Martin McShane: Multilayered commissioning

Martin McShaneI walked into a room recently which was jam packed with secondary care clinicians and managers. I was the lone commissioner. The meeting was a peer review visit to support the development and improvement of vascular services. I recognised the chair. We had both sat together in an ante room awaiting interviews for a senior registrar job over twenty years ago! He is now a professor and I am, allegedly, a bureaucrat.

I have read the standards produced by the Vascular Surgical Society of Great Britain and they have significant implications for how we will need to commission services. In fact we will have to work hard with our main provider to implement the standards so we can continue to make sure the people of Lincolnshire can locally access high quality services. Those services need to be affordable. I was asked if, as the commissioner, we had the money to invest in the necessary changes.

“No,” was my response. The reaction in the room was one of astonishment, bewilderment, and anger. Of course what I should have said was “Yes.”  Both answers are right. We don’t have the money unless we deliver the efficiencies set out in our Strategic Operating Plan. Our QIPP (Quality, Innovation, Productivity and Prevention) initiatives require comprehensive clinical engagement to address thresholds and variation in practice. The point I was trying to make is that I don’t really decide how the money gets spent – clinicians do. It is a finite budget so if they want investment in something new let’s stop wasting money on the ineffective or inefficient.

What was interesting was how passionate the clinicians in the room were about improving quality and defending local services. There is a lot of debate about “why on earth are we making GPs commissioners?” I think commissioning is not about the buying of health services. If it was it would be a lot easier. Commissioning is about leadership, politics, and change management as well as the ubiquitous “commissioning cycle.” It is done at multiple levels and is about giving people influence and accountability for the best use of resources. Without perhaps realising it the consultants in the room already have far more commissioning influence than they realise.

Commissioning by GP consortia brings together the last bastion of generalism in the health system to build value for money, bottom-up through the system. It gives GP practices influence but also accountability for commissioning, two things they lack at present.  Other specialists, such as vascular surgeons, already wield enormous influence on the commissioning process. Specialised commissioning, NICE, Royal Colleges’ standards and guidance have all shaped and informed the commissioning decisions I have been involved in over the last decade or more. They are informed and influenced by specialist interests. Can we challenge the thinking that there is a necessity for tokenistic representation of specialist interests on the boards of consortia?

By the way, neither of us got the job.

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.In April 2011 he was made Director of Commissioning and QIPP for the newly formed Lincolnshire PCT Cluster. There has, however, been no major change to the road network.