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Martin McShane: Nietzsche and commissioning

25 Jul, 11 | by BMJ Group

Martin McShane

As part of the development of our Clinical Commissioning Groups (CCGs) the seven GP CCG chairs now have a place at the NHS Lincolnshire Board meetings.  The agenda was not particularly unusual. We were required to approve the Equality and Diversity Strategy. We had a couple of papers dealing with our legacy document and the transition planning process. There were the important performance and financial monitoring reports. It is the time of year when we present the annual governance, audit committee and annual reports and summary financial statements. We had a formal letter from the Strategic Health Authority (SHA) to note and an associated action plan (completed – in case they read this!). We reviewed the Board assurance framework, the risk management annual report, and the business continuity management update.

Over the last seven years, working full-time in a statutory public body, I have become accustomed to the mountain of governance reporting, risk management and regulations which such a body has to abide by. Much of it is the law. Much of it is demanded by regulatory bodies. Woe betide an organisation which can’t produce evidence, on paper, that the board has considered, discussed and/or approved this or that policy or report. Although it is a lot of hard work and an externally imposed bureaucracy (mostly from parliament), if you don’t stay on top of it, it will crash down on top of you.  That being said, as a member of the public, I would like to know that public money is being used to good effect with risks being properly managed and that those charged with the use of my money can be held to account – that is what bureaucracy was originally created to do.

In conversation with one of the GPs later, he reflected that he felt he had entered a parallel universe he hardly knew existed.  I am struggling to work out myself how much of this CCGs will be allowed to ignore? They will need to do much, if not all of the corporate governance which NHS Lincolnshire currently needs to do and feed most, if not all, of the regulators we need to comply with and report to the NHS Commissioning Board – all with far less management resource than we have had (it has already shrunk in the last year).

Much was promised about a year ago. Bureaucracy was to be slashed and clinicians put in the driving seat. PCTs and SHAs were to be abolished and the NHS liberated. Liberated from what? Proper accountability? Transparency as to the use of public monies? Risk management? Legislation?

A year on and CCGs have been told they must have a lay chair of audit. That implies that there will be an audit committee. To me that implies the agenda we took this week will not be in a parallel universe but will be part of the universe CCGs will inhabit from 2013.

The NHS appears to have a Nietzschian philosophy – it seems as if the philosophy is you must first break an organisation before you make an organisation. We have tried this approach so frequently that perhaps, in the future, we could adopt a different philosophy.  Unless, magically, all the duties organisations have to comply with change, we will always end up needing to do many of the things we have always needed to do. Critically, unless you do them well they will stop you focussing on what clinicians are really interested in – patient care.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.

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  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    Nietzsche?  Huh?

  • Richard Smith

    You are right in your last line to say that what really interests clinicians is patient care. But can we go on forever putting patient care ahead of prevention and public health? Can we afford to do so?

  • Dr Angry

    Richard Smith you choose the wrong comaprison Public health and prevention are vital adjuncts to day to day patient care What wore me down in 8 years on a PCG/.PCT were the interminable discussions and “doing pieces of work around” issues And the mindless comping of statistics although the important facts like Every visit to the WIC cost more than twice as much as  a visit to a GP surgery, wer eignored for political reasons

  • Martin Mcshane

    I have waxed and waned on the issue of public health vs the individual.
    Obviously you need both.  However, if you don't address what society 'wants' then I think a large section of society will reject a system that does not value the individual. This almost happened before the turn of the century when the level of investment in the NHS was very low.  The work by Wanless comparing different systems and concluding that a nationally funded system was the best way to deliver health care for individuals but required a 'fully engaged society' to keep costs down reflects the tensions inherent between improving health and delivering health care.
    Many of the wider determinants of health require a political will and determination and a willingness by society to embrace behavioural changes which as a fully informed and reasonably intelligent adult even I find difficult to adopt (but those mini pork pies were delicious).
    I suspect the changes will happen, hopefully, but incrementally – how long did it take for all the legislation and attitudes to smoking to occur?  However I fear the economic climate and financial pressures on the NHS may whisk us back to where we were in the late 90s faster than people realise unless the professions embrace, support and lead a host of necessary change.

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