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 »

For the NHS the big question is can the number of referrals from GPs to secondary care be reduced?

Filed Under (Clinical Commissioning Groups, GP Commissioning, Health and Social Care Bill, Secretary of State) by Paul on 25-07-2012

…for the Secretary of State it’s, can he claim that his policies have made this happen?

Last week the HSJ revealed an analysis of figures that showed that the recent national downward trend of GP referrals had returned to its historical upward trajectory. In fact the current peak of referrals from GPs is now higher than its previous highest point. This is bad news for the NHS since it shows that current attempts at managing the demand for secondary care do not appear to be working. . Read the rest of this entry »

How competition between hospitals improves quality and integration of services. A report from the Cooperation and Competition Panel.

Filed Under (Competition, Cooperation and Competition Panel, Health and Social Care Bill) by Paul on 24-07-2012

Readers will remember the high noise level of the row that took place about the role of competition in the NHS in the last three months before the Health and Social Care Bill was passed. It was ferocious – with those opposed to competition claiming that one of the main things wrong with it was that there would be an increase in competition. Read the rest of this entry »

When is a ‘GP led commissioning organisation’ GP led – and when is it not?

Filed Under (GP Commissioning, Health and Social Care Bill, Secretary of State) by Paul on 04-07-2012

One of the many choices that Andrew Lansley had to make when he became Secretary of State in 2010 was whether to develop the GP led commissioning of NHS services that he wanted within the current PCT structure or whether to introduce legislation to develop that policy. Famously he decided that he needed the biggest NHS Bill in history to enact his vision. In making this choice he obviously felt that developing existing legislation would not give GPs sufficient power. To really empower GPs as the leaders of the new commissioning framework he felt he needed completely new structures and legislation. Read the rest of this entry »

Were civil servants to blame for not slowing down Lansley’s reforms – or the Prime Minister?

Filed Under (Health and Social Care Bill, Secretary of State, White Paper) by Paul on 12-06-2012

Yesterday I explained how sources are blaming the civil service for not preventing the government from carrying out some of its own policies. In particular government sources were seeking to excuse the Prime Minister from the bad political outcomes stemming from the Leveson Inquiry because, they claim, it was really the fault of the Cabinet Secretary for not preventing the Prime Minister from acting on his decision to have an Inquiry. Read the rest of this entry »

“No micromanagement of the NHS” was the Government’s election pledge – so how is that working out?

Filed Under (Foundation Trusts, Health and Social Care Bill, Hospitals, Manifestos, Reform of the NHS, Secretary of State) by Paul on 06-06-2012

Foreign Secretary William Hague is an experienced politician.

One would assume that over the years he has paid attention to the political manifestos upon which he has been elected.

Given that he has been in shadow cabinets – and now the cabinet – for some time one might reasonably assume that he also pays attention to their discussions about legislation.

Given also that he has been in the House of Commons for a very long time you might imagine that he looks hard at the legislation for which he is voting. Therefore when – in May 2010 – he signed off the Coalition agreement which stated that, “We want to free NHS staff from political micromanagement” we can assume that he meant it.

Similarly in December – when in Cabinet he agreed to the publication of the Health and Social Care Bill, and in January – when he voted for its second reading, we can assume that he agreed with the removal of the Secretary of State from ultimate responsibility for the NHS.

All of which makes his recent activities a bit of a puzzle.

In the Northern Echo’s 28th May edition he seems to be trying to drag the Secretary of State back into micromanaging the NHS. He has apparently had four meetings with Andrew Lansley about the loss of services at one of the hospitals in his constituency – the Friarage Hospital in Northallerton. These meetings have been to ask the Secretary of State to stop the downgrading of maternity and paediatric services at the hospital.

There are several hundred hospitals around England. Most of them are undergoing wide ranging service changes. If the Secretary of State has four meetings about each of them it’s going to take micromanagement to a new level of intervention.

The Secretary of State is famously good with detail, which is just as well because he will need to know the ward rounds of each sister to be able to hold detailed discussions with his colleagues.

William Hague will of course also remember that he voted through legislation to empower the quango, Monitor. His Friarage Hospital is a part of South Tees Hospitals which is itself a Foundation Trust. He will of course know that at the last election, and in the Act, he voted for the separation of Foundation Trusts from the powers of the Secretary of State to be almost total.

Therefore the Foreign Secretary will know that if he wants to try and save services in the Friarage his first point of call will be the Independent Board of the hospital. The second will be Monitor.

It is because William Hague voted in the way he did that the Secretary of State has no role to play.

Their meetings therefore are a bit of a puzzle.

At the time of the second reading of the Bill in January 2011 a number of Conservative and Liberal Democrat MPs made the point that if the Bill had already been law their maternity services and A and E departments would not have closed. They were wrong then, and they are wrong now.

William Hague will need to be a bit more careful about the platforms upon which he stands for election – and the Acts for which he votes.

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

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.

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

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

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 »

“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

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

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 »