The flickering gas lamp warmed Molly's blush. In and out of the shadows her smile turned to magic. The young man sitting opposite watched as the flame danced in her eyes..... he leaned forward and .....
Ahem, yes, well... that's enough of that thank you!
We don't do gas lamps any more!
We do electric light, fluorescent tubes, LEDs, spot-lights and lasers. As much as we might have an admiration for the gas-lamp generation, things have moved on.
Letting go, moving on is never easy. We all have a huge amount invested in the past. That's part of the reason change can be so difficult.
CCGs have a huge investment in the past. Set up in the Lansley-Lunacy period, managers lost their jobs, others clung on. Beguiled GPs batted off 'this'll never work', and jumped on the bandwagon.
The profession was divided. We all watched the conflicts of interest rows, the governance issues and by and large, GPs with scarce knowledge of management, struggle with commissioning.
Managers, with the legacy skills and anywhere near retirement, threw in the towel. Their experience lost. I think it would be generous to say CCGs have worked or fulfilled expectations. The lack of experience, talent, money, size and influence have left them beached.
Events condemning them to curios.
In the world of their predecessors, the PCTs, Mark Britnell's 'World Class Commissioning Scores' had started to bear fruit. In their final year PCT performance was at its peak.
They were scrapped; replaced with coteries, bridge clubs, point scorers and chaos.
Where are we now? What has happened to commissioning? The 5YFV has eclipsed everything; developing a top-down response to diminishing resources and untrammelled demand. Accountable care organisations are emerging, all thoughts of tendering and market testing disappearing.
Where is the evidence that CCG tendering has improved care, created better value for money or improved innovation? Who would deny the evidence; it has cost a fortune, diverted attention and made the wrong people wealthy.
CCGs struggle to 'commission' beyond doing what they did last year, for less money. Who will argue that commissioning, straddling new boundaries of care is beyond them..
Bread and butter service planning, can they do it?
A simple care pathway for an elderly citizen: services to keep her well and nourished; to keep her from falling ill or falling prey to living alone. Services to visit and support her; chiropody, bathing, tissue viability, pharmacy, hairdressing, cleaning, shopping. Making sure, if the day comes for the blue light, they are in place designed and dedicated to getting her well, confident and assessed in her own home. Services to prevent the cycle from repeating itself.
Services that might involve ten agencies. The queues of ambulances outside A&E are proof that pathway planning is beyond the majority of CCGs to imagine, let alone buy for us.
'Buy' for us with the eye watering precision that professional buyers keep the supermarkets stocked and the clothes on the rails.
Buying healthcare; flickering in the light of the gas lamp.
Modern, integrated care, the product of new models of care, can't wait for tenders, commissioners and all the palaver of yesteryear.
Can CCGs survive? Why would we want them to? We want system designers, care creators, data engineers, not a bunch of well-meaning GPs fitting the future of care around their day job.
Bring on vertical integration, capitation and population based budgets. Bring on outcome shapers.
There are too many CCGs, consuming too much resource doing too little, for not enough people in too small organisations.
There was, once, a romantic notion that a GP with a cheque book and a stethoscope was more powerful than a GP with a stethoscope, alone. Not any-more. They are a hindrance.
They belong to the gas lamp generation.
