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Where did all the flowers go?
Date: January 23, 2017
Where did all the flowers go?

The NHS “invented” the term Commissioning some years ago, probably around the turn of the century.  It is not a new term and has been used to describe the ordering or acquisition of artwork for centuries.  In healthcare it has produced less elegant results and it has been used to conceal a host of poorly thought out decisions which have been almost exclusively driven by the process itself rather than by any form of insight or inspiration.  Where is the art?

Primary care, or more specifically general practice, has suffered from an absence of imaginative commissioning in Essex for several years with the result that practices in trouble have received little or no support from NHS England, and as they have ceased to function the answer in recent years has been a reflex response of initiating the appalling procurement process inflicted upon the NHS in the name of the “market” and choice. This has given patients a variety of short term providers some of whom do not appear to be entirely wedded to the principles of general practice. The market is rarely mentioned these days as it has utterly failed to improve standards or efficiency, but its shadow continues to drive the robotic decisions of regional NHS England.

NHS England wishes to divest itself of general practice commissioning by encouraging CCGs to take on fully delegated powers. This may seem to be an excellent solution as CCGs generally have a greater interest and knowledge of primary care and they are membership organisations responsible to practices. That is at least the theory.

The reality is that NHS England is unlikely to hand over sufficient resources to the CCGs to enable the job to be done effectively, and they will be delighted to blame the CCGs for all the problems which will be uncovered when commissioning begins in reality. In effect, they will hand the CCGs a dead dog and then come back a week later and blame them for killing the dog.

The NHS in England is currently struggling to complete Sustainability and Transformation Plans (STPs) which are, in theory one hopes, an attempt to properly focus on primary and out of hospital care, or at worst a cost saving and acute care re-organisation exercise. You can guess which way NHS England chose to go in Essex. Our three STPs are entirely in line with the review of the acute services and will result in significant changes to the delivery of care, without any meaningful public consultation. Primary care is well represented in North East Essex, but even here the issues affecting GPs in W Suffolk are not those of North East Essex.

This is causing serious problems and is likely to threaten any possible success. “The Success Regime” is the mildly delusional title of the STP in “Little Essex”, which comprises all of South Essex and Mid Essex. This bizarre line-up is intended to enable the three acute trusts to work more closely together, and this makes sense, but the dictatorship of STP implementation is enforcing artificial demarcation lines in general practice and primary care. Nowhere is this more extreme than in West Essex where the CCG is working with Hertfordshire. The latest NHS England stroke of inspiration is that it would be easier (for them) if West Essex simply left the County and joined the Central Midlands, based in Leicester.

This unsupported and unilateral decision has caused significant workload for every other health and social care organisation and Essex County Council has written to Ministers complaining about the lack of consultation and highlighting the potential consequences. No practice or practitioner in West Essex was consulted about leaving the County, and therefore changing their entire professional and contractual focus.

There is good news in Essex. Anglia Ruskin University has plans for a new undergraduate medical school which would be the first in the County, and they plan to take their first students in 2018, depending on the GMC approval process. I am working part time with the team at ARU on this project, and the intention is to have a general practice facing modern medical school which will produce doctors, and hopefully GPs of the future.

The LMC is working with a number of CCGs on plans to address the workforce crisis in general practice, and we are moving towards a new model of care which will involve working at scale but which will also control GP workload. If we can control the workload and yet ensure patients are appropriately provided with care, then our current recruitment problems will soon disappear.

Things will get better, its just taking a while for the change to occur and we are struggling to get all of our commissioning colleagues on board.

Brian Balmer December 2016