Parliament spent countless hours debating the relationship between the Secretary of State and the NHS. The result, enshrined in the Health and Social Care Act, is undoubtedly a radical shift, as we have discussed on this blog. Yet, often in the NHS it is relationships – not rules – that actually determine how things do or don’t work. So, despite the endless controversies about the respective duties and powers of the Secretary of State, clinical commissioning groups and the NHS Commissioning Board, how will relationships shape the impact of the Board? There are four key relationship dynamics which will shape the character and culture of the Board – between the Chief Executive of the Board and the Secretary of State; between the Board and other national bodies; between the centre and localities; and between individual key players on the Board.
Secretary of State versus the Chief Executive
In Opposition, Andrew Lansley was no great fan of Sir David Nicholson and, although the NHS Chief Executive is too wily to admit it, the feeling was probably mutual. That this odd couple has ended up in charge must be a surprise to them both. Sir David’s appointment can be ascribed to a mixture of Treasury desire to keep control, the absence of other credible candidates and the fact that the two major protagonists got on rather better than both may have thought they would (which may not be saying much).
That their relationship is more productive than they both thought is probably down to their mutual interest in getting the reforms through. Sir David may not have been a natural supporter of the reforms but, as an administrator who craves stability (and one who is not averse to consolidating his own power base), he shared his political master’s determination to create some certainty. However, now the Act is law and Sir David has been ‘liberated’ from political control, their interests may diverge. The formal rules governing the relationship may have been written, but how this odd couple negotiate the unwritten rules will be critical.
The powers of the NHS Commissioning Board are not yet fully ‘switched on’ and won’t be for another year. This could lead to some awkward moments in the interim period. Will politicians resist the temptation to intervene? Will managers refrain from seeking to ‘buy-in’ politicians to difficult decisions? Will both blame the other?
In passing the Act, and in asserting control over the transition, Lansley and Nicholson have shown themselves to be highly effective operators. This probably ensures a dynamic equilibrium at the top, although who wins which skirmish (should they be at odds with each other) will be telling. However, the balance of power could easily shift were there to be a change in Secretary of State, although such a change in the near future is far from a foregone conclusion.
The Board against other national bodies
The Board will also need to coexist and cooperate with a series of other national bodies, notably Public Health England, Monitor, the Care Quality Commission and NICE. Each has important powers, and each has the ability to make life difficult for the others, if it so chooses.
Those involved in public health have long lamented the lack of clarity in the new public health structures. The transition blight experienced by those in the NHS seems like heartening certainty in comparison to public health. The appointment of Duncan Selbie as Chief Executive Designate of Public Health England (PHE) will no doubt see acceleration in the transition. It also creates an experienced counterpoint for Nicholson. A veteran of the Department of Health and the NHS (remember the ‘Selbie Six’ performance priorities for the NHS?), Selbie will know how to win battles in Richmond House.
This is important, as much of the detail of how the NHS Commissioning Board and PHE will work together still has to be resolved. How will joint accountability for Domain 1 of the NHS Outcomes Framework work? For example, who will take responsibility for delivering on the Government’s flagship 5,000 lives cancer commitment (which requires public health action – screening, awareness – and NHS action – appropriate referral, better treatment)? How will the Board commission screening services on behalf of PHE? What if it does it badly? Equally, how will PHE, which will have responsibility for commissioning public health observatories and cancer registries, set about providing commissioning intelligence for the NHS (currently a critical function). These are just two examples of how relationships will be critical in translating the Act into a functional working arrangement.
Monitor and the Board will need to collaborate to get the structure and level of tariffs right, balancing the sustainability of commissioning with the viability of providers, while also driving service change. Depending on the level of instability that the Board is prepared to tolerate, there could also be some interesting conversations about the level of competition in the NHS.
The Care Quality Commission (CQC) remains an organisation in turmoil and this is unlikely to change until a new chief executive is in place and the publication of the Francis Inquiry has been navigated. As such, it will be in position of weakness as the Board begins to flex its muscles. Despite recent rows over the cost of inspections (caused by the CQC making public its concerns), the Department of Health has been curiously reticent about attacking the regulator for some of its more obvious failings. Whether the Board will be so gentle if CQC performance issues are seen to be getting in the way of delivering the mandate is an interesting question.
The Board is also currently heavily reliant on NICE in terms of developing quality standards (critical for informing commissioning guidance), as well as the COF and QOF (key contractual mechanisms for improving the quality of commissioning and primary care provision). The latter two sit less easily with NICE than the former and this has not escaped the attention of some in the Department of Health. NICE is known for its rigour, not its speed. For the Board, keen to provide as much support (and exert as much control) as possible, this could be an issue. Don’t be surprised if some on the Board seek a more speedy solution.
National or local
A flagship part of the NHS reforms was always meant to be ‘liberating’ the NHS from the attentions of Whitehall and the establishment of an independent NHS Commissioning Board was a key symbol of this. Since the publication of the White Paper, however, disquiet over perceived centralising tendencies of the NHS Commissioning Board has grown, particularly amongst GP commissioning enthusiasts who fear replacement of control from Whitehall with control from Leeds (and a little bit in Maple Street). Equity and Excellence: Liberating the NHS may have proclaimed that, “The headquarters of the NHS will not be in the Department of Health or the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients. The headquarters will be in the consulting room and clinic”, but to many the headquarters look suspiciously like Sir David Nicholson’s office.
The overriding imperative for the Board will be to maintain control over both finances and performance during the transition. The reasons for this are clear: the Board will not want to inherit a mess when its powers are fully switched on any more than clinical commissioning groups will. Nor will it want an early test of what happens if it fails to deliver on the Mandate set for it by the Secretary of State. The reforms are meant to be about liberation, but David Nicholson will not want this to mean liberating him from his job.
Yet this grip from the centre, particularly when it is combined with a prescriptive authorisation process for CCGs, could set the tone for relationships between GPs – the intended leaders of the new system – and the centre. Some GP enthusiasts of clinical commissioning have already expressed frustration about the lack of flexibility they enjoy, feeling that commissioning support they may not want has been foisted upon them. These perceptions will be important – the Board cannot afford to disengage GPs from commissioning in the way that many have been under PCTs.
The behaviour of organisations – particularly new ones – is shaped by the people within them. It is therefore perhaps no surprise that some people are uneasy at the hands on role of the Board, given that to date it has been personified by one individual: Sir David Nicholson. This is inevitable. A skilled manager and highly effective operator, Sir David is an old world creature, schooled in traditional NHS management ways. People are reacting to how Sir David has worked in the past (which is the way he was expected to act). How he chooses to run the Board in the transition and beyond may be different. He has never worked in a ‘liberated’ system either. We shall see.
The people around Sir David will therefore be critical in shaping how the Board behaves (and how it is perceived to behave). We have written on this blog about Malcolm Grant before. Many of the other senior appointments read like a ‘who’s who’ of the NHS in recent years. Bill McCarthy, Jim Easton, Ian Dalton and Dame Barbara Hakin have all been major management figures in the NHS, within providers, commissioners and soon to be defunct strategic health authorities. Their appointment is a nod to continuity and stability, rather than change. A relative newcomer to NHS circles is Paul Baumann, the Director of Finance, although even he has five years at NHS London under his belt. The big beasts of the NHS remain the same and they are already well known to one another.
Perhaps the biggest area of change within the Board could come from its clinical direction, and particularly the professional leads (or domain directors) for the different aspects of the NHS Outcomes Framework. Reporting to Sir Bruce Keogh and Jane Cummings, these people will shape how the Board sets about delivering on the Mandate it receives from the Secretary of State. It is they who will be tasked with achieving the outcomes improvements which will be used to determine (as early as at the next election) whether or not the first phase of reform has been a success. Responsibility for whether the NHS succeeds in saving 5,000 lives from cancer, arresting the year on year increases in liver mortality, improving patient experience, cutting length of stay and enhancing the quality of life for people with long term conditions will rest, largely, in their hands. How they approach this task (‘top down’ initiatives? The use of financial levers? Clinical audit? Commissioning guidance? Or leaving it to local in initiative?) will go a long way towards determining the character of the Board. In many ways these roles will be what the postholders make of them and much will depend on their skills as communicators, diplomats and operators. The recruitment process is due to start shortly and the outcomes of this will say a lot about how the Board will work and indeed the level of clinical influence there will be within it.
So the rules may have largely been written, but the relationships which will go a long way towards determining the character of the new world are still being forged. Those seeking to influence change in the post-Act NHS would do well to reflect on this.