Commissioning for the future: will fact follow fiction?

Comments: 6

The House of Commons Health Committee report, published on Tuesday, raised a number of concerns about the health and social care reform programme, including fears over centralisation, accountability, integration, and choice and competition.

It is interesting how closely this report reflected the issues that arose at a recent simulation run by NHS Lincolnshire, which sought to model the NHS in 2013/14. We were invited along to observe the event and it proved to be a fascinating day, offering us a unique insight into some of the potential behaviours and dynamics that might result.

To an observer, the system felt chaotic. Participants had a positive energy and enthusiasm, but who exactly was in charge? The GPs in the exercise were unsure of the rules they were playing by and sought guidance from the centre; the role of the NHS Commissioning Board expanded as the players tried to manage the financial challenges faced by the consortia and their continuing demands for support. This reflects the Health Committee's concerns that the natural pressures for centralisation will be strong and that, in their infancy, GP consortia will be unlikely to act as an effective counterbalance.

The Health Committee also called for greater clarity over the role of choice and competition and stressed that commissioners need to have the power to determine the shape of service provision. It is remarkable how prescient the simulation proved to be on this matter too. Participants had a great appetite for integrated pathways of care: GPs and providers worked together to develop a proposal for an integrated emergency care pathway, but Monitor struggled to decide whether the proposal conflicted with its remit to promote competition. At the end of the simulated year, the issue had not been resolved.

For me, the most alarming observation of the day was the fact that the financial challenge quickly became the paramount concern across the system. In the efforts to grapple with bottom lines and savings, the patient got lost. Those representing HealthWatch and the health and wellbeing board suffered from a lack of authority and largely failed to put public health, prevention or patient experience on the agenda. It is good, therefore, to see the Health Committee report addressing these issues and calling for the strengthening of HealthWatch.

Perhaps the most striking observation was the sheer scale of the personal and organisational development challenge for GPs. As the Health Committee report starkly points out, GP commissioners face a 'daunting list of tasks – just as the resources available for administration are substantially reduced'. The Committee suggests treating authorisation of consortia as a process not an event and calls for a phased approach of earned autonomy. This, along with its calls for the continued existence of PCT clusters beyond 2013 as NHS Commissioning Board 'outposts', would certainly seem sensible given the findings from the simulation.

The question now is whether the scale of organisational upheaval and loss of staff leaves these outposts equipped to support the development of commissioners while the NHS attempts to meet the 'Nicholson Challenge' of £20 billion of savings.

Comments

#414 tim gilling
deputy executive director
centre for public scrutiny

It is interesting to note that the simulation did not appear to include a role for a council overview and scrutiny committee.

OSCs currently have wide ranging powers to get information, make recommendations and get responses from councils, PCTs, SHAs and NHS Trusts. Under the reforms, those powers will extend to all commissioners and providers of health and social care (bringing accountability to GP consortia and private sector providers).

Having a scrutiny role in the simulation may have been beneficial in demonstrating how to overcome 'confused' lines of accountability and how to bring robustness to the arrangements for commissioning and providing services that meet health needs now and tackle inequalities.

#416 Mary E Hoult
volunteer

I contributed to the Health Select Committee Report and feel their recommendations are a fair balance approach the these changes.
I also agree with Tim Gillings comments with regard to the role of Public Scrutiny without it who knows how these systems will work.

#417 john kapp
director
SECTCo

The most significant remark is 'patients got lost.' They have always been lost, because we have had a provider led NHS for 63 years, and previously. However, we are now seeking a patient-led NHS, who will be consumers in a market in which there will be competition in treatments - basically drugs or NICE-recommended complementary therapy (Mindfulness Based ~Cognitive Therapy (MBCT for depression, hypnotherapy for IBS and spinal manipulation for low back pain. These account for 2 out of 3 GP consultations and time off work. The expert patient of the future will participate in the treatment plan. Drug-free treatments will be commissioned and provided by thousands of CAM providers, ending health inequalities

#418 Sean Green
Non Executive Director
Acute Foundation Trust

I participated in a simulation on a recent NHS course with similar outcomes.
There was confusion over who was working in the best interest of the patient and how decisons were being made on contracts.

#419 Suzanne Shale
Organizational ethics consultant
Several universities, NHS Trusts

The full report on the simulation is well worth reading. The exercise is consistent with themes that emerged in my research on the ethical challenges faced by PCT medical directors. Tensions arose between these clinician's natural 'fiduciary' orientation (ie representing individual patient interests) and their 'bureaucratic' role (ie planning and budgeting for whole populations, and building their organization) and these conflicts are frequently insoluble. In the end priority has to be given to one or another, and moral leadership depended on finding an appropriate balance over time. A further theme from my research was that the most disturbing ethical challenge many medical directors identified was dealing with problematic clinical performance. The PCT's important role in 'Performer's List' management appears to have been forgotten with all the brouhaha around commissioning. The difficulties these simulators had in knowing how to deal with 'poor performing practices' (the report does not make clear what sort of poor performance was rehearsed) are instructive. Where there are clinical performance problems, revalidation will not solve them - they will simply flag them up. Patient well-being and justice to practitioners will depend on how well the situation is managed. Will GP consortia have the knowledge, skills and commitment to grasp this nettle? My research informants emphasized that one of the factors enabling PCT medical directors to do so was that they were NOT working closely alongside poor performing colleagues, and had clear accountability for the quality of care in their area. Finally, I'm not surprised HealthWatch became sidelined in the simulation. In the most patient-centred organizations, there is still little recognition of the need to support and train patient 'representatives' for their role. (Even the Kings Fund leadership development portfolio reflects the assumption that leadership in healthcare is only the concern of those paid to lead!) The plans for the NHS seem to expect that a small army of unpaid, untrained, unrepresentative, and often (axiomatically) unwell volunteers will render the system accountable.

#39838 Agung
Over the past 8 years I have worked at magenar level in the Acute sector and as a GP Surgery Manager. Both sectors of clinicians had a mix of dedicated doctors and sadly some who did not want patient and public involvement and who appeared to be more i
Over the past 8 years I have worked at magenar level in the Acute sector and as a GP Surgery Manager. Both sectors of clinicians had a mix of dedicated doctors and sadly some who did not want patient and public involvement and who appeared to be more i

Over the past 8 years I have worked at magenar level in the Acute sector and as a GP Surgery Manager. Both sectors of clinicians had a mix of dedicated doctors and sadly some who did not want patient and public involvement and who appeared to be more interested personal gain. Thankfully I believe the majority do the work to help sick people ahead of personal gain. I tried several times to encourage a patient group at my surgery but GPs seemed reluctant every time. While some GPs and Consultants understand the business aspect of value for money in commissoning services some do not and in the past have griped to PCTs about being involved in commissioning but failed to give any leadership in setting up commissioning stragtegies. Of course we must value our good GPs and while PCTs were not perfect, importantly they held GPs to account and while no doubt their has to be collaboration between clinical teams and business magenars, most business magenars in the NHS have been trained in effective business strategies and management and GPs have been trained in medicine each to their own specialty. I have concerns that a lot of GPs have the business skills to do what is required and if they haven't do they employ yet more people (using public money) to show them how? I would rather they used more time to see patients if they have any spare time than sitting in strategic meetings. I honestly found Acute consultants more proactive and open to working with magenars than local GPs who in my area I felt really didn't want to do anything positive to move commissioning on in the early days. I went to many commissioning meetings with GPs and while their clinical contribution was vital they were never able to make decisions so little moved on in early years of commissioning.Interestingly, it was amazing how many private providers contacted the hospital and the surgery offering their commisioning serices and my bet is they knew there was money to be made! So why not use the in house NHS magenar we have already to liaise with doctors to improve things. Finally, lets NOT have closed meetings for so called sensitive issues but be open on what is happening to our public money and a bit more accountability to how this public money is spent because I have seen a lot wasted in the NHS and when I worked previously for a large (and profitable !) chemical company before joining the NHS I can tell you this waste would not have been tolerated.

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