Dr Phil Hammond, broadcaster and sessional GP in Bristol

Commissioners need to be brave and speak their minds

Are you frightened of speaking your mind? I hope not, because the future of the NHS rests on those clinicians who are entering the choppy waters of clinical commissioning—or who are on the receiving end of the changes. They need to be brave enough to stand tall and tell it like it is, even if it upsets the Government or the NHS Commissioning Board (NHSCB) (or both). The climate of fear that has bedevilled the NHS in the past and cost many a brave whistleblower his or her career must end. Clinical commissioning groups (CCGs) can’t lead service change if their leaders are gagged and bound to the mast.

In November 2012, the HSJ surveyed 81 chief executives working across acute, mental health and community trusts in the NHS.1 Many had experienced bullying and were preoccupied with avoiding blame. Over one‑third said that they felt unable to take risks or speak out. If chief executives are that frightened, what hope is there for a junior doctor or nurse to raise concerns about patient care?

General practitioners have more protection from hierarchical bullying by virtue of their employment status, although many still mutter darkly about goings on at their local PCT. They fear that CCGs may just become an NHS version of Animal farm, with GPs turning on each other. But the life for those GPs who step up to the plate and make a stab at commissioning may not be any easier.

A major problem for clinicians (or indeed anyone) involved in NHS management is the recurrent tension between short‑term (often politically driven) service demands and the long‑term safety and sustainability of the NHS. In the HSJ survey, 60% of acute trust chief executives said the culture of management promotes short-term solutions, so it will be interesting to see if clinicians, via CCGs, are able to plan more for the long term without worrying about Nicholson’s blood pressure or Cameron’s re-election chances.

The NHSCB is aiming, in its planning guidance for the NHS in England, to deliver ‘the best customer service in the world.2 I thought it was a joke when I read it, and we must be thankful that very few patients will have seen this document. Every day, in every staff meeting in the NHS, we will need a passionate leader, eyes popping with enthusiasm, to cajole the staff into not just brilliant, but globally the best customer service. Is it dream or delusion?

The theory of commissioning is that if someone is providing excellent clinical and customer care you can buy more of it, whilst simultaneously decommissioning the bad care. This is where the buck stops squarely on the shoulders of commissioners. The NHSCB has promised an outcomes revolution in the NHS, starting with the publication of performance data for individual surgeons across 10 specialties by the summer of 2013. The ultimate vision is to combine clinical and patient experience data on staff and services. It can then be included in an app and be made available to help patients to choose where they want to go. The Government has also promised real‑time safety data monitoring to work as a smoke alarm to prevent future scandals.

But clinical commissioners will need to act on this information too. Will they have the nerve to speak up and decommission services from failing hospitals, surgeries, or even individual members of staff? The NHS has been awash with data for many years, but too few clinicians, managers, or politicians have been brave enough to act on it to prevent patient harm and reward successful service. Clinical commissioners must not just expand excellent care, but eliminate the unacceptable, explain the evidence in public, and take all the flack that goes with it.

  1. HSJ website. NHS chief executives highlight ‘climate of fear’. www.hsj.co.uk/news/nhs-chief-executives-highlight-climate-of-fear/5051985.article (accessed 9 January 2013).
  2. NHS Commissioning Board. Everyone counts: planning for patients 2013/14. NHSCB, 2012.G