The coalition government is in a bit of a hole.
It has inherited an economic mess not witnessed since the 1930s. Their solution is an audacious gamble: to slash public spending and hope that a predicted upturn in economic fortunes will ensure a further mandate at the 2015 general election.
The need for cuts and transparency in spending is therefore a political imperative for the new administration and a narrative of austerity is due to dominate government policy for the foreseeable future.
‘Messing’ with the NHS is fraught with dangers for politicians. Despite its shortcomings, the service holds totemic qualities in the eyes of the British public; undermining the enduring values of the NHS is a no go area for politicians.
And yet, the NHS is too expensive to ignore, too inefficient to leave alone and too important to threaten. There is great political allure in being the government to successfully improve the system, while upholding the values of the NHS. But the odds of this happening are unfortunately pretty long for the new government, with a programme of reforms described by some commentators as possibly the most momentous in the history of the NHS.
Add to this an incredibly ambitious timescale for change and the traditional under-consideration of the inertia, or potential for passive resistance among the workforce of the NHS, and the likelihood of this latest set of reforms fully succeeding narrows considerably.
Taken at face value however, there is not a lot in the white paper, Equity and Excellence; Liberating the NHS, that one can quibble with. Reducing top down “targetry”, streamlining national and regional structures, removing unnecessary bureaucracy, putting the patient at the centre of the system and focusing on clinical outcomes rather than outputs, all feel instinctively right.
Empowering clinicians, most particularly GPs, is also likely to hold ideological appeal, though maintaining standards of quality, productivity and morale in severely strained financial times and in the midst of major reform is likely to be a whole lot tougher than politicians anticipate.
So, with the likely costs of yet more restructuring and de-layering set to nudge £2bn, it is GPs working in commissioning consortia across the country, fully operational by 2013/14, who will be placed at the forefront of the reform programme and entrusted with the bulk of the £105bn health budget.
That will put GPs in control of the commissioning decisions that influence the quality and productivity of care, against a backcloth of £20bn cost improvements over the lifetime of this parliament.
Given the patchy track record of GP involvement in commissioning to date, and their hard won reputation for being a difficult bunch for governments to do business with, it is no surprise that many commentators see this as something of a leap of faith.
In a nod to good old centralism, the new NHS Commissioning Board - described by Labour as the biggest quango in the world - will develop an assurance process to hold consortia to account and a commissioning outcomes framework to monitor their performance against the National Outcomes Framework.
This has added to existing tensions with some GPs, and prompted the British Medical Association to declare that GPs will not allow themselves to be “the bad boys” or the “whipping boys” of the new board, This does not augur well. While primary and secondary legislation will be required to ensure that the commissioning consortia have statutory body status, with a range of defined activity and responsibilities, there will be considerable scope for consortia to determine the best arrangements locally for governance and organisation. This will need to include an assessment of what skills are required in the consortia and where those skills will come from, which potentially represents a serious threat to the reforms.
In a confusing contradiction to one of the central planks of the reform programme, it now seems that GPs won’t have to be involved in commissioning if they don’t want to be - presumably on grounds of disinterest, ideological opposition or self-assessed lack of competency to do it.
A defining principle of transition, however, is that, notwithstanding the above, all GP practices will be placed into a consortium. The reality, therefore, is likely to be that smaller groups of enthusiast GPs will take the lead in consortia for general momentum, strategic direction, clinical engagement, provider and community interface and, more taxingly, maintaining good relationships with the GP community.
That leaves us to ponder just where the necessary senior management skills and the “real engine room” for effective commissioning are going to be sourced. A generally accepted principle seems to be that this should cost less in the future than it does at this moment in time, and that better and cheaper means of commissioning, with leaner infrastructure, can be quickly implemented.
This also requires absolute clarity, in broad terms nationally and at more specific levels locally, about just what consortia can and cannot do, and a translation into what that means for the workforce requirements of the new bodies.
Hampering these considerations will be a requirement to live within an arbitrary management cost allowance, to be funded from savings associated with the abolition of SHAs and PCTs and to be developed as part of the post-white paper financial regime. Denying the fledgling organisations’ access to necessary management skills in the interests of austerity is misguided and incredibly risky.
No doubt tribes of management consultants and others are busily preparing seductive business cases to persuade emerging consortia that they have the solution, but the reality is that by-and-large, much of what is required in the new consortia is currently located (and improving in quality, as evidenced by the world class commissioning scores) in the doomed PCTs.
Antipathy from GPs and providers toward the current commissioning workforce must be strongly challenged. Enlightened GPs recognise that they need the experience, talent and management capacity from existing commissioners to be able to make a decent fist of the new model of commissioning, and a coordinated effort needs to be made across the healthcare system to relocate commissioning talent. This point is at least as important as the drive to reduce commissioning costs.
A systematic approach to identifying the dynamics of the current commissioning workforce needs to be undertaken urgently, with a primary aim of quickly coordinating talent and experience and providing imaginative routes for redirection across the new landscape. A talent pool focused on their contribution to shaping the new NHS, as opposed to their future livelihoods, is imperative. Leaving this to chance and treating it as a subsidiary consideration to achieving arbitrary management cost-cutting across the board makes no sense.
For once, the phrase “throwing the baby out with the bathwater” would be more than a hackneyed cliche.
We are collectively facing what might well prove to be the NHS’s most challenging time in living memory. The situation needs strong leadership, accurate resource planning and talent strategies, and an understanding that such broad and fundamental changes require a unified approach to workforce engagement. But, where there is change, there is also opportunity.
It is my strong hope that the new NHS we are all working toward could ultimately deliver better services to the public we serve. After all, isn’t that what we are here for?
Steve Barnett is a special advisor at Green Park Interim & Executive Resourcing