The shroud wavers, mostly based in secondary care, concern me. They fear any change in commissioning will result in the destabilisation of their organisation and so wish for the status quo to prevail. The counter-argument is very simple – put 100 clinicians in a room and not one will say the current system cannot improve.
The national mood music suggests an inevitability that some hospitals will close, with talk that the district general hospital model is dead being heard at conferences across the country. For some hospitals, the changes ahead could mean reformation rather than demise. But that is not to say the next few years will be easy.
Complexity and chaos predict that in order to change a system from one attractor state to another, it must be disrupted. The work of Clayton Christensen suggests this disruptive innovation is sine qua non for health service reform. The worry eating at me is that we cannot afford to break healthcare in order to remake it. A spate of closures hitting smaller units in rural areas early in the establishment of CCGs would tarnish the evolution and forever label GPs as the ‘hospital closers'.
I believe there is a different way to play this game. Think of the children's game Jenga. The tower of wooden blocks is gradually removed one block at a time, the aim being to ensure your opponent takes out the block that causes the tower to fall. Suppose for a moment that your local NHS economy is that tower and one by one the various services that are re-commissioned are taken out and placed elsewhere – for example, ultrasound services provided out of hospital. CCGs are specifically designed to undertake this task and the drive for ‘low-hanging fruit' will be too tempting for many.
But if CCGs play such a strategy, the tower will fall. Just like Jenga, there is no single block which guarantees a tumble.
Any individual block can come out at any time and almost in any order – it is the balance of the system at tipping point that counts. Therefore, any CCG can ‘take out' diagnostics or COPD. The whole of an acute trust is greater than the sum of its parts – the early moves are unlikely to cause a tumble.
Now step outside the game as we currently play it. Imagine a system where all commissioners and providers agree the tower needs to change, be smaller, be redistributed. Imagine a system where the players agree that once the blocks come out of the tower they are assembled in a coherent new model, closer to home, redesigned and cheaper through efficiency. At the same time, the tower is steadily made smaller, but without a collapse.
Is it possible to play the game in this way? Only if the players agree the principles and trust each other. The case studies on page 20 and page 29 show that other commissioners also think this is possible.
Sticking with the old rules will result in unforeseen closures or enforced spending to maintain facilities no longer self-supporting. CCGs should remember some units were only financially viable when driven by growth – as the money tightens, they will be increasingly unstable. Although current commissioners can stabilise those works – for example, the new cancer strategy for London (see page 24) – centralisation drives a limited degree of quality and efficiency. Transformation of the model is a greater challenge, but the only hope for sustainability.
Dr Chris Mimnagh is a GP in Kirkby, Merseyside and director of strategy and innovation at the Aintree University Hospital Foundation Trust