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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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What to do if you want to push on with NHS reforms – Some thoughts for national GP leads.

Filed Under (GP Commissioning, Reform of the NHS) by Paul on 24-06-2011

The national GP organisations such as the NHS Alliance and the National Association of Primary Care have, over the last couple of months made some strategic errors that now cannot be fully recouped.

(The Royal College of GPs is in a different category. As a professional membership organisation representing GPs it would always be conflicted about these reforms, as the two very different views of its previous and current president exemplify)

But a year ago both the NHS Alliance and the NAPC were looking forward to a White Paper which would put their ideas and their members on centre stage for the NHS. Now they are still faced with a range of tactical possibilities but they have learnt that they need to forge these themselves rather than to wait for the patronage of a fickle Government.

In some ways of course this is not their fault. They would take a Government at its word and expect at the very least that once a Bill has been given its second reading in the House of Commons the policy would be implemented.

But definitely, when the pause started on April 4th, they should have woken up to the way in which the axis of reform had shifted. From that date onward the only voices being heard were those in favour of the NHS (apart from a letter to the Telegraph from a group of GPs – clearly led by a Tory). The NHS Alliance and the NAPC should have mobilised their members to both flood the national and local airways and to lobby local MPs about how any rowing back would be disastrous.

Instead the political running was made, day after day, by advocates of the status quo  and whilst for the first couple of weeks the Secretary of State for Health appeared to be saying that it was still “full steam ahead” he was both a lonely voice and one contradicted by his boss the Prime Minister.

But all of these are lessons for future NHS reform under a similarly frightened Government. GP organisations are now left with the wreckage of the “car crash” and those that want to maximise the impact of GP led commissioning are left with having to maximise tactics without having much say in the strategy..

So I would look to the NHS Alliance and the NAPC to change roles now. Given that clinical commissioning groups are no longer the same as GP commissioning consortia, the role of these organisations is to fight for their members’ influence. Just as hospital doctors have argued strongly for their doctors against GPs, the GP organisations now need to be similarly sectarian.

These organisations now need to return to the position they were in 18 months ago and see their job as maximising GP influence in commissioning. They need to start this process in recognition of the fact that the Government’s reform of its reforms is designed to limit GP power over commissioning. They therefore need to get involved in limiting these limitations. The biggest of these issues involves the role of the NHS Commissioning Board.

Here is a question which brings a wry smile to the face of NHS managers. The Government’s new reforms put the NHS Commissioning Board in a difficult position. Every time the NHS Commissioning Board authorises a clinical commissioning group to have the right to take on commissioning in a local area, it means there is less commissioning power for the Government’s Commissioner of last resort – and that is called the National Commissioning Board.

So let’s pretend that the NCB was interested in maximising its power (yes I know its a strange idea but I did say let’s pretend). That would mean the NCB has an interest in not granting many authorisations of clinical commissioning groups.

The only way to stop this from happening is if there are national organisations of GPs who are prepared to fight the GP corner against the NCB. This means that these organisations need to crawl over the authorisation process both in general and in particular.

It is likely that the best GP pathfinders will apply at the beginning of the authorisation process to become a clinical commissioning group. Imagine how those GPs across the country would feel if their best exemplars were turned down by the NCB – and in whose interests would it be to clearly take an initial tough stand on authorisation? (Yep – that’s right – the NCB)

Local GPs can’t take this on without appearing to claim special pleading. It needs national GP organisations to stand up for them, against the NCB.


2 Responses to “What to do if you want to push on with NHS reforms – Some thoughts for national GP leads.”

  1. It is real mess now!!There will be particular confusion about commissioning responsibilities. In some areas clinical commissioning groups will be up and running in April 2013, others will be operating partially, and others in shadow form only. In addition there will now be more than one commissioning model that will not only create uncertainty, but a two tier service that will also create a costly and duplicative bureaucracy. We will have a Department of Health, a National Commissioning board, four SHA clusters, fifty PCT clusters, hundreds of clinical commissioning boards, dozens of clinical senates, and over 100 Health and Wellbeing boards. And we are suppose to achieve this with management budget that has been reduced by 45%. Where in all of this is the ”bureaucracy busting” that Lansley has spoken of? Furthermore, there are huge risks that the abolition of primary care trusts and SHAs will cost millions in redundancies and subsequent re-employment of staff in NHS commissioning boards. It is a complete myth that GPs in commissioning groups will have a huge impact on designing services. Emergency services like A&E will be commissioned at a certain level around a million population. Tertiary services like neurosurgery, will be commissioned by the NHS Commissioning Board. Elective care such as cataract and orthopaedic surgery, will be via patient choice arrangements. The bill may have some influence on long term conditions, but this too may be tricky as the providers with one eye on profit will come with a fixed package with very little leverage to change especially if that increases their costs and is therefore bad for profits.

    Paul,GPs will become rationers of care, which will irrevocably damage the GP-patient relationship for good.

  2. What to do if you want to push on with NHS Reforms – some answers from a national GP lead

    Paul Corrigan is absolutely right that NHS Alliance will now have to fight hard to ensure that clinical commissioning groups have the influence that they will need to be effective. He is also absolutely right that the commissioning groups (previously GP consortia) and their national representative organisations were challenged by the “Pause” and what seemed to be, initially at least, the dumbing down of GP led commissioning.

    For some of our commissioning colleagues, the Pause came as no surprise. After all, the establishment and vested interests had seen off Fundholding, Locality Commissioning, Primary Care Groups and Practice Based Commissioning. To many, the Pause seemed simply to be a re-run of past catastrophes with the dice heavily loaded on the side of those wanting to maintain the status quo.

    The leadership of organisations such as NHS Alliance, also faced an unequal battle. All the clinician leaders within NHS Alliance have “day jobs”. I myself, for instance, still work as a three quarter time hands on GP. There is a limit to the amount of time we can spend in a broadcasting studio. There is also a limit to the amount that our hard pressed members would want us to spend their membership fees on press and publicity. Not withstanding, you will see that NHS Alliance has produced a number of press releases over the last two or three weeks in strong support of frontline clinical commissioning and our leaders have been on radio and television, frequently at short notice, and without turning any requests down. Ultimately, it has been a question of fire power. Those in support of frontline commissioning have been faced with organisations with much larger press offices and large numbers of people, who work full time for those organisations. There is a limit to which already hard pressed frontline clinicians can give their free time and energy to causes, however important. In short, the weight of opposition to reform from large organisations with full time staff and greater resources has inevitably made them more visible.

    There has also been a secondary issue. The Health and Social Care Bill covers a wide number of areas. Though NHS Alliance members are strongly committed to frontline clinical commissioning, many were concerned about the powers of Monitor and the National Commissioning Board and others felt that integration needed to be given every bit as much weight as competition. NHS Alliance was not therefore in a position to put all its weight behind the Health and Social Care Bull without reservation, which made the solid championing of GP/clinical commissioning more difficult.

    A third problem was the media themselves. Discussion during the “Pause” rarely went beyond the ideological – such as left versus right and pro market versus anti market. There was little exploration of why the current system could not survive the future and little interest in the practicalities of what frontline clinical commissioning could achieve or might have achieved already. Indeed, in the middle of the “Pause” NHS Alliance produced a 46 page document entitled “Making it Better” which provided a strong case for GP/clinical commissioning and over forty examples (six in-depth) of how it was already providing solutions to the NHS’s problems. None of the national press or broadcasting media were interested – it was unwanted and seemingly unnecessary detail interrupting the fisticuffs and personality battles that were of far more interest to the press.

    It is hardly surprising that the “Future Forum” where GPs were far outnumbered by consultants and senior managers should come out with recommendations such as there needing to be a consultant specialist on every Commissioning Board. It is hardly surprising that Government, faced with the compromises of a Coalition Government should then have further sacrificed the autonomy of clinical commissioners to the NHS Commissioning Board, Tom Cobley and all. Clinical commissioners have felt like the small fish while heavyweights have been boxing it out.

    But Paul Corrigan is absolutely right, now is the time for us to press our advantage. That advantage is that the big mouths and those arm chair theorists and critics have not got any useful ideas about taking the NHS forward. They only know how to stop things happening. The epidemic of long term disease, the increasing problems of the elderly with several long term diseases and shrinking NHS resources mean that the alignment of clinical decisions with NHS decisions and finance is an urgent necessity that can no longer be put to one side. Senior managers will want to do so in order to maintain their powerbase. Consultants will want to do so because they won’t want to see GPs in any sort of a driving seat. Many GPs will want to do so because their new role – crucial and heroic – does carry great responsibility, involves added work and carries some risks. The simple fact, however, is that there isn’t another answer. As soon as clinicians, managers and the public grasp that, we can get on with making frontline clinical commissioning a reality. Meanwhile, that is precisely what most frontline commissioners are doing.

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