Over the years, I've been intrigued by the debates about conflicts of interests in the NHS. Are CCGs providers of services or genuine commissioners? Do GPs act in the interests of their patients, or do they more often line their own pockets? What are the most effective ways of ensuring that services are delivered effectively, efficiently, and within a national framework?
I have always been bemused by the issue, but perhaps I have an unusual view of the NHS, as I see primary care, incorporating GPs and CCGs, as the control centre from which all health services are co-ordinated, rather than simple service providers.
Let me illustrate this:
We recently had a new bathroom fitted at home; it's very smart and it cost us a lot more than a ‘trip of a lifetime' holiday. The work involved plumbers, electricians, carpenters, and tilers. I could have contracted with each of them separately, but not only would I have had to understand the details of each of their jobs and the limits of their capabilities, I would have had to carry all the ‘risks'; if anything went wrong, or more money was needed, the issue and the cost would have come back to me.
Instead, I went to a bathroom centre, let's call it 'Baths 4-U' and negotiated a deal; I don't know whether the person with whom I spoke was a plumber, an electrician or even an accountant, but basically, I determined the ‘output specification' of the bathroom, and left it to him to deliver the finished product. My obligation was to specify the functionality of the new bathroom, plus any specific details about which I felt strongly (please remember that the shower must accommodate my 6ft 9in height…), and between us we agreed the quality, the timescales, and the money.
This meant that I didn't need to understand the technical details of the work, and that (within limits we agreed) it was up to ‘Baths-4-U ' to carry the ‘risks'. The plumber/electrician/accountant with whom I dealt then had to deliver the work; if he was indeed a plumber, he could do the plumbing himself, and sub-contract the other non-plumbing tasks to the appropriate technical specialists; if he was a generic accountant, he'd have to buy in all the technical services, and would probably be less successful than if he were a ‘content expert.' As long as the finished product met the specifications of quality, timing and costs that we had agreed, then how he did it remained entirely up to him, and what profit he retained was none of my business. The key message is that Baths-4-U were the body accountable for the work done
So how does this relate to the current NHS? Several parallels may be seen: at an individual's level, patients are the ‘clients' with a general sense of what their needs are, but without the technical knowledge or skills to manage them effectively. GPs are Baths-4-U, able and prepared to carry the risks (and reap the benefits) of providing a service; they provide most of the basic service themselves, and then sub-contract the more specialized technical services to the expert ‘tilers' or ‘carpenters' that are the hospital consultants.
Unlike home plumbing systems, health services also function at a larger, population based level, where decisions are required that affect whole organisations, rather than individuals. Although the principles remain the same, in this case the CCG is the accountable body, with the responsibility for organising and delivering all healthcare for their entire population, The ‘client' is the NHS Commissioning Board, or any emerging local representative, that will need to define the outcomes being sought (quality, timing, price). As with ‘Baths-4-U', how they do it should not be overly prescribed, or the creativity of the provider will be stifled while the ‘risk' will be repatriated to the client, who does not have the appropriate technical knowledge.
In either case, if the accountability arrangements are clear, then there should be no conflicts of interests; quality, timing, and cost are the paramount measures, with the ‘client' determining the ‘what', and the provider having the freedom to decide ‘how'. At the ‘micro' level of the individual GP, this is generally understood, but it is yet to be seen whether at the ‘macro' level the central NHS ‘client' will manage the three main tasks required to make the accountability work and to obviate the potential conflicts: can it resist over-defining the ‘what'? Can it bear to let the CCGs decide the ‘how'? And will it actually be able to hold the CCGs to account for those three outputs: quality, timing, and cost?
Dr Jonathan Shapiro is a former GP and senior lecturer in health services research at the University of Birmingham
