Editorial Thursday 27 September 2012: What will doctors do now they are running the NHS?

Speech at 20-20 Health fringe event, Lib Dem party conference

The 20-20 Health think-tank invited me to speak to their fringe meeting at the Liberal Democrat party conference about what clinicians will be doing now they’re running the NHS.

This is what I said.

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Before I start, some brief context: it won’t have escaped your attention that such was the Prime Minister’s confidence in his Government’s health policy - the one he relaunched several times – that he sacked its author Andrew Lansley, and replaced him with bell-flinging, Murdoch-loving Jeremy Hunt. Mr Cameron also replaced the entire health ministerial team in the Commons.

It’s too early to know what Huntism means for these NHS reforms, but it certainly means 10 Downing Street is worried that things weren’t going so well.

These reforms’ stated aim was ‘liberating the NHS’, which is interesting as they create the country’s biggest QUANGO ever, the NHS Commissioning Board, which will control and oversee three-quarters of the NHS’s annual budget of just over £112 billion. The Board is authorising the new clinical commissioning groups which will spend the bulk of the money and shape services locally - and importantly, it will review them annually and can de-authorise them partly or wholly. Its chief executive is former card-carrying Trotskyist Sir David Nicholson, who has been NHS chief executive since 2007 and is not primarily famous within the service as a decentraliser of power hitherto.

The reforms aimed to reduce bureaucracy: this must be why where the NHS formerly had 10 regional bodies, it will have 31 by next April; and where it previously had 150 statutory commissioning organisations, it looks set to have 211.

All this is in the context of effectively flat real-terms funding until 2015, which is better than almost all the rest of Government is doing. Ideally, the NHS shouldn’t complain - but almost certainly will, because even if the Government can give a real-terms annual rise of 0.01% on the supply side, most health economists agree that technology, demographics and inflation push up healthcare costs by 4% a year on the demand side.

That leaves the NHS needing to make efficiency and productivity gains to the cash value of £4 billion a year over four successive financial years, which no developed world health system has ever done.

So I’m going to talk about some things I know clinicians will do, and some things I hope they’ll do.

The first thing I know they'll do is about money. Political economist John Kenneth Galbraith claimed that the 36th President of the United States of America Lyndon Baines Johnson once told him, “making a speech on economics is a lot like pissing down your own leg. It seems hot to you, but it never does to anyone else”.

Clinicians running these new commissioning groups will be making a lot of speeches on economics to their colleagues and the public. With £4 billion a year in cash to save, economics will drive changes in how and where services are delivered. Some of these changes will be uncomfortable for their fellow clinicians and unpopular with the public. Doctors have consistently proven to be the most trusted profession in opinion polling (and yes, I have seen where journalism comes down at the bottom of that list), and it will be interesting to track over time if that remains unchanged.

The cost-effectiveness of health treatments needs to become coffee-machine conversation.

Labour’s iconic health minister Nye Bevan said "The religion of socialism is the language of priorities". So doctors engaged in commissioning are going to be economic socialist priests, which may not be quite the profession they originally thought they were entering.

Of course, many clinicians will not be very engaged in commissioning: there’s a nicely cynical phrase going around - “scratch a commissioner; find an entrenched provider”. So the second thing I know those in charge will be doing is having difficult conversations with their colleagues about vested interests.

The third thing I know clinicians will be doing is knowing that they have a well-paid, in-demand day job to which they can return if the new system proves uncongenial and over-centralised. That is a unique position since the profession of NHS general management was invented after Sir Roy Griffiths of Sainsburys’ 1983 report into NHS management.

This ‘get out of jail free’ clause could act as a check and balance on the NHS Commissioning Board – or it could go completely the other way.

The last thing I know they will do is learn to stop worrying and love Comrade Sir David Nicholson. His NHS Commissioning Board will performance-manage them against two main areas: their share of delivery on the national mandate set by the Health Secretary; and not blowing up the money.

CCG leaders will only achieve these things by performance-managing their colleagues and providers. They will discover it can be tough.

It’s no secret that clinicians and managers in the NHS have not always got on splendidly: indeed clinicians going into management roles were referred to as “going over to the dark side”. I saw an interesting ‘penny dropped’ moment when a CCG leader told a conference of peers, “there’s no them and us any more, there’s us and us”. The audience nodded. Will all their colleagues nod too? We’ll see.

Now for the things I hope clinicians in charge will be doing. The first of these is outing healthcare’s dirty little secret, which is that clinicians’ and organisations’ performance and outcomes are hugely variable. The NHS Atlas of Variation sets this out in great detail.

Lest we get nostalgic, the old system had very limited success addressing this variation. Even in a relatively high-performing, progressive region such as the North-West, some hospitals delivered 80% of all the NICE-approved tests and treatments for long-term conditions and major disease areas. In other hospitals in the same region, it was 40%.

There are providers across the system to which a competent and well-informed doctor would not refer their disliked neighbour’s dog. How long was the care on many wards at Mid-Staffordshire Hospital scandalously bad, yet GPs still referred there? How often do you hear about GP practices losing their contract for poor quality or dire patient access? In the words of one fabulously outspoken clinician-commissioner, “what do we do about the crap doctors?”

So I greatly hope that clinicians will be having lots more difficult conversations with their colleagues and peers about variable performance: celebrating the good, and addressing the bad openly and quickly.

I also hope the clinicians leading these new organisations stick with it. I think there is a unique power in clinicians driving change (and have heard so many reports of primary and secondary care clinicians meeting to discuss these changes and the line ‘why didn’t you tell us this is what you wanted?’). I'm pretty sure a commissioning clinician will be harder to bullshit than a commissioning non-clinician.

Another fond hope is that these clinicians will change the system’s culture about admitting mistakes and saying sorry. Ambulance-chasing ‘no win no fee’ lawyers do not help us do this maturely, but the system is still too defensive. An apology, together with an explanation of what will change to remedy the problem, followed up after a year to ensure that change is sustained, could be very effective.

Finally, I hope that clinicians will talk to patients more, asking us about our experiences of care, explaining the risks and benefits of treatment more clearly and more fully and really involving us – the punters, the taxpayers – in making choices and decisions about our care and lives, and understanding the complexity and risk and uncertainty. There is a risk of a medicalisation arms’ race – the ‘when all you’ve got is a hammer, everything looks like a nail’ syndrome – and I think more candour about the costs, benefits, quality of life implications and risks of treatments would do us all some good.