The must-read stories and debate in health policy and leadership.

New kind of leadership

It is six weeks since NHS England and the British Medical Association announced the new five-year GP contract deal.

Described as the biggest shake-up to general practice for 15 years, the agreement proposed a rapid national spread of primary care networks: organising primary care clinicians into multidisciplinary teams, working across a group of practices that cover 30-50,000 people.

Right now, GPs are supposed to be talking among themselves to decide who is going to be in what network. By 15 May, they will need to have that figured out and also have picked a clinical director, their “named, accountable leader”.

Nikki Kanani, NHSE’s primary care lead, told HSJ that, in some areas, this new job is attracting GPs who have not engaged with the system before. “[They] have started to get more interested in what’s going on around them” and “a different style of working” that PCNs represent, she said.

By 1 July, NHSE and the BMA hope all English patients will be living in networks.

And that is when the story will really start.

The new clinical directors will hold a fair chunk of responsibility, as PCNs will sink or swim on the working relationships that develop between the clinicians involved.

The director will need to keep the constituent parts of their PCN happy and together, while representing them at clinical commissioning group, integrated care system and sustainability and transformation partnership level.

It will be interesting to see, come the summer, who has decided to take on the challenge. 

Feeding off scraps

Of all the frustrations felt by local leaders, the NHS capital funding regime features very close to the top of the list.

The “capital departmental expenditure limit” has been severely constrained over the last decade, while established “off-balance sheet” financing models traditionally used to get around the CDEL have now been banned by the Treasury.

The death of Private Finance Initiative (and its short-lived successor PF2) was confirmed by the chancellor in his spring statement, while a consultation document from the Treasury appears to also rule out any off-balance sheet models with PFI/PF2-like characteristics (though stopped short of banning off-balance sheet models altogether).

It added: “The government recognises the lessons learned from the experience of PFI and PF2 including the need for greater transparency: new ideas must be able to demonstrate that the benefits brought by private capital outweigh the additional cost to the taxpayer of using it.”

The sudden desire for transparency and signal towards on-balance sheet funding models should be firmly welcomed by fans of probity in public finance.

But this may well leave the NHS feeding off scraps for the foreseeable future.

Given the relatively generous revenue settlement already confirmed, health is going to be towards the back of the queue when it comes to the scheduled spending review later this year. This is bad news for all those budgets which haven’t yet been settled, including capital.

With no obvious private finance alternatives now available, there is a serious risk that many of the transformation plans being hatched by STPs to make their services more sustainable will never get investment and never be implemented.