COMMISSIONING
communities to self care and improve their health. 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 in- creasingly show that they are the new or- der and increasingly show that they can de- liver, 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 pre- pared 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 lib- erate 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 au- tocracy with its own agenda, trying to dic- tate 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 prat- tling 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 nominat- ed 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 cre- ate 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 le- vers of the past.
He is far too intelligent to continue in this
THE NHS ALLIANCE:
• 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 bal- ance 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 repre- sentation 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 distrib- uted 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 be- have 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 in- cludes the ability of Clinical Commissioning Groups to set activity caps and financial ceilings.
• Is concerned that the new structure will be cum- bersome and top down. The NHS Commissioning Board may have too much power and requires bet- ter 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 Na- tional 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 pa- tient services.
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 Com- missioning Board will rise or fall together. He will make sure that the National Com- missioning 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 consult- ants and managers to a diary that priori- tises 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 Nichol- son needs to see his role as facilitator not controller. NHS Alliance needs to raise its game to become an ever-more fiercely sup- portive 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 recognitise 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 improve productivity, 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 Na- tional Commissioning Board, frontline pri- mary care or Foundation Trusts – must now adapt to their exist- ence, 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!
Dr Michael Dixon
FOR MORE INFORMATION Visit
www.nhsalliance.org
national health executive Jul/Aug 11 | 25
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