Major power to be focused at centre

Prime minister David Cameron announced on Tuesday that the Commissioning Board will tell Monitor how choice and competition should be applied to NHS services, guided by ministers. It will also discharge duties of those GP consortia – now known as clinical commissioning groups – which are not deemed ready to take on responsibility for services. Concerns are being expressed the changes will impinge on local freedoms.

The changes mean Monitor, which previously had powers to promote competition, will now simply apply a “choice mandate”. This will be part of the main mandate set by the health secretary and passed to the Commissioning Board. The board will issue guidance on how choice should apply to particular services.

• Image: proposed structure

The government document said the health secretary’s mandate will set “clear expectations” about how choice should be applied.

Hempsons partner Christian Dingwall said the changes seemed to have “extended” the Commissioning Board’s role.

He said: “It will undertake commissioning for part-authorised and shadow CCGs that are not ready to go live by April 2013. And it will host clinical networks and clinical senates, featuring doctors, nurses and other professionals. A key question is: will the Commissioning Board’s duty to promote autonomy be a sufficient driver for empowering CCGs, or will the Commissioning Board end up micromanaging them?”

However, NHS Confederation chief executive Mike Farrar said another change – giving the health secretary clearer accountability for securing the provision of services – should ensure the mandate was not overly prescriptive.

He said: “It will be the secretary of state who’s held accountable for the outcomes. It won’t be in the secretary of state’s interests to deny local commissioners the ability to use better integration of care, or choice and competition.”

He thought the Commissioning Board would be able to “negotiate” on the limits of the “choice mandate”, while CCGs would be likely to challenge the board’s guidance if it meant they were “not getting the flexibility they need in the best interests of patients”.

Making the board the “default commissioner” when commissioning groups had not reached the required state of readiness was “entirely defensible” but only in the short term, Mr Farrar said. “We want to see the Commissioning Board trying to empower local consortia rather than there being inertia.”

The government confirmed the Commissioning Board would have “local arms”. It said the board’s “local arrangements” would reflect primary care trust clusters.

Commons health committee chair Stephen Dorrell said more detail was needed on the nature of the cluster-level tier of the commissioning board.

He said: “We know roughly what the commissioning groups will look like, and we know what the Commissioning Board looks like. The middle tier needs further clarification.

Mr Dorrell continued: “There’s going to be some very important decisions about the shape of local services that need to be made, and [they] are likely to be made at cluster level.

“The clusters are the ones who will be doing all the heavy lifting on the [£20bn efficiency] Nicholson challenge – and they’re the least clear part of all of this at the moment.”

One acute trust medical director heavily involved in driving reform at a regional level said: “The government talked about reducing bureaucracy, but this will be more management. The new structure puts a huge amount of power with the commissioning board. You don’t drive up clinical quality by changing the structures.”

Strategic health authorities will also be clustered later this year, the document states. It is believed arrangements could follow the four former health and social care directorates, established in 2002, covering the North, the South, the Midlands and East, and London.

The reform changes mean a greater number of SHA and primary care trust staff may be retained during the transition to the new system. A Department of Health spokesman said the planned £1bn redundancy costs could change.

HSJ understands that much of the redrafting of the bill has already happened behind the scenes while the listening exercise was taking place.

The Commons Health Bill committee, which spent eight weeks examining the bill in its original form, will reconvene when the full amendments have been published.

Its scrutiny is expected to be completed by the time Parliament rises for the summer recess, with the Commons report stage now likely to take place in early September and House of Lords scrutiny to follow.