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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The centralisation of NHS power as a method of liberating the NHS

Filed Under (GP Commissioning, GRIP, Primary Care Trusts, Reform of the NHS) by Paul on 22-03-2011

More analysis of the dual power system that has been set up within the NHS.

The two threads to this system are, on the one hand, that for the next two years the National Commissioning Board has been given the power to grip the NHS during the period of transition.

On the other hand, across the country groups of GPs (described correctly by the current Secretary of State as “enthusiastic”)  are being encouraged to set up their own commissioning consortia in their own way.

Every now and then these two systems come into contact with each other and there is a clash. Today I want to outline how the new Chief Executive of the National Commissioning Board sees the role of the NCB.

We are assisted in this endeavour not only by the long letters – about his intention to “grip the NHS” – that the NCB CEO David Nicholson has written, but also by the evidence that he gave to the Health Select Committee on March 8th .

It is worth going through this in some detail and analysing what it means.

Sir David Nicholson: …. There are a whole series of things happening simultaneously here. It is very complex and difficult to do, even for myself because I am holding two different things in my head at the same time. On the one hand, we have the transition. In any transition, and particularly a transition of this scale, you need to have a firm grip on finance and other things as you go through. If we lose financial control as we go through this next period, it will all be irrelevant because the consortia will not have budgets to debate with. We need to centralise control in the first instance in order to give the freedom further down the line. That is what is playing out,….. For example, in the planning round for this year, every PCT has to identify 2% of their budget that they can allocate nonrecurringly but can’t allocate continuously. They can only allocate it nonrecurringly if they have the approval of the strategic health authority. That is a big shift in terms of central control and is absolutely essential, in my view, in order to deliver the transition.

On the other hand, we are trying to create a system where there is more autonomy in the consortia. We are trying to give consortia the maximum amount of freedom in order to deliver the shape and nature of the organisations that they want. We are trying to do both of those things together and sometimes they trip over. I perfectly understand how they do, but it is a complicated thing to have to do.

Several issues are clarified here.

1.    He agrees that there are two very different ways of organising the NHS and that those are happening at the same time. On the one hand greater centralisation for the transition and on the other more autonomy in the consortia.

2.    He agrees that ‘we are trying to do both of these things together and sometimes they trip over”

3.    But he also says that he is not doing them together, but is sequencing these two activities. The sequence is that We need to centralise control in the first instance in order to give the freedom further down the line.

4.    So this means that the current period of time is going to see greater centralisation of NHS power than say a year ago before the coalition Government came to power.

5.    He quite correctly points to the SHAs decision to steal 2% of the PCT allocations that they can spend on behalf of the PCT, almost certainly to be spent as an “inefficient hospital fund” by the SHAs propping up those providers in their locality that cannot make ends meet.

Given that this is the current period we are living through, you might wonder if the Secretary of State has been paying attention to what the Chief Executive Officer of the NHS Commissioning Board (that he appointed) is actually doing .

Apparently, before the GPs can be given any power, all the power needs to be centralised – away from the PCTs and the SHAs – upwards to the National Commissioning Board.

And that is what is happening today. Power is moving further away from the GPs to be held – not in the local PCT or even the regional SHA – but in the National Commissioning Board.

This will mean that by the autumn of 2011 the NHS will be more centralised than at any time in the last decade. Therefore at that time, and within 18 months of a Government being elected on the apparent policy of liberating the NHS from centralised control, that control is set to become stronger and stronger.

And this centralised control is not an abstract or future issue for GP Commissioning consortia. At the time that they are finding their feet as legal sub committees of PCTs, their parent bodies will be having power taken away from them and given to the centre.

As I suggested above, the current Secretary of State has been correct to see these GPs as “enthusiastic”. I am working with them in a number of locations around the country and can vouch for their enthusiasm. However as they set up their organisations their experience is that the local power, with which they have been used to working, is moving away from them to the centre.

This will test their enthusiasm.

And as we can see from David Nicholson’s comments above they are going to experience a new, even more powerful, NHS centre.

It is this interaction more than anything else – more than any amendment to any Bill in the House of Commons – that will see the reforms possibly falter and die.

Imagine you are an enthusiastic GP who together with your colleagues is turning your attention to commissioning. You may have become a pathfinder and you look to your PCT for help. In many parts of the country, within the next few days, the mangers you have been used to working with in your PCT will be sacked – or reappointed to a body further away called a “PCT Cluster”.

At the same time as you start to work through the pathways that you want to develop, your cluster and its SHA are starting to insist that your priorities are set by QUIPP from above.

Of course as an enthusiastic GP you resist. You look to your pathfinder application and claim that this the mandate for your work over the next few months. You pitch your enthusiasm against the instruction from a newly empowered centre.

If your enthusiasm can’t overcome the centre it may wane quite quickly.

Tomorrow’s post will suggest some ways in which, over the next few months, GPs may want to bolster their power against a newly empowered NHS Centre.


6 Responses to “The centralisation of NHS power as a method of liberating the NHS”

  1. Paul, you need to get out of the self-selected bubble of enthusiasts and talk to the average GPs (of which there are around 40,000).

    I see no enthusiasm here.

    Thank you for your analysis of the conflicting threads – I see them as a difference between what the NHS will do (centralisation by another name) and what they say they will do (“Liberating”).

    Long experience tells me that this is an agenda for chaos.

    Poorly thought through, unless you are a cynic that believes this is the path to privatisation.

  2. I would add that there are strong hints from Mr Nicholson that, once he’s centralised all the power, he isn’t necessarily going to hand it all back out. Lots of functions are likely to remain in his fiefdom forever. GP Commissioners will, instead, get only a subset to exercise their new powers upon.

    It’s all rather like a child receiving a box of chocolates from a doting aunt, only to have that box taken over by their parent, who doles out individual chocs when they judge the child’s digestion can cope.

    And who is going to understand what functions have been sequested in this way and retained? Most people haven’t a clue of the full range of functions carried out by a PCT. I don’t think even the wonks at DH knew that until they scurried around to find out last autumn. The people who DO know are the managers who currently run the PCTs. But which of them are still going to be around to keep a tally of what returns to local control?

  3. Dear Jobbing Doctor

    Thanks for the comment.

    I am certainly not saying that all doctors are enthusiastic about commissioning NHS health care but there are a few who are. Their enthusiasm will only count if the other GPs in the area will allow them to lead on commissioning. There are some areas where this is happening. The difficult thing – as we both agree – is whether the NHS Commissioning Board will allow them to do so.



  4. Paul

    The 2% will work this year (each SHA is purportedly having to pass through in excess of £25m to the DH, the elephant in the corridors of Parliament?) amongst propping up technically bankrupt organisations.. but not next year, it will not be enough. The ‘contracts’ the DH is pushing for by 31 March will not be robust and as a previous NHS CE said, ‘I have no more levers to pull’. Other than performance manage clinicians (GPs in particular) who will resist at best or revolt, because that is the nature of the clinician.
    The only hope for the reforms is that entrepreneurial GPs stand together and be counted and have the belief and courage to desist performance management and intervention.
    In here somewhere there is a patient for whom services must be commissioned at the right price to deliver the right outcome. The BMA is advised to mobilise people around this agenda.
    I remain positive that despite all this complexity, there will be clinically led commissioning that will improve quality, experience, outcomes and deliver the value that this country so desperately needs..

    Hope springs eternal.

  5. Christine Burns’ comment about the likelihood that centralized control will persist after Spring 2012 is borne out by the provisions of the Bill that (1) perpetuate the traditions of cental guidance and direction (SOS mandate to NCB, NCB guidance, direction and authorization powers) (2) perpetuate the traditional levers of central power of patronage in the NCB and add some new ones (new ones like authorization powers, accounting officer veto powers; old ones like discretion to carry out “brokerage” and use contingency funds) and (3) gives Monitor the power to regulate how much space there is for local procurement and local variation on national tariff, currencies, contracts etc – in agreement with NCB. Presumably GPs could try judicial review over the “duty of autonomy” provision. And while GPs may think the idea of applying competition law and bringing the OFT and Competition Commission into the NHS is horrendous, but it does offer them a route for appeal over the contents of the national tariff document if they can build coalitions of objections to the national tariff document – which will regulate local commissioning, not just set national tariff prices.

  6. Dear Lorraine
    Your comment outlines the organisational politics that is the crux of the reforms. The Bill creates two opposing loci of power for the new NHS. Central power will continue and may be strengthened by the reforms. Local commissioning, because it will be carried out by GPs (who have another career) too, will mean that the careers of such commissioners will not be ‘owned’ by the NHS Commissioning Board the way in which PCT CEOs are. But GPs will only be able to resist the top down power of the Board if they organise the power that they have to hand. This must involve their own collective organisation as commissioners, competition law and judicial review. If the reforms work this will be a battle between GPs and the centre and locality will do better than it has done up until now. But to succeed in that battle GPs will have to use everything they have to hand.

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