The winding pathway towards re-shaping the NHS in Wiltshire

Written by Tony Millett on .

As the coalition government’s plans to bring radical change to the NHS advance by fits and starts, it’s now clear how Wiltshire will be divided into the newly termed “Clinical  Commissioning Groups” (CCGs) – which just a month ago were called “GP Consortia”. These groups will be given most of the county’s NHS budget which is currently administered by the Primary Care Trust (PCT) – in our case by Wiltshire NHS which is due to be abolished after April 2013.

At the start of the government’s reform process, Dr Helen Kingston (pictured left) wrote the application for what were then five Wiltshire GP consortia to start the process toward official formation.  Now she has told Marlborough News Online that there will be just three CCGs in Wiltshire.

The Marlborough Medical Practice will be part of the CCG that brings together the East Kennet (Marlborough, Great Bedwyn, Burbage, Pewsey and Ramsbury practices) and the North Wiltshire areas.   It stretches from Corsham in the west to Ramsbury in the east, south to Pewsey and north to the border with Swindon.  It will take in a population of about 167,000 out of Wiltshire NHS’ total of 455,450 people.

[The other two CCGs are Sarum – the south and south-east of the county based in Salisbury. And the CCG temporarily known as WWYKD – pronounced ‘wicked’ – which includes west Wiltshire, Yatton Keynell and Devizes.  Dr Kingston is joint chairman of this CCG.]

Dr Kingston, who studied at King’s College, Cambridge, and trained in Oxford and Bath, qualified as a GP in 1990. She’s a partner in the Frome Medical Practice which has a branch surgery in Warminster.  And she’s now working with lead doctors in the three groups on some Wiltshire-wide plans.

Dr Kingston acknowledges that there is a ‘tension’ between the demands stressed in the government’s health White Paper that the new structures to deliver the modernised NHS must be local and the whole service ‘patient centred’, and the tight state of the public finances.  She says there’s a difficult balance between being small and ticking the ‘local’ box and the need to find economies of scale to achieve the huge and obligatory savings within the NHS. 

With that in mind, the three Wiltshire CCGs are moving towards setting up an ‘over-arching’ organisation to provide essential management and administrative back-up right across the county.  Some will undoubtedly say this looks like the ghost of the PCT.
Others will whisper that it might even mean that eventually there will be just one CCG for all Wiltshire.  And that would not look good for a government that has made so much of its drive towards localism – pushing decision-making further down the democratic ladder.

Dr Kingston takes a positive view of the coalition government’s response to the parliamentary ‘pause’ and ‘listening process’ that followed the trenchant criticism – from within the health service and from outside – of Health Secretary Andrew Lansley’s original plans.  She’s especially pleased with the new attitude toward managers  - no longer seen as a “waste of space”.

She also backs the switch from the reliance on competition towards more “co-operation and coordination” to find the best ways to treat patients and improve care.  The ‘year zero’ approach of the White Paper has gone: “Lots of good things are happening already [in the NHS] – let’s not throw the baby out with the bath water.”

However she does admit that the drawn out uncertainty amongst so many NHS employees is not good: “We need the new order put in place so we’re not distracted.”  And she explains that the silence on the changes from the groups isn’t because people at local level “haven’t made up their minds, the structures haven’t been decided centrally yet”.

The process of these reforms has been slowed considerably – perhaps Andrew Lansley (pictured left) thinks of it as another over-long waiting time for treatment.  And the new governance requirements for the CCGs are putting extra layers into the structure – in Dr Kingston’s words “frameworks and frameworks within the frameworks.”
“If the governance arrangements become very complex – it would drive us towards a larger grouping – because the infrastructure and expertise to manage it would need to be of a higher calibre and the resources for that would become too costly for small groupings.”

There’s that hint again that in the future they might need to be a single CCG for Wiltshire – the ghostly PCT walking abroad again.

But she fully acknowledges that, even when reinforced by boards that will include a hospital doctor, a registered nurse and two lay members, the new groupings of GPs will be responsible for such huge sums of taxpayers money that they must be seen to be properly set-up and accountable.

The Wiltshire’s CCGs’ next hurdle is for their business plans, accountability and governance structures to be signed off by the PCT at its July board meeting.  If the PCT is satisfied they will become ‘interim CCGs’.
Final authorisation can only come in 2012 once the new NHS Commissioning Board comes into existence and has its say on what the government calls the groups’ “skills, competences and behaviours to do their job well.  Skills that they will need to be able to commission high quality care within their allotted resources” [from ‘Government response to the Future Forum report’ – 3.93.]

There are now a lot of people whose official job – never mind the journalists, politicians and busy-bodies – will be to peer over the GPs’ shoulders and make sure they’re doing the job properly.  And then, of course, there’s the public, the patients.

The government’s new plans for the CCGs put a tremendous onus on them to involve “patients and the public in their commissioning decisions”: “Clinical commissioning groups will be required to consult on their annual commissioning plans to ensure proper opportunities for public input…[and] will have to involve the public on any changes that affect patient services, not just those with ‘significant’ impact.”  [from ‘Government response…’ - 4.41.] (That would certainly include any future changes to the use of Savernake Hospital.)

Dr Kingston is determined to have proper consultation processes in place:  “Most people will be happy if there’s transparency.  We have to explain prioritisation and then be consistent. We have to have very careful communications with the public.”

“People would get understandably cross if they thought they’d get a different treatment in a neighbouring practice.  This involves consulting people before decisions are taken.” And for consultation she wants a reference group of the public in her area to include a “broad range of ages, geography, jobs and a balance of the sexes.”