What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West.

An ironic and slightly cruel term caught my eye in the revised NHS England rules for CCG mergers. We have only reached, at best, a waypoint on the extremely drawn out and painful reorganisation journey of the NHS’s planning and oversight functions. So inviting “future proofed” structural proposals felt a little inappropriate.

Since nobody can see where this process ends, any proposal claiming to be “future proofed” for any longer than a couple of years will surely be received with laughter.

But the NHS’s below the radar non-reorganisation reorganisation has to go on, and it is becoming clear we are beginning the next chapter.

This time there are five big factors in play:

  1. There’s a renewed backing (as highlighted by the recent Alan Milburn/PwC report) for another run at decluttering the NHS quangos , particularly NHS England and NHS Improvement, to ease the horrendous barriers in the system to decision making and to help establish clear direction.
  2. The imperative to make further big cuts in management costs.
  3. Desire to get more of the good people in commissioning, planning, oversight and regulation working on transformation instead of feeding the beast with reporting templates; or, as Simon Stevens described it last week, getting them off the “rear-view mirror, it’s all gone tits up agenda”.
  4. A number of these factors mean the next chapter is not just about binding the quangos’ regional and local teams closer together – instead, the reshaping of clinical commissioning groups and commissioning support units is part of the same process, and probably moving the boundaries between all of these.
  5. The fairly urgent need to clarify the next steps for STP leadership, governance and management. Partly this is a personnel issue: some STP leaders will stay on, in some cases they want to go back to the day job, and in some there is a desire to move them on as they are not making the right impact, or getting in the way. In others the current lead might have had enough.

These things will shape the new chapter. It’s likely, and very wise, that Mr Stevens’ preference for structural diversity – “horses for courses” – will hold fast. Some areas will benefit from a firmer hand and some won’t.

What will be the key characteristics and dilemmas?

1. Full time/dedicated leadership for STPs and building teams/structures and governance around them. Having dedicated - although not always full time - leadership seems to have worked well for two of the “success regime” projects in Devon (initially Dame Ruth Carnall as independent SR chair from outside the area, then Angela Pedder who gave up her FT chief executive post in the patch) and Essex (Anita Donley as SR independent chair, from outside the area). This is raised in the King’s Fund STP report this week. STPs won’t become legal entities but firming them up; giving them staff “seconded” from other organisations; merging CCG management, contracting and governance into bigger patches, creates a virtual structure that all these things can be hung on. New, wider commissioning structures also mean CSUs are very much in the mix – there is potential to bring their teams into these STP level structures, and reduce the contracting/transactional workload.

2. Moving or embedding staff from national bodies to independent regional/subregional structures. Where there are serviceable regional structures – like in Greater Manchester – there is scope to solve problems by moving NHS England and NHS Improvement directors and teams into them, and/or make them more accountable to these structures. NHSI has taken a step towards this with its director covering the GM area; there is also an intention for GM to do more of its own oversight/regulation work.

In some patches, CCGs working jointly are said to be making joint appointments with NHS England on specialised commissioning. Again Greater Manchester has made strides on joint specialised work. The “specialised co-commissioning” policy of recent years hasn’t worked in many parts of the country but the direction must be to transfer more responsibilities and staff out of NHS England. The next chapter has to continue the slow trend to shift staff out of the ridiculously large national bodies.

This would be a step on from the joint regional/local directors and teams between NHS England and NHS Improvement, but expect this to be tried more widely too. So far there are two joint regional nursing directors and a joint local director for the North East.

3. A structure designed to achieve big improvements in primary and community care. This is the main aim of all STPs and has become the big theme for the Five Yer Forward View project. Would driving it at STP level help? Perhaps relevant expertise/capacity could be built up, and a new structure would be liberated from the GP conflicts of interest which have often hampered CCGs’ efforts.

However, conversely, NHS England local teams did little better as primary care commissioners; the STP will be further from the ground; and, in some cases, alienating constituent CCGs will further damage the chances of winning round GPs. Many areas, given the choice, would therefore opt for CCG/borough level units leading delivery rather than STPs.

The Commissioner’s reading list

Dave West, senior bureau chief

Updated to correct references to the role of Anita Donley in Essex and the STP/success regime leads in Devon.