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The DH continues to dance around the issue of CCG freedoms

Nigel Edwards – in his masterly analysis of the Health Act – declares that “the real level of autonomy available to clinical commissioning groups is likely to be determined by the behaviour of the NHS Commissioning Board… rather than by the legislation.”

He adds: “The act does little to safeguard the system from top-down recidivism in the board.”

In that light, Andrew Lansley’s letter to board chair Malcolm Grant commanding that CCGs are to have “assumed liberty” appears significant. Its message is in tune with fierce lobbying by those champions of clinical commissioning, the NHS Alliance and National Association of Primary Care and it might be thought they have forced a U-turn from the government.

In the middle of last year, the Department of Health responded to the House of Commons health committee report on the commissioning reforms. It noted the committee’s approval of a “change from the principle of ‘assumed liberty’ to one where commissioners will earn autonomy” during the authorisation phase. It said the process of CCG authorisation “will be undertaken in line with… the principle of ‘earned autonomy’.”

However, in truth, the debate is a continuation of the dance performed by the government ever since it revealed its plans for GP-led commissioning. To attract enough GPs to the commissioning table it had to promise them relative freedom. GPs, after all, have a day job they can return to should they feel their influence is being constrained. On the other hand, the government had to reassure a whole range of stakeholders that these new GP organisations would not be allowed to do whatever they liked.

Witness the debate over clinical senates. Revealed with some fanfare in response to hospital doctors’ concern that GPs would rule the roost, a few months later the government was busy briefing how senates would fulfil a purely advisory role.

This dance is set to continue as the new system develops. Professor Grant, in his first ever interview, tells HSJ that CCGs can expect the board’s grip to remain relatively tight during the transition.

On one level, this tension is simply created by the desire of any new organisation to have freedom of action – witness the ongoing birth pangs of the foundation trust sector – and the need for the centre, where blame eventually, and inevitably, arrives – to reduce its pain.

But there are other, almost subconscious, forces at work. Significant among them is the fear of CCG leaders of being labelled “bureaucrats” – something the government wants to avoid as well.

The holy grail of these reforms is for the wave of reconfigurations and service redesign which must sweep through the NHS to be perceived by the public as led by professionals who care only for patients. To give this vision power – and justify the upheaval reform has caused – it has been regularly contrasted with the approach it replaces, in which decisions were, supposedly, made by “faceless bureaucrats”.  

To maintain this construct, CCGs must not be perceived as acting in a bureaucratic manner, making decisions which feel distant from the needs of patients. Since this is impossible to achieve consistently in a system of the NHS’s scale, having someone to blame can be handy.

A commissioning board perceived as overly officious may actually play to the advantage of CCGs in establishing their freshness.

This is not cynicism, simply a recognition of the ever-present dynamic between the NHS’s centre and its local manifestations.

More significant will be what CCGs do with their “liberty” and how the centre reacts when and if that freedom ends in “failure”.

Readers' comments (11)

  • Surely nobody believes that Lansley's letter will change anything. Creating FT's was bad enough in a NATIONAL health service but combine that with semi autonomous CCG's of varying sizes is a recipe for continual financial and commissioning conflict and confusion. Top down operationalism is inevitable. Democratising and 'GPising PCT's was an honourable alternative for all political parties.

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  • The larger probelm will be the lack of time that the GPs have to work on CCG issues. Most are engaged with busy practices - the day job. Hence most decisions will be taken by the staff support groups and will get a rubber stamp from GPs.
    There is a huge amount of freedoms for CCGs. Their ability/willingness to use them will be the bigger problem.

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  • forget about anything Lansley says, he's history come the reshuffle in early autumn - next SoS will be Hunt as long as he has a good Olympics.....


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  • Yes I read about Hunt in Roy Lilley's blog too, but he's had calls to resign over the last few hours....

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  • And if Hunt gets SoS will we see News International bidding to run a CSS???!

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  • Good analysis of the tensions around who has power in the new organisations in NHS but at the expense of any agreement on a coherent national strategy or vision of how the NHS is going to survive the next 5 years never mind the next 20! This is all about who has the power and not about why they need it - to achieve what. What a typical waste of effort and talent for so many as the NHS fragments apart. "and the band played on".

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  • Anonymous | 28-Apr-2012 9:56 am
    "at the expense of any agreement on a coherent national strategy".

    The lack of a national strategy is not a mistake. It is the point of a market model of health. There will not be a national anything. There will be lots of competeing fiefdoms determining local best fit.

    Asking Lansley for a National strategy for the NHS is like asking Darwin for an evolutionary strategy for the three toed sloth. The question doesn't make sense in his world view.

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  • Here we go again.

    PCTs where supposed to do what ccgs are ment to do.. engage GPs and clinicians in commissioning.

    PCTs where set up with a majority of GPs, but SHAs came in heavy handedly and crushed any independence.

    PCT chief execs just listened to the SHAs and just took any decisions that needed making to the board .. totally by passing the PEC.

    The same will happen again ... certainly when Lansley goes.

    PS why are most comments Anonymous??

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  • John, the path to a broken career, bullying, being forced to leave a job and general poor behaviour from HR is littered with people who dared to raise their head above the parapet, engage in constructive critical debate, challenge the perceived wisdoms, attempt to reform the aggressive if not toxic culture of heavy handedness so pervasive in the NHS.... is why we prefer to remain anonymous. It is simply not worth our jobs and health/ wellbeing plus that of our families to say what we really think in public.

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  • As long as Sir David sits atop the NHS you will have one model - Stalin style top down control. What makes it worse is that there is no plan to operationalize beyond maintaining the "Sir David Control Model" so anyone who was hoping for a different results is reminded of the quote attributed to Einstein about "insanity being defined as doing the same thing over and over, and expecting a different result." And to see Sir David publicly take postions diametrically opposed to Lansley and the legislation's bespoke intent - and not get called to task for it - is an active danger to achieving the outcomes that have been called for. Never underestimate a bureaucrat's ability to put their own motives ahead of their constituents...

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  • 12.38 refers to 'general poor behaviour from HR' - in my experience the poor behaviour usually originates with line management when they don't understand how to manage people fairly. I have found HR to be reasonable on the whole, and I speak as a union representative. I still feel the need to post anonymously though!

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