CCT in the NHS: the BMA has some concerns…but not all of them.

The BMA is expressing concerns – as well it might – about the powers of Monitor to require or enforce compulsory competitive tendering in the commissioning of healthcare services, ahead of a planned debate in the Lords (24th April) on Section 75 of the Regulations for the Health and Social Act 2012.

Lack of clarity, ambiguity and seeming ambivalence if not downright contradiction are their main complaints at present. The BMA does not wish for CCT to be mandatory, and it has set out cogent, if not compelling, arguments against such a position being taken. It also rightly argues that the sands of ministerial policy and departmental statement have both shifted alarmingly over the course of this legislation, and that they continue to do so offering no sound ground on which to build. Government and Monitor are each saying ‘Fear not, trust us, we know what we’re doing!’, which not unreasonably has the BMA – and any half-sentient being – all the more alarmed.

One line of argument put forward by the BMA is the singular importance of ‘integration’ in health services, citing in the article examples such as: the importance of trauma and orthopaedic services connecting for mutual learning and to ensure the provision of high quality, safe services across both disciplines; or, a single provider having sufficient organisational size and clout to ensure financial viability along an integrated care pathway.

Integration, they implicitly argue, should trump, where necessary, the two other commissioning pillars of competition and patient choice (the latter as determined by the CCGs – perhaps to be considered the day that irony died). What, though, I don’t hear or see in the current debate on integration in healthcare is any significant consideration that unless there is integration across health and social care services – especially for older people, people with disabilities and/or LTCs – you are merely aiming to design the best two-legged stool you can.

Those of us who can recall the introduction of ‘community care’ in adult social care in the early 90s well remember the baleful impact of CCT on integration across agencies and providers, with everyone working up to contract specifications and no further. What is less a matter of historical record, though evident from the experience of the times, was the increased strain this put on relations with the NHS, who at best were thoroughly confused about what was on earth was going on and, at worst, wanted nothing to do with the initial confusion, muddle and mess. Could the dementia consultant at the Day Hospital continue to liaise and link with the manager of the Council Day Centre, or did he have to go via the Care Managers [aka social workers] or to commissioners who would determine to which provider the next referrals should go? Could he be bothered in his busy day even to find out, let alone be prepared to be told what to do by someone outside of the NHS?

It took many years of determined effort by people who understood that patients/service users (and carers!) needed both health and social care agencies to work together in order to deliver the best outcomes for all to make any kind of move back towards the informal arrangements that used to work so well prior to CCT.

So one warning from history – while the NHS is working out how to live with the new commissioning arrangements don’t expect other agencies to rush to keep up. Health staff may be living, breathing, dreaming, dreading their brave new world – others will be keeping a safe distance ’til you’ve got it sorted.

But another warning flag to wave: who were most missing from early discussions and debates about how to design and deliver community care within social services; who, later, were least present when developments of integrated care across social care and health were being planned?

Why, it was the GPs who were no-shows: ‘too busy’, ‘couldn’t see the point’, ‘what’s in it for me?’ being some of the excuses offered. And so who now is taking the lead on healthcare commissioning, who can be relied on the take the wider view and the more visionary approach to true integration across the NHS and social care agencies (housing too anyone, public health also now back in Council hands)………?

Quite so. Bring on the two-legged stool. If you’re lucky.

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