Sunday, 17 April 2011

Frontline reform - a warning shot

On Thursday, I sat in a ‘teaching session’ in which the manager for the local rehabilitation service, told us how referrals to his service should happen. We work on a local stroke unit, dealing with a range of different needs and disabilities; we don’t choose who our patients are, and we don’t opt out of dealing with patients who have cognitive and physical needs that are too taxing for us. As a new member of the team, and still an outsider, I have been impressed by the professionalism and dedication with which the therapists treat all the patients, but as we sat there being talked to by this manager there were a number of things that struck me.

Many of my gripes centre around the prevailing sense he gave that in accepting our referrals, he was doing us a favour, rather than fulfilling his professional obligations to the patients; but I do not think that it helps us to dwell on this now. Everyday I experience forms of communication that could be improved, many of them by me, and this is not a problem that is easy to solve.

However, what is worth dwelling on is one of the tactics he was using to change the referral pathway for patients requiring rehab (well that’s how it came across). The line that he kept repeating was that commissioning had changed, and as a result of this, we couldn’t offer our patients as much choice as they were used to.

Let me repeat this, we were told by this manager that because of changes in commissioning arrangements, patients could no longer choose where they were treated, and had to fit in with the service that the NHS had set up for them.

‘Hang on a minute’, I thought. But being new, I didn’t confront him, but I did make sure that I went round everyone who had been in that meeting and asked them what impression this manager had left them with.

The main feelings were confusion and irritation. Most of the therapists that I spoke to were dismayed that the patient seemed to be wholly absent from his description of how the system worked, which irritated them. They were also confused about whom they should be referring to this chap’s services, as his message was contradictory and inconsistent.

But what was really telling for me is that they weren’t fooled by the smoke screen of commissioning intentions; they were all quite clear that the new system as they saw it presented no imperative to reduce patient choice. They were very quick to pick up on the idea that there were two things being confused here: a changing commissioning landscape and this managers ambition to select his patient group more carefully, to give him better outcome data, and more leverage in a competitive commissioning world.

This seemed to be an important lesson to me: the idea is that it doesn’t matter how confusing the healthcare reforms have become, or how confusing they continue to be, the patient remains at the heart of the service, and we need to be wary of the cynical opportunism that we saw on Thursday, of hiding beneath the health reforms to make changes that are both unnecessary and not in the patients' interests.

Much of the risk with the Health Bill comes with how people choose to interpret and implement it. We need to be mindful of the competing drivers that may shunt patient care and experience off the top of the list of priorities.

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