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 »

Migrant Health Care

Filed Under (Health Improvement, Migrant Health Care) by Paul on 30-09-2011

Last Friday I spoke at a conference organised by the Migrant Rights Network on the subject of migrant access to health care. I was asked to run a session on the role that the new clinical commissioning groups have in improving that access.

My argument was based partly on how the Health and Social Care Bill is framed at the moment – that is a duty of the clinical commissioning group to the population covered by their geographical boundaries, and not just their registered population. In many parts of the country this duty must lead CCGs to seek out the hard to reach groups in their localities to ensure that the CCG is commissioning care for them and not just for a part of their population. Read the rest of this entry »

How Andrew Lansley made PFI popular with the NHS

Filed Under (Hospitals, PFI, Secretary of State) by Paul on 27-09-2011

Yesterday I explored some possible explanations of what might lie behind last Thursday’s announcement by the Secretary of State that 22 trusts have problems of financial and clinical stability because of PFIs. Today I want to explore the NHS reaction to this to show how that demonstrates the current Secretary of State’s lack of political touch necessary to do the job.

Last week the Secretary of State achieved something that was really quite remarkable. His attack upon the potential clinical and financial stability of 22 trusts meant that he forced their CEOs and representatives to come into the public domain to say that, for their hospitals, the cost of PFI wasn’t that bad. Read the rest of this entry »

It just may be that 22 hospitals really ARE on the brink of losing financial and clinical stability. But it probably isn’t just ‘caused’ by PFI.

Filed Under (Hospitals, PFI, Secretary of State) by Paul on 26-09-2011

Last Thursday Andrew Lansley tried to highlight the cost of PFI to the NHS and did so by listing 22 trusts which he said were claiming that their clinical and financial stability was undermined by their PFI deal. Read the rest of this entry »

What do you need to do to carry out health service reform?

Filed Under (Health Policy, Narrative of reform, Public service reform, Reform of the NHS) by Paul on 22-09-2011

This week I spoke to a meeting of international CEOs from various countries and different parts of their respective health services. They wanted to know how the reforms were going and what the prospects are for the NHS. Read the rest of this entry »

A New Ally for Local Clinical Commissioning Groups – Local Government

Filed Under (Commissioning Board, GP Commissioning, Localities) by Paul on 20-09-2011

Regular readers will recognise that one of the themes of this blog over the last 9 months has been how, despite the heady intentions of the Secretary of State in July 2010 to localise power in the NHS, recent practice in setting up the reforms has been to give ever greater power to the centre – in the shape of the National Commissioning Board.

My recent experience within the reform programme of the NHS has underlined the impact this is having on local experience. Just in the last few weeks a number of GP leaders of local commissioning groups have expressed surprise at how they are being treated by the local arms of the NCB (in the shape of clustered PCTs and SHAs). They are being told to come to meetings at a few hours notice; to change their plans at a weekend’s notice and generally getting a good introduction to the centrist culture of the NHS. Up until now most GPs have avoided this experience because the NHS centre has not seen them as being sufficiently powerful to bother with.

Now they are being put ‘in charge’ of local commissioning they are beginning to experience the combination of instruction and capriciousness that is the hallmark of central NHS management culture and, unsurprisingly, it’s a bit of a shock.

GPs say in wonderment, this can’t really be an example of what the Government means by localisation can it? And of course they have a point.

Since December last year when the quid pro quo for going ahead with the publication of the Bill was the appointment of David Nicholson to be CEO of the National Commissioning Board there has been a powerful tussle going on between centralising and decentralising forces within the NHS reform programme. Over this period the Government’s capacity to implement its reforms has grown weaker and weaker, leaving a power vacuum into which the NCB has walked.

The nascent clinical commissioning groups are beginning to get the fuller force of the authority of the NCB brought to bear on them – and its proving to be an unequal struggle.

So how can a group of local GPs who still do not properly exist as an organisation, empower themselves in such a way as to ensure that they can achieve something locally? This is an even bigger problem because if a group of GPs gains a reputation of wanting to do what they think is best for their local patients rather than what they are told to do by the NCB, they may well find that the process of becoming authorised by the NCB is very hard.

So how does a nascent GP group play this power game?

The leadership of the NHS in the DH have always quite rightly felt that given the size of the NHS they do not really have to pay much attention to other parts of government. So therefore outside of social care, the NHS, at the centre, has never really seen local government as being of any relevance.

At a local level the NHS has had to work with local government and local GPs, whilst they may not have had a structural relationship with local government, recognise that through its services local authorities are important structures.

The one localising part of the Bill that has been maintained and even strengthened during the Government’s great reform retreat has been empowering local authorities through the Health and Well Being Boards. The Conservative part of the Government has seen the empowering of local Government as an easy way of giving something to their Liberal Democrat allies. This has looked like a cost free part of the great retreat.

Across the country shadow boards are being set up that that bring together local health partners with the possible clinical commissioning groups, and they are learning how to think through real partnership working.

Over the next 18 months it will be very much in the interest of local government and the Health and Well Being Boards for their nascent clinical commissioning groups to thrive. If from April 2013 local clinical commissioning groups have not been authorised to carry out local NHS commissioning, then that commissioning will be nationalised through the National Commissioning Board. (NCB)

Under such circumstances there will be no local governance of local NHS commissioning at all.

Local authorities are used to having to battle with all forms of Government to ensure that their localities have any say at all in the development of local services. The fact that they will now have to battle with the NCB to gain any influence over local commissioning will be familiar to them from so many other areas of policy.

What will become clear to local government is that if, from April 2013, they want any influence at all over the local commissioning of NHS services they will need to have an authorised clinical commissioning group on their patch. It is therefore strongly in every local authority’s interest to support their local clinical commissioning groups in developing as organisations and then in gaining authorisation.

I am sure that over the next 18 months, local government will increasingly come to recognise this and support their local GPs. However it would be very helpful if local GPs were to recognise that now. Close links with local government are one of the few power bases into which the NHS NCB will not have inroads. The NCB will not understand local government or the influences on it.

Therefore it is enormously in the interests of clinical commissioning groups, as they receive increasingly strident instructions from the NCB, to be able to say that whilst this may be something that of course the NCB wants, it is not something that their local authority wants.

This could create a new axis of power. One that local government is good at, but the NHS needs to learn. That is the ability to stand up for local needs against an onslaught from the centre.

Engaging employees: The Circle example

Filed Under (Employee ownership, Reform of the NHS, Third party provision) by Paul on 19-09-2011

Long term readers of the blog will remember the Health White Paper statement from July 2010 when the Coalition Government made the extravagant promise, on page 36, that “Our ambition is to create the largest and most vibrant social enterprise sector in the world”

Admittedly this was written when they were having a revolutionary moment (an approach that has since been overwhelmed by layers of fear and conservatism) but it is still an important and interesting aim to think about. Read the rest of this entry »

A discussion with diabetes clinicians about NHS reforms

Filed Under (Health and Social Care Bill, Narrative of reform) by Paul on 16-09-2011

This week I attended the European Conference on Diabetes in Lisbon where I talked to a group of British diabetes clinicians. As is usual in these events they had spent the day talking with European colleagues about the latest clinical developments and were now spending the evening looking at the much more organisational issue of NHS reform. Read the rest of this entry »

The hospital is dead, long live the hospital: Sustainable English NHS hospitals in the modern world

Filed Under (Health and Social Care Bill, Health Improvement, Hospitals, Reform of the NHS) by Paul on 15-09-2011

Today, September 15th, we are publishing, through the think tank Reform, a pamphlet about the necessity to convert the work of NHS hospitals into a much more sustainable set of business models. These changes will be difficult for both those inside the NHS and for those outside. However not facing up to the need for these changes will build into the NHS much greater inefficiencies, and outcomes that fail to reach the level of safety that we have come to expect. Read the rest of this entry »

With elective care in the NHS how is patient choice faring?

Filed Under (GP Commissioning, Patient Choice) by Paul on 12-09-2011

Over the next few weeks the Bill will be going through a quiet period, so it’s a worthwhile opportunity to take a different look at some of the highly politicised issues that we discussed last week. Today I thought it would be useful to run through a review that was published in July this year by the Cooperation and Competition Panel concerning how patient choice for any willing provider was actually working. Read the rest of this entry »

The big show down. The BMA and its fight with patient choice

Filed Under (BMA, Patient Choice) by Paul on 09-09-2011

Last week’s BMA briefing on the Health and Social Care Bill not only argued their continuing opposition to the Government reform, but demonstrated how much they wanted to move the NHS away from modern society.

In June readers will remember that the Government’s reform of its reforms argued that they would amend their Bill to make it clear that they would outlaw any Health Minister that argued for a change in the proportion of NHS services that were provided by the public sector, the private sector or the voluntary sector. They did this because they had been stung by the accusation that they had a policy of increasing the share of NHS services to be provided by the private sector.

So, true to their principles, they reversed the policy from being one in favour of increasing the size of the private sector to one where you were not legally allowed to have a view on it at all.

This new law would outlaw a policy where a Minister, or Monitor, argued – for example – for a higher proportion of third sector organisation hospices providing services for end of life care.  The outlawing of this statement was meant to prevent the accusation that the Government was in some way against NHS public service provision.

If the current state of provision was, say, 30% private, 30% third sector, and 40% public sector then freezing proportions may in some way make sense. But given that for most parts the NHS provides well over 90% of provision, this policy freezes provision in very unequal proportions.

The aim of this new law was to argue that Government could not have a policy of increasing the proportion of care from a sector. However the Government was NOT saying that they would stop individual patients from choosing whatever provision they wanted. So if a large number of patients chose, for example, to move their end of life care from an NHS hospital to a voluntary sector hospice, the government would say this was up to them and not caused by Government policy.

It was not having a policy which would tell patients what to do that has made them fall foul of the BMA. .

At the time I suggested that whilst the BMA and other public sector trades unions would welcome the fact that the Government no longer wanted to have a policy of increasing competition in the NHS, the policy of Government neutrality would not appease them.

They would not rest until the Government had a policy of outlawing the private sector from providing any more services for NHS patients.

Last week’s BMA briefing made it clear that this was now their position.

“ In relation to the increased use of the private sector in providing care, the changes in the Bill put a duty on the Secretary of State, Monitor and the NHSCB not to ‘exercise  <their> functions for the purpose of causing a variation in the proportion of services provided  by any sector. This does not prevent such a variation taking place as a result of market forces < e.g. patients choosing more providers from a particular sector through AQP- any qualified provider>

The BMA believes that

  • Although the Government has attempted to address concerns about the increased use of the private sector, there is still too much emphasis on using ‘market forces’ to shape health services. The Bill still allows for there to be an increase in the use of private sector providers”

BMA briefing page 2

This is a really important explanation of the BMA’s position and it gives us a view of the kind of society that they want to create. It demonstrates how far they are prepared to change the nature of an open society in order to appease their own fear of the private sector.

Since they argue that the Bill is flawed because it “allows for there to be an increase in the use of private sector providers”, presumably a good Bill would in some way outlaw any such increase.

Since the Bill does not ‘prevent such a variation taking place as a result of market forces – for example patients choosing more providers for a particular sector’  presumably a good Bill would in some way outlaw patient choice if that choice was to result in a higher proportion of NHS care being provided by the private sector.

In an open society this is extreme stuff. It is worth a moment’s quiet thought about the sort of society these restrictions would create.

The BMA want a bill that would make it illegal for private sector organisations to provide a higher proportion of NHS health care than they do at the moment. Even more shocking is the fact that the BMA would be satisfied with a Bill that would make it illegal for patients to choose to have their operation carried out by a private sector provider if that movement increased the proportion of provision for NHS patients from the private sector.

In the past there has been much talk by the BMA about their concern that patients are individually not really up to making these choices.

But here it is clear that they are not frightened of the individual capability of patients to make these choices but they are really worried that the overall outcome of making these choices might increase the proportion of private sector providers for NHS patients.

They want to restrict patient choice for directly political reasons.

But what sort of society do they want to create?