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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How can GPs develop organisations without succumbing to the traditional bureaucracy of a top down NHS?

Filed Under (GP Commissioning, GPs, Reform of the NHS) by Paul on 21-03-2011

In late January, following on from David Nicholson’s letters to NHS CEOs, I blogged about the importance of him and the NHS Commissioning Board gripping the transition of the next two years. I posed his expectations of how the reforms would develop (though being gripped by him) and how GPs wanted to develop their own organisations in their own way. It is no secret that the vast majority of GPs hate bureaucracy and it’s no secret that David Nicholson is good at running things from the top.

Since December, when David Nicholson was appointed and when the Government agreed that they would at the same time go ahead with the development of locally based GP Commissioning organisations, they appear to have agreed a dual way forward which have not just different but opposing intentions. At the time I expressed a belief that the top down approach would start to put GPs off – and I want to talk about some very different experiences that follow on from that clash.

In the last two months it is clear that things are happening in very different ways in different parts of the country. Some clusters are being formed with their only intent being to encourage GP Consortia to develop as they want. Other PCT clusters see their job as telling GP Consortia what they should do and how they should do it.

I am really heartened by the fact that this is different in different parts of the country. I was anxious that the dead hand of “top down” would crush GPs so it’s great to see that – so far- this has not happened everywhere.

In today’s post I want to celebrate two experiences that I had where GPs have educated all of us in doing things in a very different way- and will follow this up tomorrow with suggestions about how other consortia could resist being told what to do.

GPs have demonstrated that they can bring game changing skills and expectations to this interaction between locality and centre in commissioning.

They have been asked to pick up this commissioning role because they are clinicians who also have the experience of small business people. These experiences provide them with weapons against centralised bureaucracy and need to be used as such.

The first experience came when  I was working with a local authority to set up a Shadow Health and Wellbeing Board. When it is set up this will be an important body that will integrate the different commissioning responsibilities for local government and GPs. There were draft terms of reference – a necessity for any Board having  membership, aims methods etc etc. (it was a bit boring but it did what I felt was necessary.  The aim of the meeting was to move this agenda forward. There were 30 minutes of rather stilted discussion with the leader of the Council showing little enthusiasm about chairing another such body.

Then one GP said that she felt this looked like a bureaucratic takeover by the local authority of what GPs were meant to be doing and it really didn’t seem to be the sort of body that could actually achieve things for people’s health. Another GP joined in and pretty soon it was clear that in reality nobody around the table wanted to set up a body which was going to be simply bureaucratic. Instead the discussion led to the suggestion that a series of small task and finish groups be set up on issues such as the frail elderly where there could be some immediate joint impact. Towards the end of the meeting a rejuvenated leader of the Council said they would really like to chair that.

The second experience came at a meeting between a number of PCT non-exec directors and some GPs from a local area to talk about the transfer of powers and duties that needs to take place between now and 2013. After all, until that date, PCT NEDs will be responsible for receiving the money from the DH and will therefore need to ensure good governance.

The first half of the meeting was really about trading anxieties. How on earth could non exec members maintain their governance responsibilities when there was all this structural change going on? The PCTs remain responsible for the money, and the outcomes for the money, but the accountable officer is removed from the PCT to the cluster. It all seemed really difficult.

A GP then said that this all seemed to be going about things in the wrong way. What was important was how GPs and PCTs could start taking new risks straight away. Patients needed a better value for money NHS and that could only be achieved by much better appreciation of risks – especially the risks of not achieving better value for money. The GPs in the room made the very sharp point that they engaged in very difficult risks every time they saw a patient. They were really used to risk.

The NEDs became animated by a real rather than an abstract discussion with the GPs which ended on a much higher note than it started.

Both of these turnarounds were caused by GPs speaking up against the norm that bureaucracy had expected to develop. My point is that they spoke from their experience. The very experience that was the reason they were asked to do this job.

Keep this happening and something new could emerge. Over the next few months this is going to get very difficult because there will be very strong forces trying to hedge them around with stifling bureaucracy. If GPs feel they can use their experience to strongly resist this it will be a major step forward for the reform programme.


One Response to “How can GPs develop organisations without succumbing to the traditional bureaucracy of a top down NHS?”

  1. An excellent piece. If GPs can remain true to their natures as doctors and small business owners, then the reforms have a chance of success. If they try to “manage the market”, take responsibility for the viability of providers, and concentrate on concepts like leadership and strategy, then we may as well have stuck with PCTs.

    Perhaps it will end up being a matter of size? Small consortia may find it easier to behave like customers, and forge constructive long-term relationships with their providers, and simply call for (rather than try to establish) better and alternative services. Large consortia will be more drawn to try to exert control, which didn’t work so well for PCTs, and probably won’t for GPs either.

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