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 White Paper – Some issues (1)

Filed Under (Public Health, Reform of the NHS, White Paper) by Paul on 15-07-2010

What is the responsibility of the National in the English NHS? (Part One)

In fact there are several really important issues contained within this theme and it will take several blogs to cover it all!

The White Paper aims to make very major changes to the responsibility of the National in the English NHS. Lets go through these one by one.

  1. A National Commissioning Board will be created
  2. The Secretary of State no longer be responsible for the day to day running of the NHS but will lay out a ‘short formal’ mandate for the NHS Commissioning Board. This will hold the Board to account.
  3. BUT the Secretary of State keeps political control of the outcomes of all reconfigurations that political local government refers to him.
  4. The Health Bill will put NICE on a firmer statutory footing securing its independence and core functions.
  5. The Department will publish an information strategy.
  6. The Department will create a set of tariffs (although later on this becomes the role of Monitor)
  7. A national Public Health Service will be created and a public health white paper will be published this autumn.

In this post I will deal with points 1 and 2

1     A National Commissioning Board will be created

The NHS Commissioning Board will be accountable to the Department for living within its annual NHS revenue limit and subject to clear financial rules. This arrangement will introduce greater financial transparency between the Government and the NHS. The NHS Commissioning Board will allocate resources to GP consortia on the basis of need.

The Board will have five main functions:

  • Providing national leadership on commissioning for quality improvement
  • Promoting and extending public and patient involvement and choice
  • Ensuring the development of GP Commissioning consortia
  • Commissioning certain services
  • Allocating and accounting for NHS resources

The Board will establish in shadow form as a special health authority from April 2011 and will go live in April 2012.

This contains a number of very important changes in one reform. At the moment the NHS looks to the DH as its central office. The Commissioning Board will become the HQ not for the NHS but for the commissioning of health care with NHS money. This is a very radical change in itself and will need skills and capacity that comes from commissioning not – as the current NHS head office does – from having run hospitals. Some of this expertise will come from NHS Commissioners and some will come from the experience of buying health care in the private sector and from other services. 

At the moment the commissioning of services that will be carried out by the Board take place in a number of different locations. GP services themselves are commissioned by PCTs in the locality, as are maternity services. Specialised services are commissioned at both a National and Regional level. Taken together the budget for this set of services will be well over 25 billion. It will be vital that this is carried out in an active way by the Commissioning Board and for this it will need to attract the current individuals with the highest level of skills.

(Incidentally the White Paper says that maternity services – as against all other services – should NOT be commissioned by GPs. This is weird. It is difficult to see this surviving the scrutiny of the House of Parliament. The reason for this could be that this is one of the sets of services of which the Conservatives are pledged to stop the closure in hospital. Therefore they do not want to unleash the power of GP led commissioning on them as they know they will be forced to change. I look forward to the Parliamentary debates where this is defended!)

However given the change in the role of the Secretary of State (see 2 below) the day to day accountability for the NHS will pass from Parliament.  This is a very important shift constitutionally and there is a “Catch 22” in the implementation of the Write Paper. The only way in which MP’s scrutiny of the Secretary of State can be so radically diminished is if the very people who will lose this power actually vote for it. The current democratic system (MPs) will find it very difficult to vote for this without some recognition that the democratic accountability must sit elsewhere. So the National Commissioning Board will have to find ways of carrying that out.

This is not an internal Parliamentary matter but is at the core of what many thousands of people experience as democracy. People pay for the NHS through their taxation. They know that Parliament is the body that raises that taxation and so they go to their MP to ask for redress. Every Friday and Saturday in MP’s surgeries there are thousands of people who raise the NHS with their MPs and most of these MPs say “I will raise this with the Secretary of State”.

This results in the Department of Health – under the Secretary of State – receiving thousands of letters and formal written Parliamentary questions from Members of Parliament. This matters a lot to ordinary people and if the Secretary of State says “nothing to do with me” MPs will want to take it somewhere.

There is an alternative, but it will need very careful building up before it becomes the same conduit for the public as MPs to the Secretary of State, and that is the combination of the National Commissioning Board and the Health Select Committee. The Board must take its responsibility to MPs and Parliament very seriously. It simply will not be sufficient for it to say that is a matter for the Secretary of State when the latter is saying “nothing to do with me”. So one of the main activities of the Board is ensuring Parliamentary accountability for the expenditure of £110 billion.

It will simply not be enough to say that this is a matter for Health Watch. Health Watch does not reach into our pockets and tax us. Parliament does.

So the Board must take seriously every letter and question from MPs and answer them with vigour. To supplement this the Chair and the CEO of the Board must appear before the Health Select Committee on a monthly basis. ALL English MPs, through their select committee members, must be able to raise issues at those meetings to ensure that their constituents do not lose Parliamentary Accountability.

Once a year the Secretary of State needs to be held to account for how the Board has discharged this democratic accountability. Of course there should be a debate about what goes into the mandate from the Secretary of State BUT there needs to be a separate discussion with Parliament about whether Parliament feels that this accountability is working for their constituents. If it is not then the SoS must sack the Board. 

2     The Secretary of State no longer be responsible for the day to day running of the NHS but will lay out a ‘short formal ‘mandate for the NHS Commissioning Board. This will hold the Board to account.

NHS services will continue to be funded by the tax payer. The Department of Health will receive funding voted by Parliament and will remain accountable to Parliament and HM Treasury for NHS spend.

The Secretary of State will still be in charge of the Department of State and will through that develop the mandate for the NHS Commissioning Board .

The crucial part of this relationship is how the public and Members of Parliament hold the NHS to account when it is not through the Secretary of State (see above). Whilst the Secretary of State will try and remove himself from responsibility for the NHS the public will still wish for Parliament to discharge that responsibility.

The White paper is aware of how important this mandate will be to the architecture of the NHS. In effect the SoS will be handing over about £110 billion and will be saying “I would like some health care for that please”. How that is phrased and what goes into that mandate will set the equivalent of the operating framework for the whole NHS. For what the SoS says to the NHS Commissioning Board will prove to be the focus of what the Board says to the GP Commissioning Consortia. If the board agrees to the mandate then they will have to parcel that up into the number of commissioning consortia that exist.

There is a problem here – as there is with the Board’s relationship to the consortia. In the real world of real contracts both sides of the contract negotiate. The Secretary of State might say “Here is a large sum of money. I want a 10% drop in deaths from cancer in three years to be delivered with that money”. A worthy aim but what if the Board thinks that it’s just not possible? They have to negotiate with the SoS on what the mandate means otherwise they take on something that they know is not possible.

In all other situations when such a large sum of money is being given to an organisation one of the sanctions for not succeeding is to move to another organisation. Or in more prosaic terms to ‘sack the board’. Given the public importance of this Board, and given the flak that it will be taking daily from public expectation, it will demand of the Secretary of State the ability to run itself without interference.

But as we shall see in the next blog and probably regularly over the next few years, the Secretary of State has kept control of the main way in which cost can be taken out of the system, that is substantially reconfiguring hospitals. So on the one hand he will be telling the Board to produce x for y but will be saying that they also need to fund z even though commissioners will not want to.

This part will not work.


3 Responses to “The White Paper – Some issues (1)”

  1. Interesting points, as one would expect!

    But isn’t the truth on the first point that the WP is trying to configure the NHS like a nationalised corporation of old – they had supposedly independent boards too but in the end the Sectretary of State could never get away with “nothing to do with me”.

    On the second – of course you are right – if consortia won’t commission from the hospitals are the government going to prop them up as lame ducks for ever?

  2. On point 1 are you missing the new role of local authorities to oversee public health with an enhanced scrutiny role over the local NHS? Perhaps in future constituents will complain to their councillors about local health issues rather than MPs. If so, it will be interesting to observe the power dynamics between GP commissioners, foundation hospitals and local authorities.

  3. This is an important point. The resources for the NHS will only be coming from national taxation but within the White Paper the accountability will be coming from local government. This means that parliament will have the responsibility of paying for the whole of the NHS without any accountability and local government will have all the accountability but with none of the responsibility to raise payment.
    If I was a local councilor I would say that the Government has to spend more money. If I was an MP I would refuse to raise any money for the NHS without some accountability to me.
    The passage of the Bill through Parliament will be interesting…

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