My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

An example of how power is drifting away from the Government reforms

Filed Under (Conservative party, Health Policy, Reform of the NHS) by Paul on 18-03-2011

Another post from inside the world of politics about the next steps in the Government’s NHS reform plans. A number of my friends in the NHS have asked me to explain the impact of the Government not having a compelling narrative on the reforms. How can something as seemingly flimsy as a narrative have an impact on something as seemingly powerful and concrete as a new organisation which is central to the reform? Read the rest of this entry »

Continuity and discontinuity in NHS reforms

Filed Under (Health Policy, Reform of the NHS) by Paul on 17-03-2011

As I said the other day regarding the BMA special meeting, sometimes all of us can engage in discussions that become very internally focussed. All of us are guilty of this because all of us have special interests in either a specific aspect of our work or a theme of the reform programme.

In writing the blog I am sometimes conscious that it reflects my particular interests in what is going on, and that maybe I am too internal in my debate. Read the rest of this entry »

Do not tie our negotiating hands…. Watching yesterday’s BMA meeting

Filed Under (BMA, Reform of the NHS) by Paul on 16-03-2011

I spent some of Tuesday afternoon watching a webcast from the BMA special representative meeting and I must say I am really glad that they didn’t have webcams in the trades unions and political congresses and conferences when I was engaged from the late 60s to more recent times. Read the rest of this entry »

Today’s BMA special representative meeting:- Who shall we attack the Government, or the BMA leadership?

Filed Under (BMA, Coalition Government, Reform of the NHS) by Paul on 15-03-2011

Over recent years we have heard a great deal (and quite right too) about the importance of clinical leadership. It’s true that the NHS needs much more at every level.

But we have not heard so much about the equally important experience of clinical “followership”. Whilst it’s true we need hundreds of very good clinical leaders, it’s also the case that we need thousands of very good clinical followers. If you have the former without the later you don’t really get much leadership. Read the rest of this entry »

Has the Liberal Democrat Spring Conference caused any damage to the Government’s programme for NHS reform?

Filed Under (Coalition Government, Health and Social Care Bill, Health Policy, Liberal Democrat Party, Reform of the NHS) by Paul on 14-03-2011

Over the last weekend the rank and file of the Liberal Democrat Party chose the NHS reforms as the big issue around which to mobilise opposition to their leadership in their Coalition Government. Why they chose NHS reforms is an important issue, after all the Lib Dem membership had a range of policies that might be viewed as ones on which their leaders had ‘let them down’, however the one they chose was support for NHS reform. Read the rest of this entry »

How far do health experts think NHS reforms will have progressed by the time of the next election?

Filed Under (GP Commissioning, Health Policy) by Paul on 10-03-2011

Regular readers will know that last week I attended the Nuffield Health Summit.

One of the sessions was on the future of commissioning. A number of us answered questions about where we thought the Government reforms to commissioning were going to end up. Read the rest of this entry »

Where there is no vision NHS reform perishes

Filed Under (Health Policy, Reform of the NHS, Secretary of State) by Paul on 09-03-2011

Last week I went to the first day of the Nuffield Trust Health Summit.

This was held under Chatham House rules. Let me explain what that means because it colours how I post about it. It means that I am allowed to say what was said at the event but not who said it. So you can say “there was a big row about something” but not who was taking part in the row. Read the rest of this entry »

Before the Health Select Committee

Filed Under (Accountability, GP Commissioning) by Paul on 07-03-2011

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Never quite sure about writing anything about the House of Commons in case I get done for contempt but on March 1st I gave evidence to the House of Commons Health Select Committee. They are carrying out an in depth enquiry into how the Bill will ensure Commissioning works in particular looking at the role of the NHS Commissioning Board. They had asked me to give evidence – so it was pretty relaxed. Read the rest of this entry »

Integrated Health Partners and the issue of making money out of commissioning

Filed Under (GP Commissioning) by Paul on 04-03-2011

There was an interesting story in the Guardian on March 2nd. For the first time in public this was testing an important part of the proposed architecture of the new system. It reported on the firm IHP (Integrated Health partners) and an innovative attempt by them to incentivise GPs to develop better value for money health care from their commissioning budget. Read the rest of this entry »

Emerging themes from the NHS Commissioning Board and from GP Commissioning Consortia – they don’t have to be the same.

Filed Under (GP Commissioning, Reform of the NHS) by Paul on 02-03-2011

David Nicholson’s 17 February letter to all the Chairs and Chief Executives of the NHS in England outlines his vision for the future of the NHS and in particular the organisation of which he is now the chief executive,  the NHS Commissioning Board.

The week this letter was published I had spent two sessions with the leaders of 10 GP Commissioning consortia (3 pathfinders, 7 not) in 2 very different localities. So it is interesting to compare the vision from the top and the vision from the bottom.

David Nicholson’s letter is worth reading closely. Compared to the current Secretary of State’s difficulty in outlining a compelling vision for how the reforms will really impact on the NHS and its public, his letter succeeds in outlining a vision. He even – on page 6 – acknowledges that all these words about co-production and subsidiary will be seen as ward words by those who have experienced his main management style of ‘grip.’

But even though these words may be some distance from the reality they do, as I say, paint a picture of a potential relationship between the top of an organisation and the bottom. From the top of the organisation David Nicholson is doing his best to try and construct the theory and practice of liberation.

Page 5 outlines what he sees as the role of the NHS Commissioning Board and in the absence of any greater clarity from the Secretary of State let’s take that at its word at the moment.

There are 8 roles that he outlines which are to,

1. Provide leadership to the commissioning system in improving health outcomes

2. Describe the challenges and priorities for the commissioning system, based on patient and public insight and the requirements of the national mandate

3. Support consortia to achieve authorisation and will operate a rules based intervention system to ensure consortia remain fit for purpose

4. Make financial allocation to consortia and set the financial strategy for the commissioning system

5. Provide leadership and support for quality improvement across the system

6. Champion a patient-centred approach to developing health services

7. Set the Commissioning Outcomes Framework to track local delivery and design the quality premium to create financial incentives for consortia to improve quality and outcomes and drive value for money and,

8. Translate national Quality Standards into commissioning guidance for consortia and standard contract and pricing mechanisms for local use.

As he goes on to explain,

“So while consortia will have the freedom to shape services and drive improvements locally, they will do so within a national framework and with support and guidance from the NHS Commissioning Board. This will mean creating an integrated system between consortia and the Board, which supports the delivery of national accountabilities as well as local priorities”

Now it may be me, but if I am in a local independent organisation and a national organisation that gives me my money says that it wants to integrate with me, I get the feeling that it wants to limit my independence enormously.

He is doing his best but in reality the way in which he outlines the nature of power within this relationship reflects that he has spent a lot of his managerial experience running large organisations. The experience of running large organisations doesn’t inherently make for bad managers, but the resulting view of the how the world works is very different from the view that comes from running a small one.

Many of the GPs that are now coming to terms with running GP commissioning consortia have a strong managerial experience of running small organisations. They judge their budget in the hundreds of thousands of pounds. NHS senior managers judge their budget in the tens of millions and the leaders of the NHS have judged it in tens of billions.

There is a gap here.

Over the next few months many of the new GP Commissioning Consortia will experience being run by the new PCT clusters (which in turn will be “gripped” by David Nicholson). Over the next 13 months, as the SHAs disappear, the emerging GP Commissioning Consortia will be increasingly gripped by the NHS Commissioning Board.

Then one of two things will happen.

The GP Commissioning Consortia will buckle down to be gripped by the National Commissioning Board. They will be, in David Nicholson’s terms, be integrated into the board and become a part of a top down structure.

Or it will resist this. They will insist on becoming separate organisations with their own systems and their own view of what they want to achieve.

If this happens the negotiations that exist between the NHS Commissioning Board and the GP Commissioning Consortia will be just that – negotiations. A GP Commissioning Consortia will say we want to achieve x and the NHS Commissioning Board will say no you should achieve y and there will be a discussion between them before they agree a new position.

This will be a brand new set of relationships for the way in which the centre of the NHS works with its local organisations.

It will recognise that they have a right to negotiate what they want with the Board rather than just simply do what they are told by the centre.

If GP Commissioning organisations feel they can successfully negotiate with the NHS Commissioning Board then the NHS will have really changed.

If, on the other hand, David Nicholson succeeds in integrating them into the NHS Commissioning Board very little will have changed