Critics of the Health Act say the reform plans are about central control. In reality, the exact opposite is achievable if people are committed to making it happen, says John Rooke.
Earlier this year, following a summit at Number 10 and as part of the shiny new narrative of the coalition government’s approach to the NHS, the “four Fs” were announced:
- commitment to the founding principles of the NHS;
- commitment to funding real terms increases every year;
- commitment to making it fit for the future;
- freedom for local decision making.
We all know that there are hang-ups in the NHS about autonomy or more accurately the perceived lack of it. If not born from, then certainly nurtured by the decade of waiting list reduction and the financial turnaround of 2006, there is a feeling that “we aren’t allowed to…”.
Using NHS chief executive Sir David Nicholson’s analogy that PCTs are the “incubators” of clinical commissioning groups, there is no surprise that this perception of a lack of local freedom has passed from parent to child in the commissioning sector.
The first sight of the new management structure of the NHS Commissioning Board sent ripples across my favoured medium, Twitter. The trends from the scholarly, sage, moderate and sensationalist characters that operate in this space focused principally on two key issues. First, the style of this new organisation and the culture it would create, especially for CCGs. The second issue was the significant numbers of very senior managers at a local office (currently PCT cluster) level.
There was not one comment suggesting that this national structure would enable CCGs to flourish as local organisations, run by the most trusted people in British society, accountable to the local public.
There was little about how the commissioning board could create the right environment for CCGs and health and wellbeing boards to make stepped improvements in system reform and hence delivery of the quality, innovation, productivity and prevention plans.
The opinion, albeit from this small sample, was that the NHS Commissioning Board was designed to be “command and control” and by definition CCGs were doomed to a future of immense scrutiny and servitude.
Yet the foreword to the Liberating the NHS white paper states: “Healthcare will be run from the bottom up, with ownership and decision making in the hands of professionals and patients.” This aim is universally reinforced, regardless of the audience, whenever I hear Sir David Nicholson and his colleagues talk of the reforms.
But why does the NHS family not believe it? Why are many of us still waiting to be told what to do next? Personally, I do believe this aim and fortunately I am not alone.
The clinicians that make up Bedfordshire CCG feel they have the opportunity of a generation to create an organisation that is built upon the best evidence and takes the best traits from other health systems.
We are using the luxury of time in shadow form to try to establish good organisational health, culture and governance so that when we go live we have established the correct values, attitudes and behaviours to make this policy and organisation a success. Below are examples of how some of our work programme is unfolding.
Pressure ulcers: In the summer our CCG held its inaugural board meeting. An immediate priority was to take a zero tolerance approach to pressure ulcers. As a result we have engaged all our NHS providers in the Safety Express initiative to eliminate all grade 2, 3 and 4 pressure ulcers by December.
Early warning systems: We are developing notification processes so that each incident captured can be reported through to a central team that collates the rich quantities of soft intelligence to establish early warning signs of any problems with services provided to our population.
Board to ward: Our clinicians, especially our newly appointed clinical directors, are increasingly visiting providers – either announced or unannounced – to talk to staff, patients, families and carers about the quality of care offered.
Organisational health of general practice: Our practices are creating a multifaceted primary care quality framework that provides an understanding of how the practice is performing, how well it is organised and what key stakeholders, such as those referred to by the practice, think of it. With the majority of contacts with the NHS in primary care, this is an obvious place to start to improve experience and outcomes.
Cancer outcomes: Working with Macmillan Cancer Support, more than 150 of our GPs are undertaking retrospective reviews of cases of cancer to establish any trends in the outcomes for our population.
Membership organisation: to increase ownership, engagement and dialogue with the local communities we are proposing to emulate the foundation trust model and seek members from local clinicians from all disciplines, local authorities, the public and our staff. Using the membership to form a council of governors will keep our organisation accountable to the communities it serves and the values those communities set.
Maximising independence of older people: There will be new locality-based provider forums at which providers, carers and patients solve local issues preventing integration of services driven by an outcomes-based specification from the commissioners.
Our clinicians’ priority is to build an organisation which attains the highest quality and safety.
The most important point in all of this is that no one is telling us what to do and no one is stopping us. We are being actively encouraged by our PCT cluster, the SHA and the Department of Health to innovate and make decisions with our local population with what I can only assume is the aim of making the NHS the envy of the world.
It seems to me that freedom of local decision making in the NHS may have something in common with Tinkerbell. It is more likely to exist if you believe in it.