Nicholson: leading hospitals to be reshaped by commissioning board

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.”