Reworking the NHS

I am going to make this simple. The NHS is not set up right and the current change has not improved much. Everything is still commissioned/contracted in silos; the organisations do not have real cross-commissioning capabilities and as for performance monitoring – still poor.

So we need a different solution that drives integration and supports joint working. Well that is not too difficult really if you think about things slightly differently. And it is not too difficult to divide up existing contracts into parts so that they can be managed and driven in different ways. So her is my thinking:

‘Primary Care’. Primary Care is the delivery of the first element of care. There are several services that provide primary care by this definition. It reflects the continuum that NHS England describes from NHS Choices, through community pharmacy and general practice to out of hours and A&E. Why can’t they be commissioned together? Bring every contract they we hold in which any person rolls up and ask about their health or needs acute care. Include the police, ambulance and paramedic services and others. Fix the total budget and manage it in such a way that co-operation drives profitability and creates a will to manage demand. Look at the capability of each element of the service to one-stop manage as much as possible without unnecessary transfers, signposting and referrals. Build capacity in the most accessible and least expensive elements of the continuum.

‘Continuing Care’. Again there are several services that provide continuing care for patients with medium and long term conditions. General Practice might be considered the backbone, but many patients are admitted to hospital – so called unplanned care – or to care homes. So again, let’s bring all of the contracts together – health and social care. Commission Consultants to work side by side with GPs, community pharmacy, community services, social services, housing with voluntary and charitable organisations. For it to all work people must remain well and in their own homes where possible.

‘Planned and specialist care’. NHS England is already commissioning a range of specialist services to look after people with rare and complex disorders. In this same pot I would commission all planned care from hospitals and the trauma and emergency response services. They should have national standards, national comparisons and controlled providers

‘Public Health’. All services that maintain and improve the health of nation are already commissioned from public health. Is this the one thing that we have right and are they moving in the right direction? Probably yes – they are gathering all of the contracts under their wing, stimulating providers and commissioning across boundaries and silos.

The big question is will it happen? The NHS does not need radical reorganisations and structural change. It just needs a better focus on what it needs to achieve and a better mechanism to drive cross-silo commissioning and inter-service dependency.


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