Health Matters | Paul Corrigan's blog

As I mentioned yesterday I spoke last week at the National Association of Primary Care Conference. What was really interesting was listening to the Secretary of State speak just before my panel session began. Read the rest of this entry »

Regular readers will recognise that one of the themes of this blog over the last 9 months has been how, despite the heady intentions of the Secretary of State in July 2010 to localise power in the NHS, recent practice in setting up the reforms has been to give ever greater power to the centre – in the shape of the National Commissioning Board.

My recent experience within the reform programme of the NHS has underlined the impact this is having on local experience. Just in the last few weeks a number of GP leaders of local commissioning groups have expressed surprise at how they are being treated by the local arms of the NCB (in the shape of clustered PCTs and SHAs). They are being told to come to meetings at a few hours notice; to change their plans at a weekend’s notice and generally getting a good introduction to the centrist culture of the NHS. Up until now most GPs have avoided this experience because the NHS centre has not seen them as being sufficiently powerful to bother with.

Now they are being put ‘in charge’ of local commissioning they are beginning to experience the combination of instruction and capriciousness that is the hallmark of central NHS management culture and, unsurprisingly, it’s a bit of a shock.

GPs say in wonderment, this can’t really be an example of what the Government means by localisation can it? And of course they have a point.

Since December last year when the quid pro quo for going ahead with the publication of the Bill was the appointment of David Nicholson to be CEO of the National Commissioning Board there has been a powerful tussle going on between centralising and decentralising forces within the NHS reform programme. Over this period the Government’s capacity to implement its reforms has grown weaker and weaker, leaving a power vacuum into which the NCB has walked.

The nascent clinical commissioning groups are beginning to get the fuller force of the authority of the NCB brought to bear on them – and its proving to be an unequal struggle.

So how can a group of local GPs who still do not properly exist as an organisation, empower themselves in such a way as to ensure that they can achieve something locally? This is an even bigger problem because if a group of GPs gains a reputation of wanting to do what they think is best for their local patients rather than what they are told to do by the NCB, they may well find that the process of becoming authorised by the NCB is very hard.

So how does a nascent GP group play this power game?

The leadership of the NHS in the DH have always quite rightly felt that given the size of the NHS they do not really have to pay much attention to other parts of government. So therefore outside of social care, the NHS, at the centre, has never really seen local government as being of any relevance.

At a local level the NHS has had to work with local government and local GPs, whilst they may not have had a structural relationship with local government, recognise that through its services local authorities are important structures.

The one localising part of the Bill that has been maintained and even strengthened during the Government’s great reform retreat has been empowering local authorities through the Health and Well Being Boards. The Conservative part of the Government has seen the empowering of local Government as an easy way of giving something to their Liberal Democrat allies. This has looked like a cost free part of the great retreat.

Across the country shadow boards are being set up that that bring together local health partners with the possible clinical commissioning groups, and they are learning how to think through real partnership working.

Over the next 18 months it will be very much in the interest of local government and the Health and Well Being Boards for their nascent clinical commissioning groups to thrive. If from April 2013 local clinical commissioning groups have not been authorised to carry out local NHS commissioning, then that commissioning will be nationalised through the National Commissioning Board. (NCB)

Under such circumstances there will be no local governance of local NHS commissioning at all.

Local authorities are used to having to battle with all forms of Government to ensure that their localities have any say at all in the development of local services. The fact that they will now have to battle with the NCB to gain any influence over local commissioning will be familiar to them from so many other areas of policy.

What will become clear to local government is that if, from April 2013, they want any influence at all over the local commissioning of NHS services they will need to have an authorised clinical commissioning group on their patch. It is therefore strongly in every local authority’s interest to support their local clinical commissioning groups in developing as organisations and then in gaining authorisation.

I am sure that over the next 18 months, local government will increasingly come to recognise this and support their local GPs. However it would be very helpful if local GPs were to recognise that now. Close links with local government are one of the few power bases into which the NHS NCB will not have inroads. The NCB will not understand local government or the influences on it.

Therefore it is enormously in the interests of clinical commissioning groups, as they receive increasingly strident instructions from the NCB, to be able to say that whilst this may be something that of course the NCB wants, it is not something that their local authority wants.

This could create a new axis of power. One that local government is good at, but the NHS needs to learn. That is the ability to stand up for local needs against an onslaught from the centre.

Over the next few weeks the Bill will be going through a quiet period, so it’s a worthwhile opportunity to take a different look at some of the highly politicised issues that we discussed last week. Today I thought it would be useful to run through a review that was published in July this year by the Cooperation and Competition Panel concerning how patient choice for any willing provider was actually working. Read the rest of this entry »

There was a time during the last few months when those who were defending the NHS status quo turned the US into a pariah. I heard very sensible people say in public meetings “I won’t take any lessons from the USA about health care because their system is so bad’. This became a sort of “know nothing” rejection of an entire nation – and all of its knowledge. NOTHING from the USA was any good because their overall system was so bad. Read the rest of this entry »

The national GP organisations such as the NHS Alliance and the National Association of Primary Care have, over the last couple of months made some strategic errors that now cannot be fully recouped.

(The Royal College of GPs is in a different category. As a professional membership organisation representing GPs it would always be conflicted about these reforms, as the two very different views of its previous and current president exemplify) Read the rest of this entry »

Given that I don’t know what the Government plans to do about moving forward NHS reform (and, as it seems, neither do they) I thought it might be interesting to write a couple of posts on how a government might continue with reforms – despite the fact that it looks like this one doesn’t..

Interestingly I suspect that this is something that the current Secretary of State for Health may also want to do – even if his Prime Minister no longer wants any more reform. I also think that a sizeable number of NHS staff recognise that an unreformed NHS may not survive the decade and will also want to press ahead with reform – even if the Prime Minister doesn’t. Read the rest of this entry »

Stopping hospital activity covered by tariff from growing is only a part of the problem.

Whilst I didn’t think of it at the time, on March 25^th I posted what may be the first of a series providing concrete examples of the issues that GPs need to get involved in if they are going to be successful commissioners. Some of these will relate to the tactics of commissioning – how to do things – and some of them will need to change policy which GPs need to get involved in now. Read the rest of this entry »

Today the ever helpful NHS Confederation provides the Government with some advice about its reforms. Rather than the onslaught of horror and disagreement that most other commentators offer, this is a judgement of the story to date. It recognises that there is a lot of disagreement with the Government’s position and suggests some refereeing between the Government and other stakeholders. Read the rest of this entry »

As I said in my blog on July 26^th “Liberation through conscription will not work.” Making GPs do something that they don’t want to is and was a recipe for disaster. Since there are some GPs who are , in the current Secretary of State’s words, ’enthusiastic’ about commissioning working with them will move the policy forward. Making those who don’t want to commission was daft then and is daft now. Read the rest of this entry »

This week’s posts have discussed the potential clash that is taking place on the ground as NHS reforms develop the two very different approaches represented by the work of the National Commissioning Board and the work of the GP Commissioning Consortia. This week I have posted on the two different cultures and on how GPs could be empowered in carrying out their new roles. Read the rest of this entry »