Commissioning for the future: will fact follow fiction?
08 April 2011
Tags: commissioning, nhs reforms, leadership and management, governance and accountability
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.
You can also read the Director of Strategic Planning for NHS Lincolnshire, Martin McShane's blog on this simulation exercise.
Your comments
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.
tim gilling - deputy executive director, centre for public scrutiny
11 Apr 11
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.
Mary E Hoult - volunteer
14 Apr 11
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
john kapp - director, SECTCo
14 Apr 11
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.
Sean Green - Non Executive Director, Acute Foundation Trust
14 Apr 11
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.
Suzanne Shale - Organizational ethics consultant, Several universities, NHS Trusts
15 Apr 11