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Dr Michael Dixon, who chairs the NHS Alliance, examines the extent to which Clinical Commissioning Groups have ‘had their wings clipped’ by the amended NHS reforms.

The ‘Pause’ has ended, the NHS Future Forum have reported and the Government has responded.Meanwhile, the Health & Social Care Bill continues to go through Parliament and heads for the Lords. Has anything changed?

Clinical Commissioning Groups (CCGs), previously known as GP Commissioning Consortia, have felt more than a little left out. Their future has been discussed by the NHS Future Forum, which consisted of many more managers and secondary care clinicians than GPs. The new CCGs will have to have a nurse and consultant on their governing board and their plans (and any changes to them) ratified by the Health & Wellbeing Board with clinical senates and clinical networks adding another lot of seeming ‘nosey parkers’, who can quash their plans. What happened to the Health White Paper’s promise of commissioning groups having “assumed responsibility” rather than “earned autonomy”?

Are we still on track for an NHS whose behaviour is dictated not by high-minded centralism but from the frontline consulting room? In short, have CCGs had their wings clipped? For most commentators the answer to that question is a resounding ‘yes!’. It is an impression that is not much altered by the widely-leaked plans of the new National Commissioning Board. While every Tom, Dick and Harry was commenting on CCGs – who should be on their Board, what they should do and to whom they should be accountable – the mandarins at the centre of the NHS quietly drew up their own draft proposals for the new National Commissioning Board, which have been issued for consultation. Those plans look very much like a Department of Health ‘off-the-shelf’ model. The Board will have the usual Medical Director (presumably as usual from secondary care), Nursing Director and leads in the five areas of Government policy.

Nowhere in the plans, as far as I can see, is there more than tokenistic recognition that the rules of the game have changed. There is no direct connection to CCGs and more than a hint that they will be sorted through born-again PCT clusters acting more or less as Strategic Health Authorities do at present. The National Commissioning Board looks like ‘NHS mission control’ and not the promised ‘support for clinical commissioning groups’. Why on earth aren’t they featured on it?

Phoney war

You may say that all this sounds depressing. I will admit to having been in a deep depression over the past two months. I am past that now because it is now abundantly clear that things have changed and are about to change utterly. The ‘Pause’ will, in retrospect, be seen to have been a ‘phoney war’. Idealists, some well-meaning and some full of wind, have been battling it out, while the solutions have been staring us all in the face. Those solutions are simply about how we transfer appropriate services from secondary to primary care and how we de-professionalise care and better enable individuals and communities We have done pitifully little of all of that to date and when everyone puts their boxing gloves away, these problems and the much-needed solutions will be exactly the same as they were before it all began. So the outcome of all this is that CCGs will go forward because they have to go forward.

We may have restrictions, but in truth some CCGs already have nurses and consultants on their Boards anyway. Those being held back by their PCT clusters will become bolshy, rightly so. They will increasingly show that they are the new order and increasingly show that they can deliver, like so many have in our recent NHS Alliance document Making it Better. There are now too many CCG leaders with the bit between their teeth. They are good, talented and principled people, who are concerned about their patients and prepared to fight off any forces that stand in their way. The less strong leaders simply need to realise that there are not really any rule books now. No-one else is going to liberate them, they must liberate themselves. NHS Alliance will support their cause.


Nicholson’s diary

What about the National Commissioning Board? The worst case scenario is that it proceeds according to the plans of its first draft and becomes an inward-looking autocracy with its own agenda, trying to dictate to CCGs. Its leaders will then pull on all of the old levers that used to get things done – but find the cogs and strings are broken and nothing happens. I think that is unlikely. David Nicholson is in a very odd situation. Everyone is prattling on about corporate governance, yet we have a Commissioning Board, where there is now a chief executive long before the non-exec majority have been nominated or had a chance to get their feet under the table! Which rule book of corporate governance did that come from? I hear people say that David Nicholson is now running the NHS with a rod of iron. It’s an illusion.

The NHS accounts may seem reasonably satisfactory to outsiders at present but unless we actually do something and create changes to practice and services at the frontline, the only direction is downwards. In truth, he is a man without clothes and unable to push the buttons or pull the levers of the past. He is far too intelligent to continue in this state of undress and lead a dysfunctional National Commissioning Board hoping the NHS will continue to obey the rules of old centralism. He will sue for peace. He will recognise that CCGs and the National Commissioning Board will rise or fall together. He will make sure that the National Commissioning Board is a mirror reflection of those CCGs; that they see him as their paths to success and vice versa. If this prediction is correct then expect his diary to change from seeing mainly senior DH managers and SHA chiefs or secondary care consultants and managers to a diary that prioritises CCG group leaders and an increasing number of primary care clinicians.

Sweat and status

We all have to change a little. PCT clusters must become servants not masters. CCGs must grasp the gauntlet and persuade their frontline clinicians to join the effort rather than take to the hills. David Nicholson needs to see his role as facilitator not controller. NHS Alliance needs to raise its game to become an ever-more fiercely supportive organisation of frontline clinical commissioners. These changes, all of them essential, can now be achieved without too much sweat or spilt blood if we can all recognise that the rules of the game have changed forever. Some Royal Colleges will protest, senior managers will bemoan their perceived lost status, frontline clinicians will say they are being shackled and the media will say this is one reform too much. Their wrong assumption is that the present system has done anything substantial to improvproductivity, to mainstream innovation, to support radical redesign or even to put patients first.

Improving secondary care waiting lists and introducing the GP Quality Framework were the gods of yesterday. Since then, the NHS has failed to stretch itself towards the new and more urgent priorities that it now faces. That is why CCGs represent the only cavalry that we have. That is why the NHS around them – whether it be PCT clusters, the National Commissioning Board, frontline primary care or Foundation Trusts – must now adapt to their existence, rather than vice versa. To assume that CCGs will be simply ‘will-o’-the-wisp’ and we can carry on as normal is no longer an option in any sense!

T H E  N H S A L L I A N C E :

• Is strongly supportive of Clinical Commissioning, with the purpose of improving population health and health care to individuals. The NHS Alliance
believes that there should be an appropriate balance between local freedom to meet local needs and accountability both to the centre and local
populations.

• Believes that Clinical Commissioning Group Boards should have GPs as majority members. Boards need to ensure the appropriate involvement of other clinicians and managers and have a strong representation from local communities and Independent Directors.

• Considers that NHS Commissioning is and should continue to be a function exercised by statutory bodies in the public sector alone.Recognises that NHS provision is already distributed across public, third, and independent sectors, which should continue where it can be shown in the public interest. Competition is a means to an end and not an end in itself. Those providing NHS services should clearly subscribe to NHS values of openness, transparency and accountability and behave in a manner consistent with those values.

• Is supportive of an NHS that promotes the delivery of integrated care, both vertically and horizontally. We believe that this requires reform of payment systems, particularly Payment by Results. This includes the ability of Clinical Commissioning Groups to set activity caps and financial ceilings.

• Is concerned that the new structure will be cumbersome and top down. The NHS Commissioning Board may have too much power and requires better two way connections to clinical commissioning groups, locally and nationally – as an organisation that enables rather than controls their work. The NHS Alliance wishes to see a strengthening of the Secretary of State's mandate to intervene if the National Commissioning Board becomes a hindrance to the autonomy of clinical commissioning groups.

• Welcomes the creation of Clinical Senates, Clinical Networks, and Local Health and Wellbeing Boards as a means of wider clinical involvement. They
should help, not hinder Clinical Commissioning Groups however, who are the final decision makers for their patients.

• Considers that Monitor and CQC should be required to demonstrate that they are acting in pursuit of the public interest. Their decisions and policies should be subject to challenge by commissioning groups.

• Is supportive of the purpose of Quality premiums to reward those Clinical Commissioning Groups that commission effectively. Regulations should require that Premiums should only be used to enhance patient services.

This article was first published by The National Health Executive magazine

Written by Dr Michael Dixon
Monday, 26 September 2011 9:09

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