The reforms grind on. In the stratosphere there is a lot of noise and turbulence—people arguing passionately and polemically. Meanwhile the architecture of a new system is being constructed around those of us working in the old system. People are wondering where their future lies, or if they have a future. The basic construct is becoming clearer to many of us and we are working to support its creation. This is driven by the desire to ensure that the good work done for the public and the patients in the past does not get lost in the transition between systems, and to try and secure the theoretical benefits of the new system. It is also to try and mitigate the unintended consequences, which might not be so beneficial.

Now that we have a better understanding of how the system is likely to be structured we can test what needs to be done and whether it will work. This last week has been illuminating, as I have moved between supporting the development of Clinical Commissioning Groups, Commissioning Support Services and Specialised Commissioning. I was interviewed by someone who wanted to understand how Specialised Commissioning has functioned and how it will function in the future. Responding made me think about some potential unintended consequences.

In the East Midlands, Specialised Commissioning accounts for about £670million of public money. The Carter review in 2006 proposed new arrangements for Specialised Commissioning which led to the creation of the 10 Specialised Commissioning Groups (SCG) based on the Strategic Health Authority Areas. The East Midlands SCG is accountable to the Primary Care Trusts who delegate part of their budgets for the low volume, high cost and complex care which SCGs commission on their behalf. This role will now be taken by the NHS Commissioning Board. Whereas the SCG budget was inextricably linked to that for the population of each PCT that will no longer be the case for CCGs. This must be a worry. Patients with conditions needing specialist services will be influenced by the actions and inactions occurring in those services commissioned by CCGs. Will the CCGs be that concerned about how this impacts on a budget for which they are no longer accountable? The types of treatments and interventions that the SCG commissions are high profile and often “political.” As the PCT representative on the SCG board I have worked hard with colleagues to control the incessant pressures on the budget and have supported some difficult decisions because, otherwise, the resources available for those with less headline- grabbing problems will be diverted. Will the National Commissioning Board be that worried about increasing the top slice from CCG budgets to minimise the political flack it could attract?

What is not appreciated is that the SCGs had taken on a lot of work that was not initially within their remit. It was just that PCTs agreed that doing such work, once, on their behalf, utilising the expertise of the SCG team, was a good idea. At the last SCG board I heard about the “group 3 services” that the SCG would no longer commission from 2013—these will need to be commissioned by CCGs. That may come as a bit of a surprise to some CCGs who are not yet aware of this more complex and quasi regional work. Will it need to be picked up by Commissioning Support Services? If it is, will they have people with the skills and expertise to do it safely and effectively? Will the CCGs have the money to buy this service from their Commissioning Support?
Increasingly, it is all the little things that have had pragmatic solutions forged for them over the last few years that are falling into the gaps in the unfinished architecture of the new system.  They will need catching and a place found for them. We have twelve months to do this—so maybe once the architects have finished they need to take a break and let the little things get sorted before embarking on any major new constructions?

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.