In 2010 when Andrew Lansley published his white paper, I wrote an article, concluding that it will all end in tears. In theory,Mr Lansley’s reforms were championing three issues: patients at the centre of the NHS, changing the emphasis from targets to clinical outcomes and empowering health professionals, in particular GPs. In practice, that created only illusive empowerment for GPs and patients. It was a recipe for confusion, inefficiency and demoralisation. The chaotic nature of the reforms meant they needed remedial action to make them workable even before they came into effect.
It appears another reorganisation is inevitable
A meaningless ‘top-down re-organisation’ by Mr Lansley was the biggest health policy disaster since the inception of the NHS in 1948. As a result, endless workarounds were (and continue to be) created to achieve progress. The history is repeating itself and, the Five Year Forward View is driving a ‘re-organisation’ much more significant and far reaching than that caused by the destructive Lansley NHS Act 2012. The financial climate in the NHS making its urgent implementation necessarily and increasingly another ‘top down’.
The latest mantra appears to be the Sustainability and Transformation Plans. What it means is, service redesign and financial robustness on a regional basis to, effectively, the mechanism for delivering that change. Nobody knows how it will work and there is no one implementation programme for this innovation.
However, one thing seems to be clear from the Department of Health and NHS England, that CCGs are unable to fix the underlying problems affecting most health economies. To be precise, the structures created by replacing PCTs and SHAs, at great expense and even greater opportunity cost four years ago are not fit for purpose in the eyes of those responsible for their stewardship. That the creation of STPs is deemed necessary, is also a statement on the effectiveness of NHS England’s own regional operations.
As two thirds of the foundation trusts are in financial meltdown, what limited influence CCGs had on hospitals has virtually disappeared. Most of the powers CCGs have to improve safety and accountability are being clipped. Quite a few CCG chief officers are leaving the sinking ship. Transactional commissioning, which has been the core function of CCGs, is becoming a rare commodity, and with it the sovereignty and agency of local commissioners.
Many CCGs in England are subscale – indeed a significant number of CCGs are struggling for any kind of impact because of their size. I know Simon Stevens, the NHS England chief executive, started his job with the clear message that CCG mergers are not part of his plan. He did not want leadership time consumed by thoughts of organisational restructuring and their own positions. But, this is happening at unstoppable pace.
It appears another reorganisation is inevitable. Changing health economies such as devolution in Manchester, ICOs (integrated care organisations) and the development of accountable care organisations (ACOs) is happening fast.
My fear, this too could end in tears, if, we fail to engage coal face GPs and patients.
Dr Kailash Chand OBE is the deputy chair of the BMA, and a retired GP