trusts reach the standards necessary to become foundation trusts, or if they cannot, to agree some form of strategic alliance with another organisation, so that together they might reach viability in terms of costs and quality.

However, the current changes, both planned (through the new Act) and unplanned (through crises, such as that in the mid-Staffordshire Foundation Trust) have highlighted a new, and much more significant ‘elephant in the room’, and that is the overall future of the district general hospitals (DGHs). There are several reasons why their future is now in considerable doubt.

Firstly, there is an inexorable move towards increasing specialisation, which average DGHs cannot supply; their budgets and turnover are too small, and their ability to recruit ‘premier league’ super-specialists is limited. As a result, the more ‘high-risk’ illnesses (risk being defined by cost, technical difficulty, infrastructure support, staff availability and even litigation risk) are being referred onto the tertiary ‘super-hospitals’, thus depriving the DGHs of work, income and work-related satisfaction for their high-level staff.

Secondly, there is an equally inexorable move of lower-risk illnesses out of hospitals and into the community, where their treatment might be carried out in less formal surroundings that are generally preferred by patients, by staff who can still deliver excellent care, but perhaps at a lower cost. With the shrinkage of this market too, the core business of the DGHs will become significantly smaller and will threaten their viability unless they change their form or their function dramatically.

Thirdly, there are the issues of scale; in the constant tussle between ‘small is beautiful’ and ‘bigger is better’, the size and complexity of the NHS probably mitigates against the former. Interestingly, there is a clear dissonance between the move towards super-hospitals, and the value placed on local treatment ‘closer to home’, that probably reflects the increasing polarisation of healthcare to these two extremes, which once again puts the future of the DGH in doubt. This tension is not new; as Aneurin Bevan said in April 1946, ‘I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.’ The difference is that the intensive interventions feasible today cannot easily be delivered in a small setting, reinforcing Bevan’s aphorism for the 21st century.

What next?

So what might we expect from the new system?

At a superficial glance, the new organisational structure might appear to be well placed to deliver what its designers wanted. It has attempted to separate the service from its political masters; it has declared a move to ‘localism’ and it will pass control of over two-thirds of the total NHS budgets to the CCGs.

However, there are significant structural issues that look likely to trip the system up. The first concerns the distinctions in funding of primary and secondary care.

Because the two streams are managed separately (hospital funding though the CCGs themselves, primary care through the area teams), there is no certainty that moving services from the acute sector to primary care will free up the resources to complete the transfer. However corporately minded GPs might be, they are unlikely to create extra work for themselves and their teams without the resources to manage this, and that process is entirely separate. As in so many previous rounds of NHS reform, the incentives in the system have not been properly aligned.

In the same way that the new system does not acknowledge the factors that motivate and drive GPs, the continuing emphasis on payment by results (PbR), which is a recipe for increasing activity and not improving results at all, is not helpful. In addition, the movement of the mainstream public health function into local authorities, although it might be appealing at a conceptual level (the drivers that influence the health of the population are largely outside the biomedical universe), the emerging reality seems to comprise mixed interest among local authorities, with some apparently not considering any of the broader determinants of health beyond repairing potholes and running sexually transmitted disease (STD) clinics.

So there are structural problems, but there are even larger and more significant issues in the processes that are now supposed to govern the NHS.

Lansley was probably unduly optimistic in his aspirations to have the NHS driven quite as locally as he intended, but in the intervening months and years that the Bill has evolved and become law, it has created a polarised dynamic between the CCGs at the local end and NHS England at the centre, with the power apparently settling increasingly at the central end. GPs and their PCT colleagues who took up the notion of CCGs are seeing their expectations and aspirations once again diluted and soured, with the result, even at this early stage, that there is already poor morale and reducing engagement.

Processes should not subsume outcomes

Clinical professionals in general, and GPs in particular, are in positions where they can make or break their local heath economy without ever doing anything wrong. Their motivation and enthusiasm are the only way that referrals and admissions might be reduced or prescribing improved and, if their zeal is missing (or worse still, lost), then the auguries for success are poor. Add to that the ‘Nicholson Challenge’ being pressed upon them and one can see the likelihood of short-term ‘fatigue’ in the new system and long-term disaster as new doctors consider their reasons for going into general practice in the first place, and begin to vote with their feet.

One final bit of soothsaying; if the new system was designed to preserve corporate memory while allowing new ideas and ways of thinking to emerge, then even that probably has not worked. As the CCGs and CSUs bed down, not only are they populated largely by staff who had worked in PCTs previously, but their growing ways of working, their modi operandi, also begin to look increasingly controlling, unimaginative and bogged down in ‘due process’. Tendering for service change, allowing experimental models of care, anything that rocks the boat of ‘doing things right’ is being frowned upon, even if it is at the cost of ‘doing the right thing’.

The road to Hell, they say, is paved with good intentions and it is easy to see how an Act designed by a committee that tries to please everyone is almost bound to fail.

In fact, the issues are remediable: if the accountability of the CCGs to NHS England was simplified into one stream based on outcomes rather than on processes, then the incentives for those in the CCGs would be more positive. The oft-cited ‘conflict of interest’ for GPs would be less relevant if they became responsible for delivering all health-care for their population, in any (appropriate) way they chose, ‘sub-contracting’ to others what they didn’t do themselves (and hence maintaining vicarious responsibility).

If the rules governing changes in the acute sector were simplified, and allowed more flexibility of function as well as structure, then some innovative and dynamic solutions to these ‘wicked issues’ would emerge. In addition, if those working in the NHS, especially at senior level, could see something positive about which they could be enthusiastic and in which they could invest their hearts and souls, then I suggest that this might be ‘another fine mess’ we could actually reverse.

Table 1. Summary of main suggestions in the White Paper Equity and excellence: liberating the NHS.

  • Shared decision-making: ‘no decision about me without me’
  • Choice of any provider, consultant-led team, GP practice and treatment
  • Hospitals need to be open about mistakes
  • Stronger voice for patients and the public
  • Focus on outcomes and quality standards. Reduced mortality and morbidity, increased safety and improved patient experience and outcomes
  • No targets without clinical justification
  • A culture that puts patient safety above all else
  • Money to follow patients across the NHS to promote quality, efficiency and choice
  • Providers to be paid according to performance based on outcomes, not just activity
  • Professionals and providers to have more autonomy and accountability
  • Greater freedoms and less political micromanagement; ministerial powers over routine decisions to be limited
  • Devolution of power and responsibility for commissioning to GPs and their practice teams working in consortia
  • More connection between local NHS services, social care and health improvement
  • An independent NHS Commissioning Board to lead on the following: achieving health outcomes, allocating and accounting for resources, quality improvement and patient involvement
  • All NHS trusts to become, or be part of, a foundation trust
  • Monitor to become an economic regulator, promoting effective and efficient provision, competition, regulating prices and safeguarding continuity of services
  • Enhanced role for the Care Quality Commission as a quality inspectorate across health and social care
  • Ring-fenced public health budgets, reflecting population health issues, with ‘premiums’ to reduce health inequalities
  • £20 billion efficiency savings by 2014,to be used to improve quality and outcomes
  • NHS management costs to be reduced by more than 45% over the next 4 years
  • Radical de-layering and simplification of a number of NHS bodies
  • Debate on health should no longer be about structures and processes, but about priorities and progress in health improvement for all
  • Implementation to be bottom up

This piece is based on an article published in Clinical Medicine in August 2013: 2013, Vol 13, No 4: 374–7

The NHS in Lewisham: a victory for natural justice?

Vox PopuliLewisham Healthcare NHS Trust is a mid-sized organisation (turnover in 2010/11 was about £220m) that includes acute hospital and local community services.  It produced a surplus of about £1m in that year, having overcome recurrent deficits to achieve sustained surpluses over a relatively short time http://tinyurl.com/p9yvq93. It epitomizes the successful integrated NHS organization: financially stable, well liked by its users, and expecting to achieve Foundation Trust status until external events overtook it.

Its misfortune was to be sited close to the vast, failing South London Trust, which was put into administration in July 2012, with losses predicted to exceed £60m annually. In early 2013, the Secretary of State for Health Jeremy Hunt agreed with the administrator (Matthew Kershaw, from McKinsey) that the Lewisham Trust should merge with part of the dissolved South London Trust, with the downgrading of its University Hospital and the closure of its A&E Department http://tinyurl.com/oqn57lu.

This decision was challenged legally, and a judgement has overturned it http://tinyurl.com/pn27366 , although the Government is considering an appeal.

The judgment is important, not only for the Trust, but for the messages it sends out about the NHS, its drivers, controls, and self determination. There are at least three main points:

1  Externally driven NHS Trusts may as well be directly managed units

Over the past few years, the Lewisham Trust has shown the value and impact of self determination.  It successfully overcame its financial problems, absorbed community services, and built up a reputation as a thriving, effective organization, a significant ‘player’ in its local health economy. If these achievements are discounted, and its future determined by Whitehall, then staff (clinical and otherwise), users, and local organisations such as the Council, will all see themselves as entirely disenfranchised; how that perception is incorporated into a political agenda of ‘localism’ poses an interesting challenge.

2  Expectations raised and dashed are worse than no expectations at all

The current NHS reforms in England are based on a few simple foundations. The first acknowledges clinicians’ impact on the processes and outcomes of health care by involving them in driving these; doing so produces a degree of ‘buy in’ and responsibility amongst clinicians, and develops a new and appropriate line of clinical accountability. The second is an extension of this: as general practitioners instigate most NHS spending through their prescribing and their referrals, they should be involved in the strategic spending decisions as well as the operational ones. This allows more rational and coherent planning, with the ‘ownership’ needed for responsible, accountable working.

The Clinical Commissioning Groups (CCGs) currently finding their feet are the organisational embodiment of these simple foundations, with responsibility for around two thirds of the entire NHS budget of £108 billion, and some influence over the rest. The key tasks they face in their first year are not only to learn to walk (by getting themselves established, and their members engaged), but also to run (by producing considerable savings, and starting to plan their future, more strategic activities).

These tasks would be hard enough, but if the application of their new found skills were to be immediately overturned by Governmental dictat, then all the efforts that have been applied in overcoming GPs’ natural cynicism about involvement in commissioning will have been wasted; the noise of the ensuing disenchantment is likely to drown out for many years any attempts to achieve the same aims.

3  ‘Vox populi’ is not democracy

If the lay press is to be believed http://tinyurl.com/qx2xvve , the recent judgement seems to have been driven entirely by local activists trying to save their hospital. Whilst local support is helpful, it would be bad for any part of the welfare state if national policy was only the result of local pressure.

The NHS was designed to be both egalitarian and utilitarian, and as such, ‘broad brush’ strategy needs to be driven in a systematic, rigorous fashion. The recent Health and Social Care Act http://tinyurl.com/pj3j4v3 suggests that decisions about service configuration should be made by CCGs working together, with appropriate input from NHS England, under the aegis of overarching Government policy. Whilst patients and the public are obviously important protagonists, it would be a dangerous precedent if major reconfigurations were seen to be driven by public demonstrations.

Finally, it is worth considering how the reconfiguration exercise might have been handled better. Once the South London Trust had been disbanded, it should have been the CCGs working with NHS England who made the strategic ‘macro’ decisions about the overall shape of service delivery; the operational details, the ‘micro’ decisions, should (in theory at least) been left to the new delivery organisations to define themselves, in response to an outline brief (‘what is required’) rather than any overprescriptive, micromanaged approach (‘this is how we want you to do it’). Broad brush strategic management needs the high level players to be involved, but preferably not the politicians; operational delivery is best left to those who know how to do it.

This piece is based on an article published in The Conversation on 1 August 2013, which can be read at http://tinyurl.com/p6wom8j