The Department of Health went through a phase of insisting that the White Paper did not constitute structural change and instead represented a ‘delayering’ of the existing structure. This was, of course, a political construct designed to address the strange commitment made in the Coalition Agreement that the Government would, “stop the top-down reorganisations of the NHS that have got in the way of patient care…reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.”
Any doubt that the reforms were going to be communicated in a technocratic manner should have disappeared the moment anyone read this dreadful phrase. If ever there is proof that the Department of Health has been in thrall to management consultants, then this is it. However, there was an important reason underpinning the delayering concept: saving money by stripping out bureaucracy. Whether it is desirable to further reduce management within the NHS (others would argue that in fact we need more management) is a moot point. Delayering was a key argument for why the reforms were necessary now. Taking out layers of management would unlock resources for patient care, contributing towards the golden £20 billion that Sir David Nicholson, doyen of NHS managers, has stated needs to be saved.
Yet, as the reforms emerge from the pause, it appears that delayering has given way to relayering. A whole plethora of bodies have emerged from the pause, aimed at placating those concerned with the implications of GP (sorry, clinical) commissioning. In truth, many of the ‘new’ bodies already existed (for example, clinical networks). What is different is that they now have national ‘sanction’ and an explicitly recognised role in the new world. This does pose a challenge to the reforms: more layers in the management structure will mean that management resources either have to be increased or spread more thinly. The former may well be politically unpalatable and the later will call into question whether any of these bodies will have the financial or management clout to effectively support or deliver commissioning.
Nonetheless, it will be important for anyone seeking to influence the new NHS to understand how these bodies will interact and indeed what their intended purpose should be. To do this, it is necessary to consider why they have been written in to the NHS system architecture (more management consultancy speak). Broadly speaking, the new bodies fall into two categories: those intended to reassure David Nicholson and the Treasury, and those intended to reassure the Liberal Democrats and the wider health community.
SHA clusters (or regional offices of the NHS Commissioning Board) and PCT clusters (or local offices of the NHS Commissioning Board) may represent a pragmatic attempt to manage the transition, but their continuation is also a mechanism for retaining a grip in a ‘liberated’ NHS. By 2013 these organisations will no doubt look very different (and smaller) than SHAs or PCTs do today, and in truth they would have been established irrespective of the pause, but the profile they have been given should primarily be seen as a signal of reassurance to those concerned that the reform process could lead to the NHS losing financial control just at the time when its grip needs to be tighter. In total, the NHS Commissioning Board, which was emphatically not meant to be the ‘headquarters of the NHS,’ is likely to have 55 offices and employ several thousand staff.
The more clinically-led commissioning support bodies – clinical networks and clinical senates – are intended to reassure those that feared that GPs would not have the necessary expertise to commission specialist services, or the desire to seek help in doing so. Clinical networks are not new and some have a strong track record in coordinating service change. For example, many cancer networks can lay claim to the credit for driving down waiting times, as well as reorganising services to ensure that patients are seen by multidisciplinary teams who treat appropriate volumes of patients. Yet, in truth, there is no homogenous model for networks. They have often developed to fill the gaps left by statutory organisations, which vary according to geography.
Networks were always likely to have a role in the new world but they now have a formal of official backing which should see their role extended and formalised. However, there is still work to be done in determining what functions networks should perform in the new world (will there be a list of functions which will be funded by the NHS Commissioning Board? Will clinical commissioning groups then be able to contract with them for additional services?). Establishing a formal role for networks may sound reassuring in the short term, but will not be enough to deliver the support for commissioning groups which their champions hope for. Work now needs to be undertaken to develop the network model, ensuring they have adequate commissioning expertise and that there is clarity about which parts of the pathway their support will be focused on.
Clinical senates are a new creation, although they build on some of the recommendations made by Sir Ian Carruthers back in 2007 when he reviewed how the case should be made for local reconfigurations, arguing that visible clinical leadership was imperative. Experience shows that clinical networks, which focus on a single group of conditions, are not always effective in making the case for change, as most reconfigurations will have knock-on implications for many different specialities. So this task will fall to senates.
Based at a population level of 1.5 -2.5 million, senates will be expected to advise on whether changes are clinically robust and, if so, to convince local communities that they are the right thing to do. This is fine in principle but recent experience suggests that it is not only reconfigurations without a sound clinical justification which have foundered. Local community passion – and political considerations – can trump clinical logic. Of course the ‘clinical case’ for reconfiguration has been undermined by the fact that not all such cases were very strong, giving fuel to those who argued that other reconfiguration should not proceed (which of course included David Cameron, Nick Clegg and Andrew Lansley when in opposition). The extent to which senates can mediate between clinical logic and local opinion (which is often driven by local clinicians) will go a long way towards determining the success – and indeed the future – of clinical senates.
A consequence of the listening exercise has been that the NHS landscape is now much more cluttered. Faced with opposition from different sources to various forms of commissioning arrangement, the Coalition seemingly decided to compromise by adopting them all. This brings different strengths to the commissioning table, but also different weaknesses. It also creates a challenge in that management resource and talent could be spread too thinly. There is also a danger that decisions could be slowed down in a logjam between the various structures that now have a legitimate claim on being part of the decision-making process.
Some layers may have been taken out of the NHS, but many different ones have been added back in. Yet clinical commissioning groups, the NHS Commissioning Board, local health and wellbeing boards, clinical networks, clinical senates, PCT clusters and SHA clusters could all have an important role to play, provided they work together rather than against each other and there is enough management resource to go round. The trick will be developing their functions in a way which complements rather than clashes.