Archive for February, 2012

History repeating itself?

Jon Glasby, editor of Commissioning for Health and Well-being discusses the problems with the current re-organisation of the health service:

“George Bernard Shaw is often credited with quoting Hegel to suggest that the only thing we learn from history is that no one ever learns anything from history. For two decades, both health and social care have been seeking to separate their provision from the commissioning of services, with a series of policies designed to create more commissioning-focused organisations buying care from a much more mixed economy of public, private and voluntary providers. Although the current Health and Social Care Bill has created significant furore with accusations of ‘privatisation’, the risk of this seems to have been somewhat overstated. Instead, one of the biggest dangers is that the largest large-scale reform of the commissioning function distracts attention from the financial savings we need to make – and actually strengthens providers relative to commissioners (again).

Over time, the NHS in particular has looked to repeated structural reorganisations in order to strengthen the commissioning of services – first devolving responsibility down to GP fundholders and total purchasing pilot, and then gradually scaling back up through PCGs, PCTS and later bigger, merged PCTs. The emphasis then shifted back to the local via practice-based and now clinical commissioning. As the service structures in place shift from large economies of scale to local responsiveness and back again – it becomes abundantly clear that there is no such thing as the perfect organisational structure for commissioning. In an ideal world, there are some things we would do at the level of the individual patient, some at neighbourhood level, some at Council level, some regionally and some nationally. Given there is no one size fits all model, we might be better off trying to work out what is best commissioned at which level – rather than constantly reorganising backwards and forwards.

Added to this what we know about large-scale structural change – the negative impact it can have on morale, productivity and service development – and the current re-reorganisation of the health service seems even harder to justify. Once again we seem to be talking about the need to strengthen commissioning, whilst actually weakening it (by reorganising it and by leaving provider interests relatively intact). Over time, this seems to have made it even harder for commissioners to influence service design and delivery – as they only just start to find their feet before they are reorganised yet again.

Ironically, when you talk to public service commissioners they often seem to have acquired this job title without the training and development you might expect to take on this crucial role. Against this background, our development programmes and our new book on Commissioning for Health and Well-being are an attempt to explore what commissioning is, where it has come from and where it might be taking us. They also look at different elements of the commissioning cycle (from assessing need to procurement and market management), as well as cross-cutting issues such as joint commissioning, user involvement and commissioning in an era of personalisation. However, these are only very small contributions to a big issue – and the danger is that this learning is disrupted and some of it lost amid another wholesale reorganisation.

Deep down we seem to believe that the perfect organisational structure exists somewhere – but that we just haven’t found it yet (since 1948). Rather than assuming that this perfect structure might be just one more reorganisation away, we might be better off supporting our current commissioners better to do the job we’ve entrusted them with – and this will take time, training and development and, above all, organisational stability.”

Jon Glasby is Director of the Health Services Management Centre at the University of Birmingham and editor of a new book on Commissioning for Health and Well-being.

Obama and the Biracial Factor: The Battle for a New American Majority

Andrew Jolivette, author of Obama and the Biracial Factor: The Battle for a New American Majority looks at the ideological battle that is at stake in the current US election campaign:

The battle for a new American political and ideological majority continues in 2012. The upcoming election for President of the United States is opening a floodgate of rhetoric laced with divisive political campaigns, racial bigotry, and a call for a politics of hope rather then despair. On Tuesday January 24th, 2012 in his third state of the union address, President Obama in response to critics and in conversation with U.S. voters presented a vision that will unite Americans, he presented the same message as he did in 2008—a message of hope!

Obama and the Biracial Factor, published today, argues that Mr. Obama was able to build a diverse coalition of supporters that represents the changing demographic and ideological diversity of the United States. The project and contributors ask if President Obama will be able to maintain this new political coalition by using an ideology of inclusion. A primary assertion in the book is that his biracial background equips him with a treasure chest of lived experiences that allow him to speak to many different people. Over the past three years the Obama administration has faced an onslaught of obstructionism and underlying rhetoric from he is “not one of us” to “he is a European socialist”. The current election campaign is a clear indication of the ideological battle that is at stake. On the republican side, consider the following recent comments and incidents:

Newt Gingrich has called Obama the “greatest food stamp” President in U.S. history.

The Lawrence Journal-World was sent an email that Mike O’Neal, speaker of Kansas’ House of Representatives forwarded to House Republicans that referred to President Obama and a Bible verse that says “Let his days be few” and calls for his children to be without a father and his wife to be widowed.

Republican Governor of Arizona, Jan Brewer was recently photographed pointing her finger directly into the face of President Obama when he arrived at the Arizona airport

Mitt Romney has said the President’s call for the “Buffet Rule” (a policy that would require millionaires to pay the same tax rate as their secretaries, 30% instead of the 15% they currently pay) is about a “politics of envy” and class division.

The irony of these assaults on President Obama and his agenda to level the playing field for middle class Americans is that the Republican primary has dramatically impacted GOP frontrunner Mr. Romney whose negative rating among independent voters went from 22% viewing him in a negative or somewhat negative light in November to a 42% negative or somewhat negative view of him in the latest polls. Obama who was down 13% points to Romney in November among independent voters, now leads Romney by 8% points in new polls. This is due in part to what we argue in Obama and the Biracial Factor, America is seeking a new ideology that unifies people rather then dividing them.

As the 2012 re-election campaign begins for Mr. Obama it is important to take note of his comments to the American people in the state of the union address last week. They are a stark contrast to conservative attacks that call for him to “get the hell out of the country” as Rep Allen West (R) from Florida said in comments to the media in recent days. Calling again upon his biracial background as a source for talking about what brings different people together, Obama, in contrast to both Romney and Gingrich, made himself look more presidential when he said to congress and the American people that:

“Those of us who’ve been sent here to serve can learn a thing or two from the service of our troops.  When you put on that uniform, it doesn’t matter if you’re black or white; Asian, Latino, Native American; conservative, liberal; rich, poor; gay, straight.  When you’re marching into battle, you look out for the person next to you, or the mission fails.  When you’re in the thick of the fight, you rise or fall as one unit, serving one nation, leaving no one behind…Each time I look at that flag, I’m reminded that our destiny is stitched together like those 50 stars and those 13 stripes.  No one built this country on their own.  This nation is great because we built it together.  This nation is great because we worked as a team.  This nation is great because we get each other’s backs.  And if we hold fast to that truth, in this moment of trial, there is no challenge too great; no mission too hard.  As long as we are joined in common purpose, as long as we maintain our common resolve, our journey moves forward, and our future is hopeful, and the state of our Union will always be strong.”

Obama and the Biracial Factor: The Battle for a New American Majority, published 1 February, can now be purchased at 20% discount from the Policy Press website.  


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