Commissioning – we must keep the fox out of the chicken coup

It is only natural that the most commercially minded General Practitioners will become actively involved in Clinical Commissioning Groups (CCGs). It’s also logical that these commercially minded GPs will already have some involvement with private companies delivering care to both private and NHS patients. There is, I believe, nothing wrong with that, especially as we must not forget that GPs are, after all, privately contracted to the NHS in the first place. This only becomes a problem when GPs are given the power to choose providers for their patients and may have a financial interest in one or more of the providers being selected.

According to a recent report, more than a third of GPs on the boards of new NHS commissioning groups in England may face potential conflict of interest in the commissioning process. The investigation, undertaken by the British Medical Journal, estimated that 426 out of 1,179 (36%) GPs surveyed who are in executive positions on NHS Commissioning Boards have a financial interest in a for-profit health provider outside their practice.

This entirely predictable predicament now has to be subject to guidance to be issued by the NHS Commissioning Board.

However honourable and decent these GPs are, (and I have no doubt that most, if not all, are) – to be faced with a choice of the best provider for a particular treatment pathway, knowing that you have an intimate personal or/or financial relationship with that provider can be at best challenging, at worst, impossible. If you exclude a provider on the grounds of conflict of interest, you are at risk of reducing appropriate choice. If you exclude a commissioning GP on the grounds of conflict of interest, you may be denying a population of patients of an expert opinion. Catch 22.

I am pleased to see a growing number of recruitment adverts from CCGs and Commissioning Support Groups for pathway mapping, service redesign and cost reduction experts to enhance the whole process and deliver an effective and independent commissioning service. Considering the high proportion of GPs with declared private interests, each CCG may need to appoint additional independent advisers to redress the balance and maintain an impartial majority.

Ideally – there should be an independent organisation to commission clinical services in a region.

Ah yes – there used to be. They were called Primary Care Trusts, and they are due to be abolished next month.

 

As predicted – NHS reform is proving to be divisive.

 Perhaps it’s because I was brought up as the difficult middle child, but I love a good spat – it gets issues out in the open and can often clear the air. If only it were that simple with all the siblings of the complex NHS family, a family that appears to be more dysfunctional by the day as the Health and Social Care Act is implemented.

No-one could doubt  the good motives of the former Health Secretary Andrew Lansley as he formulated the transfer of power to give General Practitioners not only the lead when it comes to commissioning of services, but the key to around £60 billion. But as many of us are already aware, the consequences of these changes are not all beneficial.

As predicted, GPs appear to fall into three camps. Those who don’t want all the hassle, paperwork, responsibility of balancing commissioning with face to face patient time and therefore vote with their feet through early retirement. The second group are probably the silent majority who either take an active role in a commissioning group because ‘if you can’t beat ‘em join ‘em’ or maybe take a lesser commissioning role while trying to spend as much time with their patients as possible. And the third, possibly more vocal and active group are those who favour the changes, relish their new found spending power and appear to be planning world (or at least UK) domination.

Those GPs who embrace the additional responsibilities placed on their shoulders by NHS reform are to be congratulated and supported and I have no doubt that many of the clinical commissioning groups will do an excellent job in difficult circumstances, especially when they have the good sense to bring in the appropriate commissioning and clinical pathway mapping experts. But I fear that the side effect of the bullish comments by, for example, the NHS Alliance could do much to damage interdisciplinary relationships and ultimately the patient experience and clinical outcomes.

Without doubt, the priority for any health professional must be joined up care for patients – literally from cradle to grave. Forgetting this awesome timespan, let’s just focus on a patient needing some non-urgent care that may involve some sort of surgical or specialist led intervention. In an ideal world, the clinical pathway for the patient’s condition has already been agreed within the local CCG and this pathway entails full cooperation between primary and secondary care. But according to a letter to The Times newspaper by Drs Michael Dixon and Chris Drinkwater and some of their colleagues ‘hospitals are dangerous places’ and they must ‘as an immediate imperative, shift all non-urgent care into the community’ One could argue that this makes sense but it must be viewed in context. Services can only be shifted into the community if the infrastructure creating the desired capacity is there.

 

It isn’t.

The letter goes on to mention the NHS Alliance Manifesto which is ‘formulated by frontline doctors, nurses and professionals in primary care’ Manifesto? A manifesto can be defined as ‘a published verbal declaration of the intentions, motives, or views of the issuer, be it an individual, group, political party or government’. This very much suggests a group in isolation of the whole NHS family. The NHS Alliance manifesto spells out some worthy aims but is positioned in a political, territorial way. There is more than enough bad press about hospitals without such powerful GPs proclaiming what dangerous places they are – just imagine how a Times reader with a visit planned to hospital this week must feel?

Needless to say, two days later, a response from a surgeon was printed in the newspaper and he politely points out that one of the issues with non urgent care is that over the years he ‘has witnessed a derogation of out of hours care, exacerbated by the GPs contract in 2004’ and doctors deputising services are often ‘staffed by doctors who do not have requisite skills’.

Fair point well made.

So there we have it – just one small, but potentially significant spat between primary care and secondary care siblings generated by the parent who didn’t think things through when dividing the spoils of his inheritance.

What a sad reflection of a familial relationship that should engender the very best for the patients in our care. It has  generated some unwanted side effects for professionals, trying to do their best for their patients but having to win ground and hold position all at the same time.

What a difference a week makes – not.

It really is same old same old at the moment in UK health.

David Nicholson hangs on:

With the tenacity of a desperate mountain climber teetering above a crevasse, the Chief Executive of the NHS grips to his position. Insisting ‘I am the right man to lead the NHS’ his performance at the parliamentary select committee hearing this week served only to confirm that this man is either seriously lacking in a layer of human emotion and humility, or is incapable of showing that he really does care. Either way, this is not the type of persona that the NHS needs right now. Word on the street is that he will be gone by August, so if that’s the case, why not let him go now? Apparently he has a ‘tight grip on the NHS’. If his grip was as tight on the organisation to achieve the right balance between quality and cost as it is on his job maybe there would be some hope. This man ain’t for shifting. No change there then

Julie Bailey and Cure the NHS continue to impress:

And long may she continue to voice the concerns of millions. Speaking outside the Houses of Parliament with her comments on Nicholson’s culpability, the compelling Ms Bailey was, as always, calm, eloquent and convincing. Her late mother, Bella would be proud of her – and so should all of us. Keep doing what you are doing Julie and all your friends and colleagues at Cure The NHS.

‘Billions in extra cash fails to stop the rot in the NHS’ (Daily Telegraph)

A report in the UK press this week told how Britain is slipping down the ranking in public health, compared to other Western countries. Life expectancy is increasing – which in itself could be depressing as our pension pots run out – but we are now 14^th in the list of 19. I would be more interested to see a table listing quality of life and health and wellbeing – just being alive doesn’t tell the whole story. But the key point is that spending has increased from £46 billion in 1990 to £122 billion this year but we are not seeing an improvement in the health of the Nation. The effects of a past generation of smokers, and a new generation of the obese and inactive who eat junk food continue to pile on the pressure for our struggling state funded system. How do we stop the rot? We are still looking for answers.

Jeremy Hunt attacks 'complacent' hospitals (BBC)

Apparently Jeremy Hunt, the Secretary of State for Health will announce during a speech today  that ‘too many hospitals are coasting along, settling for meeting minimum standards’ He will ‘attack a culture of "complacency" and "low aspirations", which he believes is holding the NHS in England back’. Mmm – so that would be a culture led by a Chief Executive who has a ‘tight grip’ on the NHS? So that’s another thing that doesn’t seem to be changing – the disconnect between logic, good sense and NHS reform.

Change for change’s sake is bad. Change to improve, innovate, rationalise and consolidate is good. What a pity - it’s mainly the things that need to change that are staying the same.

What a difference a year makes as NHS Reforms become real.

How interesting… Michael Dixon, Chair of NHS Alliance and Interim President of NHS Commissioners has warned that doctors would "start getting bogged down" in dealing with competition and would end up taking their "eye off the ball". He is concerned that the wording on competition in the Section 75 of the Health and Social Care Act will mean that doctors could get "bogged down" in the process of commissioning and distracted from patient care.

Reality is really beginning to bite for a GP who has been a huge supporter of NHS Reform, which transfers the shift of power to give GPs the majority of the NHS budget to commission care and services. Dr Dixon has been a bullish proponent of GP led commissioning and last year relished the new powers to be endowed on GPs, but his ardour now appears to be waning. What a difference a year makes. Less than a year even. Last May, I attended an NHS Futures Forum and struggled with Dr Dixon’s enthusiasm for this shift in power. An extract of my blog that week follows:

May 18^th 2012

‘…..Oh dear oh dear oh dear. I must be very careful how I put this but Dr Dixon’s presentation fuelled my worst fears about the effect of these NHS Reforms. He started his talk with ‘I am an independent contractor, like a plumber’. ….…..Michael is massively in favour of GP Commissioning and leads a pathfinder GP practice. He was in my opinion (I must be careful not to upset my lawyers) positively salivating at the prospect of complete control of a big chunk of the NHS budget. I found his talk of a café in his practice, his views on specialist representation and his apparent lack of empathy with secondary care quite worrying……He made no secret of the fact that a desired outcome of the reform and GP led commissioning was to migrate services away from Hospital Trusts. He continued – and I quote, as near as my notes allow, ‘I’ll be moving stuff from hospital to my practice and I’ll get money for it, therefore there needs to be total transparency’.  Baroness Young (the chair of the event) was brilliant as a devil’s advocate with her careful wording. She asked Dr Dixon his view on the fact that many patients, especially those with long term conditions do not wish to be ‘discharged’ from the care of their specialists to be handed over to a general practitioner……I asked Dr Dixon if perhaps that figure [that 30 -40% hospital admissions are avoidable] could be due to the fact that patients couldn’t get in to see their GP and how would GP commissioning improve this state of affairs. For a moment I thought he had morphed into Andrew Lansley as the question was effectively side stepped. When I queried the impression that he didn’t want specialists on ‘his’ commissioning board, he clarified that he doesn’t want hospital specialists on the board who are ‘trying to protect their budget’.  A phrase that springs to mind includes ‘pot and ‘kettle black…….’

Back to the present…

There is some merit in Dr Dixon’s demand that the wording of section 75 of the Health and Social Care Act should be changed as it appears to encourage a scatter gun approach to opening up competition for services which could be unsuitable for private involvement either due to expertise, location or supply issues. Commissioning isn’t easy. If it was, the NHS would be in a better state than it is. I would much prefer seeing GPs looking after patients, directing their care and referring them on to appropriate specialist services. But the nitty gritty of preparing tenders, assessing responses and monitoring contracts is a full time job.

I believe that carefully managed competition in targeted service areas can be a good thing for the NHS. But commissioning is a specialised, time consuming, detailed and burdensome job. Being a GP is a specialised, time consuming, detailed and burdensome job. How can GPs realistically be good at both? Dr Dixon continued in his interview with Pulse magazine that offering the tendering process for most NHS services to private firms could mean that the reforms are ‘a complete waste of time’ and that ‘GPs will walk’.

Last year, referring to his desire for autonomy and lack of interference, Dr Dixon famously said ‘GP’s don’t want to be managed – we want to be seduced’

Fun as seduction may be, it often results in consequences that aren’t always positive. I am tempted to say ‘I told you so’.

Instead I shall settle for ‘Be careful what you wish for….’