Carol Miers wrote up her notes on the speech by health expert Richard Vize at Help Me Investigate Health’s #reportinghealth event – we’ve reproduced them below with permission:
“GPs tend to be self employed business people, they hate NHS bureaucracy and hate being told what to do, now they are taken away from patient contact, they have to work on committees, they have their business interests compromised, they have become a cog in the bureaucracy and are subject to control from the Department of Health.”
This, added Richard Vize, opens up health reporting because there is now oversight from the Health and Wellbeing board which – given that GPs are vocal – will bring in an area of openness and debate.
The way NHS funding is currently organised is changing. NHS funding is split into three parts: the responsibilities for specialist commissioning, e.g. cancers and treatment, is going to the NHS Commissioning board. Public health is going to local government.
What is the CCG’s national budget?
“About £60bn is for the acute care and for the GP led commissioning groups (CCGs) to administer. Commissioning is very very hard.”
Back in 2008, Richard Vise continued, Chris Ham chief executive of the Kings fund, said that right across New Zealand, the USA, Europe, nobody has yet got commissioning right. That is, the relationship between the funding commissioner and the patient is hard to correlate.
There is a lot of hyperbole from the Department of Health, the idea is they are powerful, and that the commissioners are seizing power for the patient, that a CCG is flexible and can withdraw, contract and recommission the care provider but actually they have to work with the current provider, as there are not many.
“The private sector has been involved with health for only twenty years, while they account for 5% NHS spending this is not huge, but it is an issue.
“It is not, though, about wielding contracts but about relationships, the GP on the board idea is that they will look at individual health needs, then feed this into strategic decisions for meeting needs of that constituency.
“A good example is the treatment in Birmingham with diabetes care in the South Asian population, the micro needs of the surgery and macro policy finding a need not met, then dealing with it.”
The focus is on local needs, working with local authority groups with their new public health role, e.g. they could advise on the needs of the sexual health services and working with education to meet that and improve it.
“So the local authority with the CCG and the Health Wellbeing boards, is about the relations with clinicians in hospitals and trusts.”
PCTs failed to build meaningful relationships with provider clinicians in the trusts, integrating different areas of care.
If the reforms work, then the clinical insights can be matched up with specialist insights, with local authorities feeding in, and ideally you get integration.
So what is likely to happen over the coming few months? What to watch out for?
The question of CCG competence: From 211 CCGs, only 43 are at the start today on April 1 authorised without conditions, others need help, legal directions and 3 months notice has been given to some because getting the machinery working is tough, getting staff in and responsibility, managing, teams set-up.
There are huge financial risks: Having stripped out the specialist care, and public health care, the CCG is being separated, now handed out £60 Bn, the CCGs have the acute care which is the hardest to control. The payments are by results, the more you do, the more you get paid.
This money used to go to the acute trusts, how will the clinical commissioning groups control the demand? There is a greater risk of getting into spending problems.
With the new regulations GPs in the CCG commissioning groups can walk away if someone on high is bullying. As BMA press releases have shown GPs vocalise their disagreement, while this may help form a freer Health system, we will see the effects.
The commissioning board mandate is an assumed autonomy for the CCGs but can the NHS commissioning board deliver on this allowing the CCGs this autonomy?
Monitoring quality and raising standards: Regarding the Francis Report, Francis made calls on what they should the CCGs be doing. Are they equipped to observe the quality and safety of providers, as they cannot do it if they are not? Will there be blame when something goes wrong and who will be blamed?
Many times during the past, the GP group have cried wolf but now with this pressure and time on them the wolf might be coming.
A GP commissioner has to be giving CCG time for two days a week, but they also need to practice as well for maybe three days a week. Will they have the time? Can they do it? Will as a result there be medical errors ? This is an area to watch out for.
Reconfiguring services: Richard Vize said there was a naive Manchester GP speaking on the radio saying that he left the CCG when the finance was not enough. He was naive to think the allocation and need would easily match up. What could happen could be that hospital services may have to be shut to improve local community services and care.
Nigel Lawson said the NHS is the nearest thing the English have to a religion. It is very difficult to shut hospital services.
PCT’s have misjudged the communication of the changes, not asked the public what would you like and built hospital and other services around this. People are often in hospital for unnecessary medical testing. There needs to be sophisticated communication from CCGs to show their vision and to build the trust.
Conflicts of interest: BMJ showed recently that 36% of GPs on CCG boards have financial interest in health organisations. As lots of improvements is community movement, you might want to invest in the organisations the GPs are tied up in, through no fault of their own.
Worse, there are governance issues as GPs are not aware of this, they are not politically aware.
Competition law: Section 75 regulations, Health and social care reform Act. It is unclear, how much commissions will have to put services out to tender. EU competition law, Monitor the market regulator, Office of Fair Trading (OFT) and others complicate this.
It will take up time and effort unsuitably when it should be upon the patients. There is value in competition, for example in India and Brazil, surgical techniques, that eg can challenge the ways of doing things.
GPs rebelling:“GPs rebelling against each other, or against the LMC (local medical committee), or GP against the CCG, or GP and GP at loggerheads. Watch these relationships.
“GPs rebelling against the new regulations, no longer constrained as they were with PCT’s, they will speak out about the closures’ impacts, or speak out due to the duty of candour and the government will struggle to contain it.”
Relations with local council: There are good things about democratic oversight of the role of the Health and Wellbeing boards. Yet while the needs of areas, that strengthening could be good, yet there could be conflicts.
Simply put, local government works on the electoral cycle, GPs will tend to work on evidence based on data and there is room for conflict.
Will they succeed? Don’t underestimate the loss of corporate memory, the difficulty of relationships. Success in the health system is measured in years the PCT system itself had not been in place long enough to access it.”
Carol Miers’ References: Example NHS Salford, The commissioning board Commissioning board, CB. An NHS link on The new NHS. Info on payment linked to quality of performance, Quality premium NHS commissioning boards. More info on a new NHS tier, the Health and wellbeing boards, Richard Vise, Guardian,NHS clinical commissioning groups.