"There is a way" - Bryan Smith's open letter

I recognise some people will react along the lines of ‘here comes another self-interested input telling us what to think’.

I believe I am in the ideal position to take a dispassionate yet well informed overview of what is going on and to express this in layman’s language.

My main message is that although it is all an unholy organisational mess right now, the people of Worcestershire should not worry too much about the unfolding local situation.

We are making good progress in finding our own way out of the mess.

I say it is an unholy mess because, as you can well see, the whole NHS machine as we know it is being dismantled and rebuilt.

We all know it was not working perfectly but it was improving rapidly, here in Worcestershire as well as elsewhere. A real professional team like the Mercedes-McClaren F1 team might sensibly respond to this sort of situation by dismantling the whole car and re-building it.

For amateurs to do this to the infinitely more complex NHS organisation at a time of economic difficulty was just plain crazy.

As an experienced manager I cannot bear to see really good, highly committed people being demotivated by being described simply as ‘bureaucrats’, nor can I bear to see some of them leaving the NHS altogether or running for safety into lesser jobs which do not fully utilise their skills.

Managerial talent is a rare commodity which one cannot afford to demean and squander. In the very long-term this may not matter much, no doubt another generation of skilled managers will develop. However, in the medium term, things will surely not be as good as they otherwise might have been. One of the main proposals in the health and social care Bill is to give the GPs responsibility for commissioning most local NHS services, in addition to their existing role of diagnosing, prescribing and referring.

In Worcestershire, I understand that this will mean they contract for about £650 million of services every year. It is important to recognise that this money is not just being given straight to doctors’ practices, i.e. private companies, to spend as they see fit.

Instead, GP practices are having to group themselves together into ‘GP consortia’, and while they are operating in these consortia, GPs will be full members of the NHS answerable to a new national commissioning board. The existing commissioning body, the PCT, will be abolished in 2013.

The objective is quite sensible. It is normal practice in most businesses to ensure those who place contracts or purchase goods have recent hands-on experience of working with those goods or services.

“On the other hand it is not likely to be the magical cure-all for the ills of the NHS. Those of us who have frequently been involved in re-structuring businesses know that every fundamental change of organisation solves some problems but creates others. In Worcestershire we believe we are as well equipped as anywhere to cope with this challenge.

We have three very capable GP consortia already formed, keen to take on the commissioning role and thinking hard about how it can be done better.

If this predicted problem of GP capacity does eventually emerge I believe it is most unlikely to be manifested first in Worcestershire.

On the other hand because PCTs have been given a limited life, their staff, doctors and nurses included, are now jumping ship.

This had started to render some PCTs, though not Worcestershire, ill-equipped to deliver their responsibilities during the remainder of their life up to 2013. To counter this, the Department of Health has required all PCT staff to be grouped together into ‘clusters’ with immediate effect.

All Worcestershire PCTs staff have therefore now become members of the West Mercia cluster of PCTs alongside Herefordshire, Shropshire and Telford and Wrekin.

While I cannot quantify or prove this assertion, I believe that this situation will probably be all right as a temporary step along the route to GP commissioning but would be unsustainable as a means of maintaining the status quo in the long-term.

We in Worcestershire are therefore now committed to proceed as fast as possible towards full implementation of the GP commissioning element of the health and social care Bill.

I suppose in theory we could slam the brakes on, re-recruit a full new PCT and thus go into reverse, but this would now be extremely difficult. What we certainly cannot do is just stop.

Many people may be confused by the fact that on the one hand national spending on health is being maintained and protected from inflation while on the other hand there appears to be a need to save £20 billion in the NHS in the next four years.

The reality is that someone has estimated that the NHS actually needs to improve its productivity so that it can provide £20 billion worth of increased and/or improved services in four years’ time for the same money as at present, otherwise the service will be deemed to have deteriorated.

This is equivalent to around 20 per cent improvement in productivity.

The potential to improve by this order of magnitude is confirmed by international comparisons.

By some bizarre process this urgent need to improve productivity to cope with a growing workload appears to have got translated mainly into cutting costs and jobs.

“Admittedly, there may be some need to reduce the workforce if non-workforce costs increase faster than our protection against inflation but this should not be the major feature of the next few years.

“In Worcestershire, as in everywhere else in the country, the two provider trusts are being asked to prepare plans for achieving four per cent productivity improvement in each of the next four years. This poses particular difficulties for the Acute Hospitals Trust.

“They have to respond instantly to any demands for productivity improvements because so much of their income is via a ‘tariff’ which is a direct productivity related payment.

“Furthermore, there is a national trend to move care out of hospitals and into the home, which reduces their potential to ‘grow their way out of trouble’.

The functions of the PCT, many of which are transferring to GP consortia, are also subjected to severe productivity pressures.

The good news is that the planning for all of this is being done jointly between the three main NHS trusts (i.e. including the PCT) and the three emerging GP consortia, all working alongside the county council.

This means that whatever eventually emerges will, overall, be the best that is achievable for Worcestershire. As far as I am concerned we will not be actively looking for cuts at all during this process, rather we shall seek ways of doing things differently in order to increase productivity.

We shall also be mindful that our staff, people who are motivated by the desire to care for others, actually respond better to opportunities to extend that care rather than by being threatened with the sack.

Who is Dr Bryan Smith?

• An engineer with a background in heavy electric and chemical industry. Retired director of engineering at ICI.
• He has been a Malvern Hills Conservator, chairman of the Malvern Hills Area of Outstanding Natural Beauty and a local councillor.
• Appointed chairman of NHS Worcestershire at its inception in 2006 by the Appointments Commission (not the NHS) to act as independent overseer.
• Not a member of any political party.

What’s planned

• Under Government proposals 65 to 70 per cent of the £850 million budget of NHS Worcestershire will be split between three ‘GP commissioning consortia’ made up of GPs.
• They will be – South Worcestershire (including Worcester and Malvern) - £286 million budget for 2011/12; Redditch and Bromsgrove – £182 million and Wyre Forest – £133 million.
• The remainder of the cash to be split between Worcestershire County Council, which will have responsibility for public health and a new National Board.