Commissioning Balls

 Health secretary Andrew Lansley has a touching faith in GPs if he thinks we can spend a £60 billion NHS commissioning fund wisely. Clinical staff should have the power to purchase services for patients, but the commissioners need to include representatives from hospitals and primary care, across all specialties, and the care they purchase needs to be integrated to avoid duplication and make sure patients get treated in the right place at the right time.

 MD does however have several commissioning suggestions. Firstly, stop commissioning NHS inquiries in secret. If a scandal has reached the level of requiring an inquiry, you can be sure lots of people knew about it and failed to act, and there are lots of powerful vested interests trying to minimise the fall-out.  Being able to give evidence in secret in the knowledge that it will never be made public is a strong incentive to continue the deception. Clinical staff and NHS managers are public servants, and if they can’t tell the truth in public, they aren’t fit to serve.

 The fact that Lansley has ordered a public inquiry into the Mid Staffordshire scandal after several expensive private inquiries is a case in point. But Lansley has also announced a private inquiry into the sacking of Cornish chief executive John Watkinson after he blew the whistle on the lack of proper public consultation before cancer services were moved. The management consultancy Verita has been tasked with ensuring its independence, but the same company is overseeing the secret Bristol pathology inquiry, which patient groups fear will be a whitewash.

 The Eye has had a hand in both inquiries, breaking the Bristol story and coming out strongly in favour of an inquiry into Watkinson’s dismissal. MD has given evidence to the pathology inquiry but has been asked not to reveal any details. The inquiry and statistical analysis have been commissioned and paid for by University Hospitals Bristol (via the taxpayer), the very hospital at the centre of the allegations, and UHB will decide how much of the final report to make public. Patient advocate Daphne Havercroft has written an open letter to the Panel¹ outlining her concerns about perceived bias, especially in the investigation of 26 alleged cases of serious pathological misreporting.  

 Most alarmingly, ‘the patients affected (if still alive) and/or their families, appear not to have been informed that their case is part of the Inquiry and invited to give evidence to the Panel’ and ‘pathologists who raised the concerns were not asked to verify that the slides, reports, existing external opinions and any other material that UHB sent for review are the ones that are the subject of the allegations.’ The inquiry has responded by asserting its independence but unless these issues are openly addressed, there will be mounting calls for a public inquiry. Far easier to have inquiries in public at the outset.

 MD would also stop commissioning complex treatments from hospitals that only do a few a year, lack the appropriate experience and have no possible statistical proof of competence. MD has made this case repeatedly over 18 years, from child heart surgery to child liver surgery to cleft lip and palate repair, cancer surgery, endocrine surgery, neurosurgery, penile surgery and aneurysm repair. Major trauma and complex surgery needs to be carried out in specialist centres who have the staffing levels and resources, and do enough to gain the expertise and prove their statistical worth. We’ve known this for decades but the fact that child heart surgery still hasn’t been safely reconfigured 18 years after the Eye broke the Bristol scandal shows just how unsafe NHS commissioning is. Now the Health Service Journal reports (June 10, 2010) that in 2007-08, three unnamed London trusts performed just four Abdominal Aortic Aneurysm (AAA) repairs between them, Ealing did 6, Lewisham 7, Whipps Cross 10, Hillingdon 18, Barnet and Chase Farm 22, Epsom and St Helier 23, North West London 32 and UCL 43. High volume centres have a third the mortality of low volume centres and MD wouldn’t commission AAA repair from any centre that did less than 50 a year or didn’t subject its results to independent validation. Patients unhappy with this decision could simply choose another GP.

 1 http://drphilhammond.com/blog/category/bristol-path-inquiry/