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Nicholson: leading hospitals to be reshaped by commissioning board

The NHS Commissioning Board will use its position as “a big, powerful commissioner” to reshape England’s largest teaching and specialist hospitals in an attempt to control “the commanding heights of the health economy.”

In an exclusive interview with HSJ, board chief executive Sir David Nicholson also said the board’s direct control of specialist and primary care budgets would mean: “It’s hard to imagine a service change that’s going to take place over the next few years that the commissioning board is not directly involved in.”

The board will directly commission specialist care worth £12bn. Sir David highlighted that this meant the board would be providing “between a third and a half of the income” of the country’s largest trusts and would be “thinking about what the shape of those organisations should be”.

Sir David added: “You will see fewer units doing more things.”

He described the large teaching, specialist and tertiary trusts as the “commanding heights of the health economy”, borrowing a phrase coined by Lenin and used by former Labour prime minister Harold Wilson in relation to state control of important industry.

He said: “Harold Wilson talked about the commanding heights of the economy. Well the commanding heights of the health economy are the tertiary and specialists, and we’re going to be directly commissioning that. That will feel different, and [is] quite significant.”

In the past those trusts had not paid enough attention to their commissioners, he said, but the board would be “a commissioner you need to take notice off” and “a big powerful commissioner in the system”.

Sir David said the board would seek to standardise pricing across the providers, whereas in the past “different regional commissioners have had completely different deals with the same organisations”.

The board would also want to drive greater consistency in quality standards and ensure equitable access by clustering services around particular trusts. He said: “We can start to have a much more strategic view about the pattern of services across the country in a way nobody’s really been able to do before.”

Sir David said the board’s decisions about these large providers would have significant knock-on effects for hospital service configuration elsewhere. He said: “That’s why I [described them as] the commanding heights of the economy – because it does set that [effect on other services].  That’s a benefit of the system for us.”

He said the commissioning board – as commissioner of primary care as well as specialist services – would be actively involved in nearly all discussions about service change.

He said: “We are a player on the pitch. It’s hard to imagine a service change that’s going to take place over the next few years that the commissioning board is not directly involved in. We’re not this kind of supervisory body sat over here. We’re going to be much more engaged and involved and much less slightly standing back watching what’s happening.”

He said clinical commissioning groups would often be leading changes, where they focused on general hospital and community care, but the board would “convene, help and facilitate it”.

In relation to service reconfiguration in general, Sir David said the NHS had not “made the progress we need to” in order to make required efficiency savings. He affirmed his previously expressed view that beginning controversial service change after May this year would be difficult because of the 2015 general election approaching.

Asked about the hugely controversial reconfiguration proposals for south east London, which have been put forward by a special administrator and currently await approval by the health secretary, Sir David said: “What is pretty clear is that leaving [services in the area] as it is not an option. From what I’ve heard [the special administrator’s proposal] is a pretty compelling case.”

Readers' comments (25)

  • So much for autonomy and assumed liberty for CCGs.....SHAs and super large PCTs here we come. Such a shame given that some CCGs have been able to use recent autonomy to drive real clinically led improvements...on a positive note a fresh look at specialised commissioning and tertiary centres is welcomed!

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  • How on earth will CCGs LEAD processes which are 'CONVENED' by Sir David's henchmen? A little more honesty about the implications of his obsession with grip would be appreciated. One is that we'll see relatively little innovative clinically led change in the NHS under his grip.

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  • The reform has been about getting more local input , all the CCGs being closer to the community but this sounds like it will be the same up and down the country regardless .

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  • So, if the CCGs want to reshape their local hospital in one way, and NCB wants to shape it differently, who will win, the CCGs or the NCB?
    It sounds like a recipe for disaster -- long predicted by all the other Anons that grace these Readers Comments.

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  • These comments seem to miss the point that these services are not commissioned by CCGs, they are explicitly reserved to the NCB ie specialsit services.

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  • By the time he has finished reconfiguring the NHS these will be the only hospitals left ....

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  • 1:34 - did you read the quotes? "It’s hard to imagine a service change that’s going to take place over the next few years that the commissioning board is not directly involved in" I don't see how this equates to localism or GPs being at the heart of commissioning. This feels increasingly like a North Korean approach to healthcare.

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  • Which bit of "national commissioning board" doesn't Commissar Nicholson understand? His job is to oversee the COMMISSIONING of services not to take command of the providers. And as for controlling the "commanding heights of the health economy", this smacks of someone who sees themselves stuck in an old Labour timewarp. Perhaps Commissar Nicholson is hoping to sacked for his inability to understand the reformed structure of the NHS, rather than waiting to be sacked for his failure to prevent Mid Staffs!

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  • Faintly amusing comments from a 'Dead Man Walking' - to borrow a phrase from Thomas Hardy.

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  • DN is only doing what should have been done ages past... and what most of the "anons" would do if they were in his place!

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  • DN is a power-crazed centralist. These statements fly in the face of all that the reforms are supposed to be about. He's making it up as he goes along.

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  • The move to get better control and more standard approaches on specialised is very welcome, its clear that large specialist providers have for some while been able to play specialist commissioners off against one another. However, I am not sure what space there will be for local commissioning influence, where its all 'big boys' playing together.

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  • As CCG lead in a specialist area i cannot see in any of the published documentation any clearly worked examples of OLD nhs ways of working are going to be made better in the new system... Its all smoke and mirrors. FT provided diagnosis and treatment require community support for example from nurses and physio. how will this be provided in the "new order" when other FT will be providing those services...
    Who defines the service specification by which trusts will be judged
    Long term conditions have so many different parameters by which achievement can be measured

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  • Something may have been lost in translation but there is no coherent narrative emerging from the NHS Commissioning Board. This interview does nothing to inspire or clarify.
    Aren't FTs and their local membership supposed to shape their offer, and not the NHS commissioning board?
    Doesn't the word "commissioning" imply shared mission - common purpose derived by dialogue not diktat?
    And isn't commissioning supposed to reflect local deliberation and decision (within national standards), not central command and control?
    Is the dominant NHS model to be collaboration between interdependent networks in a national system, or is it to be competition between independent providers in a marketplace?
    Are we a National Health Service or a collection of English Healthcare Businesses? If the latter, we should be honest and adopt the new brand.
    Could we please have a coherent narrative from our political and administrative leaders?
    The service needs mentors not tormentors.
    I was not alone in retiring early from NHS management because I couldn't function in an organisation that was not being true to its core purpose, its patients or its staff. It stifles innovation and turns a deaf ear to concerns about patient safety and financial probity. I, and others like me, might be persuaded back if there is a workable and ethical model with which to engage.

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  • 'Commanding Heights'an expression used by Lenin - this displays Sir David's communist credentials. in the words of the song: Meet the new boss - same as the old boss - and yes, we've all been fooled again! Including the ministers.

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  • The prime example of the Stalin-like operation of the NCB is what is happening in Greater Manchester. The LAT are attempting to run roughshod over the CCGs and impose the desires of the local commissar (Sorry LAT Chief Executive) on the whole Health Economy. Andy Burnham has already highlighted in Parliament how “Healthier Together” is the largest source of rumour and conjecture in the current NHS. That’s because the NCB want to impose their ideas not just about changing clinical pathways but also how Medical Education should be run in Manchester.

    At least one CCG has already discussed at their Board their fears that some changes will be sneaked through before April 1st. All this with public consultation that consists of meetings at which only general principles are discussed. Hard to be opposed to a better Apple Pie when the only argument is that centralisation means better clinical outcomes. There would be a bit more concern if the LAT came clean and admitted that they want only one main bakery surrounded on the outskirts by small warming ovens that would be totally subject to whatever flavours the Chief Baker wants to provide. We must hope that that if this Government means even 10% of what it said about local decision taking it will stop this farce before irrevocable decisions are taken which the real commissioners (i.e. the CCGs) are unable to stop.

    If you want the perfect example of how the NCB follows Stalin to the letter look at the dispute with Georgia early in his reign. When the Georgians wanted more local control they were told they were being selfish and that the greater good should prevail. Await similar words from the Manchester LAT

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  • I don't know how anyone could expect the 'new' (sic) NHS to act much differently from the 'old' NHS if all the key posts were filled by senior people from the 'old NHS'.
    New job titles, same thinking

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  • As a recently retired Finance and Contracts Director, I find it hugely encouraging that David Nicholson and LATs are marking their territory and facing down CCGs with a combination of guidance and stern leadership. Financial control and national commissioning priorities have to trump the petty local interests and prejudices of CCGs, and I am confident that ex-PCT officers/politicos within the LATs/ NCB and CCGs can weave their blend of crude and/or subtle influence. Elsewhere in HSJ we read that CCGs are often preoccupied with local clinical projects rather than the major issues which shape the spending on large populations - access, chronic conditions leading to readmission, heart disease, stroke, cancer and mental health are the issues that need to be addressed with strategic and costed commissioning plans for the 5-10 year period. If CCGs are not now producing such plans, and relating these to physical capacity and configuration of service,then it will be a long time before they can be released from central control. Good commissioning is hard to do, and in its absence within CCGs, we will have to rely on LATs working with intelligent providers to construct the local strategic plans : intelligent providers are often the best commissioners anyway !

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  • Sounds like a lot of people think DH is still a communist at heart.
    Putin appears to have performed the same trick swapping between jobs, while continuing in control with the same culture of bullying and fear.

    Will be interesting to see if he pulls it off this time.

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  • Is someone not missing the point - without the NCB running the show the NHS will go into meltdown with all these shopkeepers playing at running multi-million pound businesses. Hold your nerve Dave.

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