I was recently surprised to hear some good news relating to the NHS. Not that we had found enough money to run it, but at long last the government is reported to be seriously looking at the fundamental structure of the NHS, in particular Clinical Commissioning Groups (CCGs).
Those of you with long memories will remember CCGs were created following an Act of Parliament in 2012, and from April 1, 2013, CCGs replaced Primary Care Trusts. (With hindsight has it all been a big April Fool’s joke?)
The idea at the time was that CCGs would be able to get the best possible outcomes for a local population as a clinically led commissioning service would know the needs of the local population and be able to decide what were the priorities for activity. They would then buy services for their population from local providers such as hospitals, community clinics and primary care, including optical practices. CCGs would be fleet of foot and be able to change as the needs of their population changed and so over time outcomes for the population would improve.
There are now around 200 CCGs in England and they range in size from serving under 100,000 to over 900,000 people. So has this worked?
My perception is that CCGs have not been a success. The analogy I have heard and particularly like, is that one cannot imagine a large national retailer, for example Asda, saying to each store manager: ‘run your store however you think best for the people locally – stock whatever you think is best and get your products from whichever supplier you choose.’
The outcome would be that the Asda stores would get no synergies in buying power, waste a lot of management time at each location and their consumers would be confused between the offer in one store to another. In reality, I suspect Asda stores have 90%+ the same product and layout and any relatively small difference between populations is catered for by small local regional variations suggested by each manager.
From an optical perspective I certainly do not have to look far to conclude that CCGs have not done what they were supposed to. In relatively small geographic boundaries, for example within a county, we have different pathways for the same condition. In some areas of a county, there is a pathway for minor eye conditions, in others nothing exists.
One ridiculous aspect to this is that across a county, three or four different managers from neighbouring CCGs may be working on the same pathway in collaboration with their local optical committee. These managers may also be working on other health pathways and so can be stretched to make progress on any front. They can also have different payments across the country for the same amount of work undertaken.
I do not perceive there has been a widespread improvement in outcomes. To take one example I recently referred to in this column, the growing numbers of patients whose glaucoma follow up appointments were delayed, resulting in potential loss of sight.
Another role of CCGs was to develop a joint needs assessment, including eye health, leading to a strategy for improving public health. Has this been done in many areas? Do we see reported by CCGs progress against any of the eye health outcomes for reducing preventable blindness?
I’m sure we can point to some success stories where there has been good coalition informed local commissioners and optical representatives, but these seem to have succeeded in spite of and not because of.
So are we about to go full circle back to larger commissioning entities? Surely this would give greater consistency in delivery of healthcare. In all areas there will be the elderly, those suffering from diabetes, heart disease and cancer and the pathways for these issues should be similar across the country. Where there are differences, perhaps due to geography, demographic anomalies or high number of ethnic groups, these can be catered for by local knowledge within the larger organisation.
I don’t know how much management time this would save, but it might make a dent in the extra funding, quoted recently as £2,000 per household. It would certainly help to put an end to inequality between areas for eye health and give a welcome boost to those who are trying to negotiate optical services.