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.