Covid proves that commissioning and regulation add little value

For reasons that do not need expanding much has been written about the way in which the health services, both public and independent have risen to the challenges, created by covid-19.

One of the recurring themes is that when the current difficulties end we will have embraced more effective methods of working. Telemedicine, video conferencing, working from home to mention but a few.

Many organisations and individuals had been using these techniques and approaches for some time but what we have experienced over the past few weeks is the uniform approach covering virtually every aspect of the public and private sectors. If we can do this in response to the biggest crisis since the Second World War this way of working should continue into the future.

There is, however, a whole dimension that has had very little attention and comment.

Giving providers a chance

The response to the crisis on the health services has been provider led. We have witnessed trust boards, local authorities, charities and the private sector moving at pace to work together and radically change and align service provision to meet the population’s current needs.

I’m sure that had it not been for the fleet of foot response by NHS chief executive officers and their teams, the effectiveness of the response would have been far less than it has been. The government may have set the agenda but the delivery was locally led. Yes before anyone shouts, the PPE fiasco has been lamentable and this requires a severe examination later down stream, hardly the fault of individual providers.

The emphasis should switch to the board of directors of providers to hold the focus on standards of care, performance management and accountability

My point is that if providers can react in the way they have during these challenging times they should be allowed more scope to get on with the job when things have calmed down.

The emphasis should switch to the board of directors of providers to hold the focus on standards of care, performance management and accountability. Far too much time, effort and resource is taken up in preparing for inspections and reporting to external bodies.

This also applies to commissioning. Of course there are examples of good commissioning but in my view, overall it has not been effective and brings little added value.

We need to take this opportunity to put the focus back on providers to work with each other and collaborate on which organisation is best placed to provide a particular service even if it means a trust giving things up for the overall better good. The development of strategy over a local health economy will be much more coherent if provider led.

Siege mentality vs collegiate approach

Providers are best placed to do this, however, the existing culture, management structure and approach mitigates against this and the service is littered with examples of ill conceived commissioning often by highly inexperienced people that are far from taking things forward and have in fact set things back.

As a result, at times there is a siege mentality from providers, “What we have what we hold” as opposed to a collegiate approach that would result in a much more coherent approach to overall strategic planning and service provision.

A current example of a provider recognising that a service would be better placed elsewhere is from the East and North Hertfordshire Trust. The trust currently manages the Mount Vernon Cancer Centre.

For many reasons the trust board had long felt that this highly specialised service would be better placed with a provider that had far more expertise in the specialist area of cancer. Plans are underway to transfer this service to University College London Hospitals Foundation Trust next April. This strategic move was instigated by the trust and has been widely welcomed by most involved.

Being provider led will result in increased involvement of clinicians who will be at the forefront of determining care priorities and direction of travel

As said, the emphasis and responsibility should be placed much more on the shoulders of the local board of directors. There will of course still be the need for professional regulation by bodies such as the Nursing and Midwifery Council and the General Medical Council.

Being provider led will result in increased involvement of clinicians who will be at the forefront of determining care priorities and direction of travel. Providers are also better placed to maximise patient involvement.

The regional offices of the NHS should continue with the overview, which in my experience currently appears to work well.

Post-coronavirus era

Regional offices will need high-level reports on a whole range of issues. For example, SMR, SHMI, complaints, SUI’s, infections rates to mention but a few. These returns will ensure there is oversight on performance that in turn can trigger further investigation if required.

I chaired the Medway Maritime FT for six months from November 2016. In conversation with the highly effective CEO Lesley Dwyer who was recruited from Australia I asked her what she found was the biggest difference between the respective healthcare systems between the UK and Australia.

Her reply was instantaneous “regulation”. Lesley explained that the health service in Australia has nowhere near the level of regulation that we have in the UK and that the performance of the two healthcare systems is broadly similar.

In the post coronavirus era there will be a huge backlog of work, elective surgery, a whole range of conditions that will have deteriorated during the lockdown period plus newly diagnosed conditions as a result of people not presenting either to their GPs or accident and emergency.

In the post coronavirus era there will be a huge backlog of work, elective surgery, a whole range of conditions that will have deteriorated during the lockdown period

Many trusts are currently reporting record levels of low attendances at A&E. One of the trusts that I work with reports that A&E attendances are down 50 per cent and outpatient attendances have fallen from 10,000 a week to 2,000.

On 25 April, Sir Simon Stevens issued a plea that the public should continue to use the NHS in the way they normally would, stressing that although the NHS is currently having to cope with covid-19, the NHS was still open for business.

It is self evident that Sir Simon is concerned that the NHS could be overwhelmed once the service begins to return to some sense of normality.

Even if the public begin to heed Sir Simon’s request with immediate effect, the point has passed when the collateral consequences of the pandemic cannot be avoided. There is no question that the pressure on services will be immense and the combination of the backlog and new referrals will be felt for the foreseeable future.

Common sense should prevail and there should be a shelving of many of the reporting requirements that currently sucks in so much time and effort. The suspension of many targets for an appreciable period to enable the NHS to regain some equilibrium is essential.

Test of time

In conversation with many people over the past few weeks there is a real sense of optimism that once the current crisis is over there will be no going back to the status quo. I only hope this is the case but I do have some doubts.

History tells us that in times of crisis punditry goes into overdrive. The First World War was predicted to be the war to end all wars. A cursory examination of the comments made in the aftermath of the 9/11 attack on the twin towers in New York led to people suggesting that this would herald the end of offices in tower blocks, there would be more home working and that people would be kinder to each other.

As time passes memories fade and my worry is that the love affair the nation is currently enjoying with the NHS might diminish. It will never fade, as the population knows that overall, despite at times its difficulties, we have a healthcare system to treasure and protect. Nevertheless the opportunity to seize a different approach could well be lost.

The NHS is fortunate to have such high calibre clinicians and managers who are responsible for the management of provider organisations. NHS management often suffers from a bad press, where failures are given such high profile that the perception of many is that of a poorly run service. The opposite is the case.

Despite the undoubted difficulties and challenges, the British public should derive comfort, even in these difficult times, of a service with such highly motivated, conscientious, ethical and skilful managers and clinicians. Post the covid-19 crisis the baton of responsibilty should remain firmly in their hands.