I enjoy Rabbi Lionel Blue’s thought for the day and one I caught recently seemed pertinent to the turmoil which the NHS is going through. He started his talk with, “Monday it’s kidneys, Tuesday heart, Thursday joints, and Friday blood and brains.” It wasn’t a recipe, he said, but the hospital appointments in his diary that week.
To me that summed up neatly the challenges the NHS faces; polypathology, in an elderly and ever so witty person, being managed around the provider’s convenience rather than the patient’s. Will the reforms tackle that challenge? Will they improve the patient experience? Will putting clinicians in charge make a difference?
I made a presentation to a meeting between all the clinical directors and the GP leads from the clinical commissioning groups in Lincolnshire recently. The two slides I focused on were the ones which illustrated the abrupt cessation in year on year growth in funding for the NHS and the fixed sum of money we have for the NHS in Lincolnshire. We invest about £120million in primary care services. We invest about £500million in secondary care. A 5% increase in the money needed for secondary care translates into a 20% reduction in funding for primary care. Of course, that is not likely to happen is it? Well actually it did – about 6 years ago community services were stripped of resources to prop up the acute sector. That was in an era of growth. It took 3-4 years of further growth to restore community services to a benchmark level of funding that wasn’t the second lowest in England.
The clinicians in the room were keen to work together. They understand the issues. They see the inefficiencies in the system and want to improve outcomes and experience for patients. There was a great deal of energy and enthusiasm. However, it needed to be harnessed, brought to bear in a focused and prioritised way to have a real and sustained impact. The new chief executive of the acute trust (the eighth or ninth in just over ten years – you try managing hospitals that are further apart than Manchester and Sheffield as one trust!) adroitly sought to localise issues and forge relationships to resolve them whilst maintaining the principle of centralisation where appropriate. Everyone in the room recognised that collaboration and integrated working was the way forward (although I did have the heretical concern that collaboration can sometimes wander into the territory of collusion, which is perhaps why such an agenda must be commissioner not provider driven). To deliver the scale of transformation which the clinicians envisaged requires management with the capacity and capability to do so. I fear there may not be enough “bureaucrats” left to support the huge amount of change which the clinicians were willing to embrace. This isn’t a transactional, planning, and procurement process: this is about hearts and minds, and beliefs and values, and needs conversations, relationships, and trust – the “soft” side of commissioning.
As I listened to Rabbi Lionel Blue and reflected on the meeting I did think that maybe his challenge could be met and his experience improved by a clinically led system. But then I realised he wasn’t in the room with all the clinicians in our meeting. It wasn’t just clinically led, it was clinically dominated. Someone needs to make sure the patient voice continues to be heard and listened to.
It’s just a thought….
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.