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Editor’s blog Wednesday 8 September 2010: The future of management

The future of management in the NHS isn't what it used to be.

For many clinicians, this will be seen as a good thing. For many clinicians, managers are target-obsessed, financial-balance-driven surrender monkeys to the tin Gods of the SHA and the DH, or Monitor.

There remains a degree of mutual antipathy between 'the two cultures', best encapsulated by sad remarks from various parties that managers and clinicians are taught to hate one another in training. The truth is more nuanced than that, but in general not much more.

There is a broad failure across the two trades to acknowledge the other's legitimacy. Which is a massive problem.

Andrew 'Liberator' Lansley's approach to resolving the problem is to fix the contest and let doctors 'win' management - in particular, GPs. (His first wife, for the record, was a GP).

This decision to create a 'ruling class' in itself will create another interesting dynamic.

Because if you think doctors and managers hate one another as breeds, then you should understand what most secondary care clinicians think about most primary care clinicians, and vice versa. The former think the latter are stupid; the latter think the former are arrogant.

There is going to be some proper fun when GP commissioning consortia get their act together and insist on protocol-driven secondary care, with tight adherence to Cochrane evidence, systemaic use of patient information and decision aids and formularies.

How will hospital doctors wave shrouds at the choices in concert of their colleagues in primary care? That is a question for another day - albeit a not-terribly-distant one.

Follow the money
the subject of today's sermon is money. Illiterates occasionally suggest that the Bible refers to money as the root of all evil (it's "the love of money" which the Good Book If You Like That Sort Of Thing so defines).

Money and management, to be precise. Because the whole current debate about the White Paper has a surreal air, given that we know practically nothing about how much management money will be available to the new GP commissioning consortia, to enable them to finally 'do commissioning properly'.

We can guesstimate some figures. By 2014, the Coalition Government's plan is to cut NHS management spending to 45% of the 2008-9 level of approximately £1.8 billion.

That would leave about £1 billion.

Of which the SoS's "light" Independent Commissioning Board (and any regional offices, which will in no way resemble SHAs), the new Monitor On Steroids, Economic Colossus and various other demands will suck away about one-fifth.

So GP commissioning consortia are likely to have some kind of share of £0.6-£0.7 billion (there will have to be a hefty top-slice for overspenders, on which more another day).  Clearly, nobody will spend money on external consultant to avoid staggering Liberatin' Lansley.

Speculation has focused on a figure of £6 per patient. Recent conversations with some very well-placed sources suggest that the £6 figure is deemed on the very low side, and that the haggling is occurring between £8 and £9 per patient.

It's still not a great help in the absence of knowing:
- how many consortia
- whether geographically based
- how often patients can join and leave (annually? less often?) via choice of GP
- what happens to surpluses
- what happens to overspanders

As such, things are a bit of a goatlove for anybody trying to plan for the Brave New World.

Consortia have no idea how many resources - in managers, analysts, extrenal suppliers - they will be able to afford. People who want to plan how their business (which includes social enterprises and co-ops) will work for and with consortia have a parallel problem.