Written evidence from Mr G M Rigler (COM
08)
Retired surveyor and project manager—currently
an elected governor to an acute hospital NHS foundation trust—acting
in a personal capacity, having obtained a "governor perspective
on trust performance" in accordance with relevant statutory
duties as defined by "Monitor".
A. EXECUTIVE
SUMMARY
1. It is agreed that the commissioning processes
within the NHS are inadequate.
2. The proposals being considered are unnecessarily
draconian and involve too many avoidable risks.
3. Relevant evidence is not available and
is needed to make sound decisions affecting the public health
of the nation.
B. INFORMATION
1. I am an active governor to a foundation
hospital trust that consistently receives awards for the services
it provides with staff numbers (when considered in whole time
equivalents) that are not wildly different from other similar
hospitals but the trust has moved from a substantial financial
surplus to a substantial financial deficit within a year.
2. The financial situation (at "1"
above) is considered to arise largely from the inadequacies of
the "commissioning" processes involved.
3. The inadequacies (of "2" above)
appear to be already recognized by your committee but, for clarity
in this memorandum, are considered to include too many people
involved in negotiations, complicated systems and formulae, a
need for relatively small provider trusts to take "insurance
risks" for treating accidents in exceptionally bad weather
and political interventions which adversely affect evolving attitudes
and understandings of the many people involved.
4. The above inadequacies are not manageable
at the moment since there is no practical means whereby the negotiating
parties can seek sensible redress for past errors and/or misunderstandings
: a factor that is exacerbated not only by the absence of any
"governors" within the commissioning bodies who could
provide the communication but also by the absence of any readily
available audit reports upon the commissioning processes concerned.
To this day, apart from the evidence I have received from the
trust directorate (which may be considered biased, in their own
cause) I am not absolutely sure that the trust negotiating team
has ever gained the best possible deal for the benefit of the
local population that I have been elected to represent.
5. The proposed changes do not appear to
resolve the above difficulties and there is no evidence available
to me to suggest otherwise.
6. The medical doctors that I know confirm
my opinion that they already have a time consuming job and that
the suggested move to require their active involvement in commissioning
processes could easily affect their "gate keeping" duties
in an adverse manner within our health care system—worsening
the "GP lottery" that does affect access to specialist
clinicians.
7. It is understood that affordable improvements
to the general health of our nation is required and the evidence
for success in the matter is derived from a working understanding
of appropriate elements of certain statistics which become extremely
esoteric and require a particularly expert understanding that
is not readily available to the nation at large. It is not known
whether the evidence exists to assure anyone that such skills
can be multiplied to suit the requirements implied by the proposed
changes to commissioning. In view of "6" above, it is
not likely that general practitioners can (or should) be diverted
into the detailed understandings of Public Health Statistics and
associated methodologies.
8. The concentration upon the proposed enhanced
role of the general practitioner diverts one from considering
the need for specialist clinicians to contribute to the strategies
for seeking improvements in public health. It is trusted that
some means can be found to ensure that such a pool of invaluable
advice and aspiration is harnessed into (certainly not excluded
from) the commissioning processes.
9. There is no evidence available to me
that the proposed revisions to commissioning processes represent
good value-for-money at a time of financial stringency and at
a time when public health is being stressed to the point of creating
additional illnesses.
10. There is no evidence available to me
that yet another change to the NHS (ie the commissioning restructuring)
has been sensibly designed for implementation—rather the
reverse, since redundancy expenditure (which could otherwise be
avoided) is understood to be involved in the proposed re-structuring
of the inadequate commissioning processes that do need to be improved
without demoralizing existing statistically competent people and
without disruption to the provider processes : processes which
can ill afford diversion of resources from clinical services into
the revised conduct and administration of fragmented negotiations
with a plethora of inexpert (novice ?) commissioning bodies.
11. At a time of financial stringency, it
is not considered acceptable that other public services (particularly
the armed forces) should become aware that Parliament has allowed
further changes to the health services that are not evidence based,
risk poor value-for-money, risk the demoralisation of scarce people
and appear to confuse "change" with the need for managing
"desirable progress".
12. There appears to be no evidence that
the progress (at `11' above) cannot be achieved by evolution in
a reasonable time.
C. RECOMMENDATIONS
1. Parliament should accept the need to
follow the general medical practice of seeking to make decisions
(about treatments) upon the basis of relevant evidence.
2. Relevant evidence should be sought (and
publicised) about the various issues mentioned in Section B of
this memorandum and tested for soundness before any proposals
for changes to the NHS Constitution (ie "treatments")
are approved by Parliament for implementation to secure better
public health for the nation.
October 2010
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