Dilemmas ahead for Wiltshire’s doctors but their chairman is ready for the off

Written by Tony Millett.

Dr Steve Rowlands is a GP in Trowbridge – but his main role just now is to be an important link between the current NHS and the one the coalition government has created after its radical, top down reorganisation.  He’s the man who will tackle the dilemmas the new NHS system faces – among them the new NHS 111 service, more privatisation and squeezed finances.

Sometime during the night of March31/April 1 he will change from having two jobs - Medical Director of the outgoing NHS Wiltshire (PCT) and Chairman of the incoming, GP-led Wiltshire Clinical Commissioning Group (CCG) – to being the leader of the CCG.  

In fact, of course, the CCG has been operating in shadow form – while NHS Wiltshire has remained ultimately and legally responsible for patient safety and the bank accounts.

The CCG is already involved in the current problems thrown up by the government’s decision to replace NHS Direct with the NHS 111 telephone triage service. The contracted private company, Harmoni, should have already replaced NHS Direct, but the live launch had to be delayed as tests were unsatisfactory – some very unsatisfactory.

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Dr Rowlands told Marlborough News Online: “It isn’t going well”.  But as the PCT had scheduled an emergency meeting on the contract that afternoon, he could not say much more except to emphasise that “The most important thing is the safety of the public.”

One of the last minute issues dogging the imminent change-over has been the raft of regulations from the Department of Health making CCG’s put services out to competitive tender. This can only lead to fragmentation among a multitude of private providers: what one former NHS official for the south west called ‘the demolition of the NHS and the public health system’.

The first regulations were withdrawn after protests – from CCGs among others. The new lot of regulations appear to be little different.  As one lawyer puts it, they ‘are likely to have the effect of both permitting and promoting the transfer of NHS services to the private sector.’

Dr Rowlands says this is “A nightmare.  It’s crazy.”  When the reorganisation began he took “The Machiavellian view that they’d give the job to the GPs – who’d fail – then they could privatise it all.”  Now he’s changed his mind.

Having seen the GPs in action he believes “The great strength of the GPs is that they’ve the vision to challenge what’s going on – and to make the system work.”

He knows these new regulations will bring problems: “It’ll be very expensive for us.  Competitive tendering is becoming a growth industry and it’s mostly lawyers involved.”  He thinks the Wiltshire CCG is big enough and with the resources to be sustainable and take on those bills.

Although the Wiltshire CCG was formed after they were told three smaller CCGs covering the county would not pass the authorisation process, they have kept the locality structure.  So three semi-autonomous groups (in our area it is NEW - for North and East Wilts) will have devolved budgets so they can, up to prescribed spending limits, introduce innovation from the bottom up.

In the past, GPs ideas have often got lost as strategic decisions take priority: “Now they can say – let’s try it out.”  As MNO has reported, one of the first ideas out of the blocks has been a new regime of dementia diagnosis.

The locality structure does leave GP’s with an awful lot of meetings to attend – and only the central board meeting will be open to the public.  Dr Rowlands frowns a little: “As an individual I want to be absolutely as open as possible.”  

No one wants the CCGs to be accused of being unelected people making decisions behind closed doors.

Dr Rowlands knows about making unpopular changes.  He survived the closure of Trowbridge Hospital.  He thinks people can get too attached to buildings: “I fully appreciate the emotional attachment to buildings, but it’s the services that matter.”

Wiltshire CCG’s unique selling point is its intention to bring health care ‘Closer to Home’. The cynic might think this just means GPs commissioning more treatments in their own surgeries – and so getting richer.

When Marlborough News Online asked Dr Rowlands what ‘Closer to Home’ means he gave an example that’s already being worked on: “The way I see it working, your GP will have a risk management tool – he can call up a Mr Smith on his computer – and he’s your fifty-first most high risk patient – ranked in terms of likelihood of ill health from present conditions and taking into account existing records.”

If this Mr Smith moves up the list – perhaps his chest gets weaker – one of the new CCG’s Case Managers will ‘actively manage the patient’.  If he’s in more danger of falling in his home, the Case Manager will get him the appropriate help and aids – getting him occupational therapy, physio or whatever.

There may be technology to use too.  Dr Rowlands has seen remote tele-surveillance in use in the United States and thinks it could count as a useful ‘as-well-as-not-instead’ tool - not a total replacement for meeting the GP face-to-face.  The GP is integral to this teamwork – and in our area, the team can call on the advice of a gerontologist from the RUH in Bath.

“We want to provide a wrap-around care service to fit the individual - of which the GP is a central part.”

The process of this huge reorganisation has been tough and chock-a-block with corporate, personnel and personal dilemmas: “There’s been bereavement and uncertainty” as people leave, teams are broken up and new jobs are advertised.

Recently, Dr Rowlands been through three checks: as an individual by a national body, he helped the CCG through authorisation and he has just been revalidated as a GP – “Quite good for an old man!”

He says: “Both the PCT’s interim Chief Executive, Ed Macalister-Smith, and its Chairman, Tony Barron, have been most supportive of the new CCG – and of me personally – and have left us in a good place financially.”

Now the finishing line and the starting line are just days away, he’s excited: “We’re ready to run.  And we’ve got a tremendous team – a really, really good team.”