My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Primary care is heading in the right direction – but will it get there in time?

Filed Under (Clinical Commissioning Groups, GPs, Reform of the NHS) by Paul on 14-03-2014

A year ago the main change happening in primary care was the move towards trying to finds ways to increase the size of the basic organisational structure.

1948 had seen Nye Bevan, for a whole range of very good reasons caused by the political reality, shy away from creating a salaried GP service. Having famously stuffed the mouths of consultants with gold, he gave GPs the right and the power to run their own businesses.

The real world of political achievement gave him little room for manoeuvre. Creating the NHS was not a matter of drafting the arrangements that you wanted. It took very hard bargaining with implacable foes running the medical trade union – the BMA.  Only commentators with no feel for the reality of political achievement could criticise Bevan for the compromises that he had to make to get the NHS show on the road.

One of those was to grant to the nation’s GPs the right to organise themselves as small businesses having control over their own organisations. Unlike other small businesses however, GPs have a guaranteed state income and a guaranteed state pension. A privilege denied to small shopkeepers and painters and decorators who have to operate in a real, competitive market to make their money and their pensions.

So in 1948 hospital consultants became workers with the right to moan about the management, and GPs became small businesses with the right to run their own organisations.

This split creates all sorts of problems for integrated care (about which I will blog next week), since the problem is not just about getting generalists and specialists to work together, but the much more difficult task of getting those who work for large organisations (consultants) to work with those who run their own show (the GPs).

So the 50th and 60th anniversaries of the NHS came and went with GPs still running their own show and the vast majority of them running very small businesses while over the previous 50 years nearly all other industries had undergone a considerable increase in the size of the unit of delivery.

Customer preference had used markets to turn small grocers into supermarkets. Customer preference had used the same markets to change nearly every industry with large numbers of small outlets into bigger organisational units.

Since consumer preference was not driving primary care to change, their organisational structure stayed where it was.

The problem was that medicine needed larger organisational structures to deliver all of its potential benefits Primary care needed to be actively involved in carrying out the many more diagnoses and interventions that at the moment take place in hospitals..

I, along with many other people, cannot get a blood test at my local GP surgery. Instead I have to go to an international hospital to get something that should be available in my street from my GP.

A year ago there was a greater recognition of the problem of size in primary care than had existed in the previous 60+ years. Most parts of the country were talking about the creation of federations and building sets of relationships between GP practices and one year on this trend has if anything accelerated.

Most people see this talk of federations coming in part because of the creation of CCGs. CCGs have brought GPs together for the purpose of commissioning, not providing. However most of the activities that GP leaders of CCGs need to talk to their fellow GPs about concern variations between the way they practice as providers of care. Therefore creating larger CCGs has inevitably raised a string of questions about scaling up GPs practices.

CCG leaders have experienced what every leader in the NHS has experienced for the last 60 years – primary care is vital but very disorganised. It will only really be able to fulfil its role if it takes on much larger organisational forms.

And it is this that is behind the strong move towards federations.

However there are two real problems with this set of changes.

Firstly because it takes on some very ‘hallowed’ experiences (the right to run their own organisation), this sizing up of primary care will not happen quickly. Taking on several thousand organisational leaders and persuading them to give up a lot of the power they have to run their own organisations will not be a speedy process.

Secondly this change is voluntary. GP practices that choose not to do this will not lose their registered lists or their income. In all other industries that have scaled up the failure to grow meant that you either had to work much longer hours to make the same amount of money (small corner stores) or be taken over – often the only way you could stay in business. These drivers have not been built into this change process in primary care.

In short GPs will do this at the pace that they want to, not the pace that their patients need. This means that it is done at the pace of the producers of the service rather than the consumers.

One other change with GP practices continues apace. As I noted above Nye Bevan failed to create a salaried GP service, resting power instead in the hands of a small business structure with partners. For 50 years Bevan’s compromise created a career path which saw GPs seeking to become partners in order to run established organisations.

This is now being changed – not by fiat from Whitehall – but from the new career choices that new GPs are making. For a variety of material reasons new GPs are not choosing to tie themselves to this old organisational structure. They are now choosing to become the very people that GPs 50 years ago did not want to become – salaried staff.

Newer GPs, instead of yearning for the long term relationship with a locality that partnership gives, are opting for the greater freedom provided by being salaried staff. This is partly caused by the change in gender of new GPs, with the larger number of women wanting to be able to shift their work patterns around prospective family responsibilities and partly because the relationship between place and security that was behind the creation and continuity of this model 60 years ago has changed radically. Professionals want to be able to move around and being tied to a locality through a particular organisational relationship does not give the freedom of movement that being salaried provides.

This means that the organisational structure of NHS GP service provision is primarily being changed by the wants of the new workforce.

The problem for patients is that they need larger scale primary care now and not in the 20 years it will take to work these changes through.

Does the NHS really have to create a new business model?

Filed Under (Clinical Commissioning Groups, Health Policy, NHS England, NHS Providers, Nicholson Challenge) by Paul on 12-03-2014

One of the remarkable experiences of my last year has been to witness near universal agreement that the NHS needs to change fundamentally. Nearly all of the various bits of the NHS agree with this.

Most of their speeches and papers usually agree that the need for fundamental change exists in terms of both quality and finance.

If you look at speeches from…

  • The Secretary of State
  • The Chief Executive of NHS England
  • The Chief Executive of Monitor and
  • The Chief Executive of the NHS Trust Development Agency

…they continually say that there needs to be change which touches on the fundamental.

Many talk about the next 2 years being the defining moment for the NHS with a warning that a failure to change dramatically will put the institution in peril.

So much so universal.

I am sure these four individuals (one Jeremy and three Davids) really believe in the necessity of large changes, and given that they all run big organisations with, between them, thousands of staff responsible for parts of the NHS, one might expect that their organisations would all be beavering away at the forefront of radical change.

You might expect that if you met a civil servant from the DH, or an employee of NHS England, Monitor, or the TDA they would all be raising questions about how, in order to save the NHS, you were developing your new business model. Given that the leaders of these large organisations are preaching very radical change, then you might expect their staff to be an active part of a massive engine of change.

But you would be wrong.

Whilst the leaders talk about the need for radical change, their staff enforce the old business model that their leaders say is finished.

This can be a bit bewildering for, say, a CCG. They will read NHS England’s call to action and may well start to develop some commissioning intentions and activity that will radically challenge the existing providers of healthcare to change their business model.

They will then discover that their Local Area Team, as a part of NHS England, will sharply question why they are doing something that will ‘destabilise local providers’. A wise CCG will then quote David Nicholson’s letter as a defence of such radical plans back at the NHS England employee.

Usually, and without hesitation, said employee will tell the CCG to pay no heed to that because all that matters is that the health economy breaks even financially – and that if you ask your failing local District General Hospital to do something different, they will financially fall over.

So stop it.

The leadership of Monitor and the NHS TDA both recognise that, for many of the NHS’ acute and mental health trusts for which they are responsible, the current business model is running out of time (and money). There is even encouragement for Trusts Boards to think about radically different business models and models of care.

But woe betide any board, in thinking through those new business models of care, that might opt to forgo any of the finances that come from within the existing model of care. If that happens Monitor and TDA staff will very quickly threaten them with lower ratings if they fail to squeeze every financial drop out of the existing business model.

So these important organisations have a policy of radical change in the NHS…

…and a practice of not allowing that radical change to happen.

On many Trust and CCGs boards there are one or two senior staff who think about going through the difficult process of radical change. But the difference between policy and practice within the major organisations running the NHS makes arguing for the necessary change within the NHS very hard indeed. Those against change argue that the practice of the main performance managers in fact penalises change by enforcing the status quo.

If the necessary changes in the NHS care model don’t happen this will in part be the fault of the very organisations whose leadership appear to be arguing for them.

Practice beats policy every time.

Commissioning for integrated health and social care (or just because everyone agrees with you, doesn’t mean it’s going to happen)

Filed Under (Clinical Commissioning Groups, Healthcare delivery, Outcome based commissioning) by Paul on 07-03-2014

Over the last year the idea of outcome based commissioning within the NHS has evolved from being a policy to establishing real contracts. In a little while a completely new provision for musculoskeletal (MSK) services will begin in Bedfordshire organised by a partnership of a local Foundation Trust (FT), an existing GP led MSK service, a private sector hospital group and patient charities. This partnership will replace a plethora of very different and fragmented contracts that are currently held by different organisations, each of which was contracted to provide fragmented care inputs.

It’s a big change, and the journey to establish outcome based contracts has been characterised by long periods of universal agreement punctuated by periods of intense conflict. Why has this happened?

Those with experience of working to change policy in the NHS will recognise that dangerous moment when everyone agrees that the new policy you are trying to create is correct.

It is the moment when you prepare… for nothing to happen. All sorts of people agree with a change in policy – because in the end no one cares about changes in NHS policy. What matters are the changes in NHS practice that will take place if a policy is implemented.

Unsurprisingly this has been true of the recent development of outcome based and integrated care contracts in the NHS.  From 2010, with the development of the NHS outcomes framework followed by the Secretary of State’s mandates for NHS England, most policy has argued that the NHS should start judging itself on patient outcomes and not inputs.

At the level of policy few can disagree with that. Intellectually we know that money spent on a hip replacement operation only creates real value if the patient can resume work – or walk to visit their daughter without pain. The policy of paying for outcomes and not inputs must be correct at an individual, social and economic level.

Equally most policy makers are quite rightly concerned about the current fragmented care for the elderly. So it’s interesting that when you ask older people and their organisations what would count as a positive outcome for their care the answer is very simple.

“Since you spend so much money on our health and social care, what we would like is that every time we come into contact with the health or social care system, we are more independent at the end of an intervention than we are at the beginning”.

The individual social and economic outcome of greater independence must be a good thing and, if we could achieve it, surely worth the money that is spent on the service. As a goal it’s difficult to argue against.

But current provider practice is all about fragmented inputs. Moving to new, patient based, outcomes is very disruptive of current practice. The problem is that a great deal of existing practice produces the opposite outcome for older people in that it creates greater dependence. If the long term condition of an older person becomes exacerbated – resulting in a 12 day emergency admission to hospital – this hospitalisation will normally leave the patient with a higher level of dependence. If they move wards several time during their stay, they may even have increased experience of dementia and therefore substantially increased dependence.

A contract based on paying a provider only if they achieve greater independence for this older person would therefore need a very radical shift in practice. And it is here, at the point of implementing a policy of outcome based contracts, that the near universal agreement with the policy disappears. Providers recognise that in order to maintain financial sustainability they will need to radically change the way in which they operate.

It is at this stage that we are told that working to patient outcomes will destabilise the NHS.

And if we take that last sentence literally it is true. The current stability of much of the existing model of care from providers has evolved from the experience of fragmented care that many patients regard as normal. Integrated, outcome based, health and social care will destabilise these existing models of care – and that will be a good thing. .

Because policies really don’t matter if they aren’t implemented, and over this calendar year we will see whether the NHS and social care can bring about the change that comes from working towards outcomes.

In recent weeks Oxfordshire Clinical Commissioning Group (CCG) passed proposals for the CCG to work with existing providers to develop outcome based contracts for older people and mental health services. The CCG have now reached the point where they have to negotiate with existing providers the radical changes that working to outcomes will being.

By deciding to work with existing providers the CCG have demonstrated that the development of outcome based contracts does not have to involve market based procurements. The CCG recognises that existing providers may have the capability to radically reorder their priorities. But they have the option to hold an open market procurement for the roll-out of 2014-15 contracts should dialogue at the point of contract agreement not be successful.

As in Bedfordshire outcomes based contracts will necessitate new ways of working which will need new forms of provider partnership.

Elsewhere the movement is gaining widespread support with CCGs backing prime and alliance models of contracting, to change and challenge the commissioner/provider relationship where existing models simply don’t work. Along with Oxfordshire, other CCGs leading the way include Cambridgeshire, Bedfordshire, Bexley, Northumberland, Croydon, and Staffordshire.

In all of these locations and more, the crunch will come when the idea moves from being a policy to making the necessary changes in the practice of provision.

How will Liberal Democrats reconcile their policy of keeping Britain in Europe with their policy of not using competition to improve the use of NHS resources?

Filed Under (Clinical Commissioning Groups, Coalition Government, Competition, Liberal Democrat Party) by Paul on 11-03-2013

We have learnt that Coalition Governments get into a rhythm. Every year now, in early March, there is an attempt by the Coalition to change some or other policy just before the spring Liberal Democrat Party Conference so that party members can feel that they are having an impact on the Government. Read the rest of this entry »

Architectural problems with the new NHS reforms (number 64).

Filed Under (Clinical Commissioning Groups, National Commissioning Board, Reform of the NHS) by Paul on 06-03-2013

The new NHS reform architecture contains within it a number of problems that have always been predictable. As I have suggested on many occasions previously this is in part a consequence of the very many different and opposing minds that have been shaping the reforms as they have been developed. The famous pause in April 2011 led to a considerable strengthening of the centre at the expense of CCGs in the localities. Since then the reforms have always been a combination of greater decentralisation, combined with greater centralisation.  Once that process began relationships between the NCB and the CCGs were always going to be difficult. Read the rest of this entry »

‘Commissioners not providers – should decide what they want to be provided; they need to take into account what can be provided… but in the end it is the commissioners whose decision must prevail.’ Francis recommendation 129

Filed Under (Clinical Commissioning Groups, Contracts) by Paul on 27-02-2013

We are just over a month away from the implementation of the new NHS reform architecture on April 1st. So I thought it might be timely to speculate a bit on what is likely to happen. Since some of the biggest changes concern the nature of commissioning it might be worthwhile starting there.

Read the rest of this entry »

How do Andy Burnham’s proposals stack up against his own attacks on Government policy?

Filed Under (Clinical Commissioning Groups, GPs, Health Policy, Labour Party, Local Government) by Paul on 18-02-2013

2 “The Government is wrong to carry out an unnecessary top down reorganisation.” 

A few weeks ago Andy Burnham made an important speech launching a major consultation on Labour’s Health Policy. What he described as “the biggest consultation on health and social care policy by the Labour Party for 20 years” is obviously an important event. My Monday posts are discussing his policy proposals in a particular way. Read the rest of this entry »

The NHS Confederation makes its case for a year of change in NHS hospitals

Filed Under (Clinical Commissioning Groups, Health Policy, Healthcare delivery, Hospitals, Independent Reconfiguration Panel, National Commissioning Board, Secretary of State) by Paul on 02-01-2013

The Government’s NHS reforms have done little to prevent the main change that will have to take place to ensure that our health service survives and thrives in any meaningful way in the future. That is the major reorganisation of many of the patient services that are at present delivered from NHS hospitals. In the last few days of 2012, the NHS Confederation has been putting the argument for change.   Read the rest of this entry »

When 360 degree assessment might just become very important

Filed Under (Accountability, Clinical Commissioning Groups, National Commissioning Board) by Paul on 28-11-2012

Following on from my post on Monday about the way in which local CCGs might use the Secretary of State’s mandate to hold the NCB to account, I have had my attention drawn to some activity from the CCGs themselves. I was suggesting that since the mandate lays a number of responsibilities on the NCB to listen to the changes that the CCGs say are necessary to bring about integrated care, the CCGs could use it to hold the NCB to account. Read the rest of this entry »

Turning the tables. How might CCGs use the Secretary of State’s mandate to hold the National Commissioning Board to account?

Filed Under (Clinical Commissioning Groups, Health Policy, National Commissioning Board, Secretary of State) by Paul on 26-11-2012

This is my third post about the mandate because I think this is such an important part of the new NHS architecture. This one is looks at it from a different point of view – in a way that could turn the whole politics of the mandate on its head. Read the rest of this entry »