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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Centralisation, grip and improving NHS efficiency

Filed Under (Creating public value, Expenditure, Health Policy, Reform of the NHS) by Paul on 06-07-2011

One of the outcomes of the Government’s June 2011 reform of its July 2010 NHS reforms has been the increased centralisation of Government control. As I will explore later in the week, the first set of reforms that was intended – in the heady days of July 2010 – to liberate the NHS and localise decision making is now set to provide much more national centralisation of commissioning than has ever previously existed.

A measure of Government incompetence can be seen in the scale of the defeat of its original intention to liberate the NHS and provide local control. From April 2013 the starting point for many of these reforms will be that much more health care is being commissioned by a national organisation called the NHS Commissioning Board than ever before. People all over the country will have had their local PCT abolished and seen it replaced by this national organisation now responsible for commissioning their care.

Some of this nationalisation of local commissioning has been caused by the Government having to change its mind about the timing of a universal policy of GP commissioning. But some of it has been caused by a growing panic over the ability of the NHS to make the necessary £20 billion savings over the next few years.

There is a common sense belief that you need a national centralised system of grip to save sums of money of this size. However like a lot of common sense beliefs, the idea that the only way to save money is through central power is just not true. In fact the illusion of command and control in the NHS is just that – an illusion. Running a national programme that tells people which budgets to cut in Wigan and Wolverhampton gives the appearance of something happening, but it’s just that  – an appearance.

Around the country at the moment there are a number of very interesting conflicts going on between the SHAs’ QIPP organisation, who are demanding that local health economies save sums of money that fit into certain boxes on certain dates, and GP organisations who are saving money – but in different boxes and at different rates.

In some places GPs are simply pretending that the boxes are being filled in in the way the QIPP planner wants. They know that at the end of the year the money will have been saved but not necessarily in the way that the QIPP planner wanted – and surely what matters is that the money is saved?

Other GPs are sticking to their guns. They know where they can save the money and are insisting that this is what they are going to do – and the QIPP organiser can move on to something else. These disagreements on how to save the money – top down or bottom up have spawned a new cottage industry in the NHS – a person who negotiates between saving the money in real piles of fivers through the GPs, or filling in the QIPP boxes irrespective of what is happening in the real world.

There are two very different world views about how economics works here. The first, from the top, is that public money can be controlled by a set of accounting officers who shout at the people underneath them to do certain things in line with a plan. This is called public sector accounting.

The second is a set of economic incentives that depend upon organisations and individuals operating within those incentives to develop better value for money. This is called economics.

The Government set out in those halcyon days last July believing in economics, but have increasingly lost their nerve and now believe that a strong centre shouting at people will save them the money.

Crucially for the NHS they are wrong. As a method of improving value economics trumps accountancy every time.

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One Response to “Centralisation, grip and improving NHS efficiency”


  1. […] This post last week shows how the Government’s reforms, far from being localist or decentralising, will in fact result in a centralisation of healthcare commissioning. It is a cutting critique of the centralising tendency: There is a common sense belief that you need a national centralised system of grip to save sums of money of this size. However like a lot of common sense beliefs, the idea that the only way to save money is through central power is just not true. In fact the illusion of command and control in the NHS is just that – an illusion. Running a national programme that tells people which budgets to cut in Wigan and Wolverhampton gives the appearance of something happening, but it’s just that  – an appearance. […]

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