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GPs buried under trusts' workload dump

The closure of Lewisham A&E has knocked my faith in commissioning

Do I see a future in clinical commissioning? I did, says Lewisham CCG chair Dr Helen Tattersfield, but now I am not so sure

In Lewisham, as in many CCGs all over the country a group of experienced GPs have given up hours of precious clinical and personal time, sacrificed the needs of their practices, attended seemingly endless meetings, training and assessment sessions.

Why have we done this? For financial gain? Career status? Personal aggrandisement? Sometimes, perhaps, but in Lewisham it is because we saw an opportunity to make a difference. To get all the different players; primary, secondary, community, council and voluntary sector to work together, to involve patients in  their care and produce a local service where all parts had agreed aims, combined their resources and where the tide of illness flowing into secondary care was diverted into effective health promotion and community based care.

We had begun this work and were daily becoming more effective (we should have done, with the amount of money spent on our training). We were helped in this by both a  council and local healthcare trust  sharing the vision and willing to put aside old ways of working to create something new.

We impressed those who came to test our readiness for authorisation, not just because we had the required documents but because our new collaboration had already had significant impact in referrals, reduced unnecessary hospital admissions and spectacularly increased the level of children’s’ immunization.

We were rightly proud of this, proud of our local trust, key in the changes in secondary and community care required to bring this about, and inspired by the co-operative spirit of our Local Authority.

Decisions about me, without me

Then came the problems of South London Healthcare and the TSA. The only solution to their problems being the effective selling off of our local trust, and the passing of acute services to the indebted trust next door. Providing assets to reduce debts and planning income to secure viability.

Our population, one of the  most deprived in the country, was told they will get better care by travelling out of borough (an expensive and stressful journey for many) to one of now four admitting trusts.

The council having to spread their already limited social care resources across four trusts to safeguard the needs of Lewisham residents,  but we as commissioners are expected to create new pathways of care, ensure minimum number and length of hospital admission with four providers for whom our work is an insignificant fraction and with whom any influence at all will require complex and time consuming  collaboration with any combination of five neighbouring CCGs.

We have very little influence too with our local population and GPs who, with no trusted central provider, will reject local pathways for the perceived ‘quality care’ at central London Foundation Trusts. Some even wonder if local commissioning will have any role at all.

Do I see a future in clinical commissioning? Obviously I did, I and my fellow directors would not have committed so much to make this work if not, but now I am not so sure. Can we keep GPs engaged having taken them on a journey of local co-operation to end up at a destination of external determination? It is hard to see this just as it is hard to see GPs of the future committing their time and efforts to NHS initiatives.

So ‘no decision about me without me’ becomes ‘all decisions about me depend on the needs of others’, where those ‘others’ are indebted Trusts, failed institutions and specialists in ivory towers. Meanwhile, local commissioners must return to the substitute bench, while the professional players get on with the match.

Dr Helen Tattersfield is the chair of Lewisham CCG and a GP in Bromley.

Readers' comments (7)

  • It is a game - the illusion of power placed in the hands of GPs to supposedly make local decisions on the basis of their patients' needs.

    The reality is the strategy is designed to deliver more to the private sector, starve local NHS services and allow a rapid transition to an effectively privatised health service with merely an 'NHS' badge on the door to give the appearance of legitimacy.

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  • and this is surprise because...?

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  • Wake up and smell the coffee. But it's too late to stop it now.

    You should have all had the moral courage to decline to prop up this ludicrous idea. Now you'll just have to accept the blame on the chin.

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  • Whilst I am thankful that there are noble and well meaning colleagues amongst our ranks I am equally amazed by the degree of naivety displayed by otherwise intelligent and experienced professionals. Did you really think it would be different?

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  • Are you going to resign as chair now or wait for further fiascos?

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  • Welcome to the real world of commissioning as currently experienced by the acute sector. You made the mistake of being driven by patient needs, when the government wants you to be driven by greed.

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  • We should remember that before the merger that created S London Healthcare Trust a number of hospital clinicians, led by myself, outlined in detail why the merger could never succeed. Lewisham Hospital managed to escape at first, but sadly all of our predictions have been proved right. The truth is that we cannot afford the number of hospitals we have in S London. Much as it would be lovely to have lots of well-staffed A&E departments it is not sustainable without an immense injection of resources which will not happen. So we have to make the best of a bad job. We have already seen the stresses caused by the closure of the Sidcup A&E; Darent Valley Hospital boasted it could pick up the slack, but it has proved unequal to the task. While some specialist areas will show major improvements (eg stroke management) the run-of-the-mill problems will wait longer outside the A&E departments that remain, elderly patients will be shunted from acute to step-down facilities (and back, when they prove to be too unwell), with substantial dislocation and shortening of lifespan. Beds are already under severe pressure; running at a bed occupancy of over 85% is not workable, but SLHT is around 90-95% already.

    The solution proposed by the interim administrator is to my mind (not least because all his conclusions match our own from five years ago) the least bad option. If we want Rolls-Royce services we have to pay for them. The money isn't there. Put it there and general practice, through CCGs, will be as bankrupt as the old SLHT. It is painful, but what is the alternative?

    Of course one could argue that if the PFI debt had been written off all those years ago, and its ongoing excess costs met by government, all the original units would have been viable and none of the original, and current, painful reorganisations would have been necessary. It is a lesson; PFI is a con - an unaffordable, sub-prime mortgage foisted on us by a government (Blair's and Brown's) that thought it could get away with unlimited borrowing, feeding dreams and keeping the true costs off the balance sheet. Those costs have been painfully revealed, and SLHT is not alone in struggling. Like Greece, we must face the facts and find the least bad way to live within our means.

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