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.
- Read the discussion paper: Commissioning for the future: Learning from a simulation of the health system in 2013/14
- You can also read the Director of Strategic Planning for NHS Lincolnshire, Martin McShane's blog on this simulation exercise.