Fixing the fence

I have just spent a very enjoyable three months working in a community dementia team which is part of a large mental health trust. It was enjoyable because the work was interesting, the team were more than welcoming, and their interest in and compassionate approach to their work – the care of vulnerable people who are often very difficult to care for – was clear. It was also the first time for quite a while that I have worked in detail on the provider side of the fence, which did make me stop and think a bit.

For the last few years, I have worked on the other side – in commissioning organisations. Prior to that I worked on the provider side in another financially neglected area of healthcare – learning disability services. (When I say ‘financially neglected’ I mean in comparison to other areas of healthcare: the whole system is underfunded.) So I’ve seen the NHS world from both ‘doing’ and ‘buying’ perspectives.

I don’t disagree with the split between commissioning and providing in principle: I think objectivity in what is commissioned helps people to focus on what is provided, and also that effective commissioning should lead to a better overview of the system as a whole and a more joined-up approach across health and social care. (Though I do think commissioners need to have worked on the provider side to understand how services really work in practice.) However, what strikes me now is that it is becoming increasingly difficult for each ‘side’ to understand the language and the timeframe for change of the other. This isn’t about the organisations I’ve been working with, it’s about the system as a whole.

Commissioners who speak of budgets, data collection, immediate service change and targets often seem alien to practitioners: where, in that language, are the needs of the patients in their care right now? Providers, on the other hand, vex commissioners when they point out (in discussion or by their practice) that the needs of people using services don’t neatly fit the boxes assigned to them.

This is just the start of the problem. Not sharing language makes it hard to develop trust and respect which are key to effective partnership working. Add to this the very significant challenge that neither ’side’ has enough resource to either commission or provide the an ideal service, and the ’sides’ can end up more interested in defending their position than creating solutions.

The less money there is, the more we all haggle, and the more we try to make a problem someone else’s responsibility (the classic health v social care argument, for example, though it also happens on a more local scale within as well as between organisations). Trying to shift responsibilities is a waste of time in the short term and a waste of resources in the long run, and it generates negativity which saps the good will and creativity needed to make the system work at its best.

All of this might be effectively managed (and often has been until relatively recently), by both ‘sides’ investing in building productive working relationships and in understanding the opposite perspective. However that’s been stymied by the current obsession with the market. Competition, and the commercial rules that go with it, has been made more important than partnership. Commissioners are being urged to look for greener fields elsewhere. But (at the risk of extending this metaphor too far!), without regular feeding of their root system, NHS providers can struggle to keep their fields looking green and healthy enough to withstand the odd frost. And anyway, the fence between commissioner and provider has become a solid wall, the kind that generates whispers on either side.

This isn’t an argument for just throwing money at services. (Though clearly, from the news over the last few days, significantly more resources are required if the NHS is to meet need, let alone expectation.) But it is an argument for knocking down artificial walls and market constructs that get in the way of building the kind of healthy working relationships which are key to delivering more effective services for the ever-increasing needs of an ageing population. Now more than ever we need more certainty for NHS providers and re-investment in effective partnerships across both sides of the NHS fence.


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