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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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At last a narrative (if a little naive) for the Secretary of State

Filed Under (Clinical Commissioning Groups, GP Commissioning, Narrative of reform, Secretary of State) by Paul on 08-11-2011

As I mentioned yesterday I spoke last week at the National Association of Primary Care Conference. What was really interesting was listening to the Secretary of State speak just before my panel session began.

Here we are just 18 months into his tenure and I think at last he is discovering a narrative. Of course this was to an audience that completely agrees with the direction of his NHS reforms, so the main thrust of the narrative should not have been be too difficult to determine. This is after all the audience who thought of GP-led commissioning before he did. So it doesn’t come much easier than explaining what you are doing to people that really want you to do it.

The narrative was simple (if somewhat internal to the audience of GPs),

I believe that you know what is best for your patients so I am getting rid of all the people and organisations that hinder your acting on that knowledge and will give you commissioning of local NHS services.

He remembered talking in the past with GPs who felt they could not follow their own priorities because there were central political targets, and there was the national operating framework to divert them from what they wanted to do locally. You will have ‘legally backed freedoms without political interference and without central interference’.

He did not understand why some people kept on bringing up the conflict of interests that would exist because the GP who makes the clinical decision in patients’ interests would be making the same decision as a commissioner. The ‘ethical responsibilities’ of the GP were the same in both decisions.

This was reflected in the opening lines of both of the first two questions that were asked. Both genuinely thanked the Secretary of State for trusting them and their profession with such an important task for the future of the NHS. This was a really genuine relationship where a politician had expressed trust in a profession to do something important and the profession was picking up the task.

But what the Secretary of State seemed to miss was the next part of both questions which said, if we are to be trusted with these important tasks, why is the centre telling us what to do in such “a heavy handed way”? The first aspect of heavy handedness expressed by a GP concerned the rollout of the 111 emergency numbers. The Secretary of State missed the point of the question by saying that of course 111 needed to be a national issue.

The second question involved further heavy handedness but inter alia the questioner mentioned that David Nicholson had said, to the same conference on the previous day, that he was also interested in seeing GPs pick up the task of commissioning.

The Secretary of State seemed genuinely delighted and a little surprised that his CEO of the National Commissioning Board agreed with him on this issue and went on to joke about what an unlikely couple they made with each of them moving towards the other’s position.

What he missed however was the dissonance that his audience were experiencing between the ‘promise’ of local power of commissioning and the ‘reality’ of how the NHS – here and now in 2011 – is working. Developing CCGs in 2011 was meant to be about taking power, but the experience was one of being pushed around.

I think the GPs brought this up with the Secretary of State because they wanted him to do something about it. They wanted him to stand up for them against an overbearing centre – and they wanted him to know about this because, well, he stands next to that centre.  After all his narrative was that they were being asked to do what was best for their patients without being told what to do centrally. Yet here they were experiencing the centre telling them what to do.

So at last the Secretary of State had a narrative. The problem was that it didn’t fit in with the world experience that his most fervent supporters were having.

I was left with the question – does he really not know that they are being told what to do by their PCT and SHA clusters? Or is he being disingenuous?

Does he really believe that under his reforms the National Commissioning Board will not be experienced by GP-led commissioning groups as them being told what to do?

My worry is that he really doesn’t think that is happening, or will happen.

This presents him and his narrative with its greatest problem. It’s OK when your narrative is rejected by your opponents. That is what conflict is all about. But it’s important that your narrative is accepted by the people that support you. For that to happen it has to describe the world that they actually experience and not just the one he would like it to be.

In the panel discussion in which I was later involved the majority of the audience felt that the NCB had more power than the CCGs.

In fact I was asked by one GP how was it that my view of the relationship between the CCG and the NCB was one of conflict – whereas the Secretary of State seemed to have a utopian vision of that relationship. Which was right?

I replied that I had always found it was best – when trying to change the world – to actually recognise and live in the world I was trying to change.


3 Responses to “At last a narrative (if a little naive) for the Secretary of State”

  1. Paul you keep ignoring the fact tha there will be huge confusion about commissioning responsibilities too. 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.

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

  2. I agree with the artical and Kailash Chand.

    But first one MUST accept that this IS a NATIONAL service and NOT a local individuals oportunity to do as they like.

    Can anyone name just one national or international company that does not follow policy laid down by the head office ?- not one!

    This mess of another “VISION” without any attempt to providing a CPA – Critical Path Analysis. Is at the root of the failings of ALL the previous and now this reshuffl.

    Can you for one minute, imagine what would have happened if the space exploration had gone ahead just with a “VISION” ?

    They would never have got off the ground.

    So when are we going to see THE FIRST CPA for the NHS ? Instead of a mountain of reports; green & white papers etc.
    Pluss enough hot air to replace all the power stations.

    We have had years & years of talk and reports, so can we now, just for once, get on with planning on a CPA.

    Only when that is done can one say there is a plan. Properly evaluated & targeted; identifying what, when, where & how & at what cost, with a controlable timetable.

  3. […] recently as November 8th I posted about his speech to the NAPC where he thanked them for their enthusiasm. But, as I noted, at that […]

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