Last week I talked about a number of the potential promises that the NHS could make to the English people in exchange for the extra money they will be giving it.
This week I’ve been focusing on implementation issues because, nice though it is for national organisations to promise better care, the money the NHS is being given is real (and not being spent on better birthday presents for the kids), so the promises also need to be real. They actually need to be delivered right across the country.
On Monday, in a trip down memory lane, I outlined how the last Labour Governments used ‘deliverology’ to create and monitor the chains of delivery that were necessary to achieve their maximum waiting time targets between 2001-10.
Yesterday I had a rather jaundiced look at the capacity of commissioning to implement nationally by locally buying new care policies. Today I want to explore other capacities that commissioners in both the NHS and local government can bring about.
For the last three years I have been working with a group of leaders of the new care model called the Multispecialty Community Providers (MCPs). These are all about developing a much-extended primary care model – beyond the usual primary and community care, crucially linking into the voluntary sector but also into a number of activities historically carried out within hospitals. (The category of ‘outpatient’ has always puzzled me as you have to go INTO hospital to become one. Shouldn’t outpatients be treated outside hospitals?)
GPs have been crucial to the development of MCPs, indeed many MCP leaders are GPs. But in a small number of cases the leadership for developing these new models of care have come from CCGs. Leaders here have shown that CCGs can be both imaginative and powerful in developing very new models of care. Whilst most of this development has not involved CCGs buying new care models, they have still been very active in developing them.
Given that this has been the case how could CCGs be used as a national implementer of the new promises of care to the public?
The main driver for change has been the knowledge that the CCGs gain from their understanding of the health needs of their local population. This provides a critique of existing health care provision. If we had started developing NHS services by focusing on the health needs of the local population, we would have configured services very differently. Pick any disease pattern and we would certainly have developed not only a very extended set of primary care skills (see my posts last week on cancer diagnosis and diabetes remission) but we would also have created a much less fragmented skillset of NHS and other public services.
CCGs have a thorough knowledge of their population’s health needs and possess a strong critique of the current system of care. The problem for many CCGs is that they don’t step up and act on that knowledge. It is in some way set aside from what they do. For many the gap between what knowledge tells them to do and what is actually there is so large and acting on those health needs so destabilising of the current system, that they leave that knowledge behind.
However if they do act on it they have allies close at hand. Local government has a contradictory attitude to the NHS. At a political level they are afraid of large scale change and anything that might destabilise the status quo, but at a service delivery level, at the level of representing local people and their need for NHS health care, local government profoundly recognises the need for change.
One of the interesting things about Health and Well Being Boards is that, in bringing together two sets of public services – local government and the CCG-led NHS – they generally bring together two very different sets of priorities. Whilst the NHS is mainly worried about services for older people, most top tier local authorities are very concerned about policies for children in their area.
In poorer areas local government recognises that thousands of local children go to their first day at school without being ‘school ready’. That from before that first day inequalities enter strongly into their lives that school find very hard to reverse. Consequently, local government is quite critical of the current configuration of children’s services and would like to see change.
If (see yesterday’s post) buying different health care to align with local needs – seems beyond most CCGs, what can they do to move services into new models of care?
It may seem an obvious point, but the first thing CCGs have to do is act. They need to develop a plan of activity for change. If they are passive and reactive then there is little hope of them changing health care in their locality. Statutorily they all have a plan – but what not all them have is a set of actions based upon that plan.
In looking at what has worked with CCGs helping to develop new models of care, the first thing is to convene a meeting between local government and local providers of health and care to discuss the gap between current provision and need. Particularly to involve primary care who need to play a much wider role than they do at the moment.
In convening this group commissioners have a great deal of knowledge about population health care that no-one else does. The problem is this knowledge is not public knowledge – it therefore exists only as a sort of private critique of what is happening. Given local and regional media is very interested in health and health and social care, popularising this knowledge makes a considerable difference.
When local media recognise that the real needs of the population are some way distant from the provision, this inevitably leads to a critique of the commissioners themselves. But if you are going to have a plan of action that challenges the status quo CCGs need to be able to accept that some criticism will come their way.
It is not the fault of providers that their view of the health and social care needs of the local population is often very limited and based upon what they provide as a part of an already fragmented care model. It is in no way their fault that their view of health care needs is based upon what they control, but it is the fault of the CCG that providers are not regularly and publicly provided with a different view.
From their experience with models of care it is clear that CCGs can play a powerful role in developing new ones. But it is equally true that this is a variable set of capacities that are differentially spread around the country. If the NHS nationally is to look to CCGs to develop new models of care across the country, variations in current capacities will create big gaps in delivering that change.
Tomorrow is the NHS’ birthday and I’ll be posting a birthday blog.
Next week I will be concentrating on mental health.