"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Wednesday, 15 June 2011

Localism and centralising

Localism gets a very good press. People regard it as being a good thing that policies and services are tailored for the locality rather than a one-size-fits all. This works if the localism gives better services, but it can give worse services, in which case localism becomes a postcode lottery. There is a lot to be said for a hybrid where basic standards are applied everywhere, and localism is applied on top, but the issue is where to draw the dividing line.

The NHS reforms were initially sold as localism. The whole "put GPs in control" message was designed for patients to look at the doctor they trust and think "you should be determining my care, not that faceless bureaucrat miles away". Of course, it was never that simple. Some policies, like public health, can only be applied to large groups of people (in the reforms, this is moving from the 152 PCTs to the 50 or so county/unitary councils). In the case of rare conditions - organ transplants, rare cancers - most GPs do not come across such patients, so it makes sense to centralise the care in a few specialist centres where every patient will get expert care and to centralise the commissioning. This is the case at the moment, specialist commissioning is carried out by the Department of Health.

However, as details of the policy started to appear, it became more obvious that the government's policy is actually centralising decision-making, rather than devolving it.

There are 152 PCTs covering, on average, 330,000 people (there are a few PCTs that cover over three times that many). A GP practice will cover, on average 6,000 people. GPs have to be commissioned, and this is currently done by PCTs. Similarly, dentists, opticians and pharmacists are also commissioned by PCTs. This is the case of local knowledge being used to design the care for a local population.

The government is creating a new super-quango called the NHS Commissioning Board. (Know anything about that? Despite all their bluster about quangos during the election last year, the Tories kept quiet about the NCB.) This is essentially the Department of Health, SHAs and a quarter of PCTs all rolled into one. This quango will do the specialist commissioning that the Department of Health currently does, and it will also oversee the commissioning work done by the new GP-based clinical commissioning groups and set guidelines. Since the NHS White Paper was published a year ago the figure "80% of the NHS budget" was constantly thrown around. This figure refers to PCT spending and most people assumed that the GP consortia (now renamed clinical commissioning groups) would take over that budget. However, at the health select committee a couple of months ago, the Secretary of State mentioned a figure of £60bn (roughly 60% of the NHS budget). He pointed out that primary care commissioning (GPs, opticians, dentists, pharmacists etc) would be carried out by the new super-quango.

Over the last few months the government has been forced to re-think the artificial deadline they set for when PCTs will be abolished. The government has now agreed that GP commissioning groups will only do commissioning "when they are ready", but the April 2013 deadline for PCTs still remains. Currently 90% of England is covered by "pathfinder" consortia, many of which are far too small to provide effective commissioning. Under the government's previous plans such consortia could buy in commissioning from private companies, however, yesterday the Secretary of State confirmed that the new clinical commissioning groups would be statutory bodies and would have a responsibility to do the commissioning themselves. When pushed, he confirmed that they would not be allowed to buy-in the commissioning. This is significant because it will mean that there will have to be a re-think about the smaller pathfinders. Further, the Secretary of State confirmed that (unless there was an important reason otherwise) the commissioning groups would be expected to share borders with local authorities. The original Pathfinders were set up with no regard to local authorities boundaries. This means that the figure of 90% of the population covered by Pathfinders will surely change.

So who will do the commissioning in the areas where the local GPs are "not yet ready"? The PCTs will be abolished in 2013. The government says that this commissioning will be carried out by the new super-quango the National Commissioning Board.

However, it goes further. In response to demands that there is more clinical involvement in commissioning, the government has decided to set up new organisations called clinical senates. (When the government says that they are reducing the number of administration tiers in the NHS, point out that with the NCB and clinical senates they are simply replacing tiers, not removing them.) The senates will oversee the work of the local commissioning groups but will be part of the NCB rather than be locally based.

Further, local authority Health and Wellbeing Boards will oversee the commissioning decisions made by commissioning groups. These boards will be part of county or unitary councils and hence there will be fewer of these than there are currently PCTs. Yet again, this is centralising this responsibility.

So rather than localising decision making in the NHS the Bill will be centralising: centralising primary care commissioning and centralising oversight of commissioning. This is not a government of devolution it is a government of centralising.

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