Your views: Advice and leadership

How can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service?

We are interested in your views on this area, including:

  • What early action is being taken in your area to improve quality of services through clinically-led commissioning?  What is working well?
  • How can commissioning consortia best engage and take on views from across the range of health professions in taking their commissioning decisions?
  • What more could we do to ensure that commissioners collaborate to join up services to fit around the lives of patients and carers, and the particular circumstances of certain conditions?
In Conversations, Listening exercise: Get involved, NHS Future Forum: Pausing, listening, reflecting, improving | Tagged ,

81 Responses to Your views: Advice and leadership

  1. R Kendall says:

    Surely its rather late asking how the NHS staff themselves can drive forward changes to the service.
    The Coalition government, without any mandate or previous indication, produced radical and detailed plans which have been
    heavily criticised since being announced by the BMA, CEO’s, and front line workers. Now that certain front line services are being affected by cutting staff numbers (ie. nurses losing their posts) and the fact this has produced a certain outcry and uproar from the voters, the government seem to say they are prepared to ‘listen’. Why were you not listening and adopting sensible proposals from the heart of the service, rather than making sweeping change proposals from the ‘top’?

    • Emma Brady says:

      I couldnt agree more! I think they’re closing the door after the horse has bolted. Why does every government we have meddle with the NHS? Each time they do this it costs more money & time, taking resources away from our patients. If they stopped all the waste & restructuring they wouldnt need to stop clinical services. My current role is to cut out waste in the NHS, and there are only 5 of us across the whole of Wales. Believe me, each ward could save in the region of £1000 without having to touch the staff or the service they provide. Imagine what that adds up to for every ward in every hospital………but does anyone in the DH or government listen?

  2. Hannah says:

    If the most common intervention a GP makes is the prescribing of medication (often without regard for cost or evidence base) why oh why have the government not made any mention of including medicines management pharmacists on important steering committees and boards?

    • Wendy Sunney says:

      The policy has a mechanism within it to take care of this. The clinical commissioners are responsible for working within the total financial envelope which includes their prescribing costs. This means they are now incentivised to take account of cost-effectiveness. This contrasts with the existing system where the prescribers make decisions but the NHS management takes the consquences. To help them the clinical commissioners will be looking for assistance from medicines’ management specialists, probably within a commissioning support service although they can be internal to the consortium too.

    • Janice says:

      I could not agree more. This would have made life at a local level much easier with regards to identifying needs of GPCC and collaborative working.

    • It's a public service and should not be for private profit says:

      I agree with Hannah

  3. Antony Oodan says:

    It could benefit the NHS if the government sets up a small team of qualified people to study successful health schemes in other parts of the world and adopt a distilled version of the best practices applied abroad. Knowledge is there for the asking. But it needs to be sought and it would be a small price to pay to adopt successful practices from abroad, of course, translated to our culture. I hope the government will take this course of action to maximise existing managemnt knwledge in healthcare. I hope the government is not releuctant to learn from others. It can appease many of the critics if this exercise is carried out.

  4. andy mcgeeney says:

    Take power away from the people running targets and tick boxes. Focus on patient need and what works. Trust that front line staff know more than people in offices paid to procuce policy documents ad nauseum. Give money to ward managers to spend as they wish.

    • alyson brenchley says:

      How will you ensure equality of access without some form of overall accountability? People in offices are clinicians as well-please stop falling into the divide and rule trap.
      The system is huge and needs all sorts of people to manage it-it is not just about front line staff and ward managers-all of us need support systems as well.
      And remember much of the policy is forced on us by the governments constant meddling which results in target driven care and consatnt disorganisation.

    • NHS Manager says:

      It is because of the people in the back offices – the PCT – that for years patients were seen quicker in hospitals. Now that target is removed waiting times have increased. In what way is that a good thing?

  5. Patrick Carroll says:

    There should be a wider range of professions involved in the “new” commissioning, there is no formal mechanism in the new structure that gives nurses and AHPs a voice in GPCC. Enlightened consortia may well do this but many won’t.

    What I’ve seen working well is changes in clinical practice based on evidence but the general public don’t want to lose the “old” roles (often stereotyped perceptions) even if they don’t actually add to people’s well being.

    There is an inbuilt conflict in local commissioning, the DoH says we should commission services according to local population needs but we are also expected to provide a universal service without any form of postcode difference. Since the money is finite the two things are mutually exclusive; a Consortia can’t decide not to provide a service e.g. IVF or cosmetic interventions or bariatric surgery in order to provide enhanced services for an elderly or economically deprived population.

    • Dr Jeremy Platt - GP says:

      what is interesting is that there is no statuatory responsibility in the Bill for consortia to provide a universal service – only what they “consider appropriate”. I’ve only just realized this, and while I’m with you Mr Lansley, I now understand why you are running into political difficulty.

  6. Lansley’s emphasis on clinical leadership is the right one, as is the step to remove NHS backoffices. I am a GP and think that enthusiastic GP consortia will be able to form the necessary professional working relationships to come up with good plans for their areas – but why does it have to be said again and again: the people doing the caring, creating the NHS’ value, doing what it’s there for, is nurses and other staff in hospitals and the community, in addition to GPs. There is so much skill and intelligence, conscience and competence, that has been ignored if not worn out by disconnected management in the past. If I wanted to design a caring and sustainable ward or community service, I would ask those who do the job in the first instance (also GPs) – Who will you ask, Mr Lansley?

    • NHS Manager says:

      You want my job, you have it. But don’t expect to see your patients as well. GPs as a rule are not experienced at commissioning services. Who will you turn to when you need advice? It is naive in the extreme to expect GPs to not make mistakes.

  7. Mary E Hoult says:

    As a lay person I feel we make all these changes more complicated than they need to be for example, all this worry problems with commissioning !!! why not set up a NHS trust for each of the new transition areas that is for Commissioning Only to work in conjunction with the GP consortia and local authority each operating their area of expertise in the best interests of patients? reduce the newly appointed NHS commission board who don’t appear to have any local interest and will be to far removed to be effective allowing the big society to work in support of this transition.

  8. Joe Bush says:

    If you’re seeking “views from across the range of health professions” then I would politely suggest that including at least one representative from every one of the health professions in the NHS Future Forum might be a good starting point.

    We can get involved in a lengthy debate as to what constitutes a profession but as DH policy has consistently referred to pharmacists as health professionals (a ‘status’ with which the vast majority of pharmacists – whether employed directly by the NHS in primary or secondary care, or in community pharmacy (not to mention academia, industry etc.) – align themselves with) it would seem remiss for there to be a complete absence of pharmacy representation in the Future Forum.

  9. K Udagawa says:

    When 99% of nurses oppose your reforms, that’s when you should listen. Scrap the reforms. When a host of other organisations oppose them too (eg BMA), you should seriously be thinking about how such terrible reforms got introduced in the first place …

    • Linda Mussell says:

      99% of members of the RCN, not all nurses oppose the reforms.

    • Murmur says:

      I suspect that at least as many nurse belonging to Unison, for example, are also opposed: I certainly am!

    • Dr Jeremy Platt - GP says:

      True, it is hard to ignore – but you should ask why the RCN are so against the reforms – I would bet that a huge majority of their members are in the employment of secondary care trusts and so feel threatened. Not criticizing – I would too – but that is not really the DH’s problem….. nurses are still a minority of voters!

    • Murmur says:

      That’s a rather patronising response, Dr Platt!

      Nurses are capable of reading and understanding Lansley’s proposals and many of us do not like the content, because it paves the way for the destruction of the NHS, which we chose to work for because of a belief in public service rather than share holder profit at the tax payers` and patients` expense. As well as any of the other criticisms one can make of these ill-thought out, ideologically driven proposals.

  10. Paul Shannon says:

    I have long argued for incentives in hospitals to be linked directly to individual (or team) performance. It is also obvious to me, as a frontline clinician, that NHS productivity continues to decline. What is often frustrating is that, like myself, many experienced hospital clinicians can see how simple it would be to improve productivity by linking Consultant performance directly to reward.

    In the past, I have worked up some solutions that could be applied, exploiting the current Consultant job plan. Unfortunately, I have never managed to gain sufficient traction at a high level to implement them. Perhaps the time is now ripe to look seriously at this important issue?

    In short, as some famous economist once said when asked to sum up what Economics was all about, “people respond to incentives; all else is comment”.

    I would be very happy to help in whatever way I can.

    • Tess Harris says:

      What type of “incentives” do you envisage? Many studies have shown that financial incentives do not improve performance and sometimes lead to inferior outcomes.

      Quoting an economist on the subject makes me mistrust them even more as mechanisms for increasing productivity- except in widget-making factories where they can be quite effective.

      As the NHS is a knowledge-based organisation, payment for results or performance is likely to be a doomed management tool. What’s needed is more effective knowledge management, skilled leaders, and a focus on improving the underlying processes and systems.

    • Anna says:

      Are you saying we should have monetary incentives like the bankers? Wow that would make us really popular! Are you really saying you would try harder if you were paid for it? Dear me.

  11. Professor Paul Bywaters says:

    Once again these questions assume that ‘reforms’ have already gone through. I thought this was supposed to be a period of listening. What about asking whether we want another top down reform of commissioning which was never discussed in the general election nor mentioned in the Coalition agreement? It’s like Andrew Lansley apologising for not communicating the reforms well enough to the nurses. That’s not the problem. The problem is that people understand the reforms all too well and we don’t want them. The NHS is not for sale, as the rapper put it. Don’t encourage Lansley and Cameron by answering these questions.

    • Deborah Milburn says:

      If nobody responded to these questions Lansley and co would take that as tacit approval. They have broken down their reforms to the level of cheery soundbites presumably in the hope that this would generate positive responses. However, the comments are predominantly negative in tone as people are able to see through the ‘spin’, and the DOH and Lansley will have to address that when they announce the results of the ‘listening’ exercise.

  12. R Norton says:

    I feel it is a mistake to put GPs in charge of vast budgets. Doctors have studied medicine, they should be allowed to focus on this and other people be employed to handle such things.

    In terms of listening to the medical professionals it seems on a daily basis more and more groups of doctors, nurses etc are announcing their opposition to these reforms and yet there concerns are constantly dismissed.

    • Tess Harris says:

      I agree with the above. GPs should focus on medical matters, not managing budgets. Humans are very complicated with huge diversity of illnesses and conditions. GPs already struggle with many specialist and long term conditions. Why impose more burden on them?

      Also, fundamentally, I am opposed to giving GPs such huge budgetary control. This will just enhance the considerable and annoying gatekeeping power they currently enjoy.

    • Dr Jeremy Platt - GP says:

      How dare you Tess! The “considerable and annoying (sic) gatekeeping power” of GPs is all that stands between tax payers and a financial meltdown of the NHS. In addition to which, we only resist referral when we can do it ourselves! Please get educated.

  13. Rob says:

    The divisive rhetoric that seeks to separate the interests and motivations of clinicians, managers and other non-clinical staff really needs to end. The vast majority of people in management roles in the NHS have a passion for patient care and health outcomes every bit as strong as clinicians. Indeed, in many cases managers have clinical backgrounds or other experience on the front line of public service provision.

    When we talk about ‘what works’ in terms of changing provision for the better we know that the skills and knowledge of clinicians, patients and managers working together produce the best results.

    I don’t hear anyone saying that things can’t be improved. Functions like commissioning could be done better. However, rather than competition for its own sake a more thoughtful and collaborative approach to commissioning is likely to yield better results. That will mean working across public, independent and voluntary sectors in ways that find shared solutions and draw on the strengths that different organisations and sectors bring.

    • John Morgan says:

      Beginning in 2006 I have been involved in attempting to build a constructive partnership with management in what is now the Mid Staffs Trust and also with the South Staffs PCT
      The former have displayed outstanding ability to avoid any real engagement despite endless communication many meetings and much public acknowledgement of the need for broad based input from all parties including patients Oh and loads of action plans but no pereceptible outcomes In one long term cooperative exercise with the PCT a quality outcome was achieved on time at minimal cost by a group made up of clinicians ,commissioners,people from the private sector and voluntary organisations
      My sympathies are with Mr Lansley The parallel with Yes Minister is tragically apparent

  14. Nicky Norriss says:

    Commissioners should have more dialogue with NHS service providers . To provide high quality and joined up care, commissioners should commission servcies from local NHS providers in the first instance; If the skills, experience and delivery of the services cannot be provided from local NHS providers, only then should the tender go to private companies.

    By dealing with local NHS providers, commissioners can be assured that they are dealing with tried and tested providers who have the existing knowledge and expertise to provide appropriate and high quality services. ‘ Adopting the ‘Any Willing Provider’ concept has the ability to fragment care throughout the local population, result in ‘post-code lottery’ re standards of care and make it much more difficult to join up any local services. Private companies have a tendence to cherry-pick the ‘bits of’ of the service that they see as profitable, leaving more gaps in the services for patients.

    • Murmur says:


      Our local commissioners have never spoken to our service about what we do, what we can do and what is not possible. How on earth they have been making decisions is beyond me, because they are clearly not informed ones.

    • Mick says:

      I am a commissioner and do have regular contact with the providers we commission. I am also a nurse with 25 years experience and qualifications in the specialist areas I commission. World Class Commissioning dictates we have to work collaboratively. Unfortunatley some providers are reluctant to allow us access to the frontline staff… This is before (more)providers will have to an even glossier sheen on their ‘outcomes’ as the market gets opened up.
      Commissioning well is an involved process that requires the skills and indepth knowledge of the subject area to ascertain how outcomes have been met and quality is preserved.

    • NHS Manager says:

      I’ve noticed that too. Providers tend to tell us what they think we should know, present results that paint them in a good light. We have robust performance management which digs below the surface….which they then complain about. There does seem to be the view in the NHS that commissioners = baddies and providers = goodies. Most of my time is taken up making sure that providers do what they are supposed to do. GPs, when they take over, aren’t going to have that time. What will happen then? How many cases of fraud, lack of patient care, disputes, failures etc etc will we have?

  15. Chas Connal says:

    GPs are NOT NHS staff they are private businesses each earning over £100,000. How can they provide advice and leadership when profit is the key part of any private business. The current PCTs are not private companies they have a remit to deliver cost effective evidence based health care to the local community.
    How can a single central goverment body manage and regulate nearly 300 private companies with a budget of billions which is how the changed system is being proposed.

    • Stephen Marshall says:

      This is exactly the point! GPs and dentists can’t set their own budgets – the consortia can only commission other NHS providers. If the reforms are not to be reversed, at least do not let local knowledge be lost. The most important announcement Sir David Nicholson can make is that PCT ‘Clusters’ (which were formed to manage the transition) have a long term future -preferably forming the local outposts of the NHS Commissioning Board – as the Cluster managers with their detailed working relationships with local providers will be eminently more suitable than SHA or DH personnel (who are not commissioners) to commission and monitor the new GP, Dental (and Pharmacy) contracts. Such an announcement will also help to stem the flow of talent from PCTs/Clusters.

  16. Sarah Wright says:

    I work in the community , of course GPs should be able to make decisions that affect their patients but they need to know what services are out there in the first place to make key decisions most of them dont. In the past only a small minority have ever wanted to get involved in the many innovative ideas NHS staff are trying to get up and running in local areas ( usually only if a lunch is available). Most GPs just want things to stay the same with their district nurses taking the patient ‘ away from them’. They have little time for the LTC patients who need so much extra support. We need to be far more efficient and work more productively. If you take away the ‘backoffice’ clinical manager the front line staff will not be able to concentrate on what really matters ‘ the patient and their carer’. Involve innovative clinical managers on these groups who know how services work and know how they can be improved and made more efficient. We know things have to change but do it properly this time – anyone can say their listening.

  17. Murmur says:

    There is a very large amount of epidemiological, demographic and socio-economic data readily available, yet I see very little sign of this being used to make decisions on healthcare expenditure or targetting resources ,and thus services, at areas of need.

    Why is this?

    Will the proposed legislation address this in any way?

    • Dr Michael Caley says:

      Public health being represented on each commissioing group will allow this vital information to inform commissioning

    • NHS Manager says:

      That data that you are referring to is used routinely in the needs assessments.

  18. P.M. says:

    Service commissioning should be a collaboration between GP’s and consultants. Both groups want to see what is best for the patients and are best placed to do so.
    People in active clinical work should be making the decisions, not those who have moved away from it or never done it, they may support.
    There are plenty of consultants who have done their time as heads of department or as clinical directors and are now back doing satisfying clinical work; their skills at the economic/medical interface should be fully taken advantage of to help this process go forward. GP’s similarly. Unless those who work directly with patients are given a greater say there will be a disenfranchisement of the very people who could put things right. What has gone on in the last ten years is burocratic madness.

  19. Colin says:

    We need to first define the word commissioning. What do we expect from commissioners? How can commissioning be made evidence based? Thank you

    • Murmur says:

      In my field of work extensive guidance for commissioning of specialist services was published in the mid-90s following several years work by highly experienced clinicians in the field: it has been routinely ignored by commissioners ever since…

      What’s that phrase about horses, water and drinking?

  20. Andreas says:

    These questions are a disgrace.

    What early action is being taken in your area to improve quality of services through clinically-led commissioning? What is working well?

    If I give you an example, you will simply use it as evidence that ‘clinically-led commissioning’ works. If I say it is not working, you will simply say ‘more work needs to be done to allow clinically-led commissioning to improve quality’.

    This is a very sneaky and outrageously biased ‘listening’ exercise. The questions are leading.

    Where is the question – Do you think clinically-led commissioning will improve quality of services?

    Why have you taken away this discussion and replaced it with this nonsense. Any self-respecting analyst would despair at these are a genuine attempt to get people’s views on a subject.

    You should be ashamed.

  21. Dr Jeremy Platt - GP says:

    Certain willing provider contracts are a massive improvement in value for money and patient experience.

    Pathway redesign is important for appropriate secondary care spend and patient experience.

    • Deborah Milburn says:

      Where does mental health fit into all this? Name a ‘willing provider’ of services that will have to continue over years with uncertain outcomes and where something other than a pharmacological solution will be required and where expensive multi-disciplinary input is required.

      You are a GP – how deep is your knowledge and understanding of mental illness and personality disorder and relevant treatments?

  22. Kerry Lawrence says:

    Wards closing, hospitals closing, rehab units closing, discharges happening too quickly to make room for new patients who are usually the one’s that were discharged too early before those, I don’t know, you tell me what’s working well?

  23. mr c carr says:

    Agree with Andreas that the questions are not likely to stimulate useful thinking. Suggested topics – conflict between elective and emergency resourcing in hospitals, justification for continuing illogical heath and social care division, differences in funding per head of population in different areas – there are loads more, the “topics” are embarrassing to whoever put them out, assuming that person is honest.

    Disagree with Alison Brenchley who is reacting rather than thinking. First, why is equality so important to you? It does not exist in any other aspect of life. Second, being in an office, as a manager, does change your attitude and stops you seeing things which are blindingly obvious to those working with patients. As soon as you go into that office, you stop being a clinician. Come out.

  24. Barbara Havlin says:

    Patient experience and patient feedback!!! exactly where are the means for this to be recorded. My job as a PALS officer has been disposed of there will no longer be a dedicated PALS service in the borough and i think this is a disgrace. How will commissioners access information around particular services. This goverment do not seem to care about the opinions of patients this is reflected in the make up of the various “listening” groups they are putting together.

  25. Roger Hughes says:

    I have found that my local PCT has become very open over the past 4/5 years, and I am pleased to say that I am given every opportunity to express a patient view, meanwhile the hospital trust is a closed shop they do not want patient involvement, there has to be a new Patient and Public Involvement, allowing “enter and view rights”, this keeps the NHS on its toes, they then have to join in and play the game and listen.

  26. Dr Michael Caley says:

    The role of public health doctors and consultants in successfully implementing clinically led commissioning cannot be under estimated. Public health consultants have years and years of experience in assessing the need for services at a population level, advocating the role of prevention and creating clinical pathways and services.

    The recent health select committee report advocated public health consultants being a statutory member of commissioning organisations’ boards and I think that this is essential to avoid the NHS retrenching into a bottomless pit of ever more costly healthcare without thinking about the need for prevention and stopping people getting ill in the first place.

  27. Dr Nicholas Aigbogun says:

    Commissioning Consortia can better represent the needs of patients by including Public Health Specialists, other clinicians, patient representatives, and lay community members as statutory members of their boards.

  28. Hilary says:

    I whole heartedly agree with the need for a public health consultant to be on the GP consortia board. But there is also a need to ensure greater development of public health knowledge and skills in other board members and to ensure good access to public health skills such as data analysis, needs assessment, evidence review, cost-effectiveness analysis etc. GP consortia will have to make a lot of tough decisions around prioritisation which they have been reluctant to do in the past, public health professionals are able to make objective, population level decisions that are both clinically appropriate and evidence based.

    • NHS Manager says:

      PCTs have always been a useful place to lay the blame when something can’t be done.

      Will consortia take responsibility for the tough decisions that they are going to have to make?

  29. Ian Shaw says:

    The only way Commissioning consortia will work in the way envisaged is for the Commissining `consortia’ to represent large areas (like AHA districts) or indeed current PCT areas…. There certainly was a need for more clinical engagement with commissioning. The PCTs did have a deficit on this. However, competition will not provide it. This needs planning and engagement at a health community level with leadership from the Community clinicians and representation from secondary care clinicians. This could of course all be achieved within the current PCT structure. There is no need for expensive reforms to achieve this …..

  30. Tamsin Ford says:

    The first hospital that I worked in after qualifying twenty years ago was a small district general hospital that had one non-clinical manager – everyone else involved in management was from a clinical background. While some non-clinical managers are excellent, the speed at which they move around mean that many never really bother to fully understand the services that they are playing with. If there are to be any cuts, the health service would probably benefit from shedding many of these highly paid posts and supporting senior practitioners from all disciplines to take a more active role as they used to do.

  31. dr john tomlinson says:

    As a GP I think that having public health doctors on the boards on the consortia is vital. We need a “big picture” persepctive and we need someone to champion the idea of prevention rather than just more and more healthcare.

  32. Irfan says:

    Public Health Consultants have the skills and expertise to advice the consortia on health needs (treatment and prevention) of the local population. These are the essential tools required for commissioning high quality cost-effective health services. It is extremely important that the public health professionals are represented on the consortia to provide expert advice to the members of the group.

  33. Shamil Haroon says:

    Health strategy and health service planning should have broad based input from patients, frontline staff in community and acute providers, hospital consultants, GPs, public health consultants, commissioners and members of the local authority. Leaving GPs solely in charge of the vast majority of the NHS budget does not reflect the diversity of input that is required for health service planning and commissioning. Health and Wellbeing boards should be set up to reflect this diversity and there should be a statutory requirement for this broad representation. GP commissioning consortia should be required to employ the skills needed to effectively commission healthcare including experienced commissioners and public health specialists. There should also be robust mechanisms in place to ensure that hospital specialists and frontline community and acute trust staff feed into the commissioning and service planning process.

  34. FM says:

    Wide clincial engagement and that of all interested/appropriate parties including the patients, public, voluntary sector and specialist organisations in the commissioning process is easily and effectively achievable without falling for the ineffective recommendation made by the Health Select Committee (to have a non GP provider/patients sat on the GPCC Board).
    The Board would be where commissioning decisions are made by those who hold/are responsible the budgets. It makes sense to have a structure of Commissioning Stragegy Groups (for each area ie planned care, unscheduled care, LTC) reporting to and making recommendations to the board – it is these groups that would then facilitate wider clinical and other appropriate engagement.

    I’d suggest that having one provider on any commissioning decision making board would not be fair or effective and that the above proposal make more sense.

  35. Corinne Camilleri says:

    It is imperative that public health is an integral part of all commissioning and able to bring the population perspective and the epidemiological and critical appraisal skills to the table. This needs to be statutory, Board level presence. Consortia will be responsible for the allocation of the majority of the NHS budget and reductions in health inequality can only be achieved with appropriate public health input into acute sector commissioning.

    they are also going to have to ensure the robust analysis of new medicines/technologies/treatments. NICE cannot do them all and these are very difficult decisions.

  36. Little Bloke says:

    How can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service?…

    Value your staff.

  37. Rod Whiteley says:

    Advice and leadership from NHS staff has always been thwarted by nationally imposed standards and unnecessary layers of management. Remove these obstacles, and NHS staff will find they have much more influence.

  38. Giri Rajaratnam says:

    Leadership is not based on structures or positions within organisations but on ideas and things that matter to pts, the public and service providers. I have been impressed by the reception given to the NSF, the cancer COGs etc pt groups and service providers. Contrast this with the reception given to any of the S of S inspired reforms and modernisation programmes of the past 20 yrs.


  39. Giri Rajaratnam says:

    In the context of leadership – there are 2 issues; one is about leadership for health and the other leadership across the health care sectors.

    Leadership for health should rest with the DPH who should have the independence to be able to comment on the health of local communities and their needs. To do this he or she is likely to need high quality specialist staff as well as direct influence on the NHS commissioning and delivery system and therefore should be joint appointment between the LA concerned and the NHS Commissioning system.

    The second is about leading across the primary, secondary and community care sectors. Evidence shows this type of leadership and collaboration is critical. Unfortunately, extant financial systems based on simple income expenditure type accounting prohibit this happening. We need to modernise financial management systems and bring it into the 21st century. We need NHS organisations to fully embrace programme budgeting and to explore alternative ways of financial management which better reflects use of the NHS by pts and their flow thru the system.


  40. Dr Tom Yates says:

    This question pre-supposes support for commissioning consortia and the purchaser-provider split. I certainly don’t subscribe to the former and have reservations about the latter.
    I think the NHS currently strikes a good balance. As a clinician, I can do what I believe to be right for my patient but am governed by local regulations and national guidance designed to maximise the benefit that can be gained from a finite pot of health resources. These regulations have been worked out on a macro level by people who know what they are doing and can act rationally without their judgment being affected by their relationship with particular patients.

    For example, in Oxfordshire, GPs route orthopaedic referrals through a triage service run by senior physiotherapists which reduces costs and, nationally, NICE prevents colleagues from spending money on cancer drugs that cost a huge amount of money and only prolong life by weeks to months.
    The alternatives are capitation or fee per service.  Jerome Kassirer outlines the significant problems with these two systems in his excellent book On the Take – the former incentivises stinginess in intervention and the latter excess. Both result in the clinician having a conflict of interest between doing what is best for the patient and maximizing returns.
    The emasculation of NICE and the formation of the Cancer Drug Fund – which is to be paid for from the NHS budget – are in my opinion terrible mistakes.
    Greater integration of budgets – probably necessitating less rather than more competition – may offer a means by which health services can be further improved. For example, telephone advice lines operated by specialists could help GPs to avoid unnecessary referrals but would result in a loss of revenue to secondary care under current arrangements. Similarly, flexibility within (or abolition of) the purchaser-provider split, allowing consultant-consultant referrals, could free up GP appointments whose sole purpose is to request a referral recommended by a specialist. Ditto appointments during which a GPs sole purpose is to prescribe something recommended by a specialist reluctant to meet the cost from their own budget.
    Perhaps the greatest potential saving could be made by integrating the health and social care budgets. This would free up the large amounts of money spent on acute beds for patients awaiting social care which could be spent on nursing home beds and employing carers. The current dramatic cuts to the adult social care budget represent a false economy.

  41. F.B says:

    As far as leadership is concerned we need to have a more mature debate about what is required. The modern day NHS is a complex organisation which requires strong leadership and effective management to deliver a quality service. This requires a combination of people with the appropriate skills including (but not exclusively) clinicians, managers and other staff. Sadly we seem incapable of an intelligent discussion as we constantly focus on “bureaucracy” and then lump any sort of management into this rather than identifying just what is required. This then leads us to constant reorganisations trying to fiddle about with the 3% of the workforce that actually manage the organisation whilst the other 97% resist change and try and blame it all on managers.

    To get rid of experienced managers and throw over the management of a hugely complex health care system to people who are not qualified managers and who generally do not have experience of managing complex systems is bizarre to say the least.

  42. Emma Brady says:

    Having gone around the block in the NHS a couple of times as a clinician and now as a manager, I would say that at a National level, leadership for the NHS should be in the hands of the larger professional bodies i.e. BMA, RCN, CSP. At a local level, it should be a joint group of highly skilled managers and senior clinicians (but only the ones who want to do this!!). The less bureucracy the better – this wastes unimaginable time and money and drains morale.
    PLEASE keep the politicians hands off the NHS and let the people who have the knowledge and expertise of actually working in it make the decisions.

  43. lois orchard says:

    probably best to uncouple the NHS from politics before you sell it to the USA by stealth

  44. A Christopher says:

    If you really want clinically led commissioning stop these reforms! It could of been achieved by leaving the PCTs and SHAs in place that were working well, and changing the mix and make up of the boards. GP consortia and GP commissioning is not workable and not sustainable and will lead to years of underperforming and chaos.

    These reforms will set back the NHS by 20 years and will reduce public and patient involvement. Localism will increase variations and post code lottery.

  45. Public Health consultant says:

    GPs shouldn’t commission for their own patients as there is a conflict of interest between what the patient needs/wants and what can be afforded.
    What about all those not on GP lists? This is where public health comes in. Public health professionals can advise on commissioning of care based on an assessment of POPULATION needs, in a dispassionate way. In other words they can help with priority setting when money is ,limited. Public health practitioners are also the only ones who will point out decisions which will widen health inequalities. Therefore public health practitioners need to be involved in commissioning primary care and also secondary care. However they have been forgotten throughout the process. The leadership can and should come from these public health professionals who are trained to a high level in population health, unlike GPs who are trained in illness and social causes of illness which most do not see as their business to do anything about. Please wake up to what health workers are saying to you.

  46. Elaine Tamkin says:

    We have been working in partnership with our local trust and community colleagues to overhaul our very unwieldly urgent care system. We have jointly designed a system which should ensure that people are seen ( or not) in the right place for their level of need. We have worked hard at communicating with our colleagues, staff and the local population .The clinicians have a responsibility to hold each other to account for how the system works and we have agreed a joint budget to pay for this work. This would never have happened without GP commissioning

    • NHS Manager says:

      It has been happening for the last few years since the advent of practice based commissioning. However, GPs have been reluctant to take responsibility for decisions. I don’t blame them, it is them in the firing line when a patient can’t have the treatment they think they should have because there’s no money. The worst case scenario with all of these changes are that we are going to widen health inequalities because as consortia use up their budget (and they can’t rely on the good old PCT to bail them out) services are going to be cut and, as usual, it will be the people in the deprived areas who are, for example, more at risk of developing CVD, who will lose out. All primary prevention will be stopped because it doesn’t result in instant results….often taking 10-20 years before a difference can be seen. If we are not careful we are going to end up with an underclass of people who are not getting treatment because it is too expensive to treat them.

  47. james says:

    In response to the question how can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service?

    The answer is to listen to the views of professional organisations that represent staff when they suggest that these top down changes are not in the interests of patients, staff, the wider NHS or the future of the NHS. This will allow the staff to continue to provide the service and new staff to develop their skills and experience through being exposed to the full range of conditions (i.e. not allow the private sector to pick off profitable areas thus compromising staff training and therefore future staffing capabilities). It will also allow the staff to focus on the opportunities to incrementally improve the service at a local level – evolution not revolution!

  48. S Marsh says:

    My concern is for the ‘forgotten’ work going on in corners of the system that is not ever referred to in this hoo-ha but which is key for quality (remember that was supposed to be at the heart of every change..) For example in South CEntral SHA they have service improvement programmes run by ‘managers’, such as maternity which has worked with multiple trusts to kickstart improvement and get a greater change – eg reducing c-section rates. These programmes help hard pressed units on the ground (maternity is notoriously understaffed) to deliver something better and in the new world will simply be abolished. It is in no-one’s brief to look at system wide improvement in the new regime – plus where are the plans and reassurances about the Care Quality Commission and its role???

  49. Iam Concerned says:

    I suddenly noticed the change in terminology from GP consortia to Commissioning consortia.

    There is a lot of difference in clinical led commissioning and clinician commissioners. Clinical are not trained commissioners they will need support from commissioners who will be ex PCT staff at 4 times more money as consultants. Where is the saving and how will these improve patient care. I as a commissioning staff at NHS am very happy with the changes as this will give me much more money for the same work I do. But that’s not the point, the point is this will not improve patient care and its not the best use of tax payers money, my money.

  50. Tony McGough says:

    It takes a very good general to listen well to the poor bloomin’ infantry.

    Unions and professional bodies are all too often hidebound by their own prejudices, self-interests and traditional outlooks – I know my own union has been sending out some woefully biased political propaganda lately; for them, it sems no Tory can ever do any good. Ever. So, individual generals have to listen to individual soldiers. With real hands-on experience.

    The hope is for localism: a good general and good soldiers to invent good practice and share it willingly with others. Most people want to do the best for their patients, and rejoice in finding a better way.

  51. barbara p says:

    What early action is being taken in your area to improve quality of services through clinically-led commissioning??
    The answer in my area is that skilled and experienced commissioners are being jettisoned and replaced by GPs. The GPs are being paid at over twice the rate the commissioners received, they bring no special skills, no broad vision, push their own areas of interest regardless of the needs of the local population and bulldoze over the opinions of any other healthcare professionals.
    Is this really what is needed?

  52. George C.A. Talbot says:

    My GP has told me he has seen so many reorganisations of the NHS he has lost interest in them and is thinking of retiring. He is 63! But see the thoughtful post by Dr Tom Yates above.

    The emotive phrase “at the heart of the health service” raises another management problem; using the abilities and advices of staff well. As clinical means scientific, decisions would be clinically-led if they were evidence based. Ultimately, managements are responsible for the treatment of patients and the well being of their subordinates and the common good. Then respect for cooperation would create joined up services providing none sought freedom to pursue their interests regardless of the damage done to others.

    I assume the NHS would be an Executive Agency which allows its management freedom to manage, subject to the approval of national politicians who provide its funds and acceptance of local ones in whose areas its facilities may or may not operate. Politicians are held in low esteem but provision of healthcare involves political choices so politicians must be involved. Nor should GPs be idealised just because they are in direct contact with patients.

    To ensure decisions are taken at the lowest efficient level, NHS management must respect subsidiarity, as does the EU. Why is this never mentioned?

    To ensure socialist means work well, discipline must be enforced throughout the NHS, human nature being what it is!

    My memorandum to Scrutiny can be accessed at

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