Our experience in Lewisham shows why GPs are walking away from CCGs, refusing to be puppets for trusts and private firms
From April 2013, more than 200 clinical commissioning groups (CCGs) will be responsible for designing local health services in England and responsible for spending 60% of the NHS budget.
They hold much promise: former health secretary Andrew Lansley’s Health and Social Care Act 2012 promised that local services would be formulated around the needs of local people, influenced by local residents and led by local clinicians in partnership with other informed and committed local health and social care professionals.
Because of this potential, GP practices in many parts of the country, such as the Lewisham practice where I work as a GP, in south London, initially welcomed the new plans. We saw it as a real opportunity to improve services for local residents and remove some of the long-term frustrations of fragmented and poorly communicating services.
Since June 2011, Lewisham GPs have been working with residents, the council, Lewisham healthcare NHS trust (which provides hospital and community services) and the voluntary sector, and have been commended for their involvement in significantly improving healthcare. Lewisham received an outstanding Ofsted report in children’s safeguarding, and we’ve seen extraordinary increases in childhood immunisations, substantial savings in prescribing costs, and reductions in emergency admissions for chronic obstructive pulmonary disease (COPD). All this has been underpinned by dedicated, engaged GPs keen to see improvements in care, and promises of influence and proactive transformation in ways of working across primary, secondary and social care.
We were all set for increasingly effective partnerships, and were discussing integration of budgets and joint working practices and seeing genuine movement in our main secondary care provider, Lewisham hospital, to respond to the needs of our local population and manage responsibly within the local healthcare budget. This was true clinical commissioning: listening to patients, assessing needs and developing responsive cost effective services.
Yet all our good plans look as if they will come to nothing, because of the financial failings of our neighbouring health trust. When the South London Healthcare Trust went into administration in July 2012 after it had been losing about £1.3m a week, we began to work with the trust special administrator, Matthew Kershaw. As part of the consultation process we argued the case for local commissioning, and warned of the dangers of fragmentation of services without a central NHS trust with escalation of costs and reduction of quality and patient experience.
No argument has any weight, however, against the needs of a failing trust, foundation trusts and potential private companies eager to expand their areas of influence, and NHS managers convinced of the merits of their model of fewer larger hospitals. Those of us who have spent hours acquiring the skills supposedly to lead commissioning have been shown that, in fact, decision-making and influence remains where is always was: with central managers, computer-derived models and reasoning that takes no account whatsoever of human behaviour in real life. We are little more than window-dressing for central planning geared to the needs of large foundation trusts, and open to the interests of the private sector.
It is small wonder, then, that we as leaders start to turn away from clinical commissioning to return to our practices, where we can at least look after the interests of our own patients and help them get what they can from the remaining fragments of the NHS. Small wonder too if GPs en masse are turning their backs on commissioning just months before most CCGs are about to be authorised.
Our experience in south London is set to become more frequent over the coming months as 33 hospital trusts across England are teetering on the brink of administration.
Perhaps the greatest disappointment in Lewisham is that I believe we had a real chance of getting hospital expenditure under control and enabling patients to access services they need, where and when they need them. With the planned reconfiguration that Kershaw has now recommended which will mean the loss of the A&E department and maternity units at Lewisham hospital this chance will go, the influence of secondary care is increased and few levers remain to stop the continued shift of resources from community to acute care and most likely the private sector. The shift has no relation to what residents need or want, it contradicts the promises set out in the Health and Social Care Act, and is instead driven by self-interested secondary providers such as foundation trusts, at the expense of the needs of local residents.