Archive

Archive for July, 2013

Jul
28

I am Ben Gowland.  I am the Chief Executive and Accountable Officer at NHS Nene CCG.  I have run the Clinical Commissioning Groups Information website anonymously for 18 months, but have decided now to ‘come out’!!

When I started this site I thought it would be better to stay anonymous.  I thought it would enable me to say exactly what I wanted, and not be constrained by the impact my views might have on my CCG or on those around me. But, it turns out, I was wrong! 

As the website has grown in popularity I have been encouraged to make it my own.  The feedback has been that it is hard to trust an anonymous site, that it restricts interaction, that it creates a nervousness as to who or what is behind it (e.g. is it a trojan horse for pharma).  If the aim is to provide the greatest possible support to CCGs (which it is), and if the impact will be greatest by being me rather than by being anonymous (which I now believe it will), then coming out is the only possible way forward.

I have discussed the potential impact of the site on my CCG with colleagues.  Their feedback has been that I absolutely must make the site my own.  They looked at the content on the site and could not see any reason why it would impact negatively on the CCG, and on the contrary felt that in the NHS today openness and transparency have become critically important.

As those of you familiar with the site will know, I am passionate about the potential of Clinical Commissioning Groups.  I firmly believe that decision making about the use of NHS funds needs to sit with those directly involved in the delivery of front line care, and that those best placed to be leading this are GPs. 

In the past I have worked in organisations where managers insisted on leading organisational decision making, and on relegating clinicians to a support role at best.  Since then I have set up organisations (first Nene Commissioning as a practice based commissioning organisation, and now NHS Nene as a CCG) where clinicians are empowered and supported to use commissioning to make a real difference to the lives of their patients.

Clinical Commissioning Groups need all the help that they can get.  This website is my contribution to supporting CCGs as a collective to fulfil their potential.  In the transition from PCTs we have not had a really strong advocate, and no one really rooting for us.  Latterly NHS Clinical Commissioners has taken on this role, which we have desperately needed, and I think alongside them we need as many of us as possible giving our views and making our voices heard.

Thanks to those of you who have supported me and encouraged me up until now.  I hope that all of you will continue to work with me, and that we can work together to support and develop CCGs so that they can fulfil their incredible potential!

Jul
19

After the shambles of the RCGP 2022 GP document, it is refreshing to find a great report on the future of general practice.  The Nuffield Trust and the Kings Fund have produced a document, ‘Securing the Future of General Practice: New Models of Primary Care’.

You can find the document here.  It promotes fundamental changes to the organisation and delivery of general practice, which include linking together practices in federations, networks or merged partnerships.  It builds the rationale for this on a clear understanding of the case for change, which it articulates really well.

I think there are some areas where the report overly complicates the required change process.  But before I get into that I just want to reinforce that I think this is a great report, and one that should immediately become required reading for all CCG and NHS England staff!

First the good.  The report is really keen not to dictate to practices what they need to change into.  Instead it is keen that we have clarity on the functions required of primary care.  It suggests 5: improving population health, particularly amongst those at highest risk of illness or injury; managing short term non urgent episodes of minor injury or illness; managing or coordinating care for those with long term conditions; managing urgent episodes of illness or injury; and managing and coordinating care for those nearing the end of their lives.

I would fully support this approach.  It sets a clear outcome and leaves the form required to develop organically rather than be imposed.  What it does say is that general practice will require skilled facilitation, business planning and professional support (e.g. legal, financial, estates) when developing plans for extending service provision.  The universal experience from elsewhere is that all underestimate the support that is required.

I guess where my view differs from that of the report is the lack of ambition the report demonstrates for the role of CCGs in the transformation process.  Indeed, the report suggests that the very existence of CCGs is detrimental to the development of general practice, because the, ‘capacity for strategic work available is taken up by clinical commissioning responsibilities’!

Let us be clear.  No one is, or has ever been, better placed to facilitate the transformation of the autonomous, independent business units that are general practice than the CCGs that are membership organisations of those very practices.  CCGs understand general practice in ways that it is not possible for other organisations to, simply because it is made up of practices!  Its leaders are GPs!  I know I am stating the obvious, but this point seems lost on many outside of CCGs.

The report suggests that the required transformation cannot rely on the ‘heroic’ model of leadership where it falls to a small number of single individuals carrying those around them.  As such it suggests two things: a ‘national framework’ to guide strategic direction; and new contractual and funding options to sit alongside the existing contract. 

Here I think the report is wrong.  Yes practices need support.  But developing a framework feels like a process that will delay change starting and that in reality will not drive change.  In fact I am not sure who it will actually help.  It talks about a new contract that NHS England will offer practices covering end of life, mental health, long term conditions, older people, and children.  But these areas all fall within CCG budgets.  It does give an alternative that CCGs could commission additional services from general practice.  But we already can, so I am not clear what exactly we would be changing?

I agree the changes will not happen by themselves.  What I think we need is two things.  First we need a strong partnership between NHS England and CCGs to enable the commissioning of an extended range of services, in as innovative a way as possible.  We discussed what this might look like recently.  You can find it here http://ccginformation.com/how-commissioning-can-transform-general-practice/ .

The second is to demonstrate to practices that it is possible to make these changes, to support the willing, and to create a critical mass that will become a tipping point for wider change.  We need to spend our time not on frameworks or contracts but actively supporting the process of change, and it is CCGs ultimately who must use the unique position they are in and take the lead role in this.

The report is excellent, but it is 100% wrong to suggest CCGs are a barrier to this change.  On the contrary we are the solution, and the ones who must take on lead responsibility for the task of implementing the core suggestion of the report: the transformation of general practice.

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Jul
14

Now that the first 100 days of CCGs has passed, it is time for the first review of CCGs.  A number of articles have been produced by CCG leaders, which unsurprisingly are optimistic.

Writing in the Guardian (here) Dr Steve Kell concludes, ‘After 100 days I’m optimistic clinical commissioning is delivering’.  Michael Dixon writing in Inside Commissioning says the positive outweighs the negatives.  He states, ‘Already, it is clear that the new clinical leaders of CCGs are strong, committed and clever. They will not be deterred by the skewed rules, vested interests and paralytic inertia of the system that they have inherited.’  You can find the full article here

I, however, am not so sure.  The reality is that in the past 100 days, Andy Burnham has announced that Labour policy will be to put CCGs in a support role and give commissioning to the Health and Wellbeing Boards.  Jeremy Hunt has transferred £3.8bn to councils from CCGs.  David Nicholson has announced a review of NHS strategy to test the purchaser-provider split, and hospital chief executives have joined in saying they can’t see the value in the purchaser-provider split.

Jeremy Hunt has also made ‘taking on’ the GPs and the GP contract a priority, without any reference to the GPs’ role as commissioners.  The RCGP has produced a vision for general practice without any thought to the impact of commissioning on the profession. 

Clinical commissioning, it would seem, is not as visible as it could be.

We said on this site that the idea of the first 100 days as a honeymoon period are long gone.  Instead it is the basis upon which judgements are made as to the leadership potential for the future (see the article in full http://ccginformation.com/the-first-100-days/). 

It is undoubtedly true that CCGs have entered a turbulent political context.  But priority one has to be establishing a strong voice.  As it stands no one knows who we are.  Most members of the public could not tell you what a CCG is.

To have a strong, credible voice CCGs need to do a number of things.  First we need to develop some easily recognisable clinical leaders to become the front for CCGs.  Second we need to point to some clear deliverables.  Third we need to be clear on our key priorities for the future.  And lastly we need to set out and establish our long term vision.

Steve Kell is becoming a good lead voice for CCGs.  Collectively we need to get behind him and support him in this role.  If we do not develop a strong voice, and do not do it quickly, as CCGs we will not even get a chance to start to fulfil our potential.

Jul
08

The Royal College of General Practitioners have produced a new document, ‘The 2022 GP – A Vision of or General Practice in the future NHS’.  It is a missed opportunity for the leaders of the profession to drive real change with their members.

There are undoubtedly some helpful elements within the document.  It supports the development of federated networks, it encourages generalist led integrated networks, and it seeks the organisational development of community based practices, teams and networks.

But it fails on three counts.  It fails to make the case for change now, it fails to build on the opportunity of commissioning, and it  fails to empower general practice to take action now.  We’ll explore each of these in more detail.

The very notion of the 2022 GP starts with a far away picture of where we are going.  But the reality is that everything that is described is required now.  If it takes us 9 years to get there it will have taken us 9 years too long!

We have discussed on this site how the opportunity is now for general practice.  But to take it requires urgent action to radically transform the way general practice operates.  Page 29 of the document, however, suggests a different pace of change, ‘The current model of general practice will inevitably evolve to meet patients’ needs.  This does not require destabilising change, rather a realignment of new priorities and a new strategic focus on general practice development within the context of community led care.’

Sometimes it is incumbent upon national organisations, even membership organisations, to give tough messages.  General practice urgently needs to change.  The RCGP had an opportunity with this document to make this point, but shied away for fearing of upsetting those members who don’t want to hear it.

Absent from the document is any mention of the impact of commissioning.  It is totally ignored.  Now you could argue this is a clinical commissioning website so I am bound to say that, but as a minimum you would expect the 2022 GP to at least reference the impact of clinical commissioning, particularly given it is a legal requirement for each practice to be a member of a CCG.

Candace Imison in her blog on the King’s Fund website asks whether clinical commissioning will stand in the way of developing GP federations?  She says, ‘It would be tragic if, by developing GPs as commissioners, we undermine their growth and development as providers’.

Nearly every CCG I know is prioritising the development of primary care.  Because CCG leaders understand primary care, and because CCGs understand that the development of primary care is critical to their own success, Candace’s fear is unfounded, and in fact the reverse is true – CCGs will accelerate the development of general practice as providers.  The RCGP could, and should, have at least acknowledged this.

The final failure of the 2022 GP is that it does not make it absolutely crystal clear that it is first and foremost down to general practice to change itself.  I know this is in part a function of a royal college’s duty to gain external support, but what it does is place general practice in the role of the victim, which is not a place it needs to be.

Richard Vautrey, deputy GPC Chairman, sums this up in his comment, ‘The ball is in the government’s court – it must invest and build on the innovation and modern working of GPs across the country, or miss historic what the 2022 GP calls ‘a historic opportunity to harness the power of general practice to transform the health service we will have in 2022’.

But this doesn’t help general practice, or gain any support.  Roy Lilley’s summary of the 2022 GP was, ‘Guess what; they want more GPs.  Very dull and uninspiring’.  The document does come across a bit like ‘if you want a general practice like this it is going to cost you’, when what we needed was a document that empowered general practice to own the challenge and own the actions.

I am passionate about general practice, about its pivotal role in the health economy, and about how it sets the NHS apart from any other health system in the world.  But it desperately needs to change, and the RCGP have missed an opportunity to help it do so.

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