The letter from David Nicholson to all chairs and chief executives of the NHS in England outlines his vision for the future of the NHS and in particular the organisation of which he is now the chief executive - the NHS Commissioning Board.
I had spent two sessions that week with the leaders of 10 GP commissioning consortia (three pathfinders, seven not) in two very different localities. So it was interesting to compare the vision from the top and the vision from the bottom.
The letter, dated 17 February, is worth reading closely. Compared to the current secretary of state’s difficulty in outlining a compelling vision for how the reforms will really impact on the NHS and its public, his letter succeeds in outlining a vision.
He even acknowledges, on page six, that all these words about co-production and subsidiary will be seen as ward words by those who have experienced his main management style of ‘grip’.
But even though these words may be some distance from the reality, they do, as I say, paint a picture of a potential relationship between the top of an organisation and the bottom.
From the top of the organisation David Nicholson is doing his best to try and construct the theory and practice of liberation. Page five outlines what he sees as the role of the NHS Commissioning Board and, in the absence of any greater clarity from the secretary of state, let’s take that at it stands for the time being.
There are eight roles that he outlines:
- Provide leadership to the commissioning system in improving health outcomes
- Describe the challenges and priorities for the commissioning system, based on patient and public insight and the requirements of the national mandate
- Support consortia to achieve authorisation and operate a rules-based intervention system to ensure consortia remain fit for purpose
- Make financial allocation to consortia and set the financial strategy for the commissioning system
- Provide leadership and support for quality improvement across the system
- Champion a patient-centred approach to developing health services
- Set the Commissioning Outcomes Framework to track local delivery and design the quality premium to create financial incentives for consortia to improve quality and outcomes and drive value for money
- Translate national quality standards into commissioning guidance for consortia and standard contract and pricing mechanisms for local use
He goes on to explain: ‘So while consortia will have the freedom to shape services and drive improvements locally, they will do so within a national framework and with support and guidance from the NHS Commissioning Board. This will mean creating an integrated system between consortia and the board, which supports the delivery of national accountabilities as well as local priorities.’
Now it may just be me, but if I am in a local independent organisation and a national organisation that gives me my money says it wants to integrate with me, I get the feeling that it wants to limit my independence enormously.
David Nicholson is doing his best but in reality the way in which he outlines the nature of power within this relationship reflects that he has spent a lot of his managerial experience running large organisations.
The experience of running large organisations does not inherently make for bad managers but the resulting view of the how the world works is very different from the view that comes from running a small one.
Many of the GPs that are now coming to terms with running GP commissioning consortia have a strong managerial experience of running small organisations.
They judge their budget in the hundreds of thousands of pounds. NHS senior managers judge their budget in the tens of millions and the leaders of the NHS have judged it in tens of billions.
There is a gap here. Over the next few months many of the new GP commissioning consortia will experience being run by the new PCT clusters (which in turn will be ‘gripped’ by David Nicholson).
Over the next 13 months, as the SHAs disappear, the emerging GP commissioning consortia will be increasingly gripped by the NHS Commissioning Board.
The road ahead
Then one of two things will happen.
Either the GP commissioning consortia will buckle down to be gripped by the National Commissioning Board. They will, in David Nicholson’s terms, be integrated into the board and become a part of a top-down structure.
Or they will resist. They will insist on becoming separate organisations with their own systems and their own view of what they want to achieve.
If this happens, the negotiations that exist between the NHS Commissioning Board and the GP commissioning consortia will be just that - negotiations. A consortium will say ‘we want to achieve X’ and the NHS Commissioning Board will say ‘no you should achieve Y’, and there will be a discussion between them before they agree a new position.
This will be a brand new set of relationships for the way in which the centre of the NHS works with its local organisations. It will recognise that they have a right to negotiate what they want with the board rather than just simply do what they are told.
If GP commissioning organisations believe they can successfully negotiate with the NHS Commissioning Board, then the NHS will have really changed.
If, on the other hand, David Nicholson succeeds in integrating them into the NHS Commissioning Board, then very little will have changed.
- Paul Corrigan is a management consultant and former special adviser to Tony Blair. More at www.pauldcorrigan.com