The rulers of Renaissance cities would allow the mavericks of society - rebel artists, writers and philosophers - to criticise their government openly. Although the mavericks lived in special enclaves outside the city walls, their views were always listened to and valued. These leaders realised that the maverick ideas of the day could well be taken up by government in the future.
We are less keen on mavericks today. Asking difficult questions is not fashionable. But innovative and creative ideas still come from people who are brave enough to 'rock the boat'. That's as true in the NHS as in any organisation. The trouble is, it can often take years for good ideas to blossom. The challenge for both clinicians and NHS managers is not to be fearful of good ideas, however disruptive they seem at first.
It's almost five years since the demise of the maverick nursing development units (NDUs) based at Strelley in Nottingham, Smallheath in Birmingham, and Stepney in London's East End. Their purpose was to give ordinary community nurses the time, space and opportunity to look at how services were delivered - then improve them.1 They redesigned the way care was delivered so it refocused on the community it served. In Strelley, the nurses developed partnerships with community leaders, campaigned for a traffic-calming scheme to reduce childhood accidents, and organised first-aid courses which the residents had asked for. All the nurses tackled health inequalities and made explicit the links between health, housing, education and social services. They asked people what their health needs were, then tackled them: locality commissioning in action.2
The nurses created something new and effective, becoming empowered and motivated as a result. Yet they soon gained a reputation as troublemakers - mavericks who asked difficult questions and proposed new ways of doing things. For their trusts, the experiment seemed to have turned sour, so they withdrew their support. Without a strategic commitment to carry on, the NDUs found it difficult to attract funding. Revenue soon eroded, and all the health visitors and community nurses involved were asked to return to 'normal duties'. Many of the pioneering nurses who worked on the projects have since left the NHS.
Ironically, the ideas these nurses fought so hard to promote are now flavour of the month. The principles behind health action zones, healthy living centres and the new commissioning plans for primary healthcare underpinned the NDUs almost a decade ago. What have changed are not just structures, but attitudes and political will. Ideas which seemed radical and out of step with reality a few years ago are now political good news stories. Yet even with this political backing, translating the vision of true locality commissioning across the whole NHS requires a major shift in thinking.
Developing local commissioning groups in England, Scotland and Wales will no doubt seem like an unnecessary headache over the coming months, but let's not lose sight of the good idea as we develop the structure around it. That idea - deemed so radical in the NDUs - is that those who understand about a particular area's health needs should be involved in commissioning healthcare for the people in their patch. Health professionals are part of these new groups not because they represent doctors or nurses, but because they understand their communities' health needs.3 The issue is not the numbers of doctors and nurses serving on boards, but the quality of board members.
Creating an army of expert local commissioners is not going to happen overnight. Resources for developing these groups will need to be ring- fenced and targeted at everyone with the potential to be involved in commissioning. Some of the money must be invested in training the commissioners. Some with most to offer - those with most knowledge of local health needs - may not currently have commissioning skills. Yet if local commissioning groups are to be effective, it is precisely these people we need to develop and value in the commissioning process.
As the NDUs demonstrated, some of the best ideas came from residents themselves, so public involvement in commissioning groups should be about much more than token board membership. To gain the public's confidence, the commissioning process must be as transparent as possible and relevant to the local community. If only the GPs on local commissioning groups can elect the chair, the sense of partnership could be undermined.
Most people are aware that primary healthcare is changing, and that their GP is not the only gateway into the health service. They also know that it makes sense for the doctors, nurses and therapists who work in their area to commission healthcare. That organic link between practice and commissioning, between local health needs and delivering local healthcare, gives the new structures the potential for radical change. Local commissioning is not just about rewriting existing services into a contract. We have to make sure we clearly demonstrate the measurable benefits for patients.
With the advent of locality commissioning, the NDU nurses' maverick ideas may well be enjoying a renaissance, but this time we should listen when the mavericks challenge our ways. The 'troublemakers' who ask the difficult questions may ultimately bring us closer to our goals.
1 Christian S. An overview of NDU practices and values. Nursing Times 1995; 91(34); 11.
2 Royal College of Nursing. Profiling the General Practice Population. London: RCN, 1993.
3 Redfern S, Norman I, Murrells T et al. External Review of the Department of Health-funded Nursing Development Units. London: Nursing Research Unit, King's College London, 1997.