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The closure of Lewisham A&E has knocked my faith in commissioning



In Lewisham, as in many CCGs all over the country a group of experienced GPs have given up hours of precious clinical and personal time, sacrificed the needs of their practices, attended seemingly endless meetings, training and assessment sessions.

Why have we done this? For financial gain? Career status? Personal aggrandisement? Sometimes, perhaps, but in Lewisham it is because we saw an opportunity to make a difference. To get all the different players; primary, secondary, community, council and voluntary sector to work together, to involve patients in  their care and produce a local service where all parts had agreed aims, combined their resources and where the tide of illness flowing into secondary care was diverted into effective health promotion and community based care.

We had begun this work and were daily becoming more effective (we should have done, with the amount of money spent on our training). We were helped in this by both a  council and local healthcare trust  sharing the vision and willing to put aside old ways of working to create something new.

We impressed those who came to test our readiness for authorisation, not just because we had the required documents but because our new collaboration had already had significant impact in referrals, reduced unnecessary hospital admissions and spectacularly increased the level of children’s’ immunization.

We were rightly proud of this, proud of our local trust, key in the changes in secondary and community care required to bring this about, and inspired by the co-operative spirit of our Local Authority.

Decisions about me, without me

Then came the problems of South London Healthcare and the TSA. The only solution to their problems being the effective selling off of our local trust, and the passing of acute services to the indebted trust next door. Providing assets to reduce debts and planning income to secure viability.

Our population, one of the  most deprived in the country, was told they will get better care by travelling out of borough (an expensive and stressful journey for many) to one of now four admitting trusts.

The council having to spread their already limited social care resources across four trusts to safeguard the needs of Lewisham residents,  but we as commissioners are expected to create new pathways of care, ensure minimum number and length of hospital admission with four providers for whom our work is an insignificant fraction and with whom any influence at all will require complex and time consuming  collaboration with any combination of five neighbouring CCGs.

We have very little influence too with our local population and GPs who, with no trusted central provider, will reject local pathways for the perceived ‘quality care’ at central London Foundation Trusts. Some even wonder if local commissioning will have any role at all.

Do I see a future in clinical commissioning? Obviously I did, I and my fellow directors would not have committed so much to make this work if not, but now I am not so sure. Can we keep GPs engaged having taken them on a journey of local co-operation to end up at a destination of external determination? It is hard to see this just as it is hard to see GPs of the future committing their time and efforts to NHS initiatives.

So ‘no decision about me without me’ becomes ‘all decisions about me depend on the needs of others’, where those ‘others’ are indebted Trusts, failed institutions and specialists in ivory towers. Meanwhile, local commissioners must return to the substitute bench, while the professional players get on with the match.

Dr Helen Tattersfield is the chair of Lewisham CCG and a GP in Bromley.