From rhetoric to reality

As the financial squeeze tightens, the NHS will need a radical overhaul. Whether it will get it or not remains another matter, says Dr Michael Dixon

At the NHS’s core, we need to end that terrible disconnect between managers, who believe they are running the show, clinicians who are spending their money (and happy to remain doing so on the touchline) and patients, who sometimes feel that they are simply stooges being pushed down the tramlines created by managers and clinicians.

We need to restore a compassionate health service which balances better the pronouncements of scientists and health economists with the practical realities of the clinicians’ world and the beliefs and experiences of patients.

Clinicians and patients will need to recognise that they must work with managers to make the best of available resources and cut waste where possible, while the patients will need to see themselves as co-producers of health and services and instrumental in making the NHS sustainable. That will mean developing proper self help support and opportunities, encouraging personal health systemically and developing local communities that maintain health and reduce the call upon the NHS’s services.

That may sound utopian, so how do we make it happen?

First of all the NHS at all levels must recognise that primary care offers a major part of the solution both as commissioner of services, provider of services (traditionally often secondary care) and implementer of local health initiatives.

If primary care is to take on this leading role then this will require a major change in attitude and organisation at the Department of Health. No longer should primary care be a small sub-division of the Department of Health operating at several tiers below senior management. Primary care should have an equal footing with secondary care reflected in both the managers and the clinicians working at the Department of Health.

The culture that produces a Leadership Council that is virtually primary care free (and totally primary care clinician free), an executive board that has no primary care clinical leadership and a system that has no connection with frontline clinicians or managers in primary care must now end.

A leadership that uses the rhetoric of “a primary care led NHS,” then introduces “Transforming Community Services” (TCS) and hands 50% of community services to hospitals has become irrelevant, especially when it imposes a solution that will only increase costs, impose further unnecessary organisational change and, what is worse of all, moves the NHS back thirty years.

So hopefully, after the election, we will have a Department of Health that is relevant to the frontline clinicians and managers in the health service, which understands the reality as well as the rhetoric of innovation and service re-design.

A centre which has the insight to act, where it cannot see solutions through the eyes of patients and local clinicians and is prepared to hand power and responsibility to them rather than impose its own solutions. The iron fist of a secondary care dominated management hierarchy that has alienated and excluded local clinicians and patients is no longer relevant in the modern NHS facing difficult financial times.

The role of the commissioner needs to be strengthened so that patients get what they need and want rather than what their providers decide they should get. That means giving the commissioner at least as many cards as the provider. One consequence is that Payment by Results should become a ceiling price as soon as possible and thus strengthening the role of frontline clinicians to commission the best services for their patients.

With power, however, should come responsibility. Frontline clinicians must now all play their role in commissioning – ensuring that local services are the best possible and that they are used cost effectively. How they do this should be left to local discretion.

If local PBC consortia want budgets, then this should be tried. Where PCTs, PCT clinicians and frontline clinicians are working together – a bit like PCGs and health authorities of old – then that might be the appropriate model. The main thing, at present, is that every clinician should have a role in making sure that we do make the best possible use of scarce resources.

The same goes for patients. Elections are all about what the government will give the people – “panem et circenses” (bread and circuses). The reality is that the survival of the NHS depends upon patients doing as much as they can for themselves and for each other. “What you can do to play your part in the NHS?” needs to become the post election slogan. As a consumerist soup kitchen – the NHS cannot survive.

Tony Blair rightly perceived that in an expanding economy and NHS the wealthy would only want to continue supporting the NHS and those less wealthy if it provided services that met their expectations in terms of quality and choice.

As we move into more difficult economic times, a different argument is likely to keep the wealthy on board. The argument goes like this. If the NHS at national level is an alliance between the rich and the poor to make sure that everyone can access good medical care then, at local level, the same “social contract” demands that patients and clinicians collectively contribute towards the best use of local resources.

That means a balance between consumerism or “me-ism” and concern about others and the welfare of the rest of the local population. For clinicians, that will mean balancing the needs of the patient in front of them with all the other patients that are not.

For patients, it will mean balancing their own individual needs against those of their fellow men. A small rebalancing of the good of “self,” whether it be that of the professional or the individual patient as opposed to the best good of the best number, could well create that £20 billion that is currently required.

This new altruistic and cooperative spirit could be the foundation of redesigning community services in an altogether different way.

Imagine that we might ask local professionals and patients how they could improve and optimise community services. The answer could be integrating them with general practice and social care, their natural home rather than secondary care or even, in many cases, mental health trusts. This is a discussion that has not been possible in the headlong rush for PCTs to put in TCS plans – one which has largely ignored the voice of local patients and clinicians because of timescales (and certainly not the fault of PCTs, who have been largely the victim in all this).

Then finally there is health. Political talk of ensuring that health money is contained is fairly welcome. Because we all know in times of financial stringency, health money gets redirected into patient services. My fear, however, is that that health money will be simply put at the disposal of directors of public health and not become a dialogue between those directors and the local population and clinicians for whom they are responsible. Money for health or public health must now become synonymous with local health and local health initiatives. Health must become the responsibility of every clinician and patient and health spending must now be “owned” by all of us.

So post election, we need to see real localism, emancipated clinical leadership, effective commissioning, innovation and redesign that are encouraged rather than suppressed and co-ownership, co-production and integration at every level of the NHS. We will need to mobilise the forces of challenge and peer pressure to avoid complacency. We must avoid too much top heavy control or rampant market, which may create alienation and fragmentation respectively.

At the top, we now need an NHS that listens to its local people and clinicians and supports their aims and objectives. Just as the clinician now needs to become the servant of the patient, the wider NHS must support both rather than view them as pawns at the bottom of a beneficent management hierarchy.

Dr Michael Dixon is a GP in Devon and chairman of the NHS Alliance