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To commission or not to commission?

Lynn Young
Primary Healthcare Adviser for the RCN

Lynn Young discusses the impact on patient care of the latest health reforms, in the name of creating the “Big Society”...

Readers of Nursing in Practice must be acutely aware of the controversy surrounding the latest round of NHS England health reforms. All current structures within the NHS and a number of health-related organisations are to go by 2013.

While this may not be the most intelligent round of plans for the NHS, the government is in charge and has given its orders. Goodness knows what the impact will be on patient care as a result of such radical change and its implementation.

No one could, with any credibility, accuse our Secretary of State for Health, Mr Lansley, of being cautious or faint hearted. These are the boldest of reforms (perhaps as bold as the introduction of the new NHS in 1948) and since the publication of the various white papers a significant number of diverse views have been loudly expressed.

As we would all expect, it has been the GPs who have offered the most articulate and wide-ranging of views. A number of GPs cannot wait to get hold of the reins and drive most of health commissioning, rather then just a small part of it through practice-based commissioning; others are absolutely adamant that they wish to have no part in the exercise; and there are many in the middle who do not hold strong views either way. It is likely that once the new consortia are in place, this group of GPs will not be actively involved in shaping local service provision.

The financial climate is dire and we already know of the call from the coalition government to cut financial benefits and reduce the public sector - in the name of the Big Society. The state is about to draw back from funding certain services and providing others. Communities will have to move quickly towards driving self-help, mutual support, social cohesion and social capital. The result of no action on these fronts will, without doubt, be doubly disastrous for people living at the lower end of the economic ladder.

Families who depend upon family tax credit, child and other financial benefits are beginning to feel very frightened about how they will cope with everyday life in the future. Even the Archbishop of Canterbury has pronounced that many people are likely to descend into a spiral of desperation as a result of harsh government measures.

These issues are pertinent to nurses, regardless of where they work. High unemployment and reduced personal circumstances ratchet up physical and mental illness. The children of long-term unemployed and relatively poor parents tend not to flourish. We need to remember how critical the early years of childhood are to promoting the health and wellbeing of the adult years.

So, back to our GP colleagues: it is one thing to be eager to commission improved health services, but quite another to lead on your locality's commissioning during a time of financial cutbacks. Reduced funding means that the near future is more likely to focus on decommissioning to meet budget requirements, rather then commissioning for service improvement.

The facts are plain to all. At some point, and as soon as possible, we have to see courageous commissioning taking place - whoever is doing it, with or without GPs.

Commissioners must rapidly decommission those services that do not work; reduce those that have dubious impact; and spend public money where it can bring maximum good to the greatest number of people.

This is what the Big Society could be about if we play our cards
right: helping and supporting us, doing with us and joining up far more then in previous times. One day, the NHS may cease striving to meet the excessive demands of the articulate and relatively healthy middle class and focus attention on those who ask for very little.

Inequalities are bad for all of us, even the rich. If you wish to learn more about the horror of health inequalities consider reading the book The Spirit Level: Why Equality is Better for Everyone (see below). And, when you have read it tell me if it has changed the way you see the world.

Further reading
Wilkinson R, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin; 2010.