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.
The leaders of the National Association of Primary Care and the NHS Alliance issued a statement on February 7th which said that the experience of CCGs was more akin to suffocation rather than liberation.
Obviously, so far as the Secretary of State’s intention is concerned, he believes that his policy has been about increasing power for local GPs. For more than a year he has talked about the enthusiasm of local GPs to take commissioning on board.
But over time that enthusiasm has come up against the real world of how the National Commissioning Board actually operates. Because they will be easier to performance manage, CCGs have been under unrelenting pressure to cover larger areas. That is why we have seen the number of CCGs tumbling every month.
CCGs are also under extreme pressure not to employ people themselves but to employ Commissioning Support Organisations who will employ ex-PCT staff.
This pressure is backed up by the fact that the NCB will be the organisation that decides whether a CCG can be authorised. So this pressure from the NCB on CCGs is backed up by power.
The Secretary of State has been oblivious to the way in which his policy is being implemented. For, let’s not forget, the reform policy is being implemented by managers that the Secretary of State said were the very people from whom he was trying to liberate the NHS.
I hope he loses a bit of sleep over the fact that the people he said were the main problem to the NHS are the very same people he has chosen to put in charge of running his reforms. If these people were the problem in July 2010 why are they the solution in March 2012?
So it’s not surprising that he should have lost control of the implementation.
This problem has now reached such proportions that he has written a letter to every CCG telling them that as far as he, as Secretary of State, is concerned they, the CCGs are in charge,
The draft of this letter can be read here.
As far as the Secretary of State is concerned there is nothing new in this letter. It restates the Government’s policy intent to give GP commissioners power.
However the fact that he has to write it demonstrates the problem he has with the implementation of his policy on the ground.
His problem is that CCGs do not experience what he says in his letter as a fact. “You will have the freedom with your new powers and responsibilities, to commission services in ways that best meet the needs of your patients” Their experience is of being pushed around and threatened.
Not many CCGs experience the fact that they have freedom to commission services in ways that best meet the needs of their patients.
To take a real example very few GPs have good words to say about what are universally referred to as ‘the bean counters from QIPP’. I have posted before about the fact that many GP commissioners can save the equivalent money that QIPP requires them to – but not in the ‘boxes’ that QIPP requires.
The best CCGs ignore these pressures, but in my experience they are not the norm. Most fold under the pressure of meeting the expectations of their NCB bosses.
Many will read this letter and reflect that if this is freedom then the Secretary of State has a strange concept of what freedom is.
The letter also promises, “you will have the freedom to work with whoever you want to in commissioning health services.” and “as statutory organisations you will be able to choose your commissioning support from whatever organisations from whichever sectors are best able to meet your needs and requirements, and every effort is being made to help you exercise choice wherever possible before April 2013”
This is really stirring stuff for CCGs but it is so very different from their experience on the ground. Individual CCGs are being told how many staff they will be able to employ themselves – so that they will have enough management money left over to employ the staff from the Commissioning Support Organisations that are being set up and hosted by the NCB.
The NCB has a mantra which states that CCGs can employ 10 staff per 100,000. This will allow them sufficient cash left over to employ ex-PCT staff from the new CSOs.
The Secretary of State’s freedom to “work with whoever you want” feels rather different from the reality of the NCB trying to reduce its redundancy costs by making CCGs employ staff from CSOs.
In terms of power CCG leaders now have a letter from the Secretary of State which contradicts what the NCB is trying to do. They will make their own judgement about how much power this gives them to face the pressure from the NCB.
As I said all last week the Secretary of State has paid no attention to the way in which others have been implementing his Bill.
He has lost control.