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 »

Why NHS England is not in fact in charge of the NHS in England. (or an SHA by any other name would smell as sweet)

Filed Under (National Commissioning Board, NHS England, Strategic Health Authorities) by Paul on 11-03-2014

Having posted about last year’s developments in the politics of NHS reform, I would now like to look at what is happening to reform within the NHS itself.

I stopped blogging just before the Health and Social Care Act began to be implemented in April 2013. If it seems as if the Act has been around for a lot longer than 11 months that’s partly because most of the new architecture was up and running before last April.

How does it seem a year on?

The most significant impression I have is that very few people within the NHS actually understand how their organi

sation fits into the system. One of the main reasons for this, which I reflected on last week, is that the politicians who were responsible for the reforms have not taken the time and effort to explain how they should work. So no one has explained to the people who have to make the system work how each bit of it interacts with another.

This political failure was compounded by the fact that one of the main parts of the new architecture, the NHS Commissioning Board, was allowed to change its name to NHS England from April 2013. This change of name was deliberate in that it gave everyone in the NHS the impression that one organisation was in charge of everything.

If an organisation is called “NHS England” then it seems reasonable that the average person in the NHS – working in England – would believe that this is in fact the organisation in control of the NHS in England.

Once the name sticks the legal fact that it isn’t in charge of the NHS seems a bit contrary.  The law becomes secondary to the organisational title.

This leads to many happy hours of explaining to people that whilst the label “NHS England” may appear to put that organisation in charge of the NHS in England that is not in fact the case.

Consider the important example of an NHS local hospital trying to develop a new model of care. This is a really important issue for the future of the NHS and tens of local hospitals are trying to do just this.

Since NHS England is a commissioning organisation of specialist and GP services it has a role in these areas – deciding what care it wants to commission.

But it has no role in deciding what new model of care an NHS provider should develop.

Locally that task falls to the Board of the hospital itself. It is the Board that has to work through the possible future offer of health services and to work out with local commissioners what they might want to commission.

Nationally, if the local hospital is a Foundation Trust, then the board needs to work with Monitor to think through how they will assist with that development.

If they are not an FT that task is carried out by the NHS Trust Development Agency.

Both of these organisations have the legal responsibility to help Boards develop their models of care.

NHS England – at a national and local level – has no power over provider’s boards.

But that does not of course stop them from claiming it.

They do so because NHS England, at a local and national level, has a lot of staff who previously worked for Strategic Health Authorities (SHAs) and, when they worked for the SHAs, they were used to telling providers what to do. For non FTs SHAs had the responsibility to performance manage such organisations.

The fact that they now work for an organisation that has no such role does not stop them from exercising it.

However, as I said last week, you can hardly blame staff in NHS England when the Secretary of State himself regularly ignores the law, that he voted for, enshrined in the Health and Social Care Act.

Many commentators seem to wish for the SHAs to be recreated sometime soon. In fact I am told that many of the staff of NHS England see this as inevitable. They are imminently expecting another reorganisation to give them back their powers to run the system.

So having created a title that gives them the appearance of running everything, all they need now is a law to back that up.

Architectural problems with the new NHS reforms (number 64).

Filed Under (Clinical Commissioning Groups, National Commissioning Board, Reform of the NHS) by Paul on 06-03-2013

The new NHS reform architecture contains within it a number of problems that have always been predictable. As I have suggested on many occasions previously this is in part a consequence of the very many different and opposing minds that have been shaping the reforms as they have been developed. The famous pause in April 2011 led to a considerable strengthening of the centre at the expense of CCGs in the localities. Since then the reforms have always been a combination of greater decentralisation, combined with greater centralisation.  Once that process began relationships between the NCB and the CCGs were always going to be difficult. Read the rest of this entry »

Let’s not shed any real tears for the passing of Strategic Health Authorities

Filed Under (Failure regime, National Commissioning Board, Strategic Health Authorities) by Paul on 25-02-2013

In the last few weeks I have been fortunate enough to have been involved in a simulation about how the new NHS architecture will work rolling forward. I don’t know if you have ever been a part of a simulation but they gained traction in the early 1990s when the famous Rubber Windmill (pioneered by Alasdair Liddell) took place. This rolled forward the new architecture of the time and gave people playing the simulation the opportunity to see not only how the architecture would work but much more importantly what they would actually do in this new world. Read the rest of this entry »

The NHS Confederation makes its case for a year of change in NHS hospitals

Filed Under (Clinical Commissioning Groups, Health Policy, Healthcare delivery, Hospitals, Independent Reconfiguration Panel, National Commissioning Board, Secretary of State) by Paul on 02-01-2013

The Government’s NHS reforms have done little to prevent the main change that will have to take place to ensure that our health service survives and thrives in any meaningful way in the future. That is the major reorganisation of many of the patient services that are at present delivered from NHS hospitals. In the last few days of 2012, the NHS Confederation has been putting the argument for change.   Read the rest of this entry »

Meeting the mandate and improving health literacy

Filed Under (National Commissioning Board, Patient involvement, Self Management) by Paul on 17-12-2012

The Secretary of State’s mandate for the National Commissioning Board lays clear responsibilities on it to improve the capacity of patients to self manage. In fact the mandate says that the board must become dramatically better at involving patients,

“2.5 The NHS commissioning board’s objective is to ensure the NHS becomes dramatically better at involving patients and their carers and empowering them to manage and make decisions about their own healthcare and treatment. For all the hours that most people spend with a doctor or nurse, they spend thousands more looking after themselves or a loved one.”

Readers will know that I have been working with a number of organisations to improve the ways in which the NHS can help patients to better self-manage. Read the rest of this entry »

When 360 degree assessment might just become very important

Filed Under (Accountability, Clinical Commissioning Groups, National Commissioning Board) by Paul on 28-11-2012

Following on from my post on Monday about the way in which local CCGs might use the Secretary of State’s mandate to hold the NCB to account, I have had my attention drawn to some activity from the CCGs themselves. I was suggesting that since the mandate lays a number of responsibilities on the NCB to listen to the changes that the CCGs say are necessary to bring about integrated care, the CCGs could use it to hold the NCB to account. Read the rest of this entry »

Turning the tables. How might CCGs use the Secretary of State’s mandate to hold the National Commissioning Board to account?

Filed Under (Clinical Commissioning Groups, Health Policy, National Commissioning Board, Secretary of State) by Paul on 26-11-2012

This is my third post about the mandate because I think this is such an important part of the new NHS architecture. This one is looks at it from a different point of view – in a way that could turn the whole politics of the mandate on its head. Read the rest of this entry »

How CCGs can stick to their mandate and develop patient-led value for the NHS.

Filed Under (Clinical Commissioning Groups, GP Commissioning, Health Improvement, National Commissioning Board, Patient involvement, Self Management) by Paul on 21-11-2012

This evening, at about 18.15, I am speaking to the NHS Alliance conference in Bournemouth. My theme tonight, as it has been for some time now, is how the NHS can develop better public value by viewing people with long-term conditions as ‘assets’ rather than as ‘costs’. Read the rest of this entry »

How might last week’s mandate from the Secretary of State impact upon the NHS over the next few years? How can it make integrated care a reality?

Filed Under (Clinical Commissioning Groups, Integration, National Commissioning Board) by Paul on 19-11-2012

One of the main consequences of last year’s pause in the passage of the Health and Social Care Bill was a blizzard of amendments to the statutory duties of every single NHS organisation. Amongst the many contradictions that arose from these amendments, there was one constant. By the time it became an Act, after the Bill was amended and re-amended in the Lords every single possible organisation had had a duty to create integrated care laid upon it.

Last week’s mandate for the NCB from the Secretary of State has begun to put some flesh on the bones of how it will be expected to carry this out,

2.1 We want to empower and support the increasing number of people living with long term conditions. One in three people are living with at least one chronic disease. By 2018 nearly 3 million people, mainly older people, will have three or more conditions all at once

2.7 As a leader of the health system, the NHS Commissioning Board is uniquely placed to co ordinate a major drive for better integration of care across different services, to enable local implementation at scale and with pave from April 2013

2.8 The focus should be on what we are achieving for individuals rather than for organisations- in other words care that feels more joined up to the users of services with the aim of maintaining their health and well being and preventing their condition deteriorating as far as possible. We want to see improvements in the way that care

  • Is coordinated around the needs, conveniences and choices of patients, their carers and families- rather than the interests of the organisations that provide care
  • Centres on the person as a whole rather than on specific conditions
  • Ensure people experience smooth transitions between care settings and organisations including between primary and secondary care, mental and physical health services, children’s and adult services and healthy and social care- thereby to reduce health inequalities
  • Empowers service users so that they are better equipped to manage their own care as far as they want and are able to.

The NCB will quite rightly pass many of the main ways to implement this mandate onto CCGs. I will explore in a later post what that might mean.

But the NCB is not only a performance manager of CCGs it is also commissions health care itself.

The NCB commissions £12 billion of specialist health care. If it takes the Secretary of State’s mandate seriously we would expect to see this enormous buying power used to ensure that the services that it buys bought from specialised providers would be part of an integrated care pathway.

This will not be easy (but NOTHING about creating integrated care in the NHS will be easy) because most specialist commissioning is a specific episode of care. However specialist episodes of care, like all other care, need to be part of a pathway of care. The NCB will have to put these episodes alongside the care before, and especially after, the specialist episode to turn it into a pathway. This will be difficult because care on both sides of specialist episodes will be commissioned by local commissioners (CCG and local authority).

But if the NCB wants to demonstrate how it is carrying out its mandate it will have to make this happen.

However there is a much more direct impact that the NCB has through the £20+ billion of GP services that they buy. (One of the odder aspects of this localising reform was the nationalisation of the commissioning of GP services that has taken place.)

GPs will be key to integrated care. Indeed it is very difficult to understand how there can be an integrated care pathway without them.

So if the NCB is going to carry out its statutory duty to develop integrated care, and if it is going to play its role in developing that part of the mandate on integrated care, it will need to radically develop the GP contract. That contract, like every other part of the NHS needs to contain incentives to develop integrated, not just episodic, care. Read the rest of this entry »

Why does the new architecture of the NHS have to pretend so hard to be something else?

Filed Under (Foundation Trusts, National Commissioning Board, NTDA) by Paul on 18-07-2012

Monday saw the NHS Trust Development Authority  (NTDA) appoint its second tier of staff. Leaving aside the fact that it looks now as if the NHS is a completely closed shop – with no external advertising for what are all very important posts being filled over this month or so – there are some very good people being appointed.

As the new architecture emerges from the mist it is clear that the NTDA is really very important. Read the rest of this entry »