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.

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Fragmentation was built into the delivery of the NHS from its inception. That is why it finds creating strong patient pathways so very hard.

Filed Under (Integration, Patient involvement, Self Management) by Paul on 29-10-2012

There are many conservatives resisting NHS reform who sincerely believe that recent reforms (and for that matter those of 2001-7) have fragmented what has always been an integrated NHS. For them the reason the NHS finds integration so very hard is because all these reforms have introduced fragmentation through relationships such as commissioning and competition.

This belief that the NHS was intrinsically integrated goes along with a belief that during the ‘good old days’ the NHS operated as a command and control organisation. The belief was that the NHS was essentially integrated because the person at the top, the chief executive, could tell everyone what to do – ergo the NHS must have been integrated.

The belief was that an organisation with a single CEO must be integrated. But, as I have said many times, the idea that the NHS was a command and control organisation was false. It wasn’t. It was a command institution – with no control. A lot of shouting and very little authority.

No, the reason the NHS finds the provision of integrated services for patients so very hard is because it was set up in 1948 and has been developed in a fragmented way ever since.

This fragmentation has been built into the very way in which it works.

In 1948 NHS hospitals were nationalised with consultants becoming salaried staff in state-owned hospitals.

In 1948 primary care was set up through GP services that were created around private sector small business.

These two very different parts of the NHS were created in very different ways to carry out very different services.

For a variety of political reasons Nye Bevan had no choice but to create these two parts of the organisation in very very different forms. My point is not just that the staff in these fragmented parts of the NHS have different training and ideas about medicine but they work for and in very very different organisations, with very different incentive structures.

Any ‘fragmentation’ introduced by the reforms is minimal when compared to these intrinsic and fundamental differences which did not create an integrated organisation in 1948, and have not done so in the last 60 odd years.

I make these points to underline the extent of the task to be undertaken to create integrated care. Too many attempts to develop integrated care fail because they assume it is simply a matter of putting different bits of very different organisations together.

Over the last month I have had several discussions with groups of both consultants and GPs. There is a lot of moaning about each other, and occasionally some comments bordering on contempt, in the different groups.

A long while ago, in the early 1980s, I taught East End district nurses and health visitors in London. These were a group of staff who had made the choice to work outside of the hospital in what were very difficult communities during very difficult times for those communities. I often asked them why they had chosen to leave the hospital to work in the community and nearly all of them were clear that they wanted more space to work for themselves. They didn’t speak ill of their hospital based colleagues, but they saw them as having very different motivations and drives for different areas of nursing.

The development of integrated care is essential for NHS patients and is essential for the future economics of the NHS. Integrated care will work only if these doctors and nurses fundamentally work together.

The reason integrated care is so is difficult comes not from one or two small issues but from the essentially fragmented nature of the NHS.

Over the next few weeks I will post about the various large scale changes the NHS needs to be able to make to mainstream really integrated care.


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