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Burning the NHS

 

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Friday, 12 August 2011

Burning the NHS

It’s easy to destroy things. Whole gangs of us are acting like imbecilic hoodies, staving in the windows of the new NHS, looting and burning for the sheer hell of it.

Or we stand there ineffectually in our riot gear tut-tutting that it has all gone wrong without actually doing anything to restore order.

Nobody wants to turn clinicians into managers, but for one reason or another a lot of otherwise sensible people think this is the point. It isn’t.

The job is to make them commissioners, right? After all, that’s what they already do and if we just let them get on with it everything will be fine.

This is an even more dangerous fallacy not only being peddled in Whitehall but in surgeries and conference halls by doctors themselves. It’s based on the idea that GPs are already de facto commissioners. Of course sending someone to hospital or prescribing them pills is an act of commissioning, just as telling a joke in the pub and making a few people laugh is an act of comedy. But you wouldn’t want to make a stand-up career of it.

This isn’t commissioning, it’s general practice. Real commissioning is planning, analysing, working with others, meeting, negotiating, leading, taking difficult decisions that affect not just individuals but entire populations, and being prepared to be held to account for those decisions, not just by the person sitting opposite you – the elderly patient full of gratitude and respect – but the teenage thugs on the local papers, the bruisers at county hall.

Commissioning is not something clinicians do naturally, but something they will need to learn, a completely new skillset requiring complex networks of support. Or it’s something they will need to buy in. Or both.

It’s clinical commissioning, not clinician commissioning, a term chosen with care to reflect the fact that the clinician’s part in commissioning will be to advise, consult and guide, not necessarily do.

The idea of moving commissioners closer to the problem is brilliant, but who are the commissioners? Another fallacy is that we’ll ship them in from the PCTs.  If commissioning was something we’d cracked under the old system it wouldn’t be the old system, so where is the commissioning cavalry going to ride in from?

Remember world class commissioning?  It wasn’t a commissioning system, but training wheels for commissioners, to help them get their balance, get them up to speed, and eventually learn about brakes and gears. It got some of them on the road to being half-decent commissioners, but it had only just got going when the road was closed.  

So let’s not create a new mythology in the name of clinical commissioning. There are currently a few dozen real commissioners – medical directors with vision, brains, diplomatic skill and energy who have worked with the PCT to change things from the inside; GPs, practice managers and other primary care professionals who have driven local change by harnessing dissatisfaction or enthusiasm – usually both – and brought together all the stakeholders to look at referrals, start to manage performance, get to grips with local health intelligence and make a start at commissioning; PCT managers who got it and made it happen; and consultants who cut holes in the hospital perimeter fence to let them all in.

There are lots of people, clinical professionals and others, who can articulate the problem or propose a solution, but who still aren’t commissioners or even close.  We keep looking for the clinical commissioner, hoping for an archetype, a model we can clone. Here is the news: a clinical commissioner is a team, a group, a network, not an individual.

But we like it simple. Managers are the problem. PCTs are the problem. Doctors are the problem. The centre is the problem. The system is the problem. The solution is to find all the problems, set fire to them, smash them up.

It’s not a system problem. It’s a cultural problem, an education problem and a problem that wasn’t solved in some golden age of the recent NHS past, any more than the problems of society were once solved by friendly policemen boxing the ears of small boys caught scrumping for apples.

Clinical commissioning is something we have never understood or done in our warring factions, but it needs to be learnt fast and done together.

 

 
dkb123
dkb123 says:
Aug 12, 2011 01:48 AM
At last someone who knows what he is talking about, The system will not change by giving the same people different titles, the problem is that GPs, commissioners and the management of the NHS are on a different planet and speak a foreign tongue, Start talking to the ordinary patients sat in the outpatients clinics longer and longer. Its no use wagging your finger like a headmaster at naughty boys saying that the perfects will restore order at any costs, the answer is to understand the problems not consultants that sit on the bed in £300 suits or doctors educated at Eaton worrying that they are keeping up with the latest golf club fashion, start meaningful engagement with the most important people in the Health Service, and you know who that is.
simon@simondodds.com
simon@simondodds.com says:
Aug 12, 2011 08:58 AM
Hurrah! You hit the nail on the head Ed. The issue here is that none of us know how to do this because none of us have had to do this before. We are sailing in uncharted waters. Of course many of us think we know how we would do it but that is not the same as showing evidence of competency with a portfolio of successful commissioning challenges. This is not a "tame problem" - one that we can just diagnose from the symptoms, look up the treatment and follow the tried-and-tested recipe. This is a "wicked problem" - and it requires a competely different approach. It is not a manager-versus-doctor issue; that is the symptom, not the disease - this is a "we are going to have to learn how to do this collectively and collaboratively" issue and that will require some skills that appear in short supply at the moment. Skills like respectful challenge, active listening, emotional intelligence, healthcare operations management, learning-by-teaching. These are all part of the Improvement Science paradigm that has been gaining momentum over the last 50 years (http://www.saasoft.com/blog): a greater-than-the-sum-of-the-parts combination of human and process factors. These IS skills are not inborn - they are learnable and we don't have much time to learn by trial-and-error. So who can teach IS? Well - maybe someone who has demonstrated conscious competence through their track record and their ability to explain how they do it might be a reasonable place to look! There are a lot of these teachers out there ready and willing to share their learning.
DrMikeT
DrMikeT says:
Aug 12, 2011 09:01 AM
At last a few paragraphs of sense. Commissioning is a new set of skills. Hitting a six may earn very brief applause from the crowd, but to win a test series is a complex business and takes the whole team to play together. There may be some lessons to learn from the playing fields of Eaton, if not from the individual Etonian.
harry.longman@gmail.com
harry.longman@gmail.com says:
Aug 12, 2011 09:52 AM
Some of the best common sense written in recent months. The gang culture must be tackled head on - we are all on the same side. Locking up the few criminals would be a fine thing, though they won't be handing themselves in. And "not standing by" can get you beaten up. But no, those who want the NHS to work, from all the gangs (politicians, doctors, managers, staff) will need to agree on what binds us. The system is broken, but as the Ed says, its a symptom of something deeper that needs to change, the way we think.
gillians
gillians says:
Aug 12, 2011 10:49 AM
Something has been forgotten here - Healthwatch (currently known as LINks) This body of volunteers in their 60s, 70s. and 80s will miraculously be transformed into advocats, and deal with such things as complaints. They already carry out inspections and report their findings to the CQC. The majority left when PPIFs were changed into LINks and newcomers are just getting used to the work involved. Most will leave so a new set of volunteers will need to be found.
kevin.parkinson@derbyshire.gov.uk
kevin.parkinson@derbyshire.gov.uk says:
Aug 12, 2011 11:17 AM
NHS workforces need to rethink how systems use their combined resources to balance the need for immediate decisions to reduce expenditure, whilst investing in experience based co-design health, care and housing support in the longer term. System Managers know that the complexities of NHS services are immense, often duplicated, overtly bureaucratic, have high transaction costs alongside inadequate procurement and contract management skills and requires all elements of the patient pathway to have timely information to make informed decisions and hold providers to account. Commissioners must focus their attention away from ambiguous objectives and contextual goals and pay on outcomes by utilising available comparators and engender strategic instruments and knowledge assets to generate adaptive systems and keep control of financial envelopes. As with any system, commissioning is the easy replicable element, its the local market and sector management that often lets the end to end system down. Contracts which reward service providers for enriching the customer experience and performance regimes that draw on a wide range of non-financial incentives as levers to adjust both the diversity and intensity of provider incentives and rewards will focus adjusting much needed workforce attitudes towards delivering outcomes rather than being paid for effort alone. This change to established structures and patterns of working will be difficult but not impossible if the correct building blocks are achieved, like engagement and debate from the people who work to deliver services alongside the people they serve so that both professionals and the public can design services that support improvements in own care and health care.
janetturner
janetturner says:
Aug 13, 2011 03:25 PM
This blog was brilliant, it brought a smile to my face. Commissionig should be done by people that have knowledge of the NHS PROVISIONING SERVICES, AND A LARGE KNOWLEDGE OF THE VOLUNTARY SECTOR BY WORKING VOLUNTARY IN DIFFERENT SECTORS,& AND I MEAN EXPERIENCE WORK AND TO ACCUMULATE SKILLS & KNOWLEDGE OF HOW THINGS WORK IN THE DIFFERENT SECTORS, A KNOWLEDGE OF ALL WHAT EACH SECTOR CAN PROVIDE & WHAT EACH SECTOR HAS TO OFFER IN SERVICES.THEY MUST BE ABLE TO LINK WITH OTHER SECTORS TO PROVIDE SERVICES. THIS SHOULD BE CONTINUED ALL THE WAY THROUGH THE NHS SYSTEM . SKILLS, ESSENTIAL SKILLS, ARE VERY IMPORTANT IN ORDER TO MAKE THE NHS REFORMS A SUCCESS. IT IS THE BIGGEST STEP FOR THE NHS SINCE ITS FORMATION but IT CAN WORK & MUST WORK, so KNUCKLE DOWN.IT IS JUST A MATTER OF FINDING WHAT DIFFERENT SECTORS CAN OFFER AND USE THE BEST SERVICES AVAILABLE. GO FOR QUALITY, HAVE FEEDBACK FROM PATIENTS ABOUT THEIR NEEDS & THE SERVICE PROVIDED. IT IS A MATTER OF QUALITY CONTROL FOR THE PATIENT.TO GAIN EXPERIENCE RECIEVE TRAINING, READ UP & USE OBSERVATION SKILLS, EVEN IF IT IS BY WATCHING FILMS OR DOCUMENTARIES. USE THE BEST SERVICES AVAILABLE FROM EACH PROVIDER. IF ONE IS BEFRIENDING, DON'T USE THEM FOR CARE UNLESS THIS PROVIDER IS ALSO GOOD FOR BEFRIENDING.
rgjackson
rgjackson says:
Aug 15, 2011 12:14 PM
An unfortunate simile.Writing as a GP who has spent 30 years talking to patients and who is now a Lead Commissioner for one of our bigger CCGs, I am finding the experience much more positive than some of the comments above, particularly the fatuous drivel about Eton and golf clubs.We have excellent support from our PCT and we are certainly making tremendous improvements, not least in our Public Engagement programme.
The NHS is not an end ii itself, it is simply a means to an end (satisfactory patient care within budget), and I wish we could leave behind the emotional outbursts and concentrate on the challenges which face all of us irrespective of Government or political ethos.
dkb123
dkb123 says:
Aug 16, 2011 08:18 AM
We have all forgot that GPs are Private Contractors, Snouts and Troughs spring to mind, 'And you could not tell the Pigs from the farmers',
PLilburn
PLilburn says:
Aug 16, 2011 11:56 AM
Hear Hear

I agree that the skills may not be found by recycling PCT/SHA staff and that Commissioning will demand work from teams and groups.

Why train an individual GP from scratch when they could work in partnership with another highly skilled professional from another discipline to fill the skills required?

I recognise the hybrid management skills you have described as part of a professional Project Manager's portfolio:
respectful challenge, active listening, emotional intelligence, primary and secondary healthcare operations, complex problem solving,overseeing and pulling together stakeholders and teams,informatics and governance, stakeholder engagement, expected outcome and benefits identification and tracking etc.

These skills have not traditionally been harnessed for fundholding or commissioning purposes in the past.

Instead of recycling the same old faces and approaches, why not partner each Clinical GP Commissioning Lead with a Professional Clinical/ Project Management hybrid?

Paula Lilburn
CSci