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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Small things can make the big changes

Filed Under (GP Commissioning, Primary Care Trusts, Reform of the NHS) by Paul on 26-11-2010

A part of my week is spent with quite large health policy and political issues. Either writing my blog or in giving talks about the large scale changes that the NHS is going through. Interesting work on a very big scale.

But most of my week is spent working with health organisations on the ground, trying to make sense of what they might do and how might they do it to maximise their effectiveness. Whilst I am not involved in the nuts and bolts of operational management some of this development work is very granular and detailed.

This mixture of policy and detail makes for an interesting week. I often think that the one thing that would make my work as a special adviser in Whitehall much much more effective would have been another Paul doing what I am doing now and meeting up every evening after work. Trying to make change happen on the ground in real time is the best way of learning what is actually happening to policy. And by that I don’t mean studying it in some abstract way but trying to really make it happen.

Coming up against the details sometimes throws into sharp relief the big things that need changing – if change is really going to happen.

I have spent quite a lot of this week in different parts of the country in meetings between GPs and PCTs concerning working through the detail of setting up GP Commissioning Consortia. Partly because of the economics of the NHS, at the moment part of these meetings are not just concerned with the future, “How are we going to make this work?” but also concerned with the present, “How do we stop ratcheting up a big deficit between now and April 2011”.

The GPs recognise that the two are linked. They are getting into the detail of how to save the PCT’s budget because they know that from next year in some places this will be their budget. So interestingly, in looking at this year’s budget and in listening to GPs talking about new forms of economics, we are beginning to see how GP commissioning may actually work.

It may not be GPs’ responsibility yet, but they are recognising that this is money for which they will very soon have responsibility. So they might as well start to assume it. This leads to some interesting communications – or as often miscommunications -between PCTs and GPs.

The small point – that is really a big point  – concerns the contractual relationship that exists between most hospitals and most PCTs. At these joint meetings of GPs and PCTs, they have to come up with ways of saving money in the next 17 weeks of the financial year. Most of it concerns restraining hospital expenditure.

The GPs have in their mind a contractual relationship that is similar to the contracts that their practices have with suppliers of goods and services. If we want this service then we will pay this amount of money for it. If we want 7 of these we will pay 7 times that price. If we think we might want 20 over the year we will pay for them as we use them and only pay for 17 if we use 17.

They think that this is the contractual relationship that must exist between commissioner and provider of health care. And so when they say In December let’s just send less of x and then we will have to pay for less of x. They are a bit surprised that, for many PCTs the contractual form that they have between PCT and a hospital doesn’t appear to work like that.  It is not that precise. A block contract appears to contract a block rather than a specific service for a specific patient.

The miscommunication is the GP saying, “Why don’t you use the contract to do x?” The PCTs saying “we can’t”. The GP thinking that must mean you are daft because that is what a contract is. It only slowly it dawning on both sides that the contractual form between most hospitals and most PCTs is not sufficiently granular to work as GPs want and need them to work.

After a few minutes both sides of the PCT and the GPs understand what is going on and this usually leaves the GPs saying something to the effect of “But that is really daft. How can you control anything as a buyer if that is the contract you are working with”?

The PCT then says, “Now you understand what we have had to work with all that years” expecting sympathy.

But the GPs then say, “But this contractual form is so daft why have you as the purchaser agreed to use it?”

To which the PCT answer is, “Because we were told to”.

To which the GPs answer is, “More fool you for agreeing. We wouldn’t”.

And this is the small thing that is really a big thing. On the ground around the country GPs are beginning to get real experience of the forms of contracts that the DH has been delivering for PCTs and thinking, “This won’t work for us. The contracts have NOT been created to maximise the power of purchasers. They have been created to maximise the stability of the whole health local economy”.

This means that the tools PCTs have been given have not given them the opportunity to maximise the efficiency of the resources they are given.

The GPs that want to commission want to carry out that task. And to do that they will need and demand different tools to do it with. If they are told that they can’t create those tools then they know from the beginning they are being given tools which will mean they can’t succeed.

If they are given those tools then they will succeed and there will be a shock to the NHS system.

The little but important issue of form of contract could be the issue that successful or unsuccessful GP commissioning turns on. If they are allowed to use the sorts of contracts they know they believe they have a chance of making this work.

If they have to use the contracts that the PCTs have been using then it probably won’t work very well.

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