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Brain ache


Dr Peter Weaving is an unashamed enthusiast of clinical commissioning. Cumbria, where he practises as GP and is a locality lead has been hailed as a trailblazer by Andrew Lansley as an example of what GP commissioning can achieve. Not all share Dr Weaving's enthusiasm however and he himself is a realist about the scale of the challenges ahead, not least getting local consultants on board and the challenge the NHS faces to create £20 billion efficiency savings.

The learned professor scribbles a line on the blackboard and swings back to face the class ready to pick his next victim with a brisk point of the chalk. My fellow pupils shift uneasily in their seats and pretend to study their papers. Our names are written in two inch high letters in front of us; clearly visible to our eagle-eyed teacher who has promised to ‘cold call' if no volunteer is forthcoming.

For reasons which currently escape me I am sitting in a Harvard Business School master class. Our teacher, who was introduced to us as ‘He is to business, what the pope is to religion' is Michael Porter who is focusing his considerable brain on healthcare reform around the world.

The class is well attended today with only Steve Field absent - a note from his Mum said he was pausing and listening -leaving about 90 assorted health trust chief executives, medical directors, deans of medical schools, GP commissioners and representatives of organisations such as Monitor. A young man arrives late and not only has to sit at the front but write out his own label – ‘Paul Bate' adding the name of his organisation simply as ‘No.10'.

Professor Porter bounces around the room working up a sweat, writing and questioning energetically, occasionally freezing like a heron about to strike; waiting for a stuttering student to construct a response. Even if you are able to answer it is immediately followed with supplementary and unexpected follow-up questions until the depth of your ignorance is plumbed. As an average to mediocre student I am familiar with this treatment but suspect it is a new experience for the assembled dons. The hardest questions to answer are the simple ones:

‘Why does healthcare cost more? Each year I go to PC World I expect a better, faster computer that not only does more than the last one but is cheaper. Why isn't health care like that?'

Through a series of case studies we had read up on as homework :‘Those of you who haven't read this afternoon's papers need to skip lunch', we explore the concept of Value-Based Healthcare – how to measure it and how to deliver it. We acknowledge we are very good at measuring things that can be counted but fail to measure the things that count – health outcomes that matter to patients. Our billing system is a joke and ‘Secretary Lansley' needs to address that. We need to bundle tariffs so that we can commission pathways and cycles not individual fragments of activity.

We look at examples of healthcare delivery as varied as the new stroke service for London, the provision of healthcare for homeless people and a reorganisation of antenatal care to look after high risk pregnancies ,which is now about 60% of women. We listen to and question the chief executive, a cardiac surgeon, of the Cleveland Clinic; a phenomenal clinical leader with no formal management training who, when appointed as boss of this $6Bn health organisation, phoned our teacher and said simply ‘Help'.

Recurring themes run through our lessons – measure outcomes not just activity, develop pathways through and between different sectors, clinicians need to collaborate, volume generates value – hospitals or departments need to merge to produce greater throughput and better outcomes.

Finally our silver-haired academic deals with the Nicholson challenge – the £20Bn the NHS has to save – ‘You can do it easy, the money's in the system, it's like shelling peas'. At which a senior clinician in one of our more illustrious teaching hospitals observed that he had never found shelling peas particularly easy.

Class dismissed.