Regular readers will recognise that one of the themes of this blog over the last 9 months has been how, despite the heady intentions of the Secretary of State in July 2010 to localise power in the NHS, recent practice in setting up the reforms has been to give ever greater power to the centre – in the shape of the National Commissioning Board.
My recent experience within the reform programme of the NHS has underlined the impact this is having on local experience. Just in the last few weeks a number of GP leaders of local commissioning groups have expressed surprise at how they are being treated by the local arms of the NCB (in the shape of clustered PCTs and SHAs). They are being told to come to meetings at a few hours notice; to change their plans at a weekendâ€™s notice and generally getting a good introduction to the centrist culture of the NHS. Up until now most GPs have avoided this experience because the NHS centre has not seen them as being sufficiently powerful to bother with.
Now they are being put â€˜in chargeâ€™ of local commissioning they are beginning to experience the combination of instruction and capriciousness that is the hallmark of central NHS management culture and, unsurprisingly, itâ€™s a bit of a shock.
GPs say in wonderment, this canâ€™t really be an example of what the Government means by localisation can it? And of course they have a point.
Since December last year when the quid pro quo for going ahead with the publication of the Bill was the appointment of David Nicholson to be CEO of the National Commissioning Board there has been a powerful tussle going on between centralising and decentralising forces within the NHS reform programme. Over this period the Governmentâ€™s capacity to implement its reforms has grown weaker and weaker, leaving a power vacuum into which the NCB has walked.
The nascent clinical commissioning groups are beginning to get the fuller force of the authority of the NCB brought to bear on them – and its proving to be an unequal struggle.
So how can a group of local GPs who still do not properly exist as an organisation, empower themselves in such a way as to ensure that they can achieve something locally? This is an even bigger problem because if a group of GPs gains a reputation of wanting to do what they think is best for their local patients rather than what they are told to do by the NCB, they may well find that the process of becoming authorised by the NCB is very hard.
So how does a nascent GP group play this power game?
The leadership of the NHS in the DH have always quite rightly felt that given the size of the NHS they do not really have to pay much attention to other parts of government. So therefore outside of social care, the NHS, at the centre, has never really seen local government as being of any relevance.
At a local level the NHS has had to work with local government and local GPs, whilst they may not have had a structural relationship with local government, recognise that through its services local authorities are important structures.
The one localising part of the Bill that has been maintained and even strengthened during the Governmentâ€™s great reform retreat has been empowering local authorities through the Health and Well Being Boards. The Conservative part of the Government has seen the empowering of local Government as an easy way of giving something to their Liberal Democrat allies. This has looked like a cost free part of the great retreat.
Across the country shadow boards are being set up that that bring together local health partners with the possible clinical commissioning groups, and they are learning how to think through real partnership working.
Over the next 18 months it will be very much in the interest of local government and the Health and Well Being Boards for their nascent clinical commissioning groups to thrive. If from April 2013 local clinical commissioning groups have not been authorised to carry out local NHS commissioning, then that commissioning will be nationalised through the National Commissioning Board. (NCB)
Under such circumstances there will be no local governance of local NHS commissioning at all.
Local authorities are used to having to battle with all forms of Government to ensure that their localities have any say at all in the development of local services. The fact that they will now have to battle with the NCB to gain any influence over local commissioning will be familiar to them from so many other areas of policy.
What will become clear to local government is that if, from April 2013, they want any influence at all over the local commissioning of NHS services they will need to have an authorised clinical commissioning group on their patch. It is therefore strongly in every local authorityâ€™s interest to support their local clinical commissioning groups in developing as organisations and then in gaining authorisation.
I am sure that over the next 18 months, local government will increasingly come to recognise this and support their local GPs. However it would be very helpful if local GPs were to recognise that now. Close links with local government are one of the few power bases into which the NHS NCB will not have inroads. The NCB will not understand local government or the influences on it.
Therefore it is enormously in the interests of clinical commissioning groups, as they receive increasingly strident instructions from the NCB, to be able to say that whilst this may be something that of course the NCB wants, it is not something that their local authority wants.
This could create a new axis of power. One that local government is good at, but the NHS needs to learn. That is the ability to stand up for local needs against an onslaught from the centre.