The key to healthcare delivery models lies within natural communities – not in bloated commissioning organisations, says Charles Alessi.

The thrust of the government’s NHS reforms is localism, and small is indeed beautiful if it shortens lines of communication, improves engagement and ties health, local authorities and populations in arrangements around natural communities.

We have a long history of trying to aggregate the delivery of care and see this as a magic solution to delivery and the administrative burdens. While this may be appropriate for the hyper acute and specialist services, it does not carry through to mainstream delivery of healthcare.

Some strategic health authorities are trying to corral clinical commissioning groups into larger and larger entities in the belief that this will deliver efficiencies and liberate resources. What this action demonstrates is a dearth of understanding of primary care and this does not bode well for the new NHS Commissioning Board, which will have the commissioning and performance of primary care at the heart of its core business.

We seem to love large commissioning and contracting organisations, although very few have delivered what they were designed to (the pan-London shared commissioning services experiments come to mind). We then become disillusioned when they develop a persona in their own right and forget who is their customer (in this case it will be the clinical commissioning group) by demoting that relationship in the way they think and act. We need to understand that the solutions lie in our natural communities, not in aggregated commissioning and contracting bodies dealing with large, amorphous populations.

These reforms are about making health and social care delivery more congruent and moving to co-production and co-ownership. Local adherence and ownership is key, and health and wellbeing boards – where health and social care providers are exposed to the public scrutiny of justifying their use of resources in the light of their outcomes – are the marker of this. Scrutiny needs to happen in the full light of day to have the local population enjoined in the delivery.

Doomed to fail

What of the NHS Commissioning Board? How will this body interact with the locally delivered bodies? We hear of the stories of the inexorable rise of the cluster, becoming more and more powerful, and sucking in resources that should be destined for the clinical commissioning groups.

We hear of strategic health authorities bullying clinical commissioning groups to change their shape and configuration, in the mistaken belief that there is only one way to deliver efficiency and completely forgetting that local buy-in is the most difficult and most precious of all the critical determinants of success.

The NHS Commissioning Board is in the process of being set up. Where is its connection to primary care? Where is the voice of primary care within the Department of Health? Primary care needs to be at the heart of the system to deliver commissioning of the service, like the letters through a stick of rock. Leaders of clinical commissioning groups need a voice in this powerful body to ensure it is not an institutionally focused organisation like the NHS seems to have become.

We have an opportunity of a lifetime to reach out and develop a healthcare system that will punch above its weight. We can only do this if there is a good and robust connection with the delivery of care and this can only be through population-focused delivery systems organised at a human scale and based on natural communities.

Yes, we need the efficiencies of size, but there are better ways of delivering them than the crude attempts at forcible aggregation. Why not give the groups the challenge to deliver and let them come up with solutions?

This transition is the most challenging in a generation. The commissioning board will be enjoined to let go while simultaneously maintaining a tight grip. The NHS is going to need hundreds of new leaders who are joined to and part of their natural communities and whose style of distributed leadership is not one we have celebrated in the past.

All this in an environment where the money is fast running out and management options around seeding initiatives are doomed to fail given the lack of resources to fund them. We need new models of delivery and the answer is within us and within our natural communities.