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At the heart of general practice since 1960

A year since the official launch of CCGs, GP commissioning has made no difference

Retired locality chair Dr Peter Rudge argues that the only way to change the system now is to involve patients

I worked for eight years as a clinical commissioner in a variety of roles for NHS Plymouth, more latterly as PEC Chair for NHS Plymouth then as the Chair of the Western locality of Northern Eastern and Western Devon CCG. 

In the eight years I worked as a clinical commissioner, I saw three management teams come and go, and similar levels of change in key providers and local authority partners. Delivering real lasting change without consistent health and social care leadership was difficult. With every change, it also seemed largely as though the environment that had been created by predecessors was cleared out and new work begun by the new team. No one asked about what needed to be left intact and what needed to be weeded out. Being seen to act seemed more important than assessing new priorities. System incentives heavily rewarded ‘doing’, regardless of where that led, so long as annual financial balance was achieved.

I began to feel that the NHS in general had no unifying vision of what it wanted to achieve and where it was going as an organisation. It started to feel less like an organisation, and more like a National Health System rather than a National Health Service.

There are three main challenges for GP commissioners at the moment are reducing (or just stabilising) the rising costs of care, commissioning whole-person care while the system fragments, and the lack of leadership.

The costs of care have been rising for decades, and the market approach is not going to be a panacea. Competition can work to reduce cost and improve quality when used wisely, but it is hard to see this working at scale in the NHS. There is little evidence that a competitive market will address rising costs of care for a national taxpayer-funded service.

We need new approaches yet there is little incentive for providers to step outside the status quo. As one manager said to me, ‘better to keep you head down and work hard – it’ll all change in three years anyway.’ 

The new Health Care Act fragmented the commissioning process and spread it across five organisations – the Local Authorities, PHE, NHS England, specialist commissioning and CCGs. Though they may not recognise it each party is interdependent, yet the system incentives rarely enable them to work together to reduce costs.  Collaboration often results in savings elsewhere in the system or tension over which organisation pays for what. Simply understanding who is now doing what has taken months; addressing the sustainability agenda will take a number of years in my view.

Commissioning remains a journey whose true purpose remains unclear. The question of who leads the NHS – managers or clinicians – is not as important as where they are leading to. Leaders don’t need to be GPs – that’s just rhetoric and PR – but we desperately need leaders who can create a vision for the new system.

Ask the patients

The largest re-organisation the NHS has ever seen has still left us with gulfs between commissioners and providers, primary care and secondary care, and health care and social care. Many of the incentives remain unchanged and they are not enough to change clinical behaviour towards increasingly limited resources and those members of the public using the services provided.

Creating a sustainable NHS is a complex problem and there will not simply be one solution. However, one thing is certain: we have limited resources – human and fiscal – to solve the problem with.

If we are to really change the outputs of this system, we need to change the system entirely. Part of the solution should be to create a ‘system regulator’ in each locality, jointly created by local patients and providers. The real solutions will not be found in the back office of highly-paid public servants, but in the creation of a real and enduring dialogue between those two key stakeholders. All of us have a role to play if we want to see an NHS fit for ourselves, and for future generations.

Commissioners must facilitate and frame this dialogue to create new system architecture. It will take many individuals, and political will, to reduce central control and allow local communities to create their own solutions to our national challenge. But I believe it can be done.

If the NHS and its commissioners do not engage the public, I see no real change happening. We will be left with rebranded, reworked attempts to address the same problems we have always had.

Dr Peter Rudge is GP in Devon and a former chair of NHS Northern, Eastern and Western Devon CCG

Readers' comments (7)

  • It shouldn't come as a surprise that little has changed in the first year. As with any reorganisation there was a slow down in decision making in the 30 months leading up to 31st March 2013 from the time LaLa anounced thechanges. It then takes organisations 18 months to 2 years to become effective. Just in time for the next election and the next reorganisation.
    Read any managment text book and it will tell you that reorganisations take massive resource and benefits are not realised for years.
    In the NHS reorganisations happen every 4-5 years so we keep getting the costs and never the benefits. This is where the real waste in the system is!

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  • CCG's don't want patients involved and when they have to be, they are very selective as to who those folk can be!

    i have begged to have a voice with an interest in mental health, but no matter how much I ask to be involved, the door remains closed.

    They invite 'chairs' from PPG's but many of them have no NHS background and no interest in mental health ... perhaps they are no up for the challenge?

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  • Involving patients is all well and good but, depending on how you ask the question, almost every patient asked would want full access to all services 24 hours a day and we all know that, wonderful as that is, it is not an affordable option. There needs to be leadership from whoever and whichever quarter it comes from, and that means having a body in charge who has no vested interest in the outcome other than to provide the best service in the most cost effective manner possible. It has been a great idea to put clinicians in charge but only really works if they are not involved, even by association, with provision of service otherwise self-interest begins to creep in. The problem with the PCT model was that the clinicians involved in making decisions were too often removed from the reality. In CCGs, the converse is true. In addition, as Shurleea mentions, "stakeholders" is such a slippery term and the definition can vary.
    Still, wait 3 years and it will all change!

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  • The creation of GP-led CCGs was just a populist, headline-grabbing move - GPs had always been at heart of PCT-led commissioning. The principal purpose of the Statute that introduced CCGs was to re-arrange the NHS, both physically and on a legal basis, to allow the admission of more private healthcare providers.

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  • Of course its too early to expect to see real change but I think you ought to start as you mean to go on and in my view this is about a developing a completely different way of finding solutions to the real issue we face...the rising costs of care...and working differently with the public we serve holds great potential.
    I don't agree with the view that those we serve will simply want everything. If they are provided with the human and fiscal reality we face I am sure they will make the difficult decisions. They are after all,one way or the other , paying for it.We just need to have the courage to share it with them.
    Until we work differently to stabilise or reduce the costs of care, re-organisations will continue to occur and we will only be left to reflect on just how much of what we did was genuinely different from what had gone before.

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  • The last re-organisation was a legal framework to dismantle the NHS after it falls into financial deficit.

    There is no doubt there is a silent Private partnership with the politicians, all lined up to get paid once out of post with directorships as their 30 pieces of silver. The Private sector will ride in on their white horse to save the NHS and we will all pay for the priviledge for generations to come.

    The NHS will slowly die as the health insurance top up, (What exactly is NI except an NHS tax) becomes unaffordable for the ill, poor and uninsurables who will all get sub optimal care.

    The swipe your credit card before you get care ethos of the US will come in with the new NHS leader, and we will all long for the good old days with PCTs.

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  • Having worked in the NHS for 13 years in various project/ programme/ change and contract management roles, the same faces come and go, as does the initial enthusiasm and the inevitable empathy and acceptance that it will be the same goal posts dressed up in a different way before some one tells you that you are now aiming for the wrong goal. It is ludicrous at the amount of money that is spent in contractors, ill thought through projects and the powers that be never learn the "lessons learnt" from previous projects/ programmes and strategic visions. Yet, the fundamentals that underpin the governments 'strategic vision' are often ill thought through, underfunded and using out of date technology and resources.

    I have always been an advocate for involving clinicians, patients and wider stakeholders and it has served me well. However, the hoops you have to jump through to justify the time in 'networking' is farcical when others cannot see the value beyond the obvious stakeholders.

    "The road to success is to go from failure to failure without losing your enthusiasm" - Winston Churchill. Clearly the government expects the NHS to live by this ethos?

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