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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Implementing the Act – developing the commissioning organisations for NHS patients

Filed Under (Clinical Commissioning Groups, Health and Social Care Bill, National Commissioning Board, Reform of the NHS) by Paul on 18-01-2012

As I said on Monday, in a few months’ time the Government will look back at the struggle it had to get the Act through Parliament and see it as a really easy risk—free activity compared to its implementation.

By the time the Bill is passed there will be about a year left for most of its implementation to take place from 1 April 2013.

There is a lot of complex new activity to develop in that year.

My day job involves working with a wide range of different NHS organisations preparing them for the new environment in which they will be working. In this new environment some of the concerns are about the new and very different equation between the increased demand for health care and the same resource, and some concern the reforms.

In the area of commissioning there is an enormous amount of change going on – and has been for some time.

I have mentioned before that when the Bill was published in December 2010 the main thrust of the reforms was centrifugal. It was driving power out from the centre to the localities and this was clearly the way in which it was developing NHS commissioning. Power would be transferred to local GP-led commissioning organisations.

Then in June 2012 there was a substantial rethink about the direction of the Bill and significant power was given to the centre of the NHS – with much more power going to the National Commissioning Board. For the last few months both models of organisation have been developing – GP-led commissioning in the localities and more power being given to the David Nicholson led National Commissioning Board.

If you had to look now – with 14 months to go before all these organisations have to be working – which is better prepared for the change?

In anticipation of the Act, most PCTs have been abolished and their workforces diminished. They have been formed into ‘clusters’ and in some parts of the country they are now being developed into bigger clusters. This indicates a clear move away from concerns about localities toward the creation of bigger and bigger units in a national system..

The clustering of the PCTs – together with the clustering of the SHA – is now looking increasingly like the organisational structure that will become the National Commissioning Body. It is forming before our eyes. Some of the new clusters will be commissioning GP services and some will be performance managing the new Clinical Commissioning Groups.

In most parts of the country you can see people settling into their new NCB chairs and already carrying out the functions for which they will be legally responsible in April 2013.

On the other hand there are now 279 clinical commissioning groups being formed. The Government has endlessly commented on how enthusiastic the GP leadership is for these organisations and a few of them are looking ready to take on commissioning.

The current role of the clustered PCTs is meant to be to help local clinical commissioning groups develop and gain authorisation. The same organisation will, from April 2013, be responsible for performance managing these CCGs.

But the large geographical areas that PCTs now cover in their clusters – whilst good for their future with the NCB – is removing them from the day-to-day local relationships that are necessary to help the local GP-led CCGs develop.

It will not surprise people to know that the clustered PCTs are much better at anticipating their performance management role than in carrying out their local development al role. GP-led CCGs rightly complain about being pushed around by PCTs that are not even full organisations yet.

For CCGs to really be effective their leadership needs to spend nearly all their time working with their members in their local practices. They need to be building the relationships in their organisation practice by practice – from the bottom up.

What I have been saying – for 18 months now – is that for CCGs to work at all they are going to have to contain very strong allegiance between the constituent practices and the GP leadership. Without that the organisation of GP-led commissioning has no traction on the day-to-day work of GP practices and will have little impact. So CCGs need all the help they can get developing their very local organisations.

But the clusters are much more concerned with reducing the number of CCGS so that they much more closely resemble the proposed organisational structure of the National Commissioning Board.

So the main reform activity taking place by the ‘old NHS’ is the development of the National Commissioning Board. The NCB has already successfully abolished the power of local PCT boards and is creating a single national organisation with a single National Board that can tell everyone what to do.

This national organisation is not well placed to encourage very local CCGs to develop.

So what is likely to happen before April 2013?

The NCB will be tasked with nationally commissioning the £10 billion (about 10% of NHS commissioned care) to be spent commissioning specialist disease patterns. Equally they will be commissioning GP services in the localities.

This is one of the odder outcomes of the reforms. Where our GPs actually work is the NHS at its most local. Different streets matter for the location of a local GP. Yet this very local activity will be nationalised and given to the NCB. That is very strange for a bill which claims to want to localise NHS commissioning. Strange or not that probably adds up to about 25% of NHS commissioning going to the NCB.

Taken together the NCB will be responsible for nationally commissioning about 35% of the NHS.

So that’s fine? That means 65% is left to be commissioned by the local clinical commissioning groups. Well…yes and no.

If these organisations are successfully authorised by April 2013 they will be commissioning all that care. But many of them will not gain successful authorisation. Let’s assume that 40% don’t make it and 60% do. That would mean that 40% of what would otherwise be locally commissioned services will be commissioned by the NCB. That’s 40% of 65% or about 26% of total NHS commissioning.

So from April 2013 the National Commissioning Board would be commissioning over 60% of NHS care – with the other 40% being commissioned by local clinical commissioning groups.

Within the next year, as the Bill is being implemented, it seems likely that the Government’s intent to localise NHS commissioning will end up nationalising much more of it than has ever happened before.

This will puzzle those MPs and Peers that are currently arguing for a Bill meant to localise power.

And that’s why the year of implementation will have much more significance than the original intentions  of the Government.


3 Responses to “Implementing the Act – developing the commissioning organisations for NHS patients”

  1. So the localism agenda is a bit of a sham?

    Well, I never!

  2. Very wise and accurate article. GPs prob getting v v frustrated. If only BMA would put as much effort behind opposition of Bill as they have for opposition of the pension proposals

  3. […] have mentioned before that the NCB will commission 10% of the whole of NHS commissioning with specialist commissioning of […]

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