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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 »

New roles need assessment and training – for everyone, not just GPs.

Filed Under (Clinical Commissioning Groups, National Commissioning Board) by Paul on 29-03-2012

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One of the main issues for implementing reforms that create new roles is that it is wise to ensure that the people who have to carry out these new roles have the capacity and the skills to succeed.

Just because people were good at doing one thing in the past, doesn’t mean that they will be good at doing something very different in the future. Read the rest of this entry »

Returning to the theme of “developing the NHS in the long age of austerity”

Filed Under (Expenditure, Health Policy, Investment, Reform of the NHS) by Paul on 28-03-2012

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The phrase “developing the NHS during the long age of austerity” was one that I first used in December 2011. It’s one to which I will return frequently over the next few months. Read the rest of this entry »

After the struggle over the Bill comes a more important struggle – over its implementation.

Filed Under (Clinical Commissioning Groups, Health and Social Care Bill, National Commissioning Board, Reform of the NHS) by Paul on 27-03-2012

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One of the really interesting tussles taking place over the next few months concerns who is actually implementing the Bill. This may sound like an odd issue to bring up because one might think that the constitutional process is obvious. The Government manages to get a Bill passed by Parliament, the Queen signs it, and the Government implements it.

But as the Bill becomes an Act the people that will carry out its implementation will be very different.

One of the things we learned last week was that both political parties in Government – who have been voting for this Bill at regular intervals for the last 15 months – are simply delighted that it has at last left Parliament. For them, the actors and actresses in the theatre of parliament, the show is over.

The Cabinet banged the table with glee that it had gone (Did they ever do that at your school? – No they never did in mine either.). There is huge relief in Parliament. The Bill has passed and outside the Select Committee no-one will give much thought to what happens next.

It isn’t this part of Government that does the implementing.

Insofar as politicians continue to be involved it is the job of Ministers to oversee implementation.

Now, I am now going to say something that may startle you. I know it may not have looked like it for the last 18 months, but this group of Ministers have had previous experience with Parliamentary legislation. Admittedly it was in opposition, but before this Bill they did know how to argue amendment and move legislation through.

(I know, I know, but I am not saying that this group of Ministers had learnt to do it well – just that they had some experience of doing it).

None of these Ministers have any experience of implementing a Bill in Government.

But the people who run the National Commissioning Board have been implementing legislation since before the Cabinet learnt to bang their desks when given a half day off at school.

So if you had to put money on who will be most effective in implementing this Bill I would not put much on the Ministers.

This partly explains the numbers in yesterday’s post. The accountable officers in 6 out of 10 PCTs are similar to the accountable officers that existed under the PCT system. The old system will reproduce itself in the new where it can. But the old system will where it can use implementation to grab more power than it had before.

So if Ministers are not really capable of implementing the Act and the NCB writes its own rules for implementation, then surely the field is open to just one sort of implementers? The National Commissioning Board.

But on the ground there is in fact another group of implementers – the GPs in Clinical Commissioning Groups. If they don’t implement this Act then not a lot that is new will happen. (If GPs – as accountable officers – decide to walk away, not a lot that is new will be implemented).

And within a few hours of the Bill’s passage the combination of the National Association of Primary Care and the NHS Alliance sent out the following letter to their members who are and will be some of the main implementers of the Act.

“The passage of the Bill has been nothing if not controversial. The NHS Clinical Commissioning Coalition of NAPC and NHS Alliance has been a strong advocate of Clinical Commissioners throughout, while working hard “behind the scenes” to ensure that we are given the necessary powers to match our new responsibilities. As clinicians, we now have a real opportunity to

transform local services and health.


The last few months have seen a sometimes polarised debate of strong political and professional opinions, which have led to passionate and public disagreement. In retrospect, we can all think of ways in which engagement could have been improved. We have also learnt some important lessons

around managing our relationships at a time of significant turmoil.

But now the parliamentary stage is over, it is vital for our patients and our populations that the profession and primary care reunites and finds ways of making the new NHS structures and arrangements work. As the NHS Clinical Commissioning Coalition, both NHS Alliance and NAPC are committed to helping you meet the challenges ahead. We must demonstrate quickly to our

patients, colleagues and the country that these changes have not been just some bureaucratic shift of organisational structure but that they will have a real and meaningful impact on the health and the health care of all NHS patients.


The NHS Clinical Commissioning Coalition is keen to support you in this process. We shall be publishing a monthly newsletter which will update you on everything that is going on and provide examples of the innovations, advances and improvements in patient care that you, as CCGs, are driving. Please let us know of any early wins as well as the challenges you face in your CCG so that

together, we can continue to win the argument for GPs being at the very heart of the reform programme.


Meanwhile, we must ensure nationally and locally that the new arrangements are allowed to work. That is why both of us are meeting regularly with the Secretary of State, ministers, Department of Health, leaders of the National Commissioning Board (NCB), Monitor and many others. We now

have an urgent mission and we are endeavouring our utmost to ensure that CCGs and their leaders are masters of their own destiny.


On April 24th we have organised a first meeting of CCG leaders following the passing of the Health and Social Bill. This represents a unique opportunity for us for us all to determine our own future April 24th will also be a crucial opportunity for us discuss progress and concerns and to put the results

of those discussions to the Secretary of State, Chairs of National Commissioning Board and Monitor as well as others. . Please also let us know of any way in which we can help you to make clinical commissioning a success in your area.”

It’s important not to underestimate the potential of this letter. These two GPs organisations plan to short-circuit the relationship between what is talked about nationally as policy and what happens to GPs in practice.

They plan to use the April 24 meeting to bring the experience of the actual implementation on the ground to the Secretary of State and present him with different implementation solutions at both a policy and a practice level.

This means that one of the answers to the question “who is going to implement the Act?” could be the people who are going to carry it out.

The next few months will show whether GPs will be the implementers of the Act or will have it implemented upon them.

Does it, Mr Cameron does it?

Filed Under (Clinical Commissioning Groups, GP Commissioning, Primary Care Trusts, Prime Minister) by Paul on 26-03-2012

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A few weeks ago I asked this question of the Prime Minister’s rationale for the Health and Social Care Bill in response to his assertion that “… our Bill gives power to doctors and nurses”. Now that the Bill has been passed and issues of implementation begin to arise I will return to this question throughout this week.

As I have often said it may have been true that the intention of the July 2010 White Paper had been to give power to GPs. At that time it was drafted it intended that GPs would form their own organisations to control the commissioning of most NHS care across the country.

But during the first 6 months of 2011 the Government failed to make the case for this radical devolution. They became frightened of the backlash – and since June 2011 the Bill has been amended again and again with central diktats and national organisations to hedge around the power that doctors will have over commissioning.

Whilst the Bill was moving in the direction of greater centralisation the Prime Minister, in despair of his Secretary of State actually explaining what was going on, was searching for a way of explaining the Bill to the public. The post-June 2011 amendments would be best explained as creating greater central accountability for the NHS to the National Commissioning Board – but in truth that isn’t really a very catchy storyline.

So the Prime Minister went back to the original version of the white paper and claimed that “first our Bill gives power to doctors and nurses”.

Now that the Bill has passed we will, over the next year, get an increasingly clearer idea of the extent to which this explanation of the reforms will hold true. We will be able to judge the Prime Minister’s success in constructing a reform process in line with his intentions.

This will also provide us with a better understanding of how good the Prime Minister is at actually governing. 

Changing the world – rather than just talking about it.

Under the previous system the people in the localities that had power over most NHS commissioning were the Primary Care Trusts. All of these had GPs on their boards – most of them having GPs as medical directors.

But the Prime Minister felt this did not give sufficient power to doctors and so he introduced an enormous Bill to change the legislation to give them more.

The way in which the spending of public money is held accountable in this country is through a chain of accountable officers. Under the old system this chain went from the Department of Health to the Primary Care Trusts where all 150 of them would have a designated officer to be accountable for the money.

This is where real power lies. If you have spent any time in the NHS you will recognise that the expectation laid upon the accountable officer in the organisation is far greater than on anyone else. There will be lots of different people in the local organisation with some power, but at the top of the pile is the accountable officer.

So one way we can judge the efficacy of the Prime Minister’s intention to give more power to doctors through clinical commissioning is to see how many of the accountable officers are, or will be, GPs. Obviously as of the end of March 2012 this picture is still forming so over the coming year this blog will keep a running score of how things are progressing.

Luckily the HSJ has already carried out a survey asking this very question.

They asked, “Is the accountable officer of your Clinical Commissioning Group a GP or a manager?”, and they have found that 38% of the CCGs do have a GP as the accountable officer.

They have also found that 62% do not.

Admittedly this is only one yardstick of power, but it is one that the whole Bill and the reform programme has concentrated on. The Bill has been trying to change who had the power over the finances of commissioning – and at the moment it looks like it will fail in just over 60% of the country.

What does this tell us about the Prime Minister’s ability to govern?

He chose his method of reform – which was to have a very large Bill (with 1000 amendments) to bring about these changes.

Through this mechanism of government he has achieved what he wanted in nearly two fifths of the country.

He could have chosen to keep PCTs and through the change process of secondary legislation said that the accountable officer within the PCT must be a registered GP.

That would have covered 100% of the country rather than 38%.

He could then have said that there needs to be a majority of GPs on every PCT board. Again that would have covered the whole of the country not just those parts that will have authorised CCGs in the next few months.

So to recap.

The Prime Minister had a policy intention that stated that “our Bill gives power to doctors and nurses”

He chose as a form of intervention a large Bill with 1000 amendments in both Houses where the coalition have significant majorities – with the result that his policy intention will be carried out in nearly 40% of the country.

Whatever you think about GP-led commissioning the link between the Prime Minister’s intention and the outcome in the country is not very efficient.

How might Labour ruin their superior political position on the NHS?

Filed Under (Health and Social Care Bill, Health Policy, Labour Party, Reform of the NHS) by Paul on 22-03-2012

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As the Health and Social Care Bill was clearing its final hurdle in the House of Commons – just after 10 o’clock on Tuesday evening – I was on the Radio 4 programme “The World Tonight” talking about the Bill.

I mentioned recently that it’s fun talking to journalists about the Health and Social Care Bill because they, as a matter of professional pride, expect to be able to explain very complex things very simply. Yet they are all to a person defeated by the experience of trying to do that with this Bill. Read the rest of this entry »

Why is the Government so pleased with itself now that it has passed its Health and Social Care Bill?

Filed Under (Coalition Government, Conservative party, Health and Social Care Bill, Health Policy, Prime Minister) by Paul on 21-03-2012

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Since the autumn of last year I have blogged several times about the rather odd truth that the Government really doesn’t seem to care much about the detail of their Health and Social Care Bill. Since June last year they have been agreeing amendments to almost every part of the Bill (and then amendments to these amendments) with a reckless disregard for whether the Bill still makes any sense at all. Read the rest of this entry »

Would 50+ doctors standing for Parliament at the next election have any impact?

Filed Under (Conservative party, Election campaign, Liberal Democrat Party) by Paul on 20-03-2012

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Last Sunday’s story in the Independent concerning at least 50 doctors standing at the next general election against members of Parliament from the Lib Dem leadership and Conservative marginals was an interesting one. Once again – as much of the campaign against the Bill has shown – it demonstrates the gap that exists between the detailed experienced of party politics and the detailed experience of medicine. Read the rest of this entry »

“The argument is not between reform and no reform. The argument is between bad reform and good reform.”

Filed Under (David Milliband, Health and Social Care Bill, Labour Party, Reform of the NHS) by Paul on 19-03-2012

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Last Tuesday unusually saw a debate on the Health and Social Care Bill in both Houses of Parliament at once. In the Lords the 3rd Reading of the Bill is the last their lordships will see of the Bill. In the Commons there was an opposition day’s debate discussing a motion advising the Government to drop the Bill. This in itself was unusual since next week the Commons will have its own opportunity to vote to drop the Bill when the real thing returns to the Commons for a debate on the changes made in the Lords. Read the rest of this entry »

Was amending the Health and Social Care act to prevent European Competition Law applying to the NHS a pointless exercise?

Filed Under (Competition, Health and Social Care Bill, Liberal Democrat Party, Narrative of reform) by Paul on 16-03-2012

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The Liberal Democrat spring conference saw a spectacular falling out between two powerful women of the left. Shirley Williams launched an attack upon Polly Toynbee because the latter had previously attacked her support for the Bill. The argument became quite heated – accusations of lying were made – and later in the week Polly Toynbee retumed the fray in a Guardian article. Read the rest of this entry »

Big policy needs smart politics

Filed Under (Health Policy, Social Care) by Paul on 15-03-2012

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Yesterday I was at the Reform conference on paying for social care for the elderly and the chair, Patrick Nolan, Chief Economist for Reform cited today’s title as something I had said in my blog. So I feel justified to use it to describe today’s post. Read the rest of this entry »

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