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A Himalayan perspective

The story so far

Dr Peter Weaving is vice chair of Cumbria CCG and a self-proclaimed enthusiast for clinical commissioning. His CCG will be seeking first-wave authorisation, edging it closer to having full responsibility for distributing in excess of half a billion pounds of healthcare throughout Cumbria in a year's time. But while his head is often in the ‘big stuff', a trip to India this month reminds him of how important it is to make commissioning a success at an individual level...


‘What your profession?' the shopkeeper asked me. I'm in Chhitkul, a tiny place 3,500m up on the edge of the Himalayas, the last village in India before Tibet. My daughter and I were persuaded into a local store by its diminutive sun-scoured owner to buy a souvenir, which was proving difficult when the only luxury items were paan and cigarettes.

‘I'm a doctor,' I replied.

‘I have problem with my penis,' was the immediate unblinking response.

‘What kind of a problem?' I asked.

‘There is a lump.'

A brief behind-the-counter examination revealed the problem to be a decent-sized inguino-scrotal hernia. After writing the diagnosis in his order book, I was shown the medication he had been given to treat his malady by a friend or pharmacist – two different versions of a combination antibiotic. It was a quinolone with an anti-protozoal, a sort of antibiotic A-bomb that would cure everything from cholera to amoebic dysentery. I broke it to him that he needed a support or surgery.

Here's the rub. Simla, 12 hours away by bus down the terrifying Hindustan-Tibet highway, has medical schools and is stuffed with clinics. These are all private, but are relied upon as much by the poor as the rich – India only spends 0.9% of GDP on healthcare. The UK currently spends about 10 times that. The reality for a shopkeeper in a subsistence farming community is that he won't make the trip.

Two weeks later India is a fading melange of sight, sound and smell, replaced by the cold reality of the sealing of the knot of healthcare reform – the bill is an Act – and what are the practical consequences?

For me as a clinical commissioner, it marks the end of the phoney war and the beginning of a frantic rush to authorisation as a statutory stand-alone NHS body, a CCG with the legal ability to set contracts for healthcare and directly employ staff.

We will sit as member organisations directly elected by local GPs, and the tension that brings – balanced or stretched – from above by the NHS Commissioning Board.

But what does the passage of the bill mean for the public and for patients? Organisationally it must look like chaos.

We have replaced a relatively simple hierarchy of management, with strategic health authorities sitting above PCTs, with CCGs, health and wellbeing boards, local offices of the NHS Commissioning Board, public health sitting with local authorities and – yes, they are coming – clinical senates.

We have raised the spectres of competition and privatisation. There is concern from patients that they may have to pay for aspects of their care. Fresh from my experience in the Himalayas, my response would be: ‘Not on my watch.'