So much for local commissioning
Posted on 7 January 2013 by Helen Tattersfield
The current controversy surrounding the plans of the trust special administrator to alter radically the services provided within the London borough of Lewisham tests the whole concept of ‘local commissioning’.
Without exception, all the key local groups who have been given the task under the Health and Social Care Act of improving the health of the Lewisham population have expressed dismay and outrage, anticipating both poorer health outcomes and higher costs.
We are told that the numerous, well-evidenced arguments, petitions, public comments and other responses to the consultation will be reflected in the final report, but as these did not seem to influence the drafting we are not confident of any significant change.
So what about local commissioning? Tasked to improve health and reduce inequalities, we have worked proactively and responsively with Lewisham residents, established powerful working relationships with the local authority, Lewisham Healthcare NHS Trust (secondary and community services), and the voluntary sector, and have a strong patient voice.
Lewisham’s (shadow) health and well-being board has agreed aims and coordinated plans for maximum effectiveness.
With the prospect of real influence on our local secondary and community care provider, for whom Lewisham residents represent 80 per cent of its income, local GPs have also been actively engaged, and the clinical commissioning group expects to be authorised next month.
We have seen improvements in the quality of secondary and primary care services, in working arrangements and in patient experience. Social care and healthcare are now working together with a single point of contact and coordinated discharge.
New pathways emphasising care in the community, health promotion and illness avoidance have been instigated, resulting in reductions in hospital admissions. GPs challenged by comparative data, and learning from each other, have dramatically improved children’s vaccination levels and prescribing.
This has been possible due to the strength of local relationships and a common purpose. Consultants and hospital nurses needed to be challenged and encouraged to work into the community, and social care had to get on to the wards to start planning discharge.
All this is exactly what is envisaged by the Health and Social Care Act, and what we as commissioners have committed precious hours to.
We are now being told our acutely ill patients will be admitted not to our local trust but to one of four out-of-borough sites, all with different local pathways and different arrangements with social and community staff, and over whom we expect little, if any, influence.
We face the prospect of our local population and GPs losing confidence in the remaining unsupported local services, and choosing to get their routine care also outside the borough. Commissioners would lose control of outpatient and routine admissions.
GPs, their influence so diluted as to be meaningless, would have little reason for remaining engaged in commissioning at any level, thereby putting in doubt any future for local clinical commissioning.
If this is the way that enthusiastic GPs who have embraced clinical commissioning have their efforts rewarded, it is hard to see how GPs will continue to engage in commissioning or any other NHS reforms in any effective manner.
So ‘no decision about me without me’ becomes ‘all decisions about me depend on the needs of others’ where those others are indebted trusts, failed institutions and specialists in ivory towers. Local commissioning returns to the substitutes bench while the real players get on with the match.
Helen Tattersfield is chair of Lewisham clinical commissioning group and a London GP
clinical commissioning groups