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.

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What to do if you want to push on with NHS Reform. Progressive practice in reactionary times.

Filed Under (Culture of the NHS, GP Commissioning, Reform of the NHS) by Paul on 22-06-2011

Given that I don’t know what the Government plans to do about moving forward NHS reform (and, as it seems, neither do they) I thought it might be interesting to write a couple of posts on how a government might continue with reforms – despite the fact that it looks like this one doesn’t..

Interestingly I suspect that this is something that the current Secretary of State for Health may also want to do – even if his Prime Minister no longer wants any more reform. I also think that a sizeable number of NHS staff recognise that an unreformed NHS may not survive the decade and will also want to press ahead with reform – even if the Prime Minister doesn’t.

What if you are?

  • A GP commissioner who wants to continue to maximise the reform of GP commissioning.
  • A trust thinking of becoming an FT.
  • A third sector organisation that is looking to provide services to the NHS.

All of them may still want to maximise reform and will want to know how they can move the reform agenda forward in the face of Government reluctance.

If you want to press ahead with reform what should you do?

Today’s post suggests a way forward for those GPs who still want to commission.

The first point is to consider is that although it is true that in the last couple of months Government policy that determines the terms of trade has turned against reform, we should not imagine that the whole tide of reforming the NHS has turned just because the Prime Minister has got cold feet. Of course the PM is significant, but as his own weakness over reform has made clear, his power is limited.

What is crucial is the way in which thousands of leading staff now act. Some will follow what might laughingly be called the PM’s “lead” on reform and will be glad to stop doing anything. But others – such as the leadership of the three organisations above – will be all be looking for ways to continue their struggle for improvement.

For 9 months from last July it appeared that the dominant philosophy within Government in regard to the NHS was pro reform. But in reality what the Government wants to change is, in terms of the real struggle in the guts of the NHS, would yield a relatively small advantage.

This was true when the Prime Minister was pro reform and it will be true now that he is anti reform.

With or without Prime Ministerial support reform of a major institution such as the NHS will never be easy. It would have been easier if the Government had not changed its mind. But the culture of the NHS would have always resisted reform with great strength and power. It would have done so if a powerful reform Bill had been passed, and it will do just the same if a weak one is.

The second point, as the current Secretary of State has learnt, is that what matters in developing reform is creating and maintaining coalitions for change. For example the reforms of the NHS which give GPs more power will not stop because a new Bill is lukewarm about the changes in commissioning. But they would be dead in the water if the majority of GP commissioners walked away from them. So what matters is real enthusiasm on the ground – not the detail of a Bill.

One of the crucial elements for the reforms’ progress is the extent to which they have the backing of the mass of GPs. In meetings between the current Secretary of State and GPs they have come to refer to this as the ‘treacle’. This seems a good metaphor for the very sticky stuff that reduces your agility as a GP Commissioner.

The Secretary of State has promised that GPs will not have to deal with the treacle, but I don’t think he can any longer keep that promise. Much of the reform of the reforms is specifically designed to limit the freedom of GP commissioners and these detailed limitations will be on the face of the Bill.

  • Specified people will be based on their Boards to limit them.
  • The Health and Well Being Board will have the right to stop a clinical commissioning group from receiving authorisation.
  • The Health and Well Being Board will be able to return commissioning plans to the clinical commissioning group and report them to the NHS Commissioning Board.
  • The NHS Commissioning Board will be able to withdraw accreditation at any time.

To continue the treacle analogy, each of these points represents a very, very large can of Tate and Lyle poured over commissioners’ feet with the express intent of restricting their agility.

So if you believe in reform what do you do about this?

If I were Secretary of State I would stop the numbers game of saying that 88% of GPs support me. Numbers no longer matter. It is the quality and confidence of the best GP clinical commissioners that matter now. So in the current straitened circumstances I would stop going for breadth of coverage and go instead for real pathfinders that can actually find a way through the forest. Recognising that there will be things coming out of the Department of Health whose aim will be to limit the power of GPs as commissioners I would encourage GPs to organise despite them.

All of the GPs with whom I have been working always intended to have a nurse and members of the public on their Boards anyway. GPs who want to commission will have to get used to having discussions about strategic commissioning with different people in the room. This may mean that there will be disagreement. That’s fine – that is what Boards are for. It is not necessary for everyone to agree. The point of having a Board is to ensure that disagreement takes place in public, and then a majority view moves forward. This may be a new experience for GPs but is a normal part of the life for the Boards of public bodies. So some discussion about how public boards make decisions and deal with conflict will mean that GPs will not necessarily lose the prize of strategic commissioning.

Another point is that the Government’s response to the Future Forum specifies that the Health and Well Being Board cannot veto the clinical commissioning groups’ strategic commissioning plan.

  • They can disagree with it.
  • They can ask for it to be referred back to the clinical commissioning group.
  • They can refer it to the NHS Commissioning Board, but
  • They can’t veto it.

Again, for GP led commissioning groups, the idea is to get used to the probability that there may be disagreement with the Health and Well Being Board. That’s fine – it’s what inter-organisational politics are about.  It is important to recognise that disagreement might arise and make sure there is time in the annual timetable to allow for it.

Both of these issues require a bit of cultural learning on the part of GPs. How to exert influence in a Board where there are different voices? How to assert control in a network of interlocking organisations when there are different interests? Both of these are important sets of cultural skills to learn if you are going to spend public money. They are not show stoppers.

The best GP Commissioners are already planning how to ensure that they can maintain organisational agility with these new sets of limitations. They will be in a position to help the rest who want to develop their strength as strategic commissioners.

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