Saturday, February 25, 2017

Changing Landscape?

Have you tried doing any talks on "NHS structures'? It's an absolute nightmare. Apart from the gazillions of bodies, there is the other small matter of having to change your slides every few years. Or depending on your experience of the NHS, maybe simply using some of your old slides!
Either way, it is no picnic at all- with the added problem being that no one quite knows whether the latest iteration is indeed the "final piece of the puzzle" or indeed adding one more layer of complexity.

Lets take a step back- and just use Diabetes as an example- just to avoid the usual dingbat response such as "what do you know about dementia, huh". So, we have NHS England, then we have 4 regional teams, we also now have 44 STPs and 50 Vanguards. Lets then add into the pot 15 Academic Health networks, 12 strategic Clinical networks. Then let's now factor in 209 (or whatever they are now) CCGs, 150 odd acute providers, who knows how many community providers and many many GP surgeries. My apologies to all those who forgot. 
Trying to have a unified policy- to tackle variation? Well, thank the Lord that the 12 labours of Hercules didn't involve sorting out care within the NHS- thats all I would say!

My personal view- (before tweets appear that NHS England says so-its good to clarify these things!)- is that in all those organisations, there are many, many individuals who are trying to do, in the main, the right thing. There isn't some massive conspiracy afoot from folks involved in them- they are trying to do the best they can- with the financial boundaries set, the challenges put forward- while trying to balance the needs of the population. The money- is a political thing- and all these bodies can only do what they are given with- as simple as that. If you want to direct your fire at anyone, these bodies are probably the wrong focus- yes, sometimes, the crunch of finances make people do things they wouldn't do to their loved ones- but thats where the lack of joined up system fails us all- the lack of appropriate checks etc.

So here's some crystal ball gazing. I see the commissioner-provider split melting away- as that has probably created more angst and variation than a lot of other things. I have worked with some fabulous clinicians who have been good Commissioners such as William Tong or Jim Hogan- but in the main, after doing this on many levels, we should leave commissioning and its structures with those who understand the nuances and are trained in it. Managers. 
Clinicians are trained to provide- and in times of need, gaps and locum crunch, please do so first.
Lets give you an example, if a GP spends lots of his or her time trying to shape services around the region while their own surgery is struggling with patients or data suggests about 7 in 10 people don't get their basic diabetes checks…then suggest you get your own house in order or help your colleagues at the ranch first. 

I see providers- acute and community fusing into bigger ones- and  gives primary care the chance to deal with one organisation rather than multiple- with multiple IT systems, personnels, lanyard colours or even fax numbers. Can primary care do it as a pack? It seems to be edging that way- and I see commissioners starting to focus on a few things-as identified by the Right Care work - universally- rather than each area having their own priorities and increasing variation. Vanguards were the kick start to look at new models of care- and they are here to stay. Lets be honest- if we believe nothing needs to change as regards models of care, and all can continue as is, then thats blatantly wrong. Don' like the Portsmouth Super six model? Well, go build your own- but don't tell me the system is perfect as it is with diabetologists working in isolation in the community.

Final bit? About STPS- and haven't they had a bad press. The ire about their "plans" does raise a wry smile- and I wonder how many have actually read financial plans of their own Trusts over the years- the projected cuts etc to make the balance sheet correct. Don't forget in the end, many of these executives also breach these very plans- as they realise the importance of patients & their safety- and rather take the heat on finances rather than safety. Its a generalisation- I admit- but isn't that far from the truth either. 
STPs- have some good ideas in them- a principle of "please work together as one body". Yes, there are flaws but then which NHS plan doesn't? Its for us to engage, try and shape the landscape in my view. The issue of money is key- and much kudos to those who raise the issue and keep the pressure on- but that should not, stop the work thats also needed to try and see whether we can join the silos of the NHS we work in.

Interesting times ahead- and those are my predictions- the biggest one of them? Let managers do what they are best at; let clinicians do what they are best at. 
Work together- we may get somewhere. Just.

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