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.

Consortia to be authorised in stages, Sir David tells HSJ