This week’s interviewee says the coach of NHS reform is heading broadly in the right direction, but wishes the driver would take more care
“I’m a nurse with many years’ experience in hospitals, now working as the director of nursing at a ‘primary care cluster’: one of the many primary care trust [PCT] successor bodies that were established recently.
I used to work at a PCT, and there we really developed our commissioning skills after the last big round of organisational changes four or five years ago. We also improved the skills of our managers – and I know there’s a political dogma that a lot of money is wasted on NHS managers, but the fact is that the UK spends less on health managers than almost any other country. We do need managers, so that clinicians can help shape management decisions without being distracted from their core jobs.
In [health secretary] Andrew Lansley’s reforms, the basic premise of involving more clinicians in commissioning is absolutely right. However, we could have got there with an evolutionary approach, rather than the revolutionary one that he appeared to adopt. Organisations like my PCT had become quite sophisticated commissioners, but I’m concerned that because of the way the reforms have been approached, we’ll go backwards before going forwards. The disruption is just unbelievable, and now another set of organisations will have to get up and running. There’s a danger that we’ll lose much of the expertise and organisational memory built up in PCTs.
The reforms also represent a very ‘big ask’ of GPs. Getting GPs to take on the responsibility for commissioning is a major challenge for them: they’re healthcare practitioners and small businessmen, not service planners. While they’re learning quickly, they don’t necessarily think strategically.
The creation of primary care clusters is part of the solution to that challenge: they’ll operate like business services companies, helping the GPs with commissioning and offering advice and support. The reason that they’re formed of a number of merged PCTs is, first, because if the new bodies’ boundaries were the same as those of the old PCTs, that would invite people to ask why we’re doing all this; and second, because so many staff have left PCTs recently that these bodies must either merge or rely heavily on interim staff.
Meanwhile, Lansley’s reforms also introduce ‘health and wellbeing boards’ to provide a link between commissioning consortia and local authorities. In theory, the reforms should help to join up health services and social care – and that’s a desirable end: in fact, I think the reforms could have gone further in bringing those two together.
However, on the boards’ broader task of making sure the commissioning consortia are meeting the needs of the local populace, I’m concerned that it will take quite some time before the councillors sitting on them understand their areas’ health needs. What’s more, while there are some excellent councillors, many have overtly political agendas or personal beliefs that colour their views. And when local authorities have big budget cuts, councillors may feel they have to focus on their core business rather than pursue partnership working.
On the whole, I welcome the changes to the reforms announced since the ‘pause’. It’s sensible, for example, to ask the regulator to foster integration of services rather than competition. I don’t have a problem with competition – sometimes it really adds value – but it can be harder to create pathways for patients if services are broken up between a fragmented group of suppliers.
The reforms are also strengthened by including lay voices and those of other healthcare professionals in the commissioning groups. The way they’re going about it – for example, by using hospital doctors from outside that locality – could be complicated to implement, but the principle is right.
On the removal of the deadlines guiding the reform, I think that’s positive up to a point. It will allow some areas to proceed at a more moderate pace, but I do think you need to have an end point when you accept that those people who haven’t managed to make the leap probably aren’t going to – and you need an alternative mechanism for dealing with that. Otherwise, you just keep on moving the goalposts.
There are still some misconceptions around these reforms: the talk is around greater local control, for example, but I expect that the national commissioning board will have quite a tight grip on targets and quality standards. Overall, most of the ideas behind the reforms seem fine to me; the problem has been in the execution.
The pause was positive, but it left people feeling in limbo. Now we’re moving forwards, and need to get on with it. It shouldn’t take us as long to get the commissioning consortia up to speed as it took with PCTs, but success will rest on our ability to build on what’s been learned and hang on to existing competencies. It’s very important that we capture the expertise of PCTs; without those skills, it will be much harder to maintain quality of care and make the reforms work.”