I worked for eight years as a clinical commissioner in a variety of roles for NHS Plymouth, more latterly as PEC Chair for NHS Plymouth then as the Chair of the Western locality of Northern Eastern and Western Devon CCG.
In the eight years I worked as a clinical commissioner, I saw three management teams come and go, and similar levels of change in key providers and local authority partners. Delivering real lasting change without consistent health and social care leadership was difficult. With every change, it also seemed largely as though the environment that had been created by predecessors was cleared out and new work begun by the new team. No one asked about what needed to be left intact and what needed to be weeded out. Being seen to act seemed more important than assessing new priorities. System incentives heavily rewarded ‘doing’, regardless of where that led, so long as annual financial balance was achieved.
I began to feel that the NHS in general had no unifying vision of what it wanted to achieve and where it was going as an organisation. It started to feel less like an organisation, and more like a National Health System rather than a National Health Service.
There are three main challenges for GP commissioners at the moment are reducing (or just stabilising) the rising costs of care, commissioning whole-person care while the system fragments, and the lack of leadership.
The costs of care have been rising for decades, and the market approach is not going to be a panacea. Competition can work to reduce cost and improve quality when used wisely, but it is hard to see this working at scale in the NHS. There is little evidence that a competitive market will address rising costs of care for a national taxpayer-funded service.
We need new approaches yet there is little incentive for providers to step outside the status quo. As one manager said to me, ‘better to keep you head down and work hard – it’ll all change in three years anyway.’
The new Health Care Act fragmented the commissioning process and spread it across five organisations – the Local Authorities, PHE, NHS England, specialist commissioning and CCGs. Though they may not recognise it each party is interdependent, yet the system incentives rarely enable them to work together to reduce costs. Collaboration often results in savings elsewhere in the system or tension over which organisation pays for what. Simply understanding who is now doing what has taken months; addressing the sustainability agenda will take a number of years in my view.
Commissioning remains a journey whose true purpose remains unclear. The question of who leads the NHS – managers or clinicians – is not as important as where they are leading to. Leaders don’t need to be GPs – that’s just rhetoric and PR – but we desperately need leaders who can create a vision for the new system.
Ask the patients
The largest re-organisation the NHS has ever seen has still left us with gulfs between commissioners and providers, primary care and secondary care, and health care and social care. Many of the incentives remain unchanged and they are not enough to change clinical behaviour towards increasingly limited resources and those members of the public using the services provided.
Creating a sustainable NHS is a complex problem and there will not simply be one solution. However, one thing is certain: we have limited resources – human and fiscal – to solve the problem with.
If we are to really change the outputs of this system, we need to change the system entirely. Part of the solution should be to create a ‘system regulator’ in each locality, jointly created by local patients and providers. The real solutions will not be found in the back office of highly-paid public servants, but in the creation of a real and enduring dialogue between those two key stakeholders. All of us have a role to play if we want to see an NHS fit for ourselves, and for future generations.
Commissioners must facilitate and frame this dialogue to create new system architecture. It will take many individuals, and political will, to reduce central control and allow local communities to create their own solutions to our national challenge. But I believe it can be done.
If the NHS and its commissioners do not engage the public, I see no real change happening. We will be left with rebranded, reworked attempts to address the same problems we have always had.
Dr Peter Rudge is GP in Devon and a former chair of NHS Northern, Eastern and Western Devon CCG
