The new band of clinical commissioning group leaders face immense challenges in an uncertain future, writes Mark Hayes
On 1 April, after a gestation period of 33 months (the African elephant’s is only 22 months), the Health and Social Care Act 2012 gave birth to the new NHS and I became the “accountable officer” for Vale of York Clincial Commissioning Group.
The act has had many opponents and should Labour win the next election in 2015 it has said it will transfer the commissioning of healthcare to local councils. So the new CCGs face the prospect that their lifespan could turn out to be shorter than their gestation.
‘Once Lansley had challenged primary care to lead the NHS we had no choice but to “step up to the plate”’
Author Owen Jones wrote an article for The Independent on Sunday on 31 March with a title leaving little doubt as to his feelings about the act: “Farewell to the NHS, 1948-2013: a dear and trusted friend finally murdered by Tory ideologues”.
Such colourful language illustrates the magnitude of what is at stake with these changes. If it all goes wrong then, aside from the cost to individual patients and their families, many careers will come to a shuddering halt; be they managerial, clinical or political.
So, in this environment, an obvious question is why have I, and the other GPs, stepped forward to become accountable officers for clinical commissioning groups?
‘Make a difference’
Back in 2010 we all had demanding and fulfilling jobs in primary care so the choice to be part of the new system was a deliberate and measured one. I think it was driven by a desire to “make a difference” and to apply the experience gained in the front line to creating a better NHS. Personally I felt that once Andrew Lansley had challenged primary care to lead the NHS we had no choice but to “step up to the plate”.
‘There is a difference between change and improvement; all improvement is change but not all change is an improvement’
The CCGs and their clinical leaders will have to be effective change agents if the NHS is to weather the coming storms. Increasing demand and financial restrictions will create problems across the whole country, with both commissioners and providers facing the prospect of significant deficits.
When we consider the recent reorganisation, we have to remember there is a difference between change and improvement; all improvement is change but not all change is an improvement. Time will tell whether we are on a path to improvement or merely change.
Jean-Baptiste Alphonse Karr, the French journalist, said in 1849 “plus ca change, plus c’est la meme chose” – “the more it changes, the more it’s the same thing”. We can see the truth of this saying if we study the final chapter of Dr Archie Cochrane’s Effectiveness and Efficiency published in 1971. In the book he paints a picture that is disturbingly similar to the current NHS. He describes the need for randomised controlled trials, increased applied (as opposed to pure) medical research and he wants more data on outcomes.
Importantly he wants this data to be comparative between units and doctors, something that seems very contemporary in this post-Francis world. He also questions the size and number of district general hospitals and suggests fewer and smaller units with more work being done in the community. Perhaps most importantly he says “there will be a marked reduction in the use of ineffective remedies and of effective remedies used inefficiently”.
With this statement he is similar to the work of healthcare academic Jack Wennberg, who described three types of care: effective care, preference-sensitive care and supply-sensitive care. CCGs will need to ensure that they commission effective care for all who would benefit from it while at the same time reducing supply-sensitive care to a safe minimum and decommissioning “ineffective remedies”.
‘This band of new leaders face immense challenges but let’s hope they are the right people at the right time’
In bringing about this change CCGs will have to enter a dialogue with their local communities. Trust and integrity will underpin this dialogue and perhaps this is where the clinicians of the new CCGs may have an advantage, in the eyes of the public, compared to the previous primary care trust managers. Although the changes on 1 April brought about a shift of power from managers to clinicians, the next more radical shift needs to be from clinicians to the public.
Empowering patients through programmes like “supported self-care” and “shared decision making” will challenge CCG leaders with a paradox. The more they distribute their newly acquired power and authority to others, the more successful they are likely to be.
So this band of new leaders face immense challenges but let’s hope they are the right people, in the right structures, at the right time, to bring about the changes required to ensure that the NHS did not die on 1 April 2013.
Dr Mark Hayes is chief clinical officer at Vale of York Clinical Commissioning Group