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'Reform could lead a transition to a non-hierarchical NHS'

The Health and Social Care Act is now on the statute book and we are at the start of implementation of the reforms.

Inevitably the transition is going to be difficult, with the apposite behavioural changes not always being as evident as they should be and the more direct managerial styles remaining visible, particularly in some parts of England.

So we are at the initial phases of a journey and in some respects this is exemplified by the recent debate around the geographic boundaries for clinical commissioning groups. The requirement in the finished state, of course, is that CCGs cover the whole of England and do not coincide or overlap.

In most cases, the process for emerging CCGs has been pretty straightforward and in most cases is satisfactorily resolved, but it left a minority of patients within circumscribed geographic areas where some more discussion was required before a final determination could be made. It may appear counter-intuitive, but I welcome this as I am really encouraged that the NHS Commissioning Board appears to have decided that it does not wish to impose a solution on the CCGs but is willing to work with CCGs to find compromises to satisfy local aspirations.

This approach to finding a solution is a real break with the past. We all remember the days when every primary care trust had to have a “Darzi” centre, irrespective of whether it was required by the local population, just because someone distant thought it a good idea.

It is a sign of a maturing system that we should be prepared to allow CCGs to come up with solutions, not expect the commissioning board or its outposts to impose them. 

Thus my contention is that the delays in reaching solutions around selected cases of CCG geography have been a sign of a new way of working, and also that new behaviours are starting to impinge on the old hierarchical structures.

What about the principles the board has proposed around resolving these geographic issues? In essence, there are only two real rules and these are that each CCG must have an area of geography it is responsible for, and that no CCG can have responsibility for an island within another CCG’s responsibility. 

The concept of population health is what all health systems are concentrating on.

Given the nature, history and culture of our NHS, we have opted to tie in CCGs to geography rather than to individual insurers as in other parts of Europe, thus both of these rules make sense, as does the principle that CCGs need to be contiguous with a local authority boundary unless there are overriding reasons against.

The rest of the principles make some sense as long as they are applied with the same maturity and sensitivity to local circumstances, which is in effect what we are witnessing in the vast majority of cases. Is the board really coming of age?

There are a few promising signs that this could be the case.  There is talk of “a sense of team” rather than a sense of hierarchy in the relationships between the board and the CCGs and also an oft-repeated concept of area directors from the board sitting at the side of CCGs rather than above them. The challenge to these area directors will be considerable as the behavioural change required will be a critical determinant of the degree of success attained. We need to remember that the board has a duty to promote autonomy and will thus be judged on whether it is being successful by the level of autonomy it has actually managed to encourage.

The CCG boundary debate is just one of many structural issues we have encountered and we will encounter many more through the transition. There is no doubt that the possibility of CCGs altering their geography as they mature and practices decide to switch is also considerable, so I suggest we will always have a few CCGs somewhere in the system where there is some debate around geography. Again this is a sign of a maturing, not a failing, system.

Whatever its merits, the Health and Social Care Act has largely removed the apparatus that acted as the big hierarchical structure at the heart of management. It is being replaced by a more locally determined and sensitive system whilst retaining the sense of core and nation which embodies the NHS. The challenge for all of us is to manage the transition to the new system. I sense we have started our journey and there are a few tentative signs some have even considered changing to second gear.

Readers' comments (2)

  • Nicholson and "non-hierarchical" are oxymoronic...

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  • Signs already appearing that CCGs are pushing back at the traditional performance management approach that the CB is starting. Chairs being given one message and COs another... I know where my betting is for who wins out and GPs may become even more disillusioned.

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