So Andrew Lansley wants GPs to take the lead on commissioning health services in England.
If you can put to one side, just for a moment, that he is completely ignoring nurses and midwives in his plans, utterly dismissing any requirement to plan at a regional level, and thoroughly vilifying every level of management in the whole of the NHS (work with me on this), I would like to consider the actual practicalities of primary care clinicians taking responsibility for buying healthcare on behalf of whole communities.
Rhetorically it all makes sense, even the soon to be demolished ivory tower of the PCT. GPs and others working in primary care are closest to the patient, their carers and their needs. Surely then it is they who are best placed to know what is needed?
During the last few months, as I have been completing my return to practice programme, I have enjoyed two very different clinical placements in what could broadly be described as a primary care setting; this has given me a real chance to consider the nitty gritty issues of the new health policy.
Half of my time has been spent with the district nursing service and the other within a prison healthcare setting. The contrasts are obvious and hardly need referencing - never mind describing. More surprising, however, are the similarities that exist between the two. While this is something best left to exploration in a future article, the most pertinent thing here is that I have developed a relationship with people from across the whole of a given community in both circumstances. There is absolutely no doubt that this relationship between the nurse and his or her various patients is exactly the relationship that the secretary of state values so highly.
So, surely if we could persuade him that doesn’t have to be just about GPs - that our profession brings so much to this new agenda, then we would be in the box seat to deliver his vision. Isn’t it obvious?
Well, no, not really.
I know I’m only just coming back to practice, and I know I am hardly objective, but there seems to be three real obstacles to anyone in primary care leading commissioning in the way we have understood it to date.
To begin with, in virtually everything we do, we are dealing with the individual. The needs of our patients come first and anything that comes in our way (like budget restraints or policy decisions) are easier to deal when regarded as decisions made by anonymous others. I really can’t imagine myself saying: “I’m so sorry Mrs so-and-so but I’m not going to refer you to the clinic because my colleagues and I have decided, following a rational review of our community’s needs, that your condition is not a priority.”
Second, we are always dealing with the immediate problem, and it is so difficult to see beyond this. I - like thousands of other nurses every day - have to respond to the patient in front of me and not the unspoken needs of the community within which I work. Even in a prison environment, where you are constantly reminded of the whole population (prisons are the noisiest places I have ever worked in) you still have to deal with your patient’s presenting condition.
Finally, to live the coalition’s dream, we have to remain clinically engaged. Every hour a GP (or any of us) spends collaborating with colleagues on discussing commissioning decisions and options is an hour away from the patient. Two hours if you take into account average travel times to convenient locations - three, four or more if you are conscientious in your preparation, and heaven knows how much extra once you are caught up with the governance arrangements of any decent organisation.
So it seems there are two potential paths along which the new NHS can be pushed. The first will simply see a reinvention of a commissioning organisation to support the new clinical commissioners; this is, I am sure, not what this government wants. The alternative, however, and perhaps the more likely, is a shift away from “commissioning” as we currently understand it and towards a less managed market where everything has a price and services are bought depending on demand. Nurses, and nursing, will become merely a commodity to be traded. Not, I am equally sure, what most of us want.
- Nursing Times believes that nurses must be actively involved in the new commissioning consortia being set up from now until April 2013, and that their involvement must be at the highest level. Sign our petition to show your support.