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Consortia to be authorised in stages, Sir David tells HSJ

Commissioning consortia could be authorised in degrees and should not “make” their own commissioning support, NHS chief executive Sir David Nicholson has told HSJ in a wide-ranging interview.

Sir David, who is also NHS Commissioning Board chief executive-elect, also said he would not tolerate regional “fiefdoms” in the board and that too many general managers becoming consortium accountable officers would be “a problem.”

He said “a relatively small number” of consortia would not have any sort of authorisation by April 2013 but added: “There will be steps you have to go up to be [completely] authorised and not everybody will get right to the top [by that date].”

He gave an example of an, otherwise authorised, consortium not being given the go-ahead to undertake mental health commissioning.

He added the board could also constrain a consortium’s “financial flexibility” if it was worried about its aptitude in this area. The board could decide “how much of [a consortium’s] resource they could allocate recurrently, how much they have to get permission for,” he said.

Sir David said the board would have to use “much more judgement” in authorising consortia compared with foundation trusts. “We’re not going to have several years of trading records in order to make that judgement,” he said.

Key authorisation tests for pathfinder consortia over the next two years would include controlling secondary care demand, managing long term conditions, improving primary care performance and engaging secondary clinicians.

Asked what he believed was the correct number of consortia, Sir David said he was “much more exercised” by commissioning support.

“You can have 250 consortia if they work together, if they pool resources and if they decide to buy rather than make their commission support.

“If you [have] got 100 consortia dealing with a great big teaching hospital [they] need commissioning support that will give [them] the muscle. Don’t create 20 different commissioning support organisations - create one big one.”

He added that knowing how a consortium would be “getting [its] commissioning support” would also be a key authorisation test.

Sir David said the board would “take an active role” in shaping the commissioning support market.

“At the moment I’m worried that people are dashing off in different directions with none of the certainty and support [required]”, he said. “I don’t think allowing a thousand flowers to bloom will deliver us what we need.”

Asked who should provide commissioning support, he said “nobody in the private sector has got the capacity” to meet the demand, while the NHS did “not have the expertise to accelerate the way that we do it”.

Regarding the role of the board in managing NHS finances over the next few years, the NHS chief executive said: “This system will take years to mature. Inevitably in those circumstances what you do nationally and what you do locally will change [over time].

“Will the commissioning board want a big grip in some areas around QIPP [the quality, innovation, productivity and prevention programme]? Of course it will. There are some areas of the country where they don’t need it now, but there will be areas where we will have to be interventionist.”

Sir David said the board would seek “to operate in a consistent way across the country”.

Drawing a contrast with the current situation where “intervention levels” depend on “which region you are in”, he declared the board would not have “fiefdoms that have different ways of working”.

He expressed his wish that “lots and lots” of GPs become consortium accountable officers.

He said it would be “a problem” if too many were general managers as this would mean the spirit of the reforms had not been properly “embraced”.

“There is a danger that the system reverts back to the past. I’m often accused of doing that, [but it is] genuinely not what I’m trying to do,” he concluded.

Readers' comments (20)

  • This is really being made up as we go along isn't it?

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  • He expressed his wish that “lots and lots” of GPs become consortium accountable officers.

    I can't see that happening. I agree that would be the spirit of the reforms but it would require real decision making and accountability and.......

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  • Yes, it seems that way. A nationwide game of Kerplunk !!

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  • Why on earth should GPs become Accountable Officers when they see the way Chief Executives get treated by 'the system'? They won't put up with it. The DH is going to end up with more control than ever - Stalin would have been proud. Perhaps all NHS staff should march on Richmond House and demand the freedoms we were promised, as is happening in the Middle East. I can just see DN giving a speech like General Gaddaffi...

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  • This all makes Heath Robinson look like an examplar of OD good practice.

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  • I think David Nicholson is taking rather a simplistic approach by talking about hunderds of consortia trying to commission separately. In Waltham Forest we GPs have already considered this and therfore are taking a "federated commissioning approach" .As we commission the largest percentage of the local hospital services we are offering to commission on behalf of other neighbouring consortia as part of our pathfinder. We are not entirely stupid.

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  • When we look back in a few year's time we will realise this was the biggest centralisation of power in the NHS since it's inception. Nye Bevan would be proud.

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  • I'm taking a shoe with me to the March in London on March 26

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  • Talking of Nye Bevan, he of course is to blame for three generations of political blood, sweat and tears as politicians try to bring doctors properly to account for the impact of their decisions, clinical, managerial and financial, and to provide direction and development in the NHS which is in the best interests of the citizens who pay for it. The current "reforms" are their latest attempt and good luck to them.

    Of course, politicians have been their own worst enemies in this process. They have failed to empower other professionals in the NHS, managers in particular. They have given free rein to their irresistable urge to interfere in nitty gritty whilst failing lamentably to give coherent strategic direction. The combative rather than co-operative politics they have fostered in Britain has defined continuity and consistency as dirty words and condemned the NHS to major and mostly unjustifiable disruption after every general election.

    The underlying conviction of the politcal establishment has been and remains that they will only get what they want if they excercise strong central control. The attempt has been made in the past to camouflage this with fine words and shallow gestures about freedom, clinical leadership and localism and so on. And so it is now. Sadly,it is as unlikely as it has been since 1948 that we shall now get that framework of transparency, progress and development in our Health Service, with accountablity between doctors and the citizen, that should be the mark of a civilized society.

    But there is one crumb of comfort for those who care for the NHS in England. At least something is happening to try and make your NHS fit for purpose in the 21 century and there is a process in which you can be involved and which you can try and influence. Elsewhere in the UK, heads are still very firmly buried in the sand.

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  • phil kenmore

    The fact that there wont be trading record on which to judge a consortia and agree authorisation will make the real choice as simple as do they believe that the GPs/leaders of that consortia will be capable enough to deliver?

    The evidence they gather to test this will be crucial. Enthusiasm, a belief they can drive change and a desire for local control will not be enough. Making sure that the GPs involved understand how to deliver corporate leadership and genuinely motivate a plethora of others (staff, stakeholders and providers) to deliver will be far more important than any technical commissioning skills that can be bought in. If the NHS CB starts in the right place they may end up with the consirtia leaders who will really deliver the goods.

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  • I am currently working with a few pathfinder consortia and GP provider services. What sets them apart is enthusiasm and the wish to think outside the box without a PCT telling them "it cannot be done".

    I fear that Sir David's plans will squash this enthusiasm and replace it with yet another generation of "corporate leadership" (to use Phil Kenmore's phrase) that keeps the NHS wrapped up in bureaucracy and stifling "top down" guidance.

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  • Anon 3.41
    I'm also working with a Pathfinder Consortia, and part of my problem is not having to tell them 'it cannot be done', but having to tell them 'actually, this has to be done'. Yes, they're enthusiatic, yes, they're dynamic, but they are still living in a world where they think:
    - the Nicholson challenge doesn't apply to them
    - they don't have to worry about making difficult choices, and actually show no willingness to make the swift choices that do have to be made
    - they don't see why a QIPP delivery Plan has to be done and can't understand why the PCT has to spend so much time doing it

    I could go on, but I'm frankly rather tired of PCTs being caricatured as oppressive bureaucracies. Many of the things that held us back (WCC and the plethora of QIPPs being just two examples) weren't of our own making, nor would we have chosen them. I agree that top down centralism will continue to be the goose that lays the rusty, inedible egg. But don't confuse that with the role and responsibility (many of which will need to be done but my Pathfinder really don't want to do) of PCTs - it misses the point entirely.

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  • labelling all PCT managers /commissioners as incompetent will not help to improve the NHS and will simply undermine the serious work that has to be done to make GP commissioning work - there is no magic wand

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  • I fully support his desire for GPs to become Accountable Officers. For too long, PCTs have been the fall guys of the system. I look forward to the day when a GP Accountable Officer is hauled in to be grilled about overspends and then turfed out with their career in tatters when they couldn't deliver in impossible circumstances.

    The reality, however, is that not many GPs are willing to put themselves in this positions. GPs have been moaning from the side lines for years and not taking much responsibility for bringing about change. A leopdard doesn't change it's spots and I cannot think of many NHS reforms that have ever got GPs to accept changes that they don't favour.

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  • mike batt

    Anon above. I am sure you are right about GPs peril when they become accountable officers. The fact that you rightly point out that PCT CEOs have been unable to control overspends though is hardly a great advert for what a good job PCTs have done.

    The problem is the stupid idea of "commissioning". What makes anybody think that you can fully understand and predict a whole countys' complex and interactive health needs, procure highly technical specilaist services (with little technical knowledge), stop FTs trying to make more money, stop GPs referring and make everything cost less each year, despite designing a system which creates more health demand.

    Commissioing is just mini centralised planning. You may as well try and do grocery shopping for 1 million people at a time, then complain that people in Kettering are eating too many satsumas. GPs will fall into all the same holes.

    Lansley's and DNs approach is not revoloutionary; it is just tinkering.

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  • The guy is an idiot. Does not know his a..e from his elbow. He is just an honorary memeber of "David`s Eato chappies

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  • "Asked who should provide commissioning support, he said “nobody in the private sector has got the capacity” to meet the demand, while the NHS did “not have the expertise to accelerate the way that we do it”. "

    So if he doesn't want the private sector to do it, and he doesn't want the NHS to do it, who does that leave? Can't see the voluntary sector being able to take this on.

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  • Really good points from Mike Batt.

    What seems to have gone unquestioned throughout the White Paper process is the NHS economy with its Commissioner/Provider (war), NHS Tariff, and one year allocation cycle.

    Me thinks that a good look into that would be more beneficial than scrapping all of the current system. Don't get me wrong, there are savings in PCT and SHA land as there would be if we looked VFM in GP practices.

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  • Good points from Mike Batt and all above

    Unfortunately there is a problem with big gov't departments where making policy is taken more seriously than implementing it. Over time the 'landscape' is littered with fragments of previous policy and initative and the whole system becomes mind-bogglingly diverse and complex. It gets harder and harder to make a change that pleases the political masters and this creates a rollercoaster of competing policies that are never completely followed through. What a terrible environment to manage large organisations providing critical services!

    It appears that the only cross-party agreement to provide consistency for the NHS has been the one to take it out of government control - to privatise it. This started with the invention of the 'internal market' and as soon as that was taken seriously there was no turning back. I don't understand the outcry at LtNHS as it is just the logical continuation of the internal market policy direction.

    Time to read 'The Doctor's Dilemma' again to acquaint us with the pleaseures of private medicine. Our best hope is for a quick and relatively pain free death for the NHS so that it's reinvention comes as soon as possible (2047 anyone?).

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  • I think that GP's should be the accountable officer. However the level of risk for them is far lower than the current arrangement. At the moment the Chief Exec can get hauled over the coals and got rid of, end of NHS career which is quite a large incentive to do it right. If this post is filled by a GP the worst that happens is that they go back to being a GP, no real loss of earnings or career. Hardly the same level of incentive to make sure they deliver.

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