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CCG Series: Re-forming the game

CCG Series: Re-forming the game
11 June 2014

Is it time to blow the whistle on unsustainable and unachievable initiatives in the NHS? The chair of South Devon and Torbay CCG explores exclusively for The Commissioning Review. 

Is it time to blow the whistle on unsustainable and unachievable initiatives in the NHS? The chair of South Devon and Torbay CCG explores exclusively for The Commissioning Review. 
As a CCG we have been going through the process of what I have termed ‘re-forming’ my addition to the Tuckman model (Forming – Storming – Norming – Performing). I believe it is necessary afeature of a healthy organisation for it to regularly review its organisational structures and whether they are fit for purpose. As part of this process I was musing on the traditional SWOT analysis and decided at present I would use a CHAF analysis instead. 
Really just a variation on a theme, this stands for Challenges, Hopes, Assets and Fears (CHAF). 
I admit this doesn’t follow the Pendleton model of positive feedback first but helped me to formulate my own ideas about where, as an organisation, we might need to focus our energies.
We certainly haven’t been short of challenges over the past year or so of formal existence, whether this be specialised commissioning, data issues or engagement with stakeholders and the public, but there are always new challenges arising. 
Managing a tightening budget and the proposed reduction in running costs when we need to be putting more resource into the redesign programme are immensely worrying. One can hope for a change/relaxation in the rules around running costs. We can ask in hope – rather than expectation – for a shift away from the annual book-balancing to a longer period of financial planning. The current model – which expects us to achieve a small surplus within year to allow us to invest upfront in alternative services and permit returns that achieve the disinvestment from other parts of the system within year so the books balance at year end – is clearly unlikely to achieve any more than modest shifts in service delivery.  Being able to invest upfront but look to return balanced books over a longer period is how private business operates, so why is this model not suitable for public services?
However, if there is one area of my CHAF that keeps me awake at night, it is fears for the future. Among these, the recent EU and local elections highlighted one that stands out for me – the general election in 2015. When the Health and Social Care Act was ‘marketed’, one of the great plus points was the loosening of control between central government and the body running the health service that we now know as NHS England. It had felt at times that the NHS was a political game of football – one where whichever manager was in charge was not only changing the team but also the rules of the game! 
The hope was that the NHS Constitution would set out the basic principles we as a country wanted for the NHS, and that the service itself would be left to get on with managing itself. Instead we have seen ‘issue creep’ with announcements coming forth about very specific policy without the real evidence that this is the appropriate way forward. For example, consider the PM Challenge fund and the 8am-8pm 7-day working. Nobody has to my satisfaction demonstrated how this untargeted project will be achievable sustainably and/or achieve expressed aims of reducing inappropriate attendances at A&E and preventable admissions. Yes, we do need to improve primary care access, yes, we need to address inappropriate/avoidable use of secondary care resources but to couch this in the very specific terms of the Challenge Fund feels (to go back to my soccer analogy) like the club shareholders dictating the tactics of the game rather than providing the appropriate environment for an effective side to succeed.  And to keep the political balance, the Labour pledge for 48 hour access to primary care is also a soundbite that sounds appealing, but have the implications of this in terms of resources and unintended consequences really been thought through?  I fear this will only intensify during the year’s run up to the election.
It was Milton Friedman who stated that, “The government solution to a problem is usually as bad as the problem.” Now I may not agree with his political stance, but I am clear that we, as healthcare commissioners, have a duty to consult with our populations. We should be listening to what our local populations tell us.  
I would rather heed their input and plan services around what they see as their priorities than some of the political manoeuvring that can only increase over the next year.

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