Planning and doing – one of the problematic schisms within NHS culture.
Filed Under (GP Commissioning, Primary Care Trusts) by Paul on 02-07-2012
Health care is essentially a very practical activity. It involves patients paying attention to the detail of looking after themselves and taking the drugs that they have been prescribed. It involves medical professionals carrying out diagnostic tests and working with patients that are experiencing pain and distress. The vast majority of NHS staff and patients experience the NHS as a very important set of practical activities.
Most of these staff are right to believe that this is the core of health care, and the core of the NHS.
The problem for such a large system as the NHS is that it cannot survive simply as a series of practical sets of relationships. The organisation of a million consultations every 36 hours and the hundreds of millions of drugs taken every day needs…. well it needs organisation. Some of the people doing this organisation are right next to the practical medical staff – and some of them are a long way away.
Those whose world is boundaried by the practicalities of their work can live in a very different world from that those that organise the organisation.
This is NOT an inevitable split but it is, for a large organisation, a debilitating one that can cause very great problems for the success of the NHS.
By now readers may be wondering why I have launched into such a general treatise on schisms within the NHS. The reason is that this interacts with current NHS reform. The development of GP led commissioning was based upon the belief that GPs – because they were essentially practical people – would ensure that both the organisation of practical activity and its execution would be carried out by the same people. GPs who led commissioning and also treated patients would be the bridge between activity and planning. Tomorrow I want to explore how well this might work.
Today I want to discuss how, in my experience, this split between planning and doing causes problems for successful change and development within the NHS.
One of my clearest experiences of this problem was when working with PCTs to develop commissioning between 2007 and 2010. I was interested to see how the PCTs planned their activity and was surprised at how well that planning had been developed. The Joint Strategic Needs Assessments carried out by PCTs with their local authorities were nearly all good planning documents. They understood their local populations and what they needed, and they recognised what the NHS needed to carry out and what changes needed to be made.
In 2007/8 the problems the PCT’s annual plans had identified were clear – overuse of A and E, the growth in the use of emergency beds (exacerbated by people with long term conditions), and the necessity of moving care out of hospitals into strong patient pathways. The way in which these issues were outlined were different in every PCT, but these were the really important issues.
The best PCTs had clear commissioning intentions built into their plans and one could read off the relationship between the size of the problems and the use of commissioning to solve them.
For many of the others though the actual powers that commissioners had – at their crudest the ability to buy different sorts of care – were not well understood. Instead there were a series of recommendations from the organisations that actually had responsibility to solve the problems through commissioning – that someone should do something about it.
The PCTs nearly all recognised the health and health care issues that they had to deal with, but the problem for many of them was that the human agency – who would bring about the necessary changes to deal with these problems – was not to be found within them. Someone should deal with the increases in the use of A and E – but they weren’t really that someone.
So the relationship between working out what problems needed to be tackled and the way in which they could deal with them, was absent from many PCTs. At the end of the year, within these PCTs, very little had been achieved in terms of tackling these problems, and not a lot had changed
Between 2007 and 2010 this improved. More commissioners understood what commissioning could and actually should do. But for some the difference between articulating the problems and what the PCT itself could actually achieve was simply absent.
As I say GPs were meant to change this. Tomorrow I will explore how they might and might not do that.
