A major purpose of the reforms to health and social care was to place more power and control in the hands of clinicians, as a means to empowering patients. As Sir David Nicholson wrote in his foreword to the Planning Framework, “The new system gives pride of place to clinical leaders. From top to bottom and across the country it assumes liberty – freedom for you to take clinical ownership and leadership, and for local communities and commissioners to decide for themselves how best to deliver care.”
Perhaps the most visible and disruptive element of this vision was replacing primary care trusts (PCTs) with clinical commissioning groups (CCGs). Led by GPs, the theory was that CCGs would behave very differently from their predecessors. Many GPs embraced this change with enthusiasm, although some of this dissipated during the messy pause and imposition of far greater restrictions on their freedom to operate than had initially been envisaged. With most CCGs not yet even authorised, it is still too early to identify whether – at a local level – the reality will match the vision.
However, at a national level, it is now possible to make an early assessment of the extent of clinical influence. The way in which the NHS Commissioning Board has begun establishing itself offers contradictory signals on the extent of clinical leadership. The Board signalled early on that it intended to organise itself around the five domains of the NHS Outcomes Framework, with a professional lead for each, reporting to either the Medical or Nursing Director. This structure provides the potential for the clinical voice to be heard loudly and clearly.
Yet the Medical and Nursing directorates have been allocated only 5% of the overall NHS Commissioning Board running cost budget and a similar proportion of the staff. Compare this with national and local operations, which account for some 68% of the budget and 76% of personnel and it is easy to see how the clinical voice could be drowned out, particularly when this allocation represents a significant reduction on support available in recent years. For example, the condition-specific policy teams within the Department of Health are largely disappearing and are not being replaced by anything with the equivalent size or reach within the Board. If money really does talk, then it is not clear that the clinical voice within the Board will be very loud.
Recent events, however, suggest that the pendulum might be swinging back towards a stronger clinical voice. The carve-up of Jim Easton’s short-lived improvement and transformation empire has seen responsibility for the new ‘improvement body’ move to the Medical Directorate, providing some much needed boots on the ground to help translate interesting ideas into action. Equally, the shift to the Medical Directorate of the Innovation team ensures clinical responsibility and oversight for an issue which is bound to continue to attract political attention (and which has Sir David Nicholson’s name attached to it).
The final weeks of 2012 also saw, after a period of prevarication which has been the hallmark of their existence in every regime they have operated under, adverts placed for the next generation of national clinical directors. There will be 24 posts in total, with eight reporting to each of the directors of domains one to three. This means that there will now be clinical leadership for over half of the substantive programme budgeting areas, as well as for cross-cutting issues such as diagnostics, pathology, integration and frail elderly, enhanced recovery and rural and remote care. This is a major victory for the organisations campaigning for formal clinical leadership where before it had been absent, such as in the areas of musculoskeletal and neurological disease.
However, all is not won. These roles will be part time (ranging from one to three days a week) and, even with the resources of the ‘improvement body’ and – for the conditions which they will exist – clinical networks at their disposal, the new national clinical directors will not enjoy the same level of backing that many of their predecessor roles did. One of the reasons why the roles of national clinical directors have been reviewed so frequently is that, in truth, their impact has been varied. Many in the health world will be able to name the directors who they consider to have been the shining examples of achievement and improvement. However, there are others who have sunk without a trace, weighed down by the system and their inability to get things done. If national clinical leadership is really to be at the heart of the NHS Commissioning Board, then the people who assume these roles will need to be more like the former than the latter. And they will have to do it in less than half a week, with only minimal resources behind them.