Health Matters | Paul Corrigan's blog

Health care is essentially a very practical activity. It involves patients paying attention to the detail of looking after themselves and taking the drugs that they have been prescribed. It involves medical professionals carrying out diagnostic tests and working with patients that are experiencing pain and distress. The vast majority of NHS staff and patients experience the NHS as a very important set of practical activities. Read the rest of this entry »

A few weeks ago I asked this question of the Prime Minister’s rationale for the Health and Social Care Bill in response to his assertion that “… our Bill gives power to doctors and nurses”. Now that the Bill has been passed and issues of implementation begin to arise I will return to this question throughout this week.

As I have often said it may have been true that the intention of the July 2010 White Paper had been to give power to GPs. At that time it was drafted it intended that GPs would form their own organisations to control the commissioning of most NHS care across the country.

But during the first 6 months of 2011 the Government failed to make the case for this radical devolution. They became frightened of the backlash – and since June 2011 the Bill has been amended again and again with central diktats and national organisations to hedge around the power that doctors will have over commissioning.

Whilst the Bill was moving in the direction of greater centralisation the Prime Minister, in despair of his Secretary of State actually explaining what was going on, was searching for a way of explaining the Bill to the public. The post-June 2011 amendments would be best explained as creating greater central accountability for the NHS to the National Commissioning Board – but in truth that isn’t really a very catchy storyline.

So the Prime Minister went back to the original version of the white paper and claimed that “first our Bill gives power to doctors and nurses”.

Now that the Bill has passed we will, over the next year, get an increasingly clearer idea of the extent to which this explanation of the reforms will hold true. We will be able to judge the Prime Minister’s success in constructing a reform process in line with his intentions.

This will also provide us with a better understanding of how good the Prime Minister is at actually governing. 

Changing the world – rather than just talking about it.

Under the previous system the people in the localities that had power over most NHS commissioning were the Primary Care Trusts. All of these had GPs on their boards – most of them having GPs as medical directors.

But the Prime Minister felt this did not give sufficient power to doctors and so he introduced an enormous Bill to change the legislation to give them more.

The way in which the spending of public money is held accountable in this country is through a chain of accountable officers. Under the old system this chain went from the Department of Health to the Primary Care Trusts where all 150 of them would have a designated officer to be accountable for the money.

This is where real power lies. If you have spent any time in the NHS you will recognise that the expectation laid upon the accountable officer in the organisation is far greater than on anyone else. There will be lots of different people in the local organisation with some power, but at the top of the pile is the accountable officer.

So one way we can judge the efficacy of the Prime Minister’s intention to give more power to doctors through clinical commissioning is to see how many of the accountable officers are, or will be, GPs. Obviously as of the end of March 2012 this picture is still forming so over the coming year this blog will keep a running score of how things are progressing.

Luckily the HSJ has already carried out a survey asking this very question.

They asked, “Is the accountable officer of your Clinical Commissioning Group a GP or a manager?”, and they have found that 38% of the CCGs do have a GP as the accountable officer.

They have also found that 62% do not.

Admittedly this is only one yardstick of power, but it is one that the whole Bill and the reform programme has concentrated on. The Bill has been trying to change who had the power over the finances of commissioning – and at the moment it looks like it will fail in just over 60% of the country.

What does this tell us about the Prime Minister’s ability to govern?

He chose his method of reform – which was to have a very large Bill (with 1000 amendments) to bring about these changes.

Through this mechanism of government he has achieved what he wanted in nearly two fifths of the country.

He could have chosen to keep PCTs and through the change process of secondary legislation said that the accountable officer within the PCT must be a registered GP.

That would have covered 100% of the country rather than 38%.

He could then have said that there needs to be a majority of GPs on every PCT board. Again that would have covered the whole of the country not just those parts that will have authorised CCGs in the next few months.

So to recap.

The Prime Minister had a policy intention that stated that “our Bill gives power to doctors and nurses”

He chose as a form of intervention a large Bill with 1000 amendments in both Houses where the coalition have significant majorities – with the result that his policy intention will be carried out in nearly 40% of the country.

Whatever you think about GP-led commissioning the link between the Prime Minister’s intention and the outcome in the country is not very efficient.

The point I made last week was that whilst the Government may have a reform policy (in truth of course what’s really exciting about NHS reform is that at the moment the government has several contradictory policies) it has lost control of its implementation. I have posted before about the contradiction between the Government’s story (that they believe in giving power to local doctors to make decisions) and the reality of what life is like for clinical commissioning groups under the National Commissioning Board. Read the rest of this entry »

For exactly these reforms the answer is ‘yes’ because they are framed in such a way as to require legislation.

But for the direction of these reforms, ‘no’. Read the rest of this entry »

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. Read the rest of this entry »

Before Christmas I wrote a post that called into question the depth of the BMA’s love for current PCT staff. I pointed out that in their latest guidance they were extolling the virtues of current PCT staff to BMA members leading clinical commissioning groups as being the best experts in commissioning. I suggested that they were doing this because in the last couple of years they have become fearful of new private sector firms selling their services to GP led commission groups. Read the rest of this entry »

(These new forms of media can be very difficult. Blog readers will probably know that I tweet to let people know there is a new post on the blog. But I am not sure whether blog readers follow me on Twitter. I assume that some of you just read the post and are not in the Twittersphere.

Yesterday I posted about the very difficult relationship between the autonomy of GPs in CCGs to make commissioning decisions for their locality, and the National Commissioning Boards central control of those decisions. Following that there was a fascinating flurry of activity about the problem – or not – of GPs making referral decisions about their patients and how those decisions will relate to the financial decisions they will have to make as commissioners.)

This question is not only at the heart of the current Government reforms but is also at the heart of the debate about the vision of professional responsibility within the NHS. Read the rest of this entry »

Last week I spoke at the National Association of Primary Care Conference and was interested to hear the Secretary of State. As I shall explain tomorrow it was good to hear him articulate a narrative explaining why his reforms were important to an audience of future leaders of Clinical Commissioning Groups. (Even if that narrative failed to encompass the real life experiences of creating CCGs that those in the room expressed to him). Read the rest of this entry »

By all accounts Dr Clare Gerada, from the RCGP, is not just a good medical politician but also a first class GP. And one the good things about the reforms in GP services up until now is that very good doctors have been able to provide good services for more patients because they have won tenders to provide those services. The tendering process has ensured that the commissioners of NHS care have the opportunity to get the best services for their local people and it is through competition that this has been achieved. Read the rest of this entry »

Following my post last week on the possible resurrection of PCTs to act as a safety net for those parts of the country that will not have organised GP Commissioning Consortia in April 2013 there has been an interesting juxtaposition in London. Read the rest of this entry »