Kailash Chand on the NHS commissioning board

Kailash ChandIn the Department of Health’s guidance Developing the NHS Commissioning Board, David Nicholson stated: “CCGs (Clinical Commissioning Groups) will be the engine of the new system and things will only be done at a different level of the system where there is evidence that this produces better results.”

However, there is wide spread concern that the NHS Commissioning Board (NCB) will replicate more of the same “micromanagement” that has dogged this coalition government. Even the most enthusiastic cheerleaders of commissioning see the NCB as their greatest risk, and they too fear that CCGs will be pawns in the strategy of implementation rather than designing regional and local services.

This surely gives credence to widespread concerns and perceptions that the NCB will suffocate, rather than liberate the commissioners.

All my working life I have been a passionate supporter of clinical engagement and support the BMA line that clinicians should be influencing service design and quality in the best interests of local populations—“commissioning” in the truest sense is using resources in the most appropriate and clinically efficient manner. However, I believe the CCGs will instead be relegated to the role of debt managers, with the dumbed down function of following central imperatives while taking the blame for care not being delivered  owing to inadequate resources. They will be performance managed to deliver government targets (commissioning outcomes framework), ensuring that there is a drive on competition internally within the NHS as well as with private providers, more private provision, and private commissioning in the NHS, resulting in fragmentation of NHS care and an undermining the trust of patients and the public in doctors, especially GPs.

The Health and Social Care Act gives CCGs the authority to generate their own priorities for whom they will provide a service, and what service they will provide. They will be under no obligation to ensure that a whole range of services is available to their catchment population. In some areas CCGs will be up and running in April 2013; others will be operating partially and some in shadow form only. In addition there will now be more than one commissioning model that will not just create uncertainty, but also a two tier service and a costly, duplicitous bureaucracy. We will have a Department of Health, an NHS Commissioning Board, four strategic health authority clusters, 50 primary care trust clusters, hundreds of clinical commissioning boards, dozens of clinical senates, and over 100 health and wellbeing boards. In the midst of these will be foundation trusts with their enhanced powers. Setting up this complex structure with a corresponding 45% reduction in the overall management budget requires a certain genius, and it is likely to put an additional strain on the system.

Furthermore, the abolition of PCTs and SHAs has costs millions in redundancies and subsequent re-employment of staff. It is a complete myth that GPs in commissioning groups will have a major impact on designing services. Tertiary services like neurosurgery will be commissioned by the NCB and elective care such as cataract and orthopaedic surgeries will be via patient choice arrangements. The NHS reforms may have some influence on long term conditions, but this too may be tricky as the providers with one eye on profits will negotiate a fixed package with very little leverage to change especially if that increases their costs and reduces their profit margins.

Then there is the potential that many CCGs will subcontract many of their activities to commercial organisations. If commissioning is outsourced, it then becomes even less clear whether GPs will be in control of the commissioning process. While CCGs may contract out much of their activity, they retain responsibility for what is done in their name. The Health and Social Care Act states explicitly in section 9 (3) that:  “a commissioning consortium has responsibility for persons who are provided with primary medical services by a member of the consortium.” CCGs cannot look to the government to bail them out if things go wrong. They may not be deemed “too large to fail” and the White Paper’s section 5.14 makes it clear that they will not be indemnified against financial failure, whether caused by weak budgetary management, errors of commissioning, or by circumstances entirely outside their control.

Involvement by GPs in commissioning creates many potential conflicts of interest. No measures are yet in place to limit the ability to contract with providers in whom GPs, their families, and business associates have a financial interest. If such contracts are set up, there is a real risk of supplier-induced demand, as in the US healthcare system, and of accusations of foul play by patients. There is simultaneously an incentive to build up budget surpluses (or reduce deficits) by reducing or delaying necessary referrals. This is likely to be exacerbated by the proposed “quality premiums.”

In fact, some CCGs faced with budget deficits have already started to ration care. NHS South West Essex has circulated a list of 213 treatments for which general practitioners can no longer refer. These include hip and knee replacements and hysterectomies. Health insurers are already gearing up to provide top-up insurance to cover procedures no longer covered under the NHS so this strategy is likely to result in both higher costs and an increase in inequality.

Patients unable to access procedures which have previously been routine are likely to be distressed when they discover they will now have to fund their own treatment.  It is possible that they will blame their GP, especially those who can neither afford nor borrow money for an operation they need to relieve chronic pain or disability.

Doctors are still the most respected group in British society. There is a real danger that these changes, many of whose practical ramifications are still far from clear, could trigger a backlash from patients, as well as significant legal and financial risks for those participating in consortia.

Indeed, it is difficult to argue with the proposition that they could easily become the scapegoats for the failings of these ill conceived changes.

The new Secretary of State for Health for England, Jeremy Hunt, has limited experience with managing such a precious public institution as the NHS. What we know of him is not hugely inspirational for those of us who care about the NHS, or work within its many structures; he promotes homeopathy, dislikes hybrid stem cell research, and voted to cap legal abortions at 12 weeks. He is a passionate supporter of the “private is better than public” mantra.

With the limited experience he has, his challenges will be insurmountable without the weighty issues of the Francis report, pensions, Monitor, foundation trusts, and regional pay which is likely to be resisted by all unions, job losses, and perhaps above all, the £20bn  savings drive, which he has been left with as Lansley’s legacy. It will soon become apparent whether the secretary of state for health or the chancellor of the exchequer actually runs the NHS. Whatever he does, he cannot afford to hold on for much longer otherwise the state of the NHS will continue to decline in his wake.

Kailash Chand has been a GP for last 30 years and is now chair of the NHS Trust Tameside & Glossop. He is on the BMA council and he was on the general practitioner’s committee. He was awarded an OBE in 2010 for services to the NHS. The views he expresses in his blog posts are entirely his own.