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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Does the reform programme act as a diversion from the necessity to improve value in the NHS? Let’s look at commissioning…

Filed Under (Clinical Commissioning Groups, GP Commissioning, Health and Social Care Bill, Primary Care Trusts, World Class Commissioning) by Paul on 25-01-2012

Yesterday’s Health Select Committee report makes an important case against the Government’s NHS reforms. It argued that the reform programme has and will act as a diversion from the main task of improving value for money for the health service.

The Government replied by saying that on the contrary the reforms were necessary in order to drive those improvements in value.

The argument is simple. Do the reforms get in the way of creating better value for money – or are they an essential step to that new value creation?

There is another argument that revolves around timing – which says that the creation of the new system will be a distraction for the next few years, but that when the new system is up and working it will save more money.

It’s worth examining this argument in more detail.

Some of the sessions in which I have been working with the NHS over the last few weeks have touched on this issue – with regard to the role of commissioning. Since this lies at the core of the reforms that may have an impact on improving value for money it is a good starting point.

Commissioners buy NHS health care on an annual basis. So it is interesting to look at the commissioning years 2011/12, 2012/13, 2013/14 and 2014/2015 to see if the reforms have disrupted them.

The commissioning year should be well under way by the October of the year before the start of the financial year (in April). I make that point because the commissioning year 2011/12 started in October 2010 just as many PCTs were being reorganised into clusters. They were beginning to shed senior and junior staff between the July 2010 White Paper and the publication of the Health and Social Care Bill in December 2011. Therefore the commissioning year 2011/12 was disrupted from its very beginning as people were being made redundant and contracts were being developed for the following year.

As the year 2011/12 progressed commissioners found it difficult to carry out their monitoring role as, over the year, their numbers were cut by between a third and a half.

In October 2011 a reclustering of PCTs was taking place with the move towards the creation of local arms of the National Commissioning Board. The commissioning year 2012/13 is probably the most disrupted because in many places whilst the new CCGs are not yet there, the old organisations (of PCTs) have been abolished.

Some commissioning staff are looking to transfer to the NCB.

Some are helping to write the prospectus for the 85 Commissioning Support Organisations that are being developed.

Some are looking to work with the CCGs.

Not many are actually commissioning.

Therefore what I have heard over the last few weeks is that in many places there is no one on the end of the phone to talk to about commissioning. Providers have to develop their own approaches to 2012/13 and then seek someone out to whom to talk about it. This is not real commissioning.

By November 2012 – for the commissioning year 2013/2014 – some of the CCGs will be authorised and in place and will probably will be picking up what to do. But others will be completing the authorisation process and they will not be sure whether they should be preparing contracts for 2013/14 or whether this should be done by the National Commissioning Board.

By November 2013 – for the year 2014/15 – there will be some who are still unsure whether commissioning is to be carried out by authorised CCGs or whether the NCB maintains its grip.

It is clear that in some parts of the country commissioning will be disrupted – perhaps severely disrupted – for 4 years. In those places the Select Committee must have been right to say that the NHS has been distracted from developing better value for money.

There are some places where CCGs have virtually taken over now for the year 2012/2013. Here I would expect good commissioning to take place which will develop rapidly to become great commissioning.

Judging on the past performance of PCTs this will probably happen in about a quarter of the country.

But even here there is a problem. What is the engine that will be used to develop good commissioners into great ones? I am not at all starry-eyed about the ability of PCTs to carry out great commissioning, but by the spring of 2010 between 20 and 30 % were ‘very good’ at the commissioning cycle.

The development programme of World Class Commissioning was levering up the skill base for these organisations. I was working with a PCT on May 22nd  2010 when the coalition programme and the abolition of PCTs was announced. That PCT had spent 2 years moving from the bottom 20% of the PCTs to the top 20%. In those PCTs they were more than capable of picking up the challenge of creating greater value.

If the PCTs had been left alone it is certain that by this commissioning round – 2 years later – another tranche would have become good commissioners.

Therefore we have had at least 4 years of very considerable disruption of one of the main ways – commissioning – that the NHS can develop better value.

Will CCGs be better at creating better value through commissioning when they are settled in? I think the best will and after 5 years of development they will be very good indeed.

But that’s 10 years after the destruction process started.

Comments:

One Response to “Does the reform programme act as a diversion from the necessity to improve value in the NHS? Let’s look at commissioning…”


  1. In general you are quire right that the reorganization orgy will severely disrupt commissioning. But there is one particular aspect that exacerbates the problem enormously and perhaps even dominates it: the management cost reduction target.

    The idea that the leading problem with cost in the NHS was too many “managers” was not based on evidence or any analysis (my analysis and that of the Kings Fund both said, if anything, there were too few managers). But the bill set an arbitrary target for cost reduction. This is the sort of target that is really easy to meet if you care about pleasing your bosses in the DH and NCB bit aren’t too worried about having the necessary capability to do commissioning well. So we dramatically multiply the damage of a major reorganization by adding an arbitrary, damaging target on top which incentivizes current organizations to shed the skills they might need to do their future job well.

    I’d go so far as to say the management cost reduction target is the guarantee that the reforms will never yield improvements.

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