In the third in our series of policy interviews, editor Andy Cowper interviews NHS Alliance chief executive Michael Sobanja.
What are the main opportunities for GPs and the primary care team in the new policy?
MS: “Predominantly, the opportunities are for GPs and general practice. One interesting thing in emerging policy is its focus on GPs as opposed to the primary care team.
“The opportunities are absolutely immense: to design and redesign services to meet local needs and wants, in a way that’s both flexible and entrepreneurial. And there is a range of opportunities to demonstrate the value of strong primary care in population management.
And where are the main threats?
MS: “This links to another point – the key issues not spelt out yet: these are accountability, performance management and management of risk. If the government don’t handle that correctly, that could threaten general practice.
“Beyond that, there is the threat of failure – there will be those who relish prospect of primary care not being up for the challenge. Should primary care be unable to rise to it, then this opportunity might never come again in this generation.”
Have GPs ‘won’ the battle with NHS managers?
MS: “That question presents a stereotypical approach. Where they are successful, health services are built around primary care, and around a partnership of managers and GPs. This will be true of the future as well. I don’t believe a successful health service can function without working together.
“That said, if you view things between the GPs and ‘the management’, the new policy is a strong step towards GP and clinical decision-making. I say it means we’ve moved the management function. GPs undoubtedly need supporting with good management.”
What are the key practicalities about a move to hard commissioning budgets, associated with risk and reward?
MS: “It’s about remuneration; management costs; who bears risk; performance management; and accountability.
“The lines of accountability are not yet clear, though we could assume they will be to the independent NHS management board, but there must also be a role for PCTs. Very little has been said about their future role, apart from local government liaison and public health, and the demarcation must be crystally clear or we’ll get a fudge that's not in the interests of patients.
“Risk raises the question of what happens when a commissioning budget is overspent. I don’t believe this government will go for a model seeking to impose the burden of risk on individual GPs or practices – if that’s right, then risk will be borne by the NHS as whole. So what are the sanctions and exit arrangements? When a commissioning function fails, does the contract go to the private sector, or other GP commissioners?
“On management costs, speaking personally I don’t favour a management allowance: I’d rather see a recognition that in commissioning budget for a population, a figure has to be recognised as attributable to management costs. The Health Secretary seems to be suggesting 1% nationally: £1 billion on just over £100 billion.
“GP commissioners should be free to arrange management costs at the level required to do the job. The other way is a fixed allowance for management puspose, ring-fenced, but that would not allow flexibility.”
How will clinical commissioning – getting GPs into management – work, as the NHS management budget is cut by 1/3 over the next few years?
MS: “See my above answer! If the NHS management cost is now £1.8 bn and is going down to £1 bn, it seems to me that we say ‘those costs have to be redistributed, and the management function at GP level must be recognised and properly funded’.
“I therefore foresee significant management structures at GP consortia level, including finance – some other party could do back office, but we need a management function of significance in consortia to handle the large sums of money we’ll be talking about.”
GPs’ readiness and ability to form clinical commissioning consortia will vary. How can the new system manage this variation?
MS: ”That’s true, although we said to the DH that when it comes to getting GPs on board, there are different levels of engagement.
“Where PBC has taken off, there are always a couple of real GP movers and shakers. If there are maybe 500 locality commission consortia, each needing 2 enthusiasts, then nationally we need 2,000 GPs to take this forward with the consent of their colleagues
“I think it’s not beyond the NHS’s ability to find that 2,000: the 2,000 GHP leaders will need the right level of support and consent from the general majority, and the BMA are saying that they expect every GP to sign up to a commissioning consortium.”
The new system fundamentally accepts that some clinical commissioners will make a healthcare pound go further than others – a ‘postcode lottery’. How will primary care take to this?
MS: “It is possible to argue that a postcode lottery has benefits, in that services should be designed to meet different populations’ needs. This has always been true of primary care in the past: services in Eastbourne and Worthing differ from Telford or Shrewsbury, because of local populations’ differing levels of dependence and need.
“One strength of general practice over the years has been its ability to meet different circumstances – so this is one of my least concerns, though we do need performance management and accountability.
“We want to avoid unnecessary and avoidable variation, not variation per se.”
How comfortable will the primary care team be with a far more explicit role in rationing care and reconfiguring and closing services?
MS: “The reality of life for the past 60 years of the NHS is that general practice has rationed throughout. It rations at every patient visit and resource allocation decision.
“Now we’re scaling that to a population basis. The philosophy of prioritisation is something general practice already does, so I see no difficulties.
“Where difficulties come is in applying this in financially constrained situation, when we might have to reduce expenditure, not just ration. If that happens, then we’ll have to communicate with our populations, and demonstrate the rationality of decisions
“Nationally, the budget suggests that for the public sector overall, the question seems not to be whether we need cuts but how they will be distributed. In healthcare terms, who better to decide than frontline clinicians allied to strong and supportive managers? NHS Alliance has always said that clinicians and managers are like a three-legged stool: it can only balance if we’re all in it together.”
Can politicians accept clinically-led service closures in their constituencies, or will every case be a special case?
MS: “Every case is a special case, but we can’t have every case reviewed as if it’s exceptional. It’s important for the NHS management board to set a framework for decision-making and a set of criteria. The government too must demonstrate trust in local clinically-led decision-making in the best interest of patients.
“If local decision-makers get second-guessed at every turn, this will get strangled in bureaucracy.”
Is the data and IT infrastructure available to make clinical commissioning work?
MS: ”Not fully at present, but one thing we learned in the last few years, was that if you wait for perfection in financial information systems prior to decision-making, you’ve got a recipe for inaction. In many cases, local clinicians know what has to happen and can do the changes with imperfect systems.
“The systems must improved, but this is no excuse to duck tough issues.”
Is the management capacity and capability available to make clinical commissioning work?
MS: “It’s a concern. A lot of managers are exiting the service now, and it’s back to the partnership point.
“Does every GP have the managerial skills and competence to make this work? No. It’s going to involve partnership working. In the NHS today, we have sufficient managerial capacity, but we have to be careful how we harness it in the new system - and we have to work in teams.”
How will the new system cope with the steady 28% of GPs who consistently tell the DH PBC survey they disagree with the policy?
MS: “Put it the other way, 72% of GPs agree or are passive. We need a relatively small number of GPs to drive this forward.
“Even if some GPs disagree with the policy, they’ll recognise that decisions have to be made somewhere and they are better decided by clinical priorities than by a remote management body without front-line expertise.”
’In five years, if we’ve moved structures and bureaucracy but the NHS has not got a culture of clinically-led decision-making, this reform will fail.’
What else is needed to make this work?
“Bluntly, politicians, the DH and new NHS management board have got to walk the talk.
“This is not about structural change: it’s an attempt to introduce cultural change. In five years, if we’ve moved structures and bureaucracy but the NHS has not got a culture of clinically-led decision-making, this reform will fail.
“We need trust and courage from politicians and senior managers in the service. Tough decisions can best be made at the front line, if those decision-makers are held to account and performance-managed.”
Does commissioning need regulation? If so, of what kind and by whom?
MS: “It needs performance management, which is a form of regulation. It needs a regulatory frame work, and the plan seems to be that the independent management board will set that.
“There will be independent elements of regulation, by the new economic regulator, which looks to be Monitor - and also by the CQC.
“My plea is for it to be made clear who regulates what; who has jurisdiction over whom - and for no duplication. At the moment, regulation is by several different bodies, and they’re not always consistent.”
Are GPs sufficiently corporate beasts to drive effective commissioning, out variations in clinical practice and close services or even whole hospitals?
MS: “A sufficient numbers of GPs have shown that they’re willing and able to act corporately and make those tough decisions. GP corporacy needs to increase, and it’s possible to have passive agreement, with people dipping in and out on little topics that interest them.
“If you look at successful commissioning groups, like NEN in Northampton, or Principia, they are where GPs accept corporate responsibility to work together. Some at the end of the spectrum may not be wiling to play but I think that’s a decreasing, small minority.
“GPs, managers and others should consider what is the alternative to clinically-driven commissioning? Top-down, centrally-managed change done by civil servants and senior managers has proven singularly unsuccessful to meet local needs and carry the resource committers (GPs).
“The other option would be to actually hand commissioning over to some elements of private sector – and I’m not anti-private sector, though that approach starts to spell the end of the NHS as we know it.
“So it’s in everybody’s interest make clinically -driven commissioning work through locality commissioning arrangements”.
Previous interviews in this series
Nigel Edwards, acting CE, NHS Confederation
Andrew Donald, chief operating officer, NHS Birmingham East and North PCT