I chaired the specialised commissioning group last week which was fascinating (and intense work). Ranged around the table were people skilled and experienced in public health, planning, procurement, finance, and a representative of the public who brought common sense and sensible challenge.
One of the key issues we debated was whether patient choice could be restricted. A medical colleague cited an example of a procedure which we can get done in the East Midlands for £50k but cost £250k elsewhere in England – with no difference in quality.
Over the last two decades much has been made of the need for the NHS to offer more choice. The current reforms emphasise any willing provider and choice. In Lincolnshire we have striven to offer choice to patients especially for specialities where capacity has failed to keep up with demand (though not necessarily need – but that is another debate). However, the feedback we consistently get is that people want responsive, safe, and effective local services. They understand the need to travel for treatment that is specialised but where a service could be provided locally they want it locally.
Clinicians also want the best for their patients. As a GP making a referral I brought to play knowledge of the patient, of the condition and soft intelligence about the quality of services. A fit 25 year old with a hernia may relish choice. The elderly patient with ischaemic heart disease, diabetes, and chronic pulmonary disease who requires a hip replacement needs close and integrated working between the hospital and out of hospital services. What I have seen is that this does not necessarily need structural integration. It does require rules and incentives which permit patients and clinicians to organise care in a fashion which best meet the needs of the patient. There are clearly circumstances where limiting choice to ensure good communication, and protocol adherence will deliver the best outcomes. Commissioners should be able to restrict choice along a care pathway when they are confident and can demonstrate that this will deliver better outcomes and better efficiency.
Delivering health care is a complex and arduous art informed by science. Too often policy makers and legislators champion a rational and conditional approach to this complexity which results in undesirable and unintended consequences. One size does not fit all. Extolling competition and choice as the solution to the problems of the health system feels too simplistic and distant from the realities professionals and patients struggle with.
My sense is that the reforms could, with some amendments, support a more flexible and intelligent set of system rules but, despite my ever prevalent optimism, they have one crucial and crippling flaw.
Some time ago I was at a conference on choice when I fell into conversation with a management trainee who had just joined the NHS from the financial sector. He said to me “I don’t understand choice in the NHS. One of the important choices you make in the financial sector is to select a really good financial advisor who can help you navigate the complexity of what is on offer and make sure you choose what is right for you. Surely the most important choice you make in the NHS is your GP?”
I am still trying to work out how these reforms answer that question.
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.