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?

This page was closed to comments on 31 May, the last day of the listening exercise. All comments have been fed back to the NHS Future Forum to consider.

The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response

In Conversations, NHS Future Forum, NHS listening exercise | Tagged ,

234 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?

    • J. Compton says:

      I agree entirely. Many senior and very experienced staff have already left the NHS as a result both of the proposed changes and Andrew Lansleys general criticism of NHS managers; many of those that are left are uncertain about their personal futures, and this current has inevitably led to stagnation and lack of any motivation. The emphasis on GP’s at the expense of other professions (nurses, pharmacists, physios to name bur a few) has further disillusioned the staff, so saying that anyone intends to listen to their advice and appears unbelievable to say the least.

    • shelley says:

      Far too late to be asking these kind of questions the reality is you are scrabbling about hoping somebody will give you a fantastic idea of how to involve staff/patients and you can pass the Bill resold (again) as it being good for us. The reality is you promised private providers years ago that under the nexy tory government they could break into our health market as the usa is saturated. Many financial donations later you have a choice do you do what is right for the public and drop the Bill or break your promise tp your donators? Your call Cameron but whoever destroys our NHS will destroy their own political party in the process once Mr Average on the street realises

    • David Mackie says:

      I agree – yet another major reorganisation is NOT what is needed.

      Secondly, some of the targets which were removed at the end of the labour government were actually beginning to work. The idea that targets are always red tape is ridiculous – targets are widely used in the public, non-profit and private sectors, and are an important way of driving improvement.

  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.

    • NHS Desparado says:

      It is good to learn from other countries, but the NHS has been the envy of most, and the moves to internal market have reduced that pre-eminence. How can commissioning work better ? By being uncommissioned. I have seen so many instances where the detail is missed in contracts, so gets squeezed out.

      Integrate, simplify, and cut the waste that markets and ‘choice’ introduce. In making prescriptions free in Wales and Scotland, the mechanisms of recharging for 20% of patients are reduced. Most patients want good care at the most local location.

    • David Robinson says:

      An interesting comparison of our healthcare model, and those of some other countries, can be read in the publication “Mirror, mirror, on the wall” produced by the Commonwealth Fund: a genuinely absorbing read.

    • Nick Lightowlers says:

      In principle you would think this was a good idea, however the research is invariably done by individuals who already have a position prior to the study and merely look to reinforce their prejudices. With the insurance model generally failing around Europe a taxation based system that is broadly utilitarian is the way forward. In France, so often lauded by the Brits. their national service is proving so costly to run that there are now very real concerns as to its affordability. The problem lies in the private sector. Where efficiency can be achieved through a repetitive production process, or off-shoring backroom jobs the realities of day to day health care is a messy and complex business. The profit motive will only drive up costs and not competition as is so wonderfully illustrated by the power companies where it has been proven that regularly changing your providers saves around 15 pence over the year. A health service cannot be subject to a profit based regime without the wide application of our NHS suffering. Just as many government ministers under the last Conservative administration ended up with directorships in the newly privatised industries we can expect the same to happen again with the current crop.

  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.

    • NHS Desparado says:

      Why are the only positive comments I see on here from some (but not all) GPs ?

      I fear that they and the foreign health insurance industries are the only benificiaries of these reforms. Certainly not the taxpayer or hapless patient.

    • Anita says:

      Dr Platt makes a key point here. Consortia will provide what is appropriate only.

      But please note : I am not with you Mr Lansley.

  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.

    • NHS Desparado says:

      I have dedicated my entire career to the NHS, started as a clinical scientist, but been one of those wicked managers for years. And I have saved lots of money from being spent unwisely, recovered the position on other projects, and always had the frontline clinician, and an integrated view of holistic patient care at heart.

      I am rather fed up with the idea that only clinicians can run the NHS, Doctors recognise specialisms in their own ranks, but they haven’t the time, energy or skills to do what I do, and external suppliers will make lots of money selling them unnecessary stuff without internal NHS skills. Your money and mine, taxes.

      Like the railways since privatisation, the costs of healthcare will soar disproportionately to the benefits gained. My advice to the government is to stop this idealogically driven madness. Its not clever.

  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.

    • NHS Desparado says:

      Lets call them PCTs. The changing all the organisations saps so much energy and goodwill.

    • Ruth Manning says:

      Exactly! You’ve kind of hit the nail on the head….you want what we already had…the PCT’s. I feel that this is just a re-branding exercise. The PCT boards that were are now “commissioning boards” and the members of those boards are now GP’s – but hang on everyone feels there should be a mix of professionals involved…end result a multiprofessional team in charge of commissioning community services AKA as PCT board! Why change things, why not try and make them better – this is such a massive waste of our taxes and our time!

  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.

    • Mary Hawking says:

      I agree with Joe Bush: the Future Forum would appear to be composed of individuals who strongly support the government approach – so I have little hope that anything constructive will emerge – but that does not excuse leaving off any representation of the areas where we know that there is not only waste (expensive) but poor organisation resulting in both risk and harm to patients and expense to the NHS.

      Where can I find the TOR?

  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.

    • Anita says:

      I agree with Prof Bywaters till the last sentence. Perhaps all the critical comment will get through. (Though I have still to find my comments written at the beginning 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.

    • Tess says:

      And how dare you Dr Platt patronise me!

      I’ve had a lifetime of being patronised by doctors – other than when I lived for 5 years in France, when I awoke from the stupor of UK medical forelock tugging general practice.

    • David Robinson says:

      Sounds like it’s getting a bit heated in here! First, I’d like to say that yes, GPs are the gatekeepers of our secondary care system, and without them our healthcare would probably be much more expensive than it is, as patients turn up at hospitals with minor complaints a GP could’ve resolved more cheaply.

      That said, giving a large budget to GPs makes me nervous. Unlike PCTs and SHAs, GPs are profit-making bodies, and given that most GPs won’t want to get embroiled in working this stuff out for themselves, most likely they will ship the commissioning function out, to other profit-making bodies. Between them they’ll take a considerable slice taken from the NHS budget pie.

      However, my absolute NIGHTMARE scenario – and I say this as a WARNING, not a SUGGESTION – is that GPs outsource commissioning to non-UK companies. Then there we’d be, a country trying to reduce its national debt, pouring money out of the country directly from the public purse (while also potentially paying benefits to ex-PCT and SHA workers who have been priced out of public service). Lovely.

      There was nothing wrong with the NHS’s value for money when the coalition came to power. I, like most people it seems, see no reason for the reform and believe it would do considerable harm.

  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
      I REGRET THAT THE FORMER SITUATION SEEMS THE MORE COMMON IN THE NHS
      My sympathies are with Mr Lansley The parallel with Yes Minister is tragically apparent

    • Su AHP says:

      I couldn’t agree more.HOWEVER I would like to suggest that Mr Lansley talks to DWP and that they too collaborate more closely. Thought – Why would a GP consortium spend on commissioning Rehabilitation services to assist patients to return to work for instance ? we know the benefit of being in the right kind of work has huge implications for mental and physical health , for families and community and to society as a whole but the financial benefits are more likely to support the DWP budget than DoH budget- They are funded in silos and dont appear to take a longterm view about anything ! People need care and support across these financial boundaries and sometimes over a longer period of time .When unemployment is so high it will be those with health issues that will not get into work ( and pay taxes) and in a year 18 months there will be an outcry as more complex, chronic, depressed and anxious patients fill the GP waiting rooms and we will have to pick up the pieces .

  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:

      Quite!

      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?

    • Anita says:

      I used to manage a public health service in a 1 hour a month meeting. If we agreed changes they started the next day. When they went to provider side of PCT I still had an hourly meeting but the operations manager had to bring her manager too, and changes became much more difficult. This last year they have been reluctant to share information with commissoners and hours were spent writing specifications, and it took many months agreeing them. With the transfer to a local trust under TCS we were not allowed to meet, information is scanty and all decisions are to be taken through a contracts meeting. Progress?

  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.

    • michelle says:

      This was exactly my reaction to these questions. There is no real consultation or listening going on here. It seems that the present government were hatching these plans for years before they were voted into power. Some might say that it was dishonest to have run an election campaign with debates on the NHS not mentioning this ‘reform’ while intending to implement (not propose) these changes almost immediately.

      I wonder why we bother responding to these questions at all, what’s the point. However, I agree with the respondent who says the volume of negative responses is in itself an answer.

  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?

    • Tess says:

      Where is the evidence, Dr Platt, for the “massive” value improvements you cite above from AWPs?

    • NHS Desparado says:

      Are these the ones that fill your pockets ?

      Excuse my cynicism. Pathway redesign is important, as is moving more care closer to home, and wherever possible avoiding hospital admissions.

      But Any Willing Provider is highly unlikely to provide joined up care, more a balkanisation of services.

  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.

    • Anita says:

      Perhaps, but it would have caused a lot less disorganisation and time wasting if PCT boards had been changed to have a higher number of clinicians rather than forming new bodies, who have to learn everything from the beginning.

  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.

    • NHS Manager says:

      I find your comments insulting, as an experienced non-clinical manager.

    • Deborah Milburn says:

      I have worked for eight years in secondary services in the NHS and my experience is that ‘good’ management has little to do with the profession of the manager. Management skills training is not routinely provided at all for clinicians, usually nurses or social workers, who move into management. (The most effective manager I have ever had was a psychologist) They are expected to be able to just do it well because they used to be responsible for running a ward or something despite the fact that it demands a different skill set.

      For those brought in from outside the public sector and without a clinical background, the ability to manage and save money appears to be the main criteria for success. This, and their seeming disregard of clinical priorities often puts them in direct conflict with clinicians as a result and enhances the view of them as ‘bad’ managers.

      The result of this is that it is pretty much down to whether your manager is a ‘natural leader’ or not as to whether you perceive yourself as well managed.

  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.

    • Tess says:

      I agree with Dr John, if we all agree that the purpose of the NHS is to improve the health the public.

  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.

    • Tess says:

      More than just value your staff: fully involve them – “go see, ask why, show respect”.

  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.

    • John Bowers says:

      I agree with Rod – the last thing the NHS needs is any more layers of management or bureaucracy – in fact eliminating some of that is the best way of reforming the system – and saving money. Nurses (and other clinical staff) are spending more time filling out forms, doing paperwork, carrying out ‘audits’, etc. – much of which is only there to keep the administrators in work or to satisfy notional targets. I witnessed a internal audit recently (whilst visiting an elderly relative) – 5 people, including a Staff Nurse, going round a hospital checking the ‘asset’ numbering of beds and mattresses – one person had a pen/ marker, one had a clipboard to record the numbers, one had a list of the numbers being checked, one had a hand held computer (doing what?) and the other appeared to be an observer. They checked one number on the bed frame and one on the mattress – which was changed and recorded on the clipboard. That is one example but there are so many more obvious inefficiencies in the service which needs root and branch reform – but it cannot be left to the managers and administrators to implement it; turkeys don’t vote for Christmas!

  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.

    Giri

  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.

    Giri

  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.

    • Andy Hadley says:

      I agree with the doctor. Integrated teams like Torbay provide the evidence – they work out what is best for the patient/client, then which rules (health or social) will support the desired outcome. Elsewhere bickering, or deeming clients as not eligable for social care results in increased health burdens when patients can’t cope.

      Integrate budgets and teams, reduce the competition/market, and enable the caring professions to do what they were trained for. Separate contracts for telephone triage, community care, secondary care etc are a nonsense, with all sorts of information, competitive and financial barriers to good joined up care.

      And as a Health Informatics manager, I see the disintegration of integrated records through the any willing provider work, and everyone but GPs working mostly in the dark.

  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.

    • Tess says:

      What do you mean by “strong leadership” and “intelligent discussion”?

      Talking heads won’t solve this headache.

  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:

    Leadership?
    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!

    • John Bowers says:

      If evolution is so good, why is the NHS costing the tax payer mor than THREE TIMES as much as it did in 1997? It seems to me that the taxpayer deserves to see some 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???

    • Mary Hawking says:

      This is one of my major concerns as well.
      There appears to be a gap in the proposed new structures in the NHS between the very small (GP Commissioning Consortia) and the centre (NHS Commissioning Board) created by abolishing all layers responsible for strategic planning and delivery of the infrastructure needed to keep the NHS functioning but not direct patient care, such as regional planning for procuring and monitoring the specialised services needed for very small numbers of patients, IT, interoperability in information provision and functions such as GP appraisal and performance management.
      The idea that many – or any – of these should be managed by the GP Commissioning Consortium would seem to me to be expecting a level of non-clinical expertise unlikely to be present in most consortia.
      Not to mention the potential for abuse when a few GPs selected by unknown criteria are given the power to close down “unsuccessful” business competitors….

    • NHS Manager says:

      Just shows the lack of understanding that the government has of the work done by the PCTs/SHAs.

  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?

    • NHS Manager says:

      It’s happening where I am as well. The result? A downturn in commissioning quality as well as quantity, oh, and we are paying them to get locums to cover their clinics as well!

  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 http://www.publications.parliament.uk/pa/cm201011/cmpublic/health/memo/m123.htm

  53. fay says:

    by involving us from the start.
    We have had improvments forced on us that have not been improvments, some have worked but a one size fits all improvment is nevr going to work on evey type of ward, NHS enviroment.
    By engaging with the different groups all can be involved. this needs to happen across all levels and areas.
    Communication can always be improved 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.

    • NHS Desparado says:

      What, like the Darzi centres which was a solution to problems in major metropolis areas, but forced onto every PCT in the land at great expense (now being quietly closed locally). Mind you, I suppose Choice works in London where adjacent Trusts are not 20 miles apart. Ministers and their advisers should really get out more, and not just at election time.

  54. Brian David Porter says:

    Advice by NHS staff need to be built into contracts of employment, and given a high priority by leaders (management and medical). However, all advice must be evidence-based and lead to active referrals to appropriate (and capablely resourced) services especially re preventive healthcare (stop smoking, weight management etc).
    But much advice has little value if staff do not follow their own advice themselves, eg staff smoker advising on stop smoking, or obese nurse advising on weight management is counter-productive.

  55. Richard Wallace says:

    LINks soon to be Healthwatch need to realise that they will be responsible for ALL departments in every aspect of the Local NHS.
    lets not have them cosying up to the PCT/Consortia for an easy life.

  56. Richard Wallace says:

    Remember patients are human beings entitled to dignity and respect and are not just an inconvenient expenditure.
    Make sure ALL contractors/sub-contractors treat patients as people too.
    We have Human Rights.

  57. Tess says:

    I have no confidence in yet another NHS re-organisation ‘led’ by a politician who produced a White Paper in July 2010 with a mere 33 references as evidence (one a broken link).

    If this is an example of NHS ‘leadership’, god help us poor bloody patients.

  58. Andrew Graham says:

    As the early comments in this section note – and it bears repeating – the government has attempted to introduce huge changes to the NHS that can potentially amount to it being dismantled over time. This has been with no real consultation. It now appears they are canvassing opinion but this is likely a mere public relations exercise. It is likely they still intend to proceed with their plans against the wishes of NHS staff and the public. Thus, any suggestion that they wish to put NHS staff at the heart of improving services is offensive and bordering on the ridiculous.

    • Betty Barnes says:

      Unfortunately as I was brought up in the 1920s I have always been very wary of the Tories adherence to the N.H.S.Any changes should never be made without a VERY FULL inquiry being made and evey aspect thoroughly discussed and inspected. Especially if privatisation should loom its head.

  59. A Bacon says:

    There are a few key areas where there is a government policy but the mechanism for its delivery is being removed by the changes. These include improved access to services for the armed forces and veterans and health partnerships schemes. Policy generally needs a mechanism to turn it into action. GPCC will not be interested and NHS CB is too national to be able to implement locally – looks like there will be a need for an intermediate tier.

  60. Matthew Norris says:

    Privatisation of the NHS creates an extremely dangerous precedent. A public health service is primarily interested in doing its job, whilst a private health service is obviously just interested in profit. Implementation of these “reforms” would be disastrous, sending us down a slippery slope towards the situation seen in the US. Over there, and possibly soon here, quality healthcare is only available to those who can afford it, and the poor are refused treatment when they are unable to pay.

  61. Alison Forrester says:

    I support many of the comments above, including

    “If you really want clinically led commissioning stop these reforms! It could have 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 commissioning brings in conflict of interest and the reorganisation will lead to years of chaos and certainly cost more. Variation in care will increase and the ‘postcode lottery’. The principle of selecting priorities according to cost-effectiveness is also under threat, not least with the Cancer Drug Fund.

  62. Scott Durairaj says:

    My concern is equality of access, experience and outcome. For many years the NHS and its workforce has experienced many years of widening inequality. Public health showing the widening gap in the worst to best life expectancy doesn’t examine other factors such as disability or race.

    Detention under the Mental Health Act still sees many communities from BME overrepresented in MHA figures. Trans people (transgender/transsexual) consider suicide prior or during the process as they are very rarely considered in the commissioning decisions. Are we genuinely expecting GP’s to better connect and understand these areas. We need specialists not in public health but in communities and how they relate to the NHS.

    20 years NHS service from being a paramedic to what the Government may call a bureaucrat has led me to know that very few people making major health planning decision consider any level of impact of those decisions on the wider population never mind those who may already be marginalised.

  63. Anna Webb says:

    User led organisations need to be involved at a commissioning level and must be supported with sufficient funding to canvass their peer group for their views and train, supervise and pay their meeting attendees. If you give people what they want money will be saved. Make the tendering process easier so that ULOs can put in bids to run services, but they will need a high level of support to do this. Someone with lived experience is far better placed to gain the trust of patients and is far less likely to be assaulted by the patient.

    Sort out the barriers to volunteering. This affects every foundation trust public governor. Why is it that we can go to a paid job and use our car, but going to a voluntary job for which we only get a mileage allowance means that our insurance goes up? Where is the logic in that? I have been told that my insurance is also higher because I am unemployed. I have the time and the willingness to work for nothing to give something back, but can I afford it? For goodness sake, make it easier for volunteers; we save the country millions of pounds.

  64. David Brown says:

    Getting the right structures and systems in place is important, but even more important is getting the right people in place. It is a universal law that if you treat people well, then they are likely to develop in positive ways and produce results greater than can be achieved by targets and an atmosphere of fear. This means that all senior management appointments (in the NHS and indeed in all organisations) should only be made if the candidate has a good track record in dealing with people, able to engender trust, enthusiasm and loyalty. Other appointing criteria should be subordinate to this essential criterion, and should only be applied upon such a foundation.

  65. JL says:

    Ask them!
    Ask the BMA. Ask the Royal College of Nursing. Ask all the main NHS bodies — and keep asking them continuously to make sure the NHS is running well. These organisations have been around for years, and have a wealth of experience ready to tap into without the trouble and expense of re-inventing the wheel for the sake of political dogma.
    You have all these experts on hand.
    ASK them, and take their advice.
    How difficult can it be?

  66. Paul Gibbons says:

    Why is there not adequate machinery for this already ? Hopefully the SHA’s and PCT’s employ relevant staff.

    • Rod Whiteley says:

      I recently took part in a Local Involvement Network exercise to evaluate a PCT commissioning decision. There was no sign of clinical leadership behind it, no sign of any machinery for clinical leadership, and no evidence that the NHS staff who would be most affected by it had ever been consulted.

      I don’t know why it has happened, but it does make me think PCTs have drifted away from patient care as their priority. GP consortia are bound to be much more aligned to patient care, so I am very hopeful they will do better. However, staff involvement should be a provider (employer) requirement, not a commissioner requirement, in order to avoid conflicts of interest.

  67. LS says:

    Why aren’t there more templated policies to pull down and customise? I’ve seen so much senior management time spent on developing weighty documents for things that all organsiations are required to have as statutory operational procedure e.g. environmental policies etc. (and individuals often don’t know much about this side of management is a cottage industry all on it’s own (and not all of it done well); surely this could standardise core policy/practice and make savings in one go?

  68. Retired NHS Manager says:

    Over the past 8 years I have worked at manager level in the Acute sector and as a GP Surgery Manager. Both sectors of clinicians had a mix of dedicated doctors and sadly some who did not want patient and public involvement and who appeared to be more interested personal gain. Thankfully I believe the majority do the work to help sick people ahead of personal gain. I tried several times to encourage a patient group at my surgery but GPs seemed reluctant every time. While some GPs and Consultants understand the business aspect of value for money in commissoning services some do not and in the past have griped to PCTs about being involved in commissioning but failed to give any leadership in setting up commissioning stragtegies. Of course we must value our good GPs and while PCTs were not perfect, importantly they held GPs to account and while no doubt their has to be collaboration between clinical teams and business managers, most business managers in the NHS have been trained in effective business strategies and management and GPs have been trained in medicine – each to their own specialty. I have concerns that a lot of GPs have the business skills to do what is required and if they haven’t do they employ yet more people (using public money) to show them how? I would rather they used more time to see patients if they have any spare time than sitting in strategic meetings. I honestly found Acute consultants more proactive and open to working with managers than local GPs who in my area I felt really didn’t want to do anything positive to move commissioning on in the early days. I went to many commissioning meetings with GPs and while their clinical contribution was vital they were never able to make decisions so little moved on in early years of commissioning.
    Interestingly, it was amazing how many private providers contacted the hospital and the surgery offering their commisioning serices and my bet is they knew there was money to be made! So why not use the in house NHS manager we have already to liaise with doctors to improve things. Finally, lets NOT have closed meetings for so called sensitive issues but be open on what is happening to our public money and a bit more accountability to how this public money is spent because I have seen a lot wasted in the NHS and when I worked previously for a large (and profitable !) chemical company before joining the NHS I can tell you this waste would not have been tolerated.

  69. Richard A says:

    Professional management and administration is vital to the smooth running of any large and complex organization. The idea that everything can be decided and run by health professionals with minimal managerial and administrative support is frankly naïve. How would government ministers cope without the support of the civil service?

    All the health professions and experienced health administrators should be involved in deciding how the current NHS structure can evolve to meet the challenges of the future. What is required is evolution, not revolution and more collaboration, not more competition. For example, why is it not possible to introduce a greater role for medical professionals in Primary Care Trusts, rather than disbanding them? Pilot studies should always be run before making any significant changes.

    Finally, a general and fundamental point; the government has no mandate for many of the changes it has proposed. They go far beyond anything that was mentioned in the election campaign, and are contrary to Mr Cameron’s personal assurance during the campaign, and also the post-election coalition agreement, that there would not be another ‘top-down’ reorganization of the NHS. Furthermore it is inappropriate that the current structures in the NHS (such as Primary Care Trusts) are being dismantled before what is obviously contentious legislation is approved by parliament.

  70. John Bowers says:

    Let me state at the outset that I am not a politician, nor do I work in the NHS or any associated industry. I am an Engineer and the father of a Teacher and a Nurse who was driven out of the NHS against her wishes by inadequate and incompetent administrators.
    My personal experiences as a patient mean that I have nothing but praise for the treatment I have had over the years from the clinical staff of the NHS. However, like all State-run or public organisations and many in the private sector as well, when an organisation gets as big as the NHS, there is inevitable inefficiency but the NHS has probably suffered more than other similar organisations because of the level of political meddling – by all political parties and governments.
    The NHS desparately needs to be reformed to eliminate waste and unnecessary bureaucracy so that taxpayers’ money is spent efficiently on patient care and treatment. I can cite so many examples of ridiculous and pointless administrative interference but the problem is that these staff refuse to accept that the system has faults – just reading the comments above is clear evidence of this. Objectivity has gone out of the window – it’s always somebody else that has got it wrong. Managers blame the clinical staff, they in turn claim to know best. Somebody needs to organise and carry out an objective assessment of all the processes which go together to make the NHS work and make it work better.
    It will take a long time but it needs to be done and trying to politicise it by claiming the changes are ideological or leading the NHS into privatisation is counter-productive. There is no case (and never will be) for privatisation of the NHS – and there’s no politician that would risk his career by attempting it, even by stealth.
    I suggest a start by cutting out waste – of materials (drugs, dressings, equipment) and of unnecessary paperwork and the administrators who invent it to keep themselves in work.

  71. Rachel Atkinson Speech and Language Therapist says:

    If you want to insure the views of NS staff like my self are taken into account how about listening to the concerns of the Royal Society of Nurses who have no confidence in the bill or Andrew Lansley? How about listening to the GPs who have spoken out about concerns of EU competition law applying to NHS providers? How about listening to the many people like my self who have written to their MPs and government ministers begging them to vote against the bill. Our voices are all there to be listened to but you’re not. If you listened to NHS professionals, if you trusted them to put the needs of their patients first (and that we do is evident from the vast amount of unpaid overtime we do on a weekly basis) you wouldn’t want to farm out their roles to private companies who’s duty is only to their shareholders. It’s an insult to hard working people to suggest that they can’t deliver an efficient service without having some kind of profit gain for their company. You don’t need to put more in place to get our opinions you just have to actually listen to them instead of trying to placate us meaningless platitudes.

  72. Louise Mowat says:

    As we all endeavour to work as multidisciplinary teams to improve patient care why can we not have multidisciplinary commissioning?

  73. David Robinson says:

    I just came from the “Choice and competition” chatroom where Dr Julian Sims makes a good point about the Peter Principle in the clinical workforce. In a nutshell, excellent clinicians are promoted into management positions for which they’re ill-equipped to serve: we lose a good practitioner and gain a poor manager.

    Good clinicians don’t necessarily make good managers. Unfortunately the NHS, like most of the world, falls into the trap of thinking that managers are more valuable, or “better” than the people who report to them.

    We need to see a sea change in the way we assess the value of leadership. Granted, managers have responsibilities, but it is the workers who add value to the business. Why not have the most gifted employees on a higher wage than the managers to whom they report? If you really think about what each job entails, there is no reason at all.

    So let clinicians do what they do best, and reward them accordingly. Don’t make them think they have to become a manager in order to be promoted.

  74. Peter Kirkbride says:

    I only ask for a single change – to remove the NHS from political control; to have it run like the BBC and the Bank of England by a independent Board of Governors, and have the decisions made by health professionals ( hospital doctors, GP’s, nurses and AHP’s, including pharmacists, radiographers, physios etc) and users, for the long-term benefit of patients, rather than by politicians for short-term electoral gain

    The Cancer New Drugs Fund is a good example of a politician playing to the gallery; lots of vote-winning publicity, but in reality large amounts of money being spent on drugs which are often ineffective and or toxic – just ask NICE!

  75. Dr Penelope Jarrett says:

    The actions which have led to improvements local to me have been collaborative efforts between local consultants at the hospital and local GPs who were interested in the particularservice e.g. diabetes. They were happening anyway, and did not need the new bill. Competition would be a threat to these in many ways, discussed on the other threads. While most clinicians welcome greater influence, it is not clear why this should only be for GPs and not all clinicians and allied health professionals, nor why the whole managerial structure had to be thrown out (unless it was to make way for management consultants to get a foot in the NHS door?).

    None of us were great fans of PCTs: they were too small to negotiate effectively with the hospitals, and too ready to jump when the Secretary of sate or his advisors said to do so. however, the managers do fulfill necessary functions which I, as a clinician, have neither the skills nor time to perform. A health authority covering a larger area than a PCt, with greater clinical representation (the PEC were too small to have real influence) could stand up to the big hospitals and the Sec of state, and make real improvements in clinical pathways.

    As for how our pathfinder consortium is going, well, it is mostly the same people as were active before. Perhaps 10% of GPs taking an active role, another 10% like myself who are interested but not active, and about 80% who do not really know what is going on, and insofar as they do are hoping it will go away in the same way that various other madcap schemes have done in the past.

    As I have said in a separate posting, I trust my colleagues locally, but I have heard tales on conflicts of interest elsewhere which are very worrying and I suspect unresolvable where GPs are commissioing services which inevitably overlap with those they themselves provide.

    • Allied Health Pofessional. says:

      As an AHP Therapist working in the community in the North West I am concerned that there is no proposed representation from AHPs at a strategic level. GP’s have no idea what our service really provides – AHPs work quietly behind the scenes, receiving open referrals, diagnosing, managing and discharging patients without needing to get GPs involved until the final discharge report. Most of our referrals come from other AHPs, district nurses, community matrons and patients themselves. AHPs provide incredible value for money. I am worried that the organisation I work for is becomming almost exclusively nurse-led. AHPs are highly qualified and skilled, but work in a different way to nurses and are accountable to a different professional body. We need representation at strategic level, discussion about our roles in parliament and influence – the NHS is not all about doctors and nurses!

      Another thing – All decisions are finance driven. Greater integration between primary and secondary care? Great – until a year ago we worked in both Acute and Community settings. Until the local hospital decided to separate the two services, providing 2 separate separate services, creating a fragmented patient pathway, lack of shared information and great risk in patient risk. Despite the AHP’s protestations the split went ahead for reasons of financial management – NO CONSIDERATOIN WAS GIVEN TO THE EFFECT ON PATIENTS OF THIS.

  76. Dr Penelope Jarrett says:

    One point I failed to make earlier: the government and DH keep saying that because GPs are involved in pathfinder consortia they must approve of them. This is not the case. Most are involved because their local PCT has lost most of its staff and they can see things will collapse if they do not get involved. Also, start up costs for management support are being given at higher rates the earlier you sign up. And as I said before, those involved in each consortium are a minority of the GPs in any given area. Most are disengaged,.

  77. Recommendations:
    • Equalities issues must be addressed throughout the process of change and there must be a gendered approach to health across the proposed new structures in the NHS.
    • There must be acknowledgement that specialist women’s organisations are a vital part of the health and social care provider landscape.
    • There must be acknowledgement of the need to provide specialist, gender and culturally appropriate services for women.
    • The lack of representation of women and those representing equalities groups on the NHS Future Forum should be addressed.

  78. Glynis Moore says:

    I have read many comments about leadership and management of the NHS on several of the listening sites and in various media reports. I feel compelled to point out that not all NHS mangaers are bad at their job, GPs will probably be no better and the majority will not participate, rather, they will have to employ all manner of support staff including managers to enable any co-ordinated function at all within consortia.
    The NHS is a great institution and should not be divided, privatised or weakened in any way. Many PCTs and acute provider Trusts have become well established and conversant with what is required for their populations and do a very good job. Consortia will require similar organisational systems and operational policies, the significant difference being that there will simply be more of them and this may prove to be much more expensive, unco-ordinated and lead to fragmentation of services and care.

  79. Raj Bhopal says:

    Dear Prof Field, I have been listening closely to the debates around the NHS reforms in England. As a doctor who has seen, from reasonably close quarters, about six NHS reorganisations in England in my 27 years in public health (including being vice-chairman of the Newcastle Health Authority), and 33 years as a qualified doctor, I think I have a reasonable judgement as to what is likely to work.

    We have seen a variety of reorganisations, particularly removing or recreating health authorities. Such reorganisations tend to create havoc and prevent continuity and coordination. The proposed reforms are, in my judgement, the most destructive and disruptive in the history of the NHS.

    I think the most important thing the NHS needs to do is integrate the primary and secondary care interface. This is not a new idea, and has been on the agenda as long as I can remember. It has never been achieved because of repeated reorganisations. The solution, in my view, is to strengthen the primary care trusts by stronger representation by primary care and secondary care. In other words, the primary care trust itself needs to be an integrated organisation. In recognition of this, we could
    have a new name-Health Care Trusts. In this way, the NHS in England will become more closely aligned to that in Scotland with unified health boards.

    Our general practitioners are world-renowned, but not for their managerial activities. They should be focusing on what they are trained to do i.e. clinical care. Ironically, the only doctors who are formally
    trained in health services organisation and management, public health doctors, are being marginalised in the current reforms. It is hard to believe these proposals are genuinely trying to improve the NHS as an integrated organisation. Indeed, as is becoming increasingly clear (though evident from the beginning to those of us long long in the tooth) the underlying objective is to create a pluralistic healthcare system driven by market principles. Unfortunately, however, the evidence from around the world and particularly the United States is that this does not work. While the United States is moving toward our system our government seems to be busy emulating the failed system in the United States. (We have seen this emulation of US policy in a number of sectors.)

    This is my only formal contribution to this debate so far. I have taken time out to write this note because I have been persuaded that your listening exercise is genuine. Hitherto, I have assumed that the reforms would be railroaded through against all opposition and common-sense. With your help, this might be avoided.

    Yours Sincerely,

    Raj Bhopal

    R S Bhopal, Bruce and John Usher Professor of Public Health
    Edinburgh Ethnicity and Health Research Group,
    Centre for Population Health Sciences,
    University of Edinburgh

    • pamela martin says:

      yes. I am a GP already participating in reshaping pathways of care to try to improve efficiency and outcomes for patients. i have been able to do this in collaboration with other health care workers including managers. we do not need the changes proposed in the health and social care for GPs to influence or even take a lead in commissioning.
      the last thing the nhs needs at present is a major reorganisation. we need to continue to progress with the collaborative working arrangements which have steadily been gaining strength over recent years. we need to follow examples of good practice which have already been taking place and roll them out. this listening exercise needs to be followed by withdrawal of the health and social care bill.

  80. Gini says:

    As has already happened with numerous demonstrations and campaigns, the people of Great Britain do not need systems to be in place to have their say. We have a voice, and it is saying loudly and clearly NO to these reforms. The government need to hear that we care about our NHS and they will not destroy it.

  81. Dr Heather Parry says:

    I have been a Consultant Anaesthetist for 27 years and feel privileged to provide epidural pain relief for women in labour, to provide pain relief and care so a woman can have her baby born by caesarean section while she is awake and supported by her partner, and to provide general or regional anaesthesia while patients have their broken bones repaired and their arthritic hips and knees replaced. However we have not even begun to have the discussion we need to have if the NHS is to do what it was set up to do: to improve the health of the nation. The Israelis have shown that they are able to keep Ariel Sharron’s heart beating for more than three years when there is no hope of his recovery from a stroke. We have had patients in Watford Hospital’s ITU for over six months before they have died, still in ITU. Every day those patients receive futile treatment someone else’s hip or knee replacement, or cataract extraction is cancelled because ‘there isn’t enough money’. Long term, futile treatment should not be part of the NHS. There are also decisions to be taken at the other end of life when babies are born before 24 weeks of gestation with almost no chance of surviving and enjoying a life without severe disability. Should these babies be treated in a way we would not allow animals to be treated or should they be wrapped up, cuddled and allowed to die? Why should these babies have the right to treatment in what may be a futile attempt to keep them alive when others don’t have the right to treatment which would improve but not necessarily prolong their lives which is declared unaffordable? We have to make these decisions however difficult they are because they can’t be ignored any longer.

  82. Jane Birkby says:

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

    Not known

    ■How can commissioning consortia best engage and take on views from across the range of health professions in taking their commissioning decisions?

    Why do we need commissioners?

    ■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?

    Again why do we need commissioners, let the doctors apply for funds?

  83. Justin Baker says:

    Since Cameron and Lansley’s plans for GP commissioning havn’t been passed into UK law, and aren’t therefore supposed to have been implement yet, the question about what “early” action is being taken to “improve” quality of services through clinically-led commissioning, shows the government has no intention of actually LISTENING to anyone before pressing GPs to progress the White Paper’s plans for clinically-led commissioning! The government puts forward this “listening” exercise as an exercise in democratic consultation, but this question strongly suggests the White Paper’s provisions are already being implemented before the consultation process is even finished and despite overwhelming public opposition.

    To reiterate, commissioning consortia are being planned as a means to pay GPs to take purchasing power away from hospitals, with the effect that red-tape will be needlessly duplicated across thousands of new consortia, hospitals will lose much of their power to benefit from bulk purchasing, and hospitals will lose the ability to subsidise loss-making aspects of their provision from profitable services. In any true democracy NONE of these plans should be ever implemented “early”.

    As for what more could be done to ensure that commissioners collaborate to join up services to fit around the lives of patients and carers, the answer is that the government could halt their plans to set-up GP consortia as agencies that take (so-to-speak) “business” AWAY from NHS hospitals, as doing so increases competition (at the expensive of patients) while reducing collaboration.

  84. James Goodhew says:

    This is simple also: hire competent managers. If they are not documented to be qualified, then provide training. Demand they attend compulsory CPD, and offer anonymous feedback to them from staff. No other healthcare staff can get away with poor performance, yet managers’ performance is not monitored in terms of patient care – or staff satisfaction with the care provided. A set of Key Performance Indicators (KPIs) needs introducing, and a system which meets ISO 9001:2008!!!

    Decisions related to this feedback should be documented and justified. If not justifiable, the manager should be held responsible for their decision and penalised. Staff within hospitals know how things should be – they simply don’t have the time or system for communication with those who can implement such changes.

    It may be possible to ask patients to vote on changes to systems! If the government really wants transparency, then prior to any formulation of solutions, they should be openly seen to ask questions and attempting to describe the problems with some accuracy.

  85. James Goodhew says:

    I almost forgot – setting up a team of experts (independent!!) was a great idea. Giving them 4 weeks to provide details of a new proposal to ‘save the NHS’ was not. A sensible approach to spending billions reforming the NHS would be to take time asking the right questions of the right people – and verifying that you get the right answers, by asking more people. This cannot be achieved in 4 weeks!!!

  86. Sally says:

    Having read all the posts and having myself had over 40 years experience in the NHS in a variety of roles and a variety of locations, I have to commend the input of Prof. R Bhopal to this listening exercise. I agree with all the points made.

    He also makes an important contribution in stating that he was uncertain that contributions would make any difference, my experience is that sometimes individual contributions can have a surprisingly big impact – one of mine did about eight years ago! However, the opposite, common, maybe cynical perspective is also very tempting as, for example, in my own area the SHA are operating on the basis of business as usual and are engaged in a process of requiring 18 hospital pathology services to compete with each other to bid for each others community pathology and only three can win it. This will break up the currently integrated primary and secondary pathology services, undoubtedly be detrimental for patients and whilst said to reduce the cost of community pathology will increase the cost of secondary card pathology. The stated published aim of the plan is to move to AWP after two years. All the fears for the future NHS are thus justified, there is no pause in this process, today pathology, tomorrow the rest of the NHS. Bids have to be in soon, contracts are being let within 8 months – so no listening in this exercise and Prof Bhopal’s concerns regarding an integrated service are justified by current evants. This brings other considerations, in how many other areas is it full steam ahead? Why are the questions so directed? Why, if there is a genuine intention to listen, is there do much stage management?

    My conclusions – The SHA’s should indeed be gone, PCT’s should have a clear and overiding
    remit to consult and coordinate as well as commission, they should have the full range of healthcare professionals leading them on their Boards and committed as well as patient/public local authority and HEI involvement, GP’s should also have a prime role. PCT’s have to have a corporate NHS identity with provider hospitals and all other deliverers of care as part of the NHS having the same corporate identity. Leadership should be vested in clinical leaders as close to the delivery of care as possible. A corporate culture should be engendered that drives out waste rather than calculating the cost of everything and knowing the value of nothing then transaction costs could be reduced once again to the long term average of 8% rather than current 14% – that saves 6% pa – roughly £7Bn pa – that is £28Bn to 2015. Then we have an integrated clinically led NHS focussed on delivering patient care. Alternatives include a US style marketised approach with little integration spending 28% on transaction costs and converting a significant portion of resources into
    shareholder profit – seen by many as the most likely end result of the current proposals.

    Other advantages of a strengthened integrated corporate NHS would be the elimination of managerial game play across the purchaser provider divide, the incentive to coordinate and cooperate in service design and an exciting incentive to compete to improve quality in the interests of patients, the increased morale amongst all staff would be seen in further increases in
    efficiency – the financial imperative to save money and the demographic imperative to meet increasing activity beneficiaries.

  87. Patricia Stevens says:

    Like any other organisation the NHS has good and bad examples of management and leadership. The proposed changes would have similar problems. Rather than spending such a huge amount on reorganisation it would be much better to spend money on looking at best practice and using the findings to improve failing areas.

  88. Janet Dickinson says:

    “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?” For starters, don’t have any commissioners and stop using the term ‘joined up services’.

    You must realise that no-one is fooled any more by the smoke and mirrors approach of wanting to look as if you’re doing something. And appointing ‘commissioners’ – aka ‘jobs-for-the-boys’ – isn’t going to make a particle of difference, so stop insulting us.

    Your answer to perceived criticism is to form a committee, who will probably all be accountants and money will be the first priority.

  89. Jenny Eastwood says:

    I am a retired NHS Consultant having at times been actively involved in service management.
    NHS staff are very fully involved in clinical work & there is no ‘slack’ to allow the addition of non clinical activities without risking a deterioration in clinical care.
    In addition there would inevitably be considerable costs involved.
    A possibilty (there is no self interest here as I am way past an age where I might be involved)
    would be to offer newly retiring or recently retired clinicians to feed back into the NHS their accumulated expertise & understanding of service needs. This would avoid a situation where already hard pressed health workers would

  90. Rajvinder says:

    listen to and accept staff concerns when they make the effort to share their experiences, then do what can be done to make the necessary improvements, Simples! the more they feel they are being heard the more likely they will make the effort.

  91. Karen says:

    This question should have been addressed years ago, if it had we might not be in this mess now!

    The bottom line is if we allow the government to dismantle the NHS we will no longer have any say in our health care.
    The private sector providers are not interested in the best options for your health care, they don’t care about what you need, only about what you can afford.
    To them the most important thing to keep healthy is their bank balance and in order to keep that in the black they will provide the absolute minimum they can get away with and charge us the absolute maximum they can for it.
    I do not want profit based health care.

    GET YOUR HAND OFF OUR NHS!

  92. Nicki Hatton says:

    I feel better advanced planning is required in light of the continuing high unemployment rate for newly qualified health professionals. As a clinical specialist physiotherapist regularly training students on placement it is extremely disheartening putting in all this time and effort alongside the students themselves to know that many of them will never practice physiotherapy. With the current cuts this is likely to worsen as many posts are frozen. The cost of training to the NHS is immense and unlike in the past the NHS won’t reap the benefit as many are unlikely to work in this area.

  93. Dr Hilary Kinsler says:

    This is really simple and obvious. MPs should stop listening to the private healthcare companies who pay them loads of cash and listen instead to the professional bodies such as Royal College of GPs, Royal College of Nursing, British medical Association etc who all say scrap this bill completely and do not privatise the NHS.

  94. Holly Lyne says:

    I have no problem with practitioners being involved in commissioning, but it cannot just be GPs, other specialists need to be involved. I also strongly feel that certain areas of the NHS are best commissioned on a national level, not by small regional groups, in order for care to be universal, rather than a post code lottery. Maternity services being one of those areas.

    You need to listen to midwives and obstetricians. You need to listen to every body who has spoken out against the proposed bill and make changes accordingly.

    If you fail to do this you will have proven yourselves incapable of listening and reflecting and incapable of doing what is right for NHS workers and service users.

    I have very grave concerns about these reforms and this “listening exercise”.

  95. judith garbutt says:

    i do not believe that this government has thought long and hard enough, I do not believe that the NHS is safe in their hands, and I believe that they have being trying to circumvent their own listening exercise, by not listening to any of the ordinary people at all, as I would have loved to attend one of the consultation meetings, but could not find out a thing about them……

  96. Void Exercise says:

    This listening exercise has to be stopped and corrected.
    I am deeply outraged that this listening exercise has been designed and implemented in the way it is.

    - There is not enough publicity. No one I know (family or friends) know that there is a listening exercise, let alone how to get involved

    - The interface has been just designed so that new participants cannot read what others have said. Am I supposed to make my point without reading the 529 other ideas that others are discussing below me?

    - 4 different sections make the navigation more difficult, and sythetizing the information impossible. This is a good way of preventing anyone from being in the position of making their point

    - There is no summary of what is being discussed which can be easily reached from this page. A document stating clearly what changes we are exactly discussing should be visible at all times.

    - There is no information on how these random comments by users are going to be processed, valued or used. There is no statement on what guarantees that they are going to be even read by someone

    - Any ethical and true listening exercise should start by listening to patients and citizens, who are the ones sustaining whatever system we come up with, and the ones suffering the consequences of any bad choice in this respect. The only section of society who seem to be giving their view here are mostly doctors, nurses and other institution workers who are aware of this sham.

    Shame on this listening exercise, Shame on Mr Andrew Lansley. Shame on our government. Shame on this authoritarian and corporation-driven proposals.
    We are citizens. We are patients. We are tax-payers. We are consumers. We have the right to be listened to, and above all, we have the right to be respected. Stop insulting us. Stop lying to us.

  97. A Patient says:

    Slightly weary hearing all these voices from NHS staff who seem to oppose change because they feel insulted or demeaned.

    As a patient, I want a system where I can see trusted doctors quickly, be treated by respect by all staff, including nursing staff, and get rid of all the seemingly random delays in tests and treatment.

    This means a culture change to improve productivity (less standing round chatting please), reduce all the bureaucracy.

    And the person who I trust most to advise me and organize my care is actually my GP – and I don’t want him hobbled by interference from everyone else who wants to interfere.

  98. mandie says:

    it is essential that service exist to meet the very complex needs of our very diverse population. If you have a very complex health condition you do not want to be a guinnie pig with no services availiable locally, you want they specialist service sthat exist to continue. This will nto happen unless they are commissioned and who will make that decision. GPs who do not know what these sevices are?
    Any provider can propose to provide the service, but for me it is the quality of the service that matters, it is the training and experience of the providers and staff and not the cost. How can I influence the commissioning process to ensure the views of the patients is actually listened to. We afterall are the consumers not the GPs.
    I for one cannot see the difference in the new structure to the old one, except that now we are in even more danger of a postcode lottery occuring.
    It is not until you need a specialist service that you find out what is availiable in your area. We need universal access to high quality services no matter where you live.

  99. Alan Spicer says:

    Apologies for reproducing an article on Pulse but it resonates so much. These concerns need to be addressed by the Government if they want to really be shown as the NHS guardian.

    “Public Service should have a service ethic, with staff who are not in it for the money, and management who are not in it for the shareholders, or forced to compete with companies that are run for shareholders.

    Instead, by 2014 all NHS hospitals will be businesses, competing with private institutions for patient income. To remain profitable, NHS hospitals will be forced to cut costs – working their human resources harder, focusing on profitable treatments and cutting high-cost ones. GP consortia will run the service. But I wonder how a GP dedicated to clinical care will find the time, or refine the skills, to do the administration required. You can already see there are contracts the private health companies are after. Consortia, meanwhile, will try to save money by denying certain treatments, and by reducing their staff costs.”

  100. Thomas Jennings says:

    The government should stop setting up GP consortia and start doing something productive with their time.

  101. Hannah says:

    I have serious reservations about handing the budgets and commissioning responsibilities over to GPs. Although I am sure inidividual GPs are generally decent and competent people and many will have altruistic motivations, GPs mainly work for private organisations and practices are businesses designed to make profit. They are the only group within the NHS who demand financial incentives to do anything. I believe this is fundamentally different from all other NHS staff (from nurses to cleaners, psychotherapists to finance directors) as tthe rest of the workforce try their hardest to help society for no other reason than that is their job role and at the end of the day they only draw their basic salary. The GP practices can make amazing amounts of money from providing what the rest of the NHS do for free (ie incentives for chlamydia screening, CVD risk checks, You’re Welcome criteria etc). The public do not, as a rule, realise that their GP not an NHS employee.

    I believe managers are needed in the NHS. The Kings Fund have provided statistics that show that the NHS has a managerial workforce that is one-third the size of that across the economy as a whole. PCT management costs only make up 1-2% of total budget so how cutting PCTs help?

    From a patient perspective I find it a nightmare to get an appointment with my GP. I want my GP to focus on providing me with primary healthcare I do not want him/her to have even less time to help me. After this reform getting an appointment will be impossible.

    The government need to realise we do not live in rural 1950s – my GP does not know me, I see someone different every time, I would not want him to decide how millions of pounds are spent. But he is arrogant enough to think he knows best. At least PCT commissioners understand they need to work hard to understand their population and thus spend a lot of time and energy ensuring they are getting things right with public engagement, needs assessments etc.

  102. Peta Kerrigan says:

    The NHS can’t be run like a private business. By it’s very nature some parts can make money and others, such as A&E and care of the elderly never will. Nor should they!
    The main thing that needs to be focused on is that the NHS is run well. It gives people healthcare when they need it, in a professional and safe way.
    Money can be saved from many a committee, change excersize etc. I agree with others that restructuring always seems to cost lots, leave inept amangers in place and not have a great possitive impact on patient care.
    The ground level staff are full of ways to help their patiens and run their departments in inovative ways that would help save money, but do we ever greally get asked? No.
    You cannot have a profitable NHS. Tjis should not be the aim. Medical advances will always mean that the NHS costs more year on year and the government has to realise this. As long as the NHS functions to provide us with good quality healthcare then we should value it and keep it. Maybe some of the services that are further away from direct healthcare could be provided differently by other providers but the direct patient care, operations, emergency care in A&E and district nursing services should always be it’s bread and butter work.

  103. robert says:

    The proposals include leadership and views from a ‘range of professionals’…this previously included GPs only…now it’s GPs + Nurses…not exactly a RANGE!! Allied Health Professionals including Speech and Language Therapists, Paramedics, Radiographers and others are qualified and experienced and many are already in leadership positions. Their voices need to be heard and they need to be involved in decision making, otherswise the NHS that is shaped over the next 5-10 years will be doctors and nurses only. AHPs don’t fight for GPs & Nurses and the same thing applies the other way around.

    The 210,000 HPC health professionals need to be represented on the comissioning groups

  104. Jill Mundy says:

    I am deeply concerned that the changes that Andrew Lansley wants to make will end up damaging our health service.

    For example, I am concerned that new commissioning bodies will not be properly accountable and will not operate in a transparent way. GPs should not be able to take decisions behind closed doors, and other stakeholders including patient groups and other health professionals should also be involved.

    It is my personal opinion that if leading health experts such as the British Medical Association give advice about the NHS then this advice should be followed. Any changes planned should be trialled in small areas for several years in order to assess impact, and for the results to be assessed by the BMA.

  105. Jodie says:

    Local commissioners need to be asking specific questions to frontline clinicians about specific services within their area – collating information from a range of health & social care providers, not necessarily just those currently in place.

    In order to commission effectively there needs to be an understanding of the service need and which profession/s are best place to deliver these. It needs to consult front line staff from a range of areas using a range of methods to maximise response rates. The majority of clinical staff do their jobs because they have a keen desire to provide a high quality professional service and will be eager to share their perspectives on what this looks like within the context of service provision and commissioning

    By turning the NHS into a series of small businesses the resulting internal competition, rather than inspiring service providers to improve for the sake of patient care, has resulted in a loss of morale and team working, a loss of trust both internally and between services that should be working together and a more fragmented and disjointed health care provision. This will only improve if there is reduced local politics and a true return to service-user centred care rather than the ambitious power struggles that are currently evident within local health economies.

  106. Richard Worth says:

    The answer to your main question is very clear! Make sure that you widen the commissioning bodies to involve more than just GPs! There is a huge expertise out there keen to improve services for patients. Just listen to them!

  107. Gareth Stone says:

    The government’s “duty to provide” a comprehensive health service must be kept. Dropping this duty would erode the foundations of the NHS.

    Any new commissioning bodies should be transparent and accountable. They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well as GPs.

  108. Emma Richards says:

    It is important that clinicians are engaged in decision making. However, one of the main reasons that GPs have not been previously involved is becasue they are independent contractors who are self-employed. Therefore, in order to get a GP involved payments had to be made to cover locum sessions which is expensive.

    I wonder where the cost savings are going to come when GPs are paid to be commissioners. I assume that no one is going to take a pay cut yet the salary of a GP is 2-3 times that of a commissioning manager!

  109. Orris Orrison says:

    It is typical of this country that wherever I look I see evidence of people agreeing contracts that have glaring ommisions that then end up with the customer, whoever that is, having to shell out considerably more money than was agreed. In the public sector this seems to be accepted with a shrug of the shoulders.
    I would also like to ask why it has been decided locally that the overpaid idiot in charge of the County Social Care department can now be in charge of Public Health. That is the business of the braoder NHS and not of social services.

  110. Dr Heather Williams says:

    We already do this. It’s called research and development, and in a technologically rich health service (we have some of the most up-to-date equipment in the world, whatever the government or the prvate sector may tell you) we can’t do anything but if we are going to give our patients the best. The scans I do for a living aren’t cheap, but if they nail the diagnosis early they are cost-effective. If you try and put in expensive restructuring on top of spending cuts, then R&D will grind to a halt and the resultant improvements in service and the associated cuts in cost will be seriously undermined. We’re already being told that scientific staff numbers will be cut under the ‘Modernising Scientific Careers’ initiative; if the NHS is to be the world-class service Lansley wants he won’t get it by getting rid of the people who can get the best out of new technologies.
    It’s a bit late for Lansley to be asking the opinion of healthcare workers now when he ignored our comments and concerns in the first consultation, to the extent that both the medics and nurses have told him to drop the bill all together. I add my voice to theirs.

  111. Alan Kitson says:

    You don’t need to restructure the NHS or open it up to competition to do this. You just need to use the systems already in place more effectively and get managers with the right attitudes and skills in position.

  112. FJR says:

    Practice based commissioning was a bit farcical-never did very much. GP led commisioning-when in my day will i find the time. are there plans to employ more clinicians to do the day job whilst we try to commision & develop new pathways? clinician input to look at the patient journey is fine. whole scale pct/sha destruction is madness when trying to save money. costs will spiral as new system tries to find its feet. most pcts work fine (mine certainly has done-even if i grouse about them at times) we are in complete disarray with the number of good pct staff that have left already. the area is in meltdown. taking on hospital trusts that have very accomplished managers & going into negotiations with them is not terribly clever.
    small steps & trial things out, the baby risks getting thrown out with the bath water i fear

  113. John Irwin says:

    I would have thought that the current professional bodies perform this function adequately. But instead of policing themselves as now, they should be responsible to an independent tripartite body which includes members of the public in cases where professional conduct is in question..

  114. ZT says:

    I think you should do as they did in the Netherlands and discuss this, along with other parts of the proposed bill, in a cross party way. After 20 years of hard work in the Netherlands they now have a Health System that is fit for the future, which won’t be broken down over night due to politics, and that has been built on solid foundations. This bill goes nowhere close to this.

  115. Paul Haworth says:

    These are dishonest and leading questions.
    Of course you know very well that most peoples’ issues with the Bill are not how best to implement its proposals, but the proposals themselves.

    We do not want a massive re-organisation which will create (and is creating) chaos and absorb huge amounts of time and resources during a period of unprecedented austerity, when there is not a shred of evidence that the changes will produce the benefits claimed for them.
    We do not want global health corporations sucking billions of pounds of tax payers money out of the NHS which should be spent on patient care.

    It is also not clear what terrible problem the reforms are supposed to solve.
    The NHS is one of the most cost-effective health services in the world, if not the most. We *still* spend less than the OECD average on health care despite big increases in funding over the last few years. The countries we are routinely compared with: France, Germany, Switzerland etc have spent billions more per year on health care for decades, and yet on current trends our outcomes are set to equal and exceed theirs, and we already perform better than other countries in many fields such as heart surgery and end of life care.
    The Comonwealth Fund recently rating the NHS top for efficiency, equity and ease of access of the countries they studied, and found that Britons were the most satisfied with their health care.
    Of course the NHS faces challenges and can always be made better, but our current model is cheap and effective and therefore the best placed, with modification and improvement, to deal with these challenges.

    This Bill is vandalism with no mandate and must be opposed by all who believe in the principles of the NHS.

  116. Joe Reynolds says:

    I worked as an AHP in NHS clinical leadership until recently. What the NHS needs is for the people with the best strategic understanding of the care system, and its contradictions and tensions to be involved in making decisions about that £80 billion budget. These people in my experience come from all manner of clinical backgrounds, and from non-clinical backgrounds too. Most GPs are good at being GPs. Some are good at taking an overview of ( at least part of) the care system, but I have known nurses and allied health professionals who had a far better perspective on how the system works now, and how it might be improved. The proper and creative tension between senior people from nursing, medical, AHP backgrounds, finance experts, administration professionals, all working together, is far more likely to lead to good decisions than any uniprofessional set of commissioners from whatever background. And clinical teams and services will work best when supported by a commissioning system which does not try to micro-manage provider services, and sticks to setting the broad framework of outcomes, leaving the clinical leaders and managers to lead.

  117. allison-physiotherapist says:

    Secondary care out patient services must NOT all be moved into the community where certain specialities -such as Rheumatology, require the facilities of the hospital, and the skills of a multi discilplinary specialist team who are based together.

    Also, out patient Physiotherapists underpin many speciality areas, diagnosing and treating and in many instances preventing hospital admission. This essential service must remain in the secondary care unit as well as in primary care, where they have excellent necessary and established facilities, and can work in close contact with their consultant colleagues.

    Musculoskeletal and rheumatological health is about to cost the nation a fortune, related to the ageing population and obesity.
    Specialist Physiotherapists can assist with and/or manage these complex difficulties, especially when already estalished in secondary care with the on site facilities.
    With respect not all commissioners will not be aware of the full picture and there has been no reassurance so far that secondary care clinicians will have the opportunity to be involved in the process.

  118. Mark Bannister says:

    “Listening Exercise” should be replaced with the epithet “lip-service”

  119. Martin Sandaver says:

    I think that the NHS has lost its way and that we are fudging the issues. There is a lack of real honesty, little clarity and a lack of integrity. There is too much protectionism of income over doing the right thing. You need a proper leader and to promote good health which you maybe need to look at Chinese medicine and exercise protocols like Qi Gong to achieve some of your aims. We build monuments to sick health in Europe and the UK and this is predicated to some extent because the pharmaceutical industries control our so called health system as they are in government, universities, hospitals and doctors surgeries and therefore research and alternatives are marginalised by a very imperfect system where side effects and toxicity cost over £2billion a year. There is no dialogue about this..

  120. sadie says:

    Hi Andrew & team,

    Did you want to make this page (Advice & Leadership) any more of a turn off? The people who will want to feed back on these points probably cannot as they are too ill, or too elderly, or too poor for internet.

    You really need to go out to the long term care patients and PHYSICALLY ask them their thoughts (no, not a petition / questionnaire / letter) with a physical visit from a Health Visitor.

    A website based listening exercise is for a large percentage of people who are NOT in need of the NHS or its reforms for about 30 years…

    Please do not encourage competition within the NHS, there will be no one to price check and monitor and the contracts will be open to ANYONE with a company. There will be security breaches and protocols missed as you attempt to wedge the private sector into the very public serving NHS.

  121. Nicole houghton says:

    Listen to what the BMA, the nursing unions and many others are saying and scrap this ridiculous bill!

    Frankly I think this question is an insult to all our hardworking healthcare professionals (I am not one) given how they have been commensurately ignored and belittled in this sham consultation exercise.

    I also think that the whole bent of this exercise utterly negates the expertise and integrity that our hardworking NHS managers have.

  122. Tony Hamilton says:

    Clinically Led Commissioning.
    We have to beware of too much influence by clinical specialists which then makes for clinical politics and the influence of star consultants. GPs (who are generalists) have a useful advisory role in this process since their different patients require to make use of all the services. However it does not follow that they should manage the system. Making managers aware of service imbalances is useful, but GPs are doctors not managers.

  123. Dr Rebecca McLaren, Consultant Child Psychiatrist says:

    7. What early action is being taken in your area to improve quality of services through clinically-led commissioning? What is working well? We do not believe you are interested in clinical advice and leadership. If you were you would have responded positively to the consultation exercise that has already taken place and to which the overwhelming majority of professionals responded in strong terms in particular over the issue of conflict of interest and elements of competition especially any willing provider. No changes were made, you ignored us. The very premise of all the questions is that this is a done deal which suggests this tiresome exercise is a sham. A view borne out by the leadked memo from David Nicholson (who interesting was also at the West Midlands SHA before he was elevated).
    8. How can commissioning consortia best engage and take on views from across the range of health professions in taking their commissioning decisions? We wouldn’t need to do this if we did away with the purchaser provider split and developed a comprehensive nationally funded integrated care model with strong professional input and educated patient representation.
    9. 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? See answer Q 8.

  124. M CARTER says:

    research has shown that the best model for most structures such as the NHS is to leave them alone, when successive Governments meddle and meddle it all goes wrong.
    Just leave things alone, the NHS does very, very well, as a ship it runs alot better, and does a heap more good that alot of other public bodies, including the Government.
    There should be a one shop comissioning body to purchase drugs, so they can have the clout that a large body has when buying things, if we have smaller comissioning bodies, drugs will become more expensive, there will be difference throughout the country. NICE might be loathed, but it is a lot better than being with out, it, we need uniformity, knowing that there is a common standard throughout for IVF, treatment of cancers etc. we must not be divided into yet more and more haves and have nots.
    The NHS staff and the public should be involved from the beginning of this process and were not……it can be pointed out that the Government represent the people and act on the best interests of the People, if you destroy OUR NHS, how does that benefit us, the people. If there are those who would or have profited by the increasing involvement of the private sector, they should hang their heads in shame.

  125. K Vines says:

    I have no idea what early action is being taken in my area to improve quality of services through clinically-led commissioning. To be honest, I don’t know exactly what it means. I go to see my doctor because I have a problem. If the problem is within his or her capability, a course of treatment is recommended, and that’s the end of the matter. If the doctor can’t handle the problem, an appointment is made for me at a local hospital, and I go there to see a specialist and, possibly, more than one. This seems to be a pretty good system and, like the education system, I can’t see any way in which much improvement could be made.
    The idea that the nation should train doctors at very great expense and then waste that training by allowing them to become competing managers seems completely daft. What we have might not be the best system in the world, but it works. If consortia were introduced gradually, we could see what improvements, if any, they might bring. If they proved to be worse, as I suspect, then it would not have been a hugely expensive or damaging exercise and the consortia could be disbanded and the old system restored.

  126. Pam says:

    I want my GP to be up to date on all clinical matters, and not to be distracted into running a consortium. I want people to go into General practice because they want to work with patients, not because they want to manage NHS structures. I want hospital doctors, midwives, members of the Community Mental Health Team, etc, to be as involved as GPs in making local decisions. I want communication between all those people and more, and with Social Services etc too. I’m impressed that my elderly mother gets help from an Elderly Mental Health team which spans both NHS and Council, and her day centre is a council operation on NHS premises, and all the people involved communicate with each other. That needs to be the model for the future.

  127. Dave Waite says:

    Start by listening to those who know! If the royal College of GP’s tell you it won’t work, the Royal College of Nurses have no confidence in the NHS privatisation or the health secretary, the Royal College of Surgeons say the reforms are ‘dangerous’ and make ‘no medical sense’ and health workers represented by Unison call for it to be scrapped, you have all the advice you need.

  128. Joel Arnstein says:

    Dissemination of best practice and co-operation are not helped by competition.
    Place commisioning and planning in the hands of elected representatives (with professional advisors to help them) if you want openess and accountablity.

  129. Julie Webster says:

    ■How can commissioning consortia best engage and take on views from across the range of health professions in taking their commissioning decisions?
    Well, how about doing the exact opposite of what Andrew Lansley and the government have done with these proposed alterations to the NHS. They have ignored what nurses and the BMA are telling them about leaving the NHS alone-too many changes will kill the NHS. Leave it alone, or at least lose the arrogance,ditch the current plans and start again from scratch with proper consultations with frontline nursing staff, doctors and health care professionals.

  130. Sue says:

    Surely you should be listening to the health professionals, not telling them what you want their future to be. The changes you propose were not voted in, you have no mandate and should abandon all proposed changes to the NHS forthwith.

  131. Dr Charles Elliot says:

    Just take a look at other privatised services if you want to see the future of the NHS under the proposals; railways, energy, telephones etc
    ask yourself who is benefiting from these…
    the customers? more choice yet terrible services and rising prices.
    the taxpayer? still subsidising the energy industry and the railways.
    the shareholders? ah now you’re talking – ‘doing very nicely thanks.
    The NHS is far from perfect but these so-called reforms will destroy the very spirit of the whole service. In the end those with money will be fine and those without will have to take whatever is left over.

  132. Thomas says:

    There are so many fundamental problems with the proposed changes to the NHS that have been identified by so many professional bodies that it seems essential to take this opportunity to shelve the bill and start afresh with ideas to improve rather than dismantle the NHS. Here are some points that particularly worry me.

    1. I think it is correct that clinicians and professional health groups are insufficiently involved in strategic decision making – a problem that can be attributed to the actions of a succession of governments. But ratherthan experimenting with a new set of largely untried structures, it makes more sense to improve the ones that are currently there. The proposed GP commissioning bodies seem to put power in the hands of practitioners who often have a limited understanding of the strategic problems of the NHS and the coordination needed to improve the different strands of the service.

    2. The government’s proposals to abolish its duty to provide a comprehensive health service, but just to provide funds for appropriate services is a sinister abrogation of duty that allows a denial of responsibility when things go wrong.

    3. Market principles, profit motives and competition are often a means of transferring tax-payer’s money to large companies with shareholders and over directors and CEOs. It is not a good way of obtaining a properly coordinated and integrated health service with proper strategic planning. Look at the energy companies and the current mess of railway administration. Planned, effective and cheap services do not happen that way. Whatever its current shortcomings the NHS remains very good value for the tax payer.

    4. NICE is an extraordinarily successful institution and brings real knowledge to bear on what is or is not effective. It is one way to limit
    the problems of post-code lottery. Any steps to reduce its influence seem retrograde. The health service must be science and knowledge-based and ignoring professional and informed evidence is unacceptable.

  133. Dr Trish Evans says:

    What is working extremely well in our area is an integrated back pain service. It is a prompt, streamlined, cost effective and patient centered pathway which has revolutionised back care for our patients and offers excellent clinical care. It has been put together principally through the co-operative working of GP’s, physiotherapists and orthopaedic specialists at the local hospital. As a GP I feel proud of this service and others like it and I feel sure this sort of service provision is the right direction for the NHS. However it is unlikely this pathway could be replicated in an open market.
    Once again the RCGP’s formal submissions represent my concerns in detail and their proposals for healthcare federations make good practical sense.

  134. W M Wong says:

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

    There are discussions between the Acute Trust and the PCT about provision of chronic conditions care in the Community. These are services for people with heart failure, COPD and rheumatic conditions mainly. The services are provided / likely to be provided by employees of the Acute Trust moving out from the hospital to patients’ homes or local GP health centres. However these initiatives may not be sustainable if the Acute Trust and PCT cannot agree on the level of funding in the short term, or commissioning consortia decide not to renew the contracts when the PCT is abolished.

    2. How can commissioning consortia best engage and take on views from across the range of health professions in taking their commissioning decisions?

    Commissioning consortia should start with NICE guidelines or other evidence based guidelines eg produced by SIGN, medical royal colleges, specialty societies, RCN, Chartered Society of Physio etc.

    Then ask representatives of directly involved professions and patients with the relevant conditions and their carers about best way to implement those guidelines locally. The commissioning consortia must be open about what can and cannot be afforded locally, and what priority will be given to one service compared to another.

    The commissioners must publish their commissioning decisions and supporting arguments.

    3. 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?

    Commissioners must be large enough to cover a significant propulation so as to reduce transaction costs. One Acute Trust does not want to negotiate 5 contracts for the one service and find it has to check every patient’s address to decide what kind of care that patient can receive.

    Commissioners should commission entire care pathways, including social and mental healthcare components as appropriate. Acute trusts could then work with community care services, social work departments, mental health providers etc to provide joined up care. However this will require a lot of managerial input to commission and to monitor, so unlikely to be achieved by GPs without a lot of support. In addition, bundles of care will almost certainly produce conflicts of interest as the commissioning GPs will be involved in providing part of the care.

  135. David38 says:

    If your house suffered rising damp in one corner, would you knock the whole thing down and rebuild hoping the same thing didn’t happen again? That seems to me how the NHS Plan is approaching improvements to commissioning. Isn’t it more effective, less risky and more expedient to build on the structures already in place with PCTs, as many contributors on this site have already suggested?

    By all means have legislation to ensure that there is more clinical involvement in their decision making, from primary and secondary care, plus the huge range of other healthcare professionals that provide services. Similarly, the involvement of patient-groups, interested voluntary organisations, community groups, the local authority where relevant, and input from public health professionals to give a broader overview (particularly in terms of ensuring equality of provision) could be similarly mandated. This already happens, to varying extents in a lot of PCT decision making, but the responsibilities of the PCT and the other participants could be more rigourously applied with legislation / changes to SLAs and contracts for providers.

    Surely it makes more sense for a fairly independent local body such as the PCT to coordinate and lead this collaborative approach than just one of the participant groups, i.e. the GPs? My local PCT has had to meet savings targets on numerous occasions since it was founded in 2005, and successfully as I understand it so I suspect they’d be well placed to continue to drive savings too.

    There are other changes to the plans that I would make to facilitate this sort of approach, retaining public health within the NHS rather than re-homing it within local authority where it surely its independence from political influence will be compromised, would be one. As would breaking down some of the artificial barriers between primary care, commissioners of care and the secondary care providers that exist in the pseudo-internal market of the NHS at the moment.

    Well informed, transparent decision making in an integrated local healthcare structure, where all relevant players are involved and there is proper oversight. Isn’t that we all want? I thought that was the motivation behind the changes proposed in the NHS Plan too. My suggestion looks pretty bureaucratic doesn’t it but surely that’s a necessary evil, and definitely no more than the structures required in the NHS Plan proposals, which are by definition new and therefore more of a risk.

    I would like to add that I second those commentators that have suggested this exercise continues the trend of previous consultations in respect of the NHS Plan, of asking questions that are focussed on how the proposals would be implemented rather than encouraging an open forum to discuss precisely what people want from their NHS and how they would like it achieved in more general terms. Across the NHS, organisations continue to prepare for the changes proposed, there is absolutely no pause there, just disruption and continuing insecurity. I eagerly await the minor tweaks, reassurance and carefully edited excerpts in the report on a deeply flawed listening exercise for a deeply flawed NHS Plan.

  136. David Mackie says:

    There are already standard ways of involving people in change.

    One standard approach in government is to try out reforms in pilot areas, check that they work, and then if independent evidence suggests that they do work, roll out the changes wider.

    I would like to see these types of best practice in adopting change considered in any proposals, however I also think that the current proposals are so flawed that the whole bill should be dropped.

    • Ann says:

      I may be wrong but I am pretty sure that there has already been some ‘trialling’ of GP consortia being given nominal or indicative commissioning budgets last year.
      I believe the majority overspent.

  137. Michael Meinen, GP says:

    At the risk of repeating myself, what is the evidence that GP commissioning improves health care, especially at a time when savings of 20 bn pounds are demanded of the NHS?
    In the envisaged new NHS, virtually all health profesionals will be dependent on winning a contract with a local consortium, which is an incentive to make a case for thir particular servises, but not others; it is also a disincentive to criticise any commisioning decision. We need a service independent of these conflicts of interest who would analyse need and plan implementation of services to meet those needs. Again, we already had them, they were called Strategic Health Authorities.

  138. Linda Heiden 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?”

    Stop refusing to listen to what NHS staff (and patients) are saying!!

    GPs are experts in medical care, and that’s where their focus must remain. Do not divert their energies, focus and priorities by forcing them to take on financial management responsibilities, too. Reshuffling the deck so that we have more financial managers at lower levels does nothing to improve patient care; it just shifts the burden of management onto medical professionals, who’ll now have to manage their business managers in addition to caring for patients!

    This reform package is profoundly wrong, opposed by the vast majority of health care professionals and of the population. Prove you are a government that is TRULY democratic by responding to our wishes and scrap this policy package.

    The underlying assumption that the UK cannot continue to afford the NHS as it stands neglects the wider picture. Scrap Trident, pull our troops out of Afghanistan, stop bombing Libya and instead sponsor negotiations between Ghadaffi and the Libyan opposition, and halt all subsidies and military supplies to Israel until it becomes a force for peace rather than occupation and oppression in the Middle East. By cutting those elements of the budget and realigning our foreign policy, we will be able to solve our financial problems far more quickly and justly than this government currently envisages.

  139. Dr Dorothea Kleine says:

    This section is titled “leadership”.

    Good leadership rests fundamentally on earning trust, listening, consulting, making decisions based on evidence and advice and empowering committed people to be involved in change.

    The Conservatives have promised us, before the election, “no more top-down reorganisations of the NHS” – now we are seeing exactly such a top-down reorganisation, pressed through at break-neck speed. Breaking promises is not the way to earn trust.

    Mr Lansley has compressed the first consultation, not involved key stakeholders such as ordinary GPs, nurses and patients, as though they were irrelevant, pressed ahead with a bill without listening to their views, the views of MPs, peers and their constituents (I think over 400.000 people have now signed the petition against the reform).
    Committed people have been sidelined and do not feel any ownership of this change process.

    It will be interesting to see whether this listening exercise is just a PR exercise (“consultation-wash”) or actually genuinely intended to guide the review of the current bill.

    Further point on advice:

    I am concerned about GPs ability to give objective clinical advice if they are put in a situation of conflict of interest between the commercial interests of themselves and their consortia (commissioning role) and their clinical judgment of what’s best for the patient (medical role). There are plenty of examples from other countries where this is happening.

  140. Dr John Lockley says:

    I am truly delighted with the government’s proposed reforms. For the whole of my working life, doctors have been at the mercy of decisions made by non-clinical managers. (And I know that most of these managers and administrators’ hearts have been in the right place, but with the best will in the world, non-clinicians cannot have the subtlety of understanding of medical issues that fully-trained clinicians possess.)

    Certainly, managers are necessary – but the final decisions in the NHS ought to be made by clinicians. It was like this at the beginning of the NHS when hospitals were run (very efficiently) by a small group of consultants and nurses with a handful of managers.

    There is another great advantage to using GPs to run the consortia. Currently almost all GPs are private providers to the NHS (we contract with the NHS to provide GP services, and have done since the inception of the NHS in 1948). We are skilled in running our units very efficiently, removing all unnecessary expenditure, overmanning or unnecessary activity. It is always remarked that primary care is the most efficient part of the NHS, and it is like this because all inefficiencies automatically have to be paid for out of our own pockets. Equally, we are all private providers! (though few people realise this when they go to see their GP practice).

    In other words, the NHS is safe (very safe) when its work is given into private hands. It is also efficient (very efficient) when organised in this way. GPs are safe hands to entrust with the NHS because we combine clinical knowledge, a personal understanding of the effects upon patients, and a long-term understanding of the importance of efficiency and effectiveness in the delivery of healthcare.

    Nevertheless I would be very happy for decision-making in the new NHS to be expanded to include consultants, nurses and other clinical staff such as physiotherapists and occupational therapists, ably supported (but in a subordinate role) by high-quality managers and administrators. This way lies an effective NHS that truly will have the needs of the patient at its heart.

    My only complaint? – that the government’s plans are only just coming into being towards the end of my career. I would dearly have liked them to have been in place for my entire working life in the NHS, because they would would have delivered so much more for the patients, supported the staff more effectively and created a much less stressful place in which to work.

  141. Jocelyn Foster-Weaver says:

    I’m sorry but these sound like ‘spin’ questions. I don’t want to be rude but if you had really wanted to know the views of front line workers you would have asked them before manufacturing your own solutions and trying to foist those onto the country. The only reason that you are ‘listening’ now is because of public outcry. How can your question possibly be sincere when bodies like the BMA, as well as front line workers are having to give their opinions of your scheme through a listening exercise that was never planned?

  142. Iain says:

    GPs are probably the worst group of clinicians to be given this role – particularly in isolation.

    Before anyone gets too hot and bothered byn the above statement I should point out that it is actually not intended as a criticism of the clinical skills of GPs in any way.

    However from my own experience less than 50% of referrals made by GPs to my specialities are actually subsequently shown to be relevant. The corresponding figure for other clinical groups is around 10% failure rates. The point is not that GPs are bad but that they have – with respect to a large range of NHS services provided by community or secondary care organisations – vey little direct knowledge of what is available and of how it should be used.
    How anyone thinks that GPs could ever possibly be the driving force behind the commissioning of services which they do not fully understand is almost impossible to believe. Adding a limited number of other groups to the mix may help but unless ALL groups are adequately represented then it still remains impossible to improve the situation.
    Involving ALL groups is clearly not feasible in small commissioning groups therefore we are rapidly back to PCT’s or larger organisations!

    These reforms as they stand have absolutely NO merit.

  143. Clifton Jones says:

    I have three observations and one comment:
    Observation 1:
    Managers who do not have a full understanding of the process which they are managing (i.e. management graduates who have not learnt the business they are managing) are dangerous – deaths have occured
    Observation 2:
    Some doctors will make good managers others won’t, these are different skills and both may be present in one individual, but frequently not. I’d cite the analogy of teaching by subject experts – some can really put it over, but others are abysmal.
    Observation 3:
    Remember Aristotle’s golden mean.

    Comment:
    The clinical case must always come first, before the financial case.

  144. Gary Hughes says:

    Simply listen to what NHS staff and patients are telling you i.e. stop the breakup of the NHS!

  145. Louise Irvine says:

    Consortia should include GPs, hospital doctors, nurses and other health professionals, public health specialists, patients and local authority reps. They should work collaboratively to redesign care pathways that provide better more seamless care for patients, as well as being more cost effective. There should be no role for competition as this would cut across the necessary collaboration. This kind of activity is already happening with success in different parts of the country under existing legislation so there is no need for a huge new bill – 3 times bigger than the one that founded the NS – to establish effective clinical commissioning. Instead we should build on what already exists and disseminate and share good practice. The NHS reforms threaten to distract health workers from this task and waste their time, energy and commitment.

  146. Dr S Anderson says:

    The Bill has been heavily criticised by the BMA, Nursing organisations, front line workers and patients. The government needs to ‘listen’ to the concerns of these organsiations and individuals and not drive top-down change that few health care professionals want.

    Key to getting appropriate ‘advice’ on local populations health rather than on an indiviudals health is involvement of public health professionals. Currently there is little detail on how GP consortia will involve public health professionals and utlise their skills. For GP consortia to be able to deliver comprehensive health care for all and in the best interest of everyone it is essential that public health professionals are involved and this should be clearly stated in any future reiterations of the Bill

  147. Angela Dunn says:

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

    I have not got a clue as there is no information in the public eye and the information that I come across in my professional capacity is so full of statistics and Jargon you practically need a linguistics degree and a translator to even get the gist of things!

    clinically-led Commissioning does not seem to be working to well in my area atm tbh. The PCT commissioning that I have been familiar with for the last 5 years is what works and that is lead by the local Voluntary development agency. No Jargon, easy to understand reports and everyone understands how it works! Seems like the government is trying to fix something that is not broken to me.

    * How can commissioning consortia best engage and take on views from across the range of health professions in taking their commissioning decisions?

    I can not answer this question as I am offering my opinion as a patient and not a health professional. However from what I gather the professionals I know have serious doubts about if the government proposals are the best way forward and so have at least some of the unions-might want to listen to what they are telling you there…..just a thought.

    * 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?

    Does this even happen in the first place? It has not been in my experience that this actually happens.

    These questions seem to assume that commissioning actually works and are very leading and badly phrased if the government wants honest opinions and not validation.

  148. Tim Cribb says:

    These questions all beg the question: no one asked for commissioners and consortia. The system for commissioning wasn’t broke so doesn’t need fixing. It may need developing and improving, like any other system, but please, not another “shake-up”.

  149. D.Wright says:

    It took a long time for PCTs to gain expertise in commissioning services so surely they are best placed to continue . I do not believe GPs are qualified to commission services for whole community. What does the average GP know about commissioning services for those who are homeless or living on the fringes of society? What services will these patients have, let alone choice? Make sure that the GPs have the support of a full range of experts. Otherwise, the gaps in services will get wider and easier for patients to fall through

  150. John Felstead says:

    Pushing down responsibility to GPs to take over from Primary Care trusts is the wrong move. Most if not all doctors go into the profession to provide clinical care. They do not sign up to become managers and paper pushers.

    I know from bitter experience what happens when professionals take on day to day micro management roles. I was an experienced Fire Officer of 25 years plus service working within a progressive cost cutting Fire Authority. In order to remove a layer of administrative staff and save the County Council money, we were given the responsibility of managing the day to day budget of our department via an online purchasing and finance system from a well known American software company with a three letter acronym.
    Where before I could get information on my budget, place an order and get someone to follow up on wrong or outstanding deliveries just by speaking to an experienced administrative colleague, I now had to do everything online. It took over my whole working life and I had precious little time to undertake project planning, provide support and encouragement to my staff and generally manage my department. All my spare time was spent feeding and managing this goliath.

    The same will happen with GPs. They already have a heavy workload in managing and running their own GP practice, and most do not want to take on the role previously undertaken by the PCT. Yes they should have more of a say regarding decisions made by the PCT to close or change hospitals or care facilities within the area, but they should not have day to day responsibility.
    It would also bring doctors sharply into the arena of treatment cost. Yes they should be aware of the cost of treatment prescribed and should not prescribe frivolously, but they should not be placed in a situation where there clinical judgements are constrained by cost issues. Politicians are abdicating their responsibility for the cost of the health service by devolving this role down to GPs. It would be easy for MPs and local politicians to say that GPs have made the decision on whether a drug or procedure is too expensive. This is not their role, it is for Parliament to decide on appropriate and sufficient funding for the NHS.

  151. Lee Stalker says:

    Having worked in the NHS and the private sector in a variety of clinical and voluntary roles the whole ethos of this clinical leadership is founded on one of the greatest mis-assumptions driven by the media and professional tribalisms. Many of the decisions on access to clinical care has been driven by clinicians either at the board level or PCT commissioners. In the organisations I have worked for there has been the majority of clinicians in middle management decision making tree.

    It appears that these reforms are fundamentally driven by the single most dominant profession being given control with minimal consideration of multi-professional team approach. In the significant majority of cases this is a sledgehammer to crack a walnut but I see no evidence in the white paper of the control mechanisms being strengthened any to mitigate those who would seek to advantageously use their clinical profession for self rather than population benefit. A simple metric would be the rise of NHS prescribing activity which does not appear to be directly correlated with the rise in activity.

    In essence decisions will always need to be made on the appropriateness of care treatments, clinicians will not always agree on priorities as this will always be coloured by personal experience, knowledge, interest and inherent bias, true clinical leadership is to recognise this and to have a system that enables transparency and collective responsibility in making these tough decisions. The NHS has invested millions in making clinicians stronger leaders which may be perceived by some professions as destabilising their power base. It appears that these reforms are more about returning this power base back to the 1940′s rather than keeping the healthcare values of 1948.

  152. Michael Simpkin says:

    This is a Dunkirk question given the damage which the new proposals have already done to the commissioning structure and the flight of NHS staff.

    Of course there are plenty example of good joint or clinically led commissioning around but they were already developing under the PCT structure and there was nothing particular in this which was holding them back. Now we have a situation where NHS staff are often even more scared to speak than they were before, where they may not know from month to month whether they still have a job or who it will be for. And you ask for advice?!

  153. The questions above assume the decision to restructure the NHS is a foregone conclusion, which misses the point that we are not learning from previous restructuring exercises. It’s not the structure that needs changing, it’s the culture of clinicians, nurses and ancillary staff that requires change together with encouragement to the general population to take responsibility for their health and well-being.

    Giving commissioning to GPs will not work because GPs are necessarily good at detail, not overview. Commissioning needs to take a helicopter view as well as an individual view – won’t happen with GPs.

    When I was Chairman of a PCT, the only way we got GPs to do anything in a different way was to give them financial incentives. Something as simple as effective prescribing, which you would think they would do anyway, had to be financially incentivised because as your previous respondent, Dr John Lockley points out, they are all private businesses and want to make money from their services.

    Nothing wrong with that but it won’t improve the quality and access of good health services if you give commissioning to GP Consortia. It was impossible to get any meaningful accountability on where additional money was spent, from GPs because they would always fall back on their ‘private business’ status. He says that if they are not efficient, the money will come from their own pockets. My experience with GPs tell me that rarely happens. If they believe they need more practice staff for their business, they lobby the PCT until they get another nurse funded by the taxpayer.

    The solution to the NHS problems is to break down the silo mentality between the medical tribes, eg consultants, GPs, physiotherapists, etc by providing incentives to encourage them to work in teams as equal partners. The other solution is to make much more use of patient focus groups, patient surveys and patient disease and injury groups to develop services that are accessible from wherever one may live in the UK.

    Restructuring is expensive (the taxpayer will always have to ‘hump’ fund changes), disruptive and cost inefficient (before the restructure, staff lose motivation and afterwards, there is a learning of up to a year to bed in new structures) and pointless (because no structure is 100% right – in time it will all change again).

    25 years ago I worked in health promotion education. I remember visiting one practice where the managing GP smiled at the changes I was suggesting that would benefit patients. He said ‘I’m not doing that. All I have to do is sit out this change because there will be another one just around the corner.’

    Please listen Mr Lansley. Look at today’s news about the private care homes losing money and paying low wages. One care manager says putting your loved parent or relative into a private care home is now becoming dangerous. Privatising the NHS by giving commissioning to GP Consortia is just as dangerous.

  154. Martin Stanley says:

    If the government is looking for more advice and leadership from NHS staff what on earth are they doing trying to force this rediculous bill through. Every NHS agency, think tank and select committee say it is wrong.
    Listen to the advice of the NHS, change the bill, make it clinically driven above GP consortia level, if you want GP consortia let them sort out local diagnosis, referral levels and community provision, the things they see and have direct influence on.
    Allow the NHS staff to drive the reforms, find the solutions to any problems and be responsive to the publics needs not the political game playing that it has suffered over the last 20 years.

  155. chris newdick says:

    One problem with existing PCT leadership is the under representation of clinicians on PCT boards. Current NHS regulations require only one person to be a clinician. That is wrong. However, we can fix that problem by changing the regulations so that (say) at least half of the board are clinicians. This would provide PCTs with the clinical leadership required.

    This makes a nonsense of exploding the entire system to achieve the same result. We should retain the existing system, but amend the “PCT Membership” regulations. To save money, we might also reduce the number of SHAs and PCTs, but the basic structures could remain intact.

    On the other hand, talk of making GPs alone responsible for commissioning NHS care is ludicrous. Most do not wish to do it alone and have no training or expertise to do so. Much better to get a range of other skills to join them on the board (including non-execs for their non-partisan experience and common sense).

  156. Genevieve Smyth says:

    Occupational therapists and other Allied Health Professionals have been driving change through a series of AHP Service Improvement Projects. This AHP lead work has delivered sustainable quaility and productivity improvments by working in collaboration with patents and commissioners. The profile of consortia boards should include Allied Health Profession representation. Too often we are represented by nurses or doctors which is inappropriate as we have very different roles. Clinicians can lead change and are having to do so through the current £20 billion of NHS efficiency savings so why this additional change to commissioing structures that has no evidence base?

  157. celticbedouin says:

    It is important that the views of all healthcare staff, from every discipline, and at every level, are taken into account. The rigid class hierarchies of our society are reflected in the structures of the NHS, as are gender and race inequalities. The result is that the overwhelmingly ruling-class and traditionally male and white discipline of medicine dominates the decision-making processes of the NHS.

    But it’s not just the other professions and ancillary staff that are left out. The general public needs to be involved in commissioning as well as evaluating healthcare. However, this should not simply involve rounding up “the usual suspects” in condition-specific pressure groups. There is an extensive literature on how to involve the public as patients, carers and communities, which should be consulted before setting up accountability structures.

    The NHS appears to have been re-organising itself more or less constantly for the 22 years that I have worked in healthcare. This, and in particular the changes in pay structures and employee evaluation systems, has led to a huge cynicism on the part of staff. We don’t have confidence that anyone at the highest levels of the NHS and of government is actually listening.

    So the first and best thing that you can do is show us that you really care what we think. And the best way to do that is to make at least some of the major changes to the white paper that we have overwhelmingly supported.

  158. J Foster says:

    This question confuses clinically-led commissioning with clinician-managed commissioning. To have clinical influence does not mean (one set of) clinicians doing it themselves.

  159. Neville Farmer says:

    The questions in this section seem to assume that Commissioning Consortia from GPs is a done deal – hardly the open to suggestions attitude one expects from a consultation like this. Hospital clinicians from nurses to consultants to pharmacists will not be heard if GPs or their ultimate shareholders are the final arbiters.

    The failure of the current system is that commissioning and clinical management is being handled by distant management staff who are hamstrung by government set standards and box-ticking. There is far too little influence from the clinicians themselves, but by handing budgets to GPs, or rather their corporate managers, you drive the decisions yet further from the hospitals and shatter the culture of co-operation that our NHS needs to survive.

    Hospitals should still be the hub of all healthcare but with more influence from GPs, care services and local people and less top-down pressure from management and central government. Give people the flexibility to find solutions and they will. Trap them with outside control and they will just find ways to please the bean-counters and inspectors. There lies disaster.

  160. J Hanlon says:

    I have worked as a public health professional in the NHS for 20 years and work closely with many clinicians, for whom I have the greatest respect. I think you will also find that many of these same clinicians have equal respect for the managers, public health professionals and administrators who help to keep the show on the road, many of whom bring a great deal of knowledge and experience to improving the health of the population and managing health services.

    I wonder whether Mr Lansley really understands the role PCTs have been undertaking, admittedly some better than others. I worry about the lack of co-ordination and strategic overview that will be inherent in the new system. It feels as though many functions which provide safety, assurance and quality will be fragmented, or worse, dismantled altogether.

    Greater clinical involvement is undoubtedly a good thing, but these reforms suggest that this was not happening at all, which is nonsense. Improvements could have been achieved by a much less disruptive change. As it is, many people who have worked very hard for the benefit of patients for years, in the face of constant reorganisation, have just about had enough of being decried as useless bureacrats and will leave. The NHS will be worse for it.

  161. Linda Waters says:

    Advise and leadership are meaningless unless we have a NATIONAL health SERVICE. Unless the duty of care to every citizen remains we will only be left with health, no SERVICE and it will not be NATIONAL.

    The duty of care must be kept or all other discussion is pointless.
    Other discussion is a smokescreen to cover the removal of the duty of care. This must not happen.

  162. Ivy Beard says:

    The proposed, Foundation Trusts, Commissioning Consortia, Consolidation, Fragmentation and Privatization should be no part of the publicly owned NHS.

    The entire Health and Social Care Bill needs to be withdrawn. Full and Proper Scrutiny in Parliament is needed. This is the responsibility the Government has when taking public money for the NHS.
    Privatizing any part of it by management takeover’s where profits can go to administrator’s, or share holders is a robbery of the public money invested in the system.

    The proposals were not in the Government manifesto or in the coalition agreement. So there is no mandate to force these proposals through, on what is a publicly owned NHS health care business.

    Meant as an insurance against illness, when needed with equality of care throughout the health service.

    The proposals are a mishmash of unaccountable variations which include inequality of care, money wasted, and it should be stopped, if crippling legal wrangles are not to bankrupt the whole system.

    Not Revolution but Evolution, means decisions by the back door and Survival of the Fittest and this is not the ethos of the NHS.

  163. Having just recently lost my husband and seeing how the hospital is trying to run without any staff it becomes apparent that the NHS needs a simple remedy. What is the point of having some of the best surgeons in the world and expensive cure treatments when there is no ground network to help the patients recover. Nurses, we need more nurses. In the news last week the hospitals were reported to neglect old patients. Well, when one is gravely ill they too can begin to look like an old, grey person who will be at the mercy of the people who can nurture them. It is the care that patients receive that can tip them into recovery. Without more rested nurses the sick haven’t got a chance and many families up and down the country will be crippled with the loss of one of their loved ones. Nurses are needed and we need them now. This alone would save the NHS.

  164. Nick Dibben says:

    My response to bullet three is – don’t subject them to competition

  165. Dominic Houghton says:

    If more involvement from NHS staff in running the health service is genuinely desired, then there needs to be less pressure on them in other areas.
    Front line staff often do not have the time to take the rest breaks supposedly mandated by the working time regulations, much less complete additional training or try to change procedures. There is also a lack of vertical communication between those working with patients and those managing areas and coming up with protocols.
    Those involved with day-to-day patient care are having to run simply to keep up with the present demand, and the incoming cuts are only going to make this worse. It is foolish to suggest that they be given responsibility for improving services until something can be done to address this.

  166. web editor says:

    This page was closed to comments on 31 May, the last day of the listening exercise. Thanks for all your comments, which have been fed back to the NHS Future Forum to consider.

    The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response.

    Annelise@DH