Reaction to the impact on general practice of a new funding formula and the future budget for specialised commissioning. Plus why front line nurses are not to blame for a lack of compassionate care

On the level

Your article ‘GP contract: DH proposes new funding formula’ laughably suggests that changes to GP practice funding will be brought in by “levelling up”, rather than the reality of levelling down.

This within a sector, which unlike the rest of the NHS, has been subjected to freezes in real core funding every year since 2006, while workload and targets have mushroomed.

‘One wonders how your journal would have covered the story had it been hospitals’

You also fail to point out that funding for core practice infrastructure and management will be removed, with practices having to further increase their workloads enormously by striving to reach unachievable new politically driven targets and enhanced services in order to try and recoup their losses.

If this threatened contractual imposition goes ahead it will inevitably have an impact on the capacity of practices to care for the sick. It will also threaten the viability of many smaller practices.

One wonders how your journal would have covered the story had it been hospitals threatened with the same destabilisation.

Dr Robert Morley, executive secretary at the Birmingham Local Medical Committee

Old concerns about compassionate care

The chief nursing officer’s “six Cs” initiative implies that front line nurses are primarily to blame for poor care and lack of compassion in the NHS, while underplaying the roles of government, regulators, NHS trust boards, commissioners and managers in setting the framework and resources within which care has to be delivered.

The front line is where these problems become visible, but it does not necessarily follow that the most important causes, and their solutions, also lie there.

‘The most junior healthcare staff have the least power to influence service delivery’

Concern about a lack of compassionate nursing care is not new. More than 10 years ago I was the policy adviser at the UK Central Council for Nursing, Midwifery and Health Visiting (the predecessor to the Nursing and Midwifery Council) when its nursing committee highlighted “the loss of caring at the core of nursing” as a major concern. 

It is questionable whether much progress in tackling this vitally important issue has been made since then, and what the CNO’s six Cs will add.

If the professional regulators and universities that educate and train healthcare professionals are doing their jobs effectively, those entering the health professions should be safe, competent and well motivated to deliver good quality, compassionate care. What happens after that is strongly shaped by the culture of healthcare organisations − the priorities they set and the kinds of behaviour that are rewarded and punished.

‘It would be surprising if the Francis report does not conclude this a “whole system” issue’

The most junior healthcare staff have the least power to influence resourcing and service delivery. They have an individual professional obligation to act ethically, and public trust in healthcare relies on this, but there is a substantial body of evidence that shows how easily ordinary people can be induced to set aside their values by the authority structures they work in.

It is the responsibility of governing boards to make sure that the culture of their organisations does not undermine the values nurses and others have been trained to respect, and it is the role of the system regulators − the Care Quality Commission and Monitor − to ensure boards set and enforce the right framework for delivering good care.

It would be surprising if the Francis report does not conclude that this a “whole system” issue.

Eileen Neilson, director at Willow Consulting (London)

Specialised speculation

Sally Gainsbury has commented a couple of times recently on the apparent growth in the size of the budget for specialised commissioning, most recently in her article ‘Gilding the NHS settlement lily’.

In particular, she suggested the budget has been increased from under £9bn to around £12bn for 2013/14 with a rate of growth of 8 per cent a year according to Department of Health figures. The implication is that this is money which would otherwise be available to clinical commissioning groups.

‘In the meantime, speculation about rates of growth is just that’

It is true the new arrangements for specialised commissioning bring the budget and responsibility for all specialised commissioning together for the first time under the auspices of the NHS Commissioning Board, whereas expenditure has previously been split three ways between primary care trusts, regional specialised commissioning groups acting on their behalf and a top-sliced fund for the National Specialised Commissioning Team.

The quantum expenditure for those services is, however, not necessarily any greater, while major areas such as HIV outpatients, radiotherapy and all chemotherapy drugs have been added, at least for the time being. Consequently, the projected budget is £11.8bn but this is money the NHS would have spent anyway, though with more diffuse responsibility.

The Carter report in 2006 recommended that care pathways for specialised services should be fully costed but this and several other important aspects were neglected; an oversight which is now being addressed.

In the meantime, speculation about rates of growth is just that. Or as a past specialised commissioner put it to me, if expenditure on specialised services had been growing as fast as people have suggested it would now account for the larger part of overall NHS spending.

The Specialised Healthcare Alliance welcomes the new arrangements for specialised commissioning with their potential to provide more equitable access to better services across England as a whole, leaving no one behind.

These services are used by local people but calling on expertise and resources in a way which only the “N” in the NHS can deliver, complementing the role of the CCGs, not detracting from them.

John Murray, director at the Specialised Healthcare Alliance