Ciarán Devane interview: 'There is a role for top-down control'

Ciarán Devane’s desk faces out across the Thames to Whitehall and his office’s reception area overlooks the headquarters of MI6. The chief executive of Macmillan Cancer Support might be sandwiched by the Establishment but today he starts out in a new role which is supposed to overturn the NHS’s old order.

Mr Devane will be in Leeds attending his first meeting in the post of non-executive director of the NHS Commissioning Board, the body which is supposed to minimise political interference from the health service.

The banishing of politicians from the day-to-day running of the NHS might have seemed a sound election promise from then shadow health secretary Andrew Lansley. However, it is widely feared a top-down monolith is being created with the all-powerful commissioning board calling the shots – not the GPs Mr Lansley promised to empower.

In his HSJ interview, Mr Devane calls for a balance to be created between commissioners enjoying “the benefit of having a local view on [their] own population” and a national “duty to maintain fairness”. This duty should mean that “if we are capable of delivering great cancer outcomes in one part of the country we are able to do that in another part as well”.

“If we are to drive the improvements we want then it’s about doing great things locally but also doing great things in a coordinated national way,” Mr Devane says. “It’s that combination which will be effective; there’s absolutely a role for top-down in the same way that there’s a role for localism.”

Mr Devane says he is not on the commissioning board “to push a particular agenda”, or as a token representative of the third sector: “I’m there as me. I’m not there as Macmillan, I’m not there as a health charity person, I’m not there as part of a trade body for the voluntary sector.”

While that is clear, Mr Devane – placed 52 in last year’s HSJ100, the annual list of the most influential people in health – says he wanted to get the commissioning board job to promote the influence of patients.

“We need to make sure that, in the same way you want the medical voices heard, it should be obvious that the patient voice is at the table, too,” he says.

“The thing I’m passionate about is creating an NHS which is patient centred, high quality, cost effective, and sustainable in the long term. To get from here to there is going to take everybody and anybody who can help.”

It remains to be seen how the board will respond to patient demands for new drugs and services. When asked how tightly the board should enforce National Institute for Health and Clinical Excellence standards, Mr Devane is adamant that commissioners are given room to innovate. “What we need to do is achieve a world where the minimum you do is the quality standard but what we want you to do is better and beyond that,” he says.

“The headroom for clinical commissioning groups and providers needs to be in place to allow them to do that.”

The word monolith has also been used in connection with NHS services which fail to respond to demand. Mr Lansley’s original reform plans were designed to boost the involvement of the private and voluntary sectors in service delivery, although opposition to the Health Bill forced the watering down of this objective.

Positive climate

Macmillan does not take NHS money to run services but uses its own funds to purchase services for the health service. Mr Devane says this makes him the “least qualified voluntary sector person” to talk about the effect of competition on charities.

However, asked if the government could use third sector organisations as cover to expand competition when the healthcare giants are likely to be the victors, he says his sector colleagues are optimistic.

“The voluntary sector can hold its own. We are well organised; we know what we are doing; services are high quality; we’ve been doing it for years; and we don’t feel that voluntary sector organisations are less well led than private sector organisations,” he says.

“We don’t fear capability; what we do fear for is the level playing field, and there are some arcane VAT things that work against voluntary organisations.”

Despite this enthusiasm, the Big Society era has not resulted in “huge change” for charities in their involvement with the NHS, he says. “But, if it creates a positive climate, that’s good.”

A positive climate is not something widely associated with the Health Bill. Macmillan supports its focus on outcomes, information transparency and empowered patients. However, there are concerns.

“A lot of the patient and public engagement is very local and very individual, without necessarily having the patient voice at the centre of things nationally,” Mr Devane says. And he also wants a greater focus on maintaining the contribution of cancer networks. “We have to worry about the uncertainty for people in the service when restructuring is going on.”

The bill and challenging public finances dominate current political debate. However, Macmillan is looking ahead. The charity is working on a plan offering a vision of services in 2030. Mr Devane says that in the current climate the charity accepts that progress on its three main objectives will not be uniform.

Macmillan’s first objective, a desire to “do more things we already know are good” such as the creation of more clinical nurse specialists, has suffered. “It’s not the time now to be going to a trust and saying we think you should increase your headcount.”

Indeed, Macmillan believes 2 per cent of clinical nurse specialist posts are at risk – a lower figure than the Royal College of Nursing has suggested. But this is nevertheless a “false economy” as these nurses “not only drive quality but save money, by keeping people out of hospital”.

However, Macmillan’s second objective of “supporting people to be well and out of hospital” is doing well. Community services – which some claim are cheaper than acute care – are “quite in the zeitgeist at the minute”, he says.

He describes progress on the third priority of “coping with long term changes in society” as “trickier”. “As we speak now there are two million people living with cancer in the UK; by 2030 it will be four million. And we all know there won’t be twice as many hospitals, nurses, occupational therapists, benefits advisers or whatever it is.

“We have to do things in a radically different way. If we don’t do it now, in 20 years’ time we won’t have the service we all know and love.”

Mr Devane gives the example of the system of follow-up appointments for cancer patients, “designed decades ago”, in which every cancer patient receives a follow-up appointment every six months. Improvements such as the use of more telephone appointments to focus resources towards more personalised care could improve services and save money, he says.

Service improvements and savings are to be made through better coordination of care. He says of NHS trusts coping with tighter finances: “Most are trying to do a good job, undoubtedly. But the difficulty trusts have is they’re bounded by themselves. The opportunities really come with the integration of tertiary care with primary care, or social care.”

Mr Devane backs Andrew Lansley’s national drugs fund for rarer cancers. “It recognised that, particularly for the rarer cancers, the population size was never there to be able to provide the level of evidence which NICE rightly demands [to approve treatments].”

According to Macmillan, 42 per cent of the population will get cancer at some stage – an increase on the widely quoted one-in-three figure. Macmillan examined the records of people who died in a year and calculated how many people had a cancer code on their NHS record.

Mr Devane notes the difference in progress in survival rates between different cancers. While breast and colorectal cancer have seen huge improvements, median survival has improved little in lung and pancreatic cancer over the past 40 years.

“If you go back to the early seventies, median survival was roughly one year; now it is roughly six years,” he says.

“If you are dealing [in future] with median survival north of 10 years, then you are automatically talking about the long term consequences, not just of the treatment, but of the cancer itself. How do you set that up so you maximise chances of long term health as well as long term survival?”

He gives the example of colorectal cancer sufferers requiring support with incontinence in order to return to work. “The cancer story is changing for many cancers into a long term conditions story.”

Power shift

Macmillan is currently working with the royal colleges and hopes to work with Health Education England on projects to help the NHS workforce to evolve to increased life expectancy.

Mr Devane predicts the NHS nursing workforce must adapt to new roles assisting self-managing, empowered patients. He predicts “new semi-specialist roles in the community” who work with practice nurses on the support of cancer patients.

These patients make the key decisions relating to their care themselves. Some may say “I want that last-ditch chemotherapy because I’m desperate to make it to that 50th wedding anniversary”, while others may shun the chemo because “actually, I’m going to travel around Europe with the girls”, he says.

It is clear this NHS non-executive director feels the patient should be in control. There will be a power struggle between the commissioning board and the CCGs and inevitably these two groupings will come to be part of the NHS’s new establishment.

But Mr Devane is determined this should not distract from the biggest shift in power – the empowerment of those who actually use health services.