Blue-sky thinking is great, but not if it fails to reach the grassroots

Pulse editor-in-chief Jaimie Kaffash tells the tale of his trip to the land of NHS managers, also known as NHS Confed Expo, where he encounters a lot of blue-sky thinking

I can’t speak NHS Manager. Despite living in the locality/neighbourhood/place since starting at Pulse in 2012, I never picked up the lingo. Sure, I know some words – I have just learnt ‘left shift’, even though that is first week Duolingo levels. But ‘after action review’, ‘system level’, and loads of talk about ‘adjacent’ and ‘unpack’ – sorry, you’ve lost me there.

All of which to say that it was lovely to be immersed in a different culture during my work holiday to the NHS Confederation conference in Manchester this week, but it felt a world away from the familiarity – and, more important, gloom – of general practice.

The people were nice, but maybe could have made us feel a little more welcome – the only session on primary care was in the smallest room in the vast conference centre, and most people were turned away at the door, which felt both symbolic and ironic.

But the one thing that really came through was the optimism: around the spending review, the 10-year plan, the ‘left shift’ (bonus marks for using it correctly in a sentence), the freedom afforded with the abolition of NHS England, and how AI will transform the world.

Health secretary Wes Streeting was given – to my eye, anyhow – a great reception. After starting his speech by saying there won’t be any interesting lines for the media present, he then announced he expects trusts to run primary care services, and GPs to run trusts. (The ultra-cynical part of me wonders whether such a statement about the little-known land of general practice doesn’t count as an interesting line to the delegates present.)

One of the annoying things about learning languages is that they evolve. When I knew a little more NHS Manager, ‘multispecialty community providers’ (MCPs, which were GPs running secondary care services) and ‘primary and acute care systems’ (PACs, which were trusts running primary care services) were the buzzwords. Mr Streeting’s comments didn’t offer detail, but they weren’t accidental – this is something we should expect in the upcoming 10-year plan and I suspect they will go further than the failed MCP and PAC experiments.

This does fit in with the prevailing wisdom around general practice. There was so much talk of at-scale general practice that I started to feel as though small practice was a dirty word. There was a lot of talk about how primary care needed to grasp the opportunities afforded to it, that it was incumbent on them to reshape their services. There was also a lot about how there was a shift away from incentives, that the QOF changes had reshaped the service, and a quite funny – if telling – line from NHS England primary care director Dr Amanda Doyle about GPs ‘arguing the toss about who pays for phlebotomy or earwax or any of that stuff that I never want to hear about again’.

Hearing this high-level talk enthused me. We can change the health service, I thought. But then I remembered my day job – because things aren’t so great there. The QOF changes haven’t really affected workload. GPs argue the toss about phlebotomy and earwax because, unfortunately, they still rely on these small pots of funding, which is akin to using tester paint tins to finish your house.

I meet some genuinely admirable GPs who are able to restructure their services, to bring in secondary care doctors to provide clinics, who are able to offer career progression and portfolio working. But they are in central locations, in training practices – which makes it no less admirable, but explains why they can do this.

Other practices don’t have these opportunities. They are struggling to meet demand, and have no headspace to rearrange their services. They are struggling to recruit GPs to work in deprived practices, and are relying on less qualified staff who require more supervision. They haven’t got time to write business plans about why they need premises upgrades, which will probably get rejected before their ICB lays eyes on it.

So what is the solution? It’s a Catch-22, but practices need their workload reduced in the first place to get the headspace needed to reduce their workload. To break this, you can’t just tell GPs about the wonderful opportunities on offer for them if they can only grasp them. This is like telling a drowning person about the beautiful beach bar.

To me, there are two ways to actually realising the Big Ideas spoken about at the conference.  The first solution has to be contractual – ‘we are taking this work off you’, or ‘here is a huge increase to the global sum to afford you some headspace’. Chucking money might be a bit small-time-thinking for NHS Managers, but it is in the first instance a lifebuoy.

The second is a bit more controversial. You need more managers at the local level who can support practices in redesigning services, or can properly think about local incentives, and even shift funding themselves. But this is the opposite of what is happening. Because outside of that conference hall, even among NHS Managers, life is a bit bleaker. ICBs are reducing headcounts, they are merging, people don’t know who is going to be in what role. Supporting practices to rethink their services is not foremost on their minds, and understandably so.

I believe in big picture thinking. But it has to be realistic and understand what is happening on the ground. So unpack that.

Jaimie Kaffash is editor-in-chief of Pulse