Dr David Colin-Thomé OBE, MBBS,FRCGP, FRCP, FFPH, FFGDP (Honorary), FQNIis an independent healthcareconsultant and formerly theNational Clinical Director of Primary Care at the Dept of Health England 2001-10. He is a member of the All Party Health Group advisory board.
David was formerly avisiting Professor at Manchester andDurham Universities, as well as a senior medical officer at the Scottish Office and Director of Primary Care at North West and London Regional offices.
He was a GP from 1971 at Castlefields Health Centre Runcorn, retiring in March 2007. His practice was leading-edge nationally, pioneering systematic management of long-term conditions and employing managed care techniques. He was an advisor to Central Manchester University Hospital from 2004 to 2007.
David has considerable experience in the public policy sector having spent eleven years as a councillor, as well as publishing regularly on primary care reform.
NHS reform blockers: 60 years experience
In my recent blog, I described why the NHS needed reforming, catalogued all Reforms since 1990, the attempted essential disrupters, and the lack of the necessary sustained change. My hope is the present NHS Reform policy will be successful as at last the public will have more authority. But my nearly 60 years of NHS involvement has identified perennial blockers to overcome- the prevailing leadership culture and disabling commissioning. The way the NHS is funded likely compounds but more of that another time.
I have long described the disbenefits inclusive of clinicians, of a sadly too common controlling style of leadership. A ‘top down’ style reinforced by a compliance-based governance. Of course manager leaders cannot allow a complete ‘laissez faire’ approach to their task, but the best I have met keep control by letting go. How can we mainstream that cultural paradigm shift? By choosing leaders for their personal attributes coupled with technical knowledge would be a start. The new Plan majors far more on localism than hitherto, can we couple this with the principle of subsidiarity - central authority only performing those tasks which cannot be performed at a local level? A development we all can continue to push.
I believe commissioning has been too narrowly defined and delivered. Secretary of State Streeting as a welcome supplement to the 10 Year Plan most encouragingly focuses on de-cluttering NHS administration. The duplicative NHS is to go and now a veritable bonfire not of the ‘Vanities’ but of maybe vanity projects. Whenever the NHS surfaces a new problem, a new quango seems to appear. ‘Creating new quangos can make for a good announcement but rarely solves the problem. Over the past decade and a half, an overly complex system of healthcare regulation and oversight has been left to spiral out of control’. The current system is too complex, and the NHS needs "more doers and fewer checkers". In total 201 organisations will be scrapped; there are more than 150 bodies currently assessing quality in health and care settings and providing guidelines. That number ‘has been allowed to increase’ over the past ten years The Government says these are not joined up and are having the opposite effect of what was intended, issuing guidance in an uncoordinated way.
I fully support this radical NHS reappraisal, and it recalls speaking at a conference when a GP had a rant about the Care Quality Commission. I responded by asking why we do need the CQC? My viewpoint was if providers had good clinical governance and leadership and commissioners truly commissioned, CQC should be redundant.
So what has commissioning achieved since 1991 when the clear separation of provision and purchasing was introduced, and 1997 when the latter morphed into commissioning? The problem as I perceive it is the change sanitised the word purchaser but has over focused on the transactional element of the role. I am NOT advocating abolishing commissioning, but desire focus on its partnership function as an enabler of systems creation and governance. The abiding culture should be relational not contractual with accountability being 2 way with all providers even if the contracts are held elsewhere. Exactly what I mean about a new style of leadership. The contracts methodology they hold could be alliancing for instance; much used in the Antipodes.
The reason I want such a change. We still have a healthcare system with many performance scandals in an existing underperforming service. Maternity services are a huge current crisis. I have been disappointed by the lack of utilising the opportunity of several reforms and invoked Machiavelli’s famous change dictum. And predominantly I see weary often dispirited staff and a worrying sense of alienation. Fertile environment for destructive strike action. Unless we can instil a sense of hope and purpose even in cash strapped times, I fear for our beloved NHS. We all love its purported values, but many feel things are done to them. An age-old prerequisite for well being is a feeling of some control of our being, and working for the NHS should have that in spades. Our Secretary of State is right; we need more doers not checkers.
So, in the limited words remaining some final thoughts. We urgently need to change how the NHS is led and managed. Commissioners as participators not a discrete authority. Providers to set and be held to account for their service output and outcomes, and to radically lessen any gaming all such standards to be in the public domain. A transparent accountability, not an imposed one. Whose NHS is it? Local budgets, not least personal ones to increase. Only then will Reform be meaningful and the bold overarching 3 shifts in policy of the current Plan be the transformative force required.
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