So Professor Malcolm Grant has been confirmed as the first Chair of the NHS Commissioning Board, albeit on the casting vote of Stephen Dorrell, after the Health Select Committee divided along party lines. He now needs to set about establishing his mark on the development of the Board, which will be no easy task given the number of dominating personalities already involved.
The less than emphatic nature of Grant’s confirmation probably says more about Labour’s determination to continue opposing all aspects of structural change associated with the reforms than it does about Professor Grant’s qualifications for the job: if you don’t believe a job should exist, then it is hard to think that anyone would be suitable. He will nonetheless consider this a less than ideal start to a job which was intended to be about depoliticising the NHS. His first task will now be to establish himself as a figure above politics, untainted by the messy early stages of reform and then transition, and reaching out beyond the entrenched positions which exist on reform.
There is scant detail on what the Chair is supposed to do. For example, it is striking that a draft document on the design of the NHS Commissioning Board, leaked to the Health Service Journal, contains a grand total of three mentions of the Chair’s role in 24 pages. It states that the key purpose of the Chair and non-executive directors will be to “hold the Board’s executives to account, and to contribute to the success of the Board’s key external relationships…ensuring the Board focuses on its core purpose.” So, acting as an external ambassador and providing internal governance – this is hardly revealing. As with many new roles, the job will be what Professor Grant makes of it.
Professor Grant’s confirmation created some hostages to fortune. Describing the Health and Social Care Bill as “unintelligible” may have been admirably honest (all bills are unintelligible – that’s why lawyers earn their money), but it will be cited every time there is a row over how the NHS Commissioning Board exercises its power (of which there will inevitably be many). Part of his role, particularly given his background, will surely be to act as a buffer for the Board against attempts to use legislation to destabilise it.
Martha Burgess offered Professor Grant some good advice before his confirmation hearing, and all of this still stands for his early months in the job. With much of the pre-appointment speculation focusing on the post going to a veteran of NHS management, a clinician or a heavy-hitting ‘name’ from the worlds of politics or business, he now needs to show why he is the right person for the job. The NHS and policymakers need to believe that his appointment is not simply a function of the Government’s desire for pay austerity ruling other more expensive candidates out. In doing so he has a number of assets: an understanding of how to project public sector organisations onto the world stage, close links with research and an ability to grasp complex ethical issues. He must make these attributes seem indispensable to his new role.
Grant will also need to avoid some pitfalls. The assertion that this is a job which can be done effectively on as few as four days a month is viewed with scepticism by many and it is not as though, with his ongoing commitments at UCL, he will have a lot spare time to top up the role. Given the level of his pay at UCL, he should also prepare himself for allegations about being a public sector ‘fat cat,’ at a time when there will be many difficult stories about NHS cuts. Finally he will also need to be careful that his role in growing UCL’s reputation as a centre of medical research excellence – surely a key rationale for his appointment – does not lead to accusations of a conflict of interest with the NHS Commissioning Board set to assume a statutory responsibility to promote research. With UCL partners set to become the biggest Academic Health Science Centre in the world and competition for research funding becoming ever more fierce, those outside the UCL partner network will be watching closely to ensure that Grant’s association does not confer perceived or actual favours.
All of this is manageable and, with his background in managing academic politics – surely as much of a viper’s nest as medical politics – he should be well placed to do so. But simply avoiding some pitfalls and demonstrating he is a sound choice for the job will not be enough to make Malcolm Grant a successful chair. Here are some thoughts on the areas where he might want to devote his limited time.
The NHS Commissioning Board will be judged on its ability to deliver the on the Mandate which will be agreed with the Secretary of State. The politics of this are complex. Andrew Lansley the pragmatist will want to ensure that the Mandate is achieved, yet at the same time Andrew Lansley the visionary will want it to be challenging, demonstrating how the focus on outcomes is delivering big early benefits. Malcolm Grant will need to manage political expectations about what can be achieved and create sufficient headroom to deliver on those commitments which we know are already ‘must do’s,’ such as averting an additional 5,000 cancer deaths by 2014/15 and keeping a lid on waiting times.
With news emerging every week about the scale of the financial gap facing some providers and the political implications of provider failure all too clear to MPs in ultra-marginals, the Board may well come under pressure to prop up failing organisations. This used to be known as system management – moving money round the NHS to balance out financial risk – and the reforms were meant to make this a thing of the past. The extent to which the Board participates in such support will be a decision over which non-executive members would do well to exercise strong oversight. It will, after all, determine quite how different the ‘new’ NHS is for both struggling providers and commissioners.
Finally, the debate about potential conflicts of interest for GPs will not go away. Although the recent example of the Haxby Group writing to patients offering them treatments from its wholly-owned private provider that “the NHS is no longer paying for” may have been foolhardy and not linked to the wider reforms, the debate within the profession about how GPs can manage duties as commissioners and providers of care – particularly when financial incentives are at stake – is far from resolved. Professor Grant’s experience in handling difficult ethical issues (both on GM foods and local government standards) may be invaluable.
On all of these issues Professor Grant can bring a perspective to the NHS Commissioning Board that David Nicholson, or other senior members of the executive team cannot. This will not be a quiet job, but then again Malcolm Grant has never shied away from controversial issues. If he is to place the role of chair at the heart of everything the NHS Commissioning Board is to do, then he should identify some tough issues and own them.