Standing at a crossroads

Summons speaks with influential Department of Health advisor on clinical commissioning Dr James Kingsland about the case for urgent and radical NHS reform in England

DR JAMES KINGSLAND has long been a champion of practice-based and now GP commissioning, having worked for years as a part-time GP advisor to the Department of Health in England. He is currently the National Clinical Commissioning Network Lead – a position which gives him a direct line to Ministers.

Dr Kingsland was previously a personal advisor to Lord Darzi and was instrumental in the development and implementation of PMS policy. He served for four years as chairman of the National Association of Primary Care and is currently president of the organisation.

Having practised on the Wirral since 1989, he is a senior partner in a PMS practice in Wallasey which was an early adopter of practice-based commissioning and is now in a first wave pathfinder consortium. Among many other roles he also serves on the NICE Commissioning Steering Group and is a non-executive director of Clatterbridge Centre for Oncology Foundation Trust.

Dr Kingsland is married with two daughters and enjoys golf, football (having only recently given up playing five-a-side), music and broadcasting, being the resident doctor for BBC Radio Merseyside

Do you think the NHS in England needs revolution rather than evolution?

Revolution brings to mind overthrowing regimes and bringing down governments. I’ve heard Sir David Nicolson say – this [NHS reform] is not a revolution but an evolution as in fish-to-man in two years. It’s really somewhere in between. It’s not revolutionary in dismantling everything we’ve built to date; it’s building on the best of what has been successfully created since1948. But the urgency to improve productivity in the current financial climate, does not allow for a slow incremental change; it’s got to be rapid and quite far-ranging.

What does your role as National Clinical Commissioning Network lead entail?

What we are trying to do is develop a collective understanding of the reforms right across England and connect leaders in commissioning – emerging and established. The network is system-wide in terms of geography but also in clinical disciplines– recognising that while GP commissioning boards will be led by their constituent general practices, the redesign of care services, the reform of our NHS will be delivered by a multidisciplinary team approach. Optometrists, dentists, pharmacists have a massive repository of information about local populations and individuals. AHPs, community and practice nurses are all resources in themselves, commit resources and do needs assessments – which is all part of commissioning.

Why is there so much opposition to the health reform bill among GPs?

There has been a lot of scare-mongering, misinformation and misunderstanding, and – sometimes – a mischievous interpretation of what’s required. I think the narrative – articulating exactly what it is that we expect GPs to do – has also been lacking. I hear GPs say: ‘yes, we want patients to be involved, to be the source of control in the system rather than the current inherent managerial control, and yes, we would like to have more say in how NHS budgets are deployed. We do want to improve outcomes for patients and be involved in care pathway design – but we don’t like the reforms’. I can only reply: ‘well what you have just described is exactly what the reforms are for. So why don’t you like them?’ And the answer is: ‘that’s not what we’ve been told. We’ve been told we’re going to have to manage contracts, procure new services and take on complex roles previously performed by PCTs thus taking us out of practice, and we’re going to have all this extra bureaucracy’. Well, I say: ‘who ever told you that is either being very divisive or is poorly informed’.

People misunderstand the word ‘commissioning’. What healthcare managers mean by commissioning is the procurement of health services and contract management. But for clinicians, commissioning focuses on the first part of the cycle which is about needs assessment and securing the best service against that need within the available resources. So when people ask – can GPs commission? I say we do that anyway. It’s called consultation and referral. The act of sitting with a patient and taking a history – that’s a need assessment. And then saying your needs can be best met with hospital and a referral – that is commissioning.

Some critics ask if it is really necessary to abolish PCTs. Why not just add more GPs to PCT boards?

Yes. I’ve heard that protectionist outlook and mainly from personnel currently working in PCTs. But that’s just plastering over the cracks. What the bill is for – is legislation for outcomes and accountability. Now that’s saying we’ve got to have a major cultural and behavioural change in the delivery of care in our NHS. And that ain’t going to happen by just supplanting a few managers with doctors, or adding a few doctors to the current structures. It’s been recognised that our NHS needs major change.

There’s been, for a long time, year-onyear growth in the NHS budget. In 1995 the turnover of the NHS was around £32 billion; by 2010 it was over £100 billion. If a company was guaranteed that sort of growth over a15-year period, whatever their annual outturn and outcomes, they might just get complacent or not be as efficient as possible. In the NHS we’ve had this massive investment but not the concomitant improvement in outcomes. We still have areas of poor health and inequalities, urgent care is broken and long-term conditions are largely managed in the wrong sector. Using international comparative data – I think our report would be ‘could do better’.

Is competition a good thing in a national health service?

Competition within the market has always been a good thing – and it’s there inherently within the ‘NHS family’. Hospitals compete against each other; GPs do too. This established competition has worked to drive up quality and is desirable. The more contentious issue is competition for the market. And that’s something new in terms of increasing the plurality of care provision. I think we’ll get it right by saying competition for the market is desirable when commissioners find a gap, or poor or inadequate provision in local services. Or we as commissioners – the clinical community – start to describe a care pathway to which a current provider says: ‘sorry we can’t deliver that for you’. Or there is no one to deliver it. Therefore what do you do? Do you continue with poor provision or do you find a new provider for the market through the any-qualifiedprovider route?

Do you think the reforms will mean more private industry in healthcare provision?

I don’t. If you understand the anyqualified- provider programme – it’s not always that attractive for new entrants. People tend to think it’s hands up anybody who wants to do NHS work and we’ll give you a contract and a load of dosh. It’s not. It’s saying where there is a need to develop a new service or the current service does not meet the needs of patients, then let’s have a new provider – if they meet NHS standards and can supply the estate and the staff at their own set-up costs and can deliver a full care pathway, not cherry pick a part of the care pathway. They may be awarded an NHS contract without having to tender – but so may others in competition for patients. And importantly that contract does not guarantee any volume of work or income. Payment is made on a cost-per-case basis using PbR and the national tariff for the service provided. Some may wish to do this. Many won’t.

Do you think 2013 is a reasonable timescale for implementation of the bill?

Oh absolutely. There is a lot of talk in the NHS about waste of resources, of time and space, all of which are important – but if we waste spirit, the current enthusiasm and innovation, that would be unforgiveable, because we may never turn that back on. This is the last chance to refresh the NHS and rejuvenate clinicians in terms of being proactive in the management of the public purse. If we lose that, I think that will be the end of an NHS free at the point of need and not based on your ability to pay. We are just starting to see some concern and despondency in the profession due to the pause. We’re certainly losing some of the spirit in our NHS management, but that we can salvage. But if we lose the spirit of the people delivering the service, we’ll never recover. Any longer than 2013 would be very damaging.

There is a big appetite out there for change; the blue touch paper has been lit. If we start to say, oh, let’s think again, not do it, and we lose the momentum already gained particularly within the clinical leaders, and turn off that leading edge which is already starting to re-engineer local services. If we lose that, we haven’t got a chance.

Interview by Jim Killgore, editor of MDDUS Summons

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