The national headline that decries a newly discovered episode of ‘postcode lottery’ in the NHS is familiar to all of us. It immediately leads to an outcry about a variation in care that is trumpeted as heralding the immediate destruction of the healthcare system unless the errant transgressor is instantly forced to fall into line with the majority.
Curiously, another dearly held tenet is the concept of individual choice. Pity then the poor clinician who has to either commission or provide care for some individual whose personal preference does not fall in with the proclaimed majority view.
Of course all of this is manageable. Variation is quite acceptable provided the individual is offered the choice of the service that is available to the majority and makes a personal and informed choice to deviate from that pathway. And that it is scrupulously documented.
But the recent statement that CCGs will be ranked according to their compliance with the nationally-set NICE framework raises serious challenges.
The new commissioning framework allows CCGs to apply local decision-making to the health service where decisions involving allocation of resources can be made by local populations. Localism has been the key word for this strategy.
And in the current age of austerity, it is seen as critical in ensuring that the local population is intimately involved in such decisions that might require the closure of a local facility to allow a more progressive community-based service to flourish.
And that is the problem about local decision-making. It allows variation. The explosion of clinical guidelines over the past decades is matched only by a similar explosion of expressions of indignation from the guideline-creators that they are not implemented universally.
People with long-term conditions, for example, often stubbornly refuse to fit neatly into the guidelines for their condition. They insist on having multiple pathologies. They have complex lives with multiple interdependencies. They sometimes even have preferences.
This will become ever more complex if the ranking of success for CCGs is according to the organization’s alignment with centrally designed guidance. It would be even more so if the design of the guidance is influenced by organizations whose primary allegiance is to their individual share-holding population.
We need then some rapid reassurance that those clinicians who step up to the mark and take on the responsibility of providing local leadership within their communities will be given the freedom to do so. If they are told that the measure of their success is their conformity with imposed frameworks devised at great distance, then the system is being designed to fail.
Regardless of the quality of a decision made at a national level, there will be a balance to strike between an individual patient’s preferences against a population’s needs. The successful CCG will manage this tension at a local level. Where conflicts occur, they can be resolved by the local population themselves. Health outcomes cannot be legislated into effect – but they can be achieved through local communities acting in unison.
If the predominant driving force behind a CCG is compliance with central edicts or a fear of being dragged into a legal judicial review, then the strategic direction of the current reforms is lost. We must be vigilant against that.
We need to be ranked on the achievement of local outcomes. That is not whether one drug was prescribed over another but whether one outcome was achieved for the community and its population. So no longer a ranking according to whether a particular stop-smoking treatment is provided to an individual, but on whether the prevalence of smoking has decreased within that community.
We must accept the challenge of defining outcomes. This is not straightforward when we have relied on proxies for so long. It is so much easier to have a system to check whether a stroke patient has had a scan within 24 hours than to assess whether they have gained maximal independence at three months after their event.
The definition of a desirable outcome must come from individual populations. Local commissioning groups will rise to the challenge of being held to account for both securing these definitions as well as their achievement.
Dr Donal Hynes is the co-vice chair of NHS Alliance and a GP in Bridgwater, Somerset