Interestingly, I suspect that the current health secretary is keen to move forward – even if his prime minister no longer wants any more reform.
I also think that a sizeable number of NHS staff recognise that an unreformed NHS may not survive the decade and will also want to press ahead with reform.
So, what if you are a GP commissioner who wants to continue to maximise the reform of GP commissioning?
The first point is to consider is that while it’s true that in the past couple of months the government policy that determines the terms of trade has turned against reform, we should not imagine that the whole tide of reforming the NHS has turned just because the prime minister has got cold feet. Of course the PM is significant, but as his own weakness over reform has made clear, his power is limited.
What is crucial is the way in which thousands of leading staff now act. Some will follow what might laughingly be called the PM’s ‘lead’ on reform and will be glad to stop doing anything. But others will be looking for ways to continue their struggle for improvement.
For nine months from last July, it appeared that the dominant philosophy within government in regard to the NHS was pro-reform. But in reality what the government wants to change - in terms of the real struggle in the guts of the NHS - would yield a relatively small advantage.
This was true when the prime minister was pro-reform and it will be true now that he is anti-reform.
With or without prime ministerial support, reform of a major institution such as the NHS will never be easy. It would have been easier if the government had not changed its mind. But the culture of the NHS would have always resisted reform with great strength and power. It would have done so if a powerful reform Bill had been passed, and it will do just the same if the Bill is weak.
Real enthusiasm needed from GPs
The second point, as the current secretary of state has learnt, is that what matters in developing reform is creating and maintaining coalitions for change.
For example, the reforms of the NHS which give GPs more power will not stop because a new Bill is lukewarm about the changes in commissioning. But they would be dead in the water if the majority of GP commissioners walked away from them. So what matters is real enthusiasm on the ground, not the detail of a Bill.
One of the crucial elements for the progress of the reforms is the extent to which they have the backing of the mass of GPs.
In meetings between the current secretary of state and GPs they have come to refer to this as the ‘treacle’. This seems a good metaphor for the very sticky stuff that reduces your agility as a GP commissioner.
The secretary of state has promised that GPs will not have to deal with the treacle, but I don’t think he can any longer keep that promise. Much of the reform of the reforms is specifically designed to limit the freedom of GP commissioners, not least the extra powers given to the Health and Well Being Boards.
Many of the changes represent large cans of sticky stuff poured over the feet of commissioners with the express intent of restricting their agility. So if you believe in reform what do you do about this?
If I were secretary of state I would stop the numbers game of saying that 88% of GPs support me. Numbers no longer matter. It is the quality and confidence of the best GP clinical commissioners that matter now.
So in the current straitened circumstances I would stop going for breadth of coverage and go instead for real pathfinders that can actually find a way through the forest. Recognising that there will be things coming out of the Department of Health with the aim of limiting the power of GPs as commissioners, I would encourage GPs to organise despite them.
GPs need to learn politics of the boardroom
All of the GPs with whom I have been working always intended to have a nurse and members of the public on their boards anyway. GPs who want to commission will have to get used to having discussions about strategic commissioning with different people in the room. This may mean that there will be disagreement. That’s fine – that is what boards are for. It is not necessary for everyone to agree.
The point of having a board is to ensure that disagreement takes place in public, and then a majority view moves forward. This may be a new experience for GPs but is a normal part of the life for the boards of public bodies. So some discussion about how public boards make decisions and deal with conflict will mean that GPs will not necessarily lose the prize of strategic commissioning.
The same goes for dealing with Health and Well Being Boards. GPs need to recognise that disagreement might arise and make sure there is time in the annual timetable to allow for it.
Both of these issues require some cultural learning on the part of GPs. How to exert influence in a board where there are different voices? How to assert control in a network of interlocking organisations when there are different interests? Both of these are important sets of cultural skills to learn if you are going to spend public money. They are not showstoppers.
The best GP commissioners are already planning how to ensure that they can maintain organisational agility within these new sets of limitations. They will then be in a position to help the others.
- Paul Corrigan is a management consultant and former special adviser to Tony Blair. More at www.pauldcorrigan.com