I have always been slightly concerned by the shroud wavers who say that any change in commissioning will result in the destabilisation of their organisation. Their premise appears to be based on a belief that maintaining the status quo is a desirable outcome.
Put 100 clinicians in a room and I suspect you won't find anyone prepared to state that the current system is incapable of improvement. So what is the reason for their predictions of doom and gloom as CCGs develop.
The literature on change management is clear as to how these refuseniks should be dealt with, but what if they have seen something that others have not? What if they are the Cassandras of current day NHS?
Complexity and chaos predict that in order to change a system from one attractor state to another it must be disrupted. The work of Clayton Christensen suggests this disruptive innovation is sine qua non for health service reform.
The worry eating at my cortex is that we cannot afford to break healthcare in order to re-make it.
Perhaps there is a different way to play this game. Think of the children's game Jenga. The tower of wooden blocks is gradually removed one block at a time, the aim being to ensure your opponent takes out the last block which causes the tower to fall. Suppose for a moment that your local NHS economy is that tower and one by one the various services which are re-commissioned are taken out and placed elsewhere, for example ultrasound services provided out of hospital. If CCGs play a competitive strategy, or even just a non strategic current best move strategy, the tower will fall.
Now step out side the game as we currently play it.
Imagine a system in which commissioners and providers agree the old tower needs to change, be smaller, be redistributed. Imagine a system in which the players agree that once the blocks come out of the tower they are assembled in a coherent new model, closer to home, redesigned and cheaper through efficiency. At the same time the old tower is steadily made smaller, but without the collapse into chaos.
Is it possible to play the game in this way?
I believe it's a yes, but only if the players agree the principles and trust each other.